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COSMETIC

Photographic Measurements in 301 Cases of Liposuction and Abdominoplasty Reveal Fat Reduction without Redistribution
Eric Swanson, M.D.
Leawood, Kans.

Background: There are no published studies of liposuction or abdominoplasty in a large number of patients using measurements of body dimensions. In the absence of rigorous data, some investigators have proposed that fat returns after liposuction. Methods: A prospective study was undertaken among predominantly nonobese consecutive patients undergoing 301 liposuction and abdominoplasty procedures meeting the study criteria (inclusion rate, 70.7 percent). Lower body dimensions were measured using standardized photographs taken before and at least 3 months after surgery. Upper body measurements were compared between women who underwent simultaneous cosmetic breast surgery (n 67) and a group of women who had breast surgery alone (n 78) to investigate the possibility of fat redistribution. Results: The average weight change was a loss of 2.2 lbs after lower body liposuction (p 0.01) and 4.6 lbs when combined with abdominoplasty (p 0.001). Liposuction significantly reduced abdominal, thigh, knee, and arm width (p 0.001). Midabdominal and hip width were more effectively reduced by lipoabdominoplasty than liposuction alone (p 0.001). There was no difference in upper body measurements when comparing patients who had simultaneous liposuction and/or abdominoplasty with patients who had cosmetic breast surgery alone. Measurements in patients with at least 1 year of follow-up (n 46) showed no evidence of fat reaccumulation. Conclusions: Both liposuction and abdominoplasty are valid techniques for long-term fat reduction and improvement of body proportions. There is no evidence of fat regrowth. (Plast. Reconstr. Surg. 130: 311e, 2012.) CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, III.

lack of rigorous study limits our present understanding of fat distribution after liposuction. The effect of liposuction on the thickness of the lower body subcutaneous fat layer has only recently been determined.1 Surveys document patient satisfaction and a subjective awareness of a reduction in body size in treated areas.2,3 There is, however, no published objective analysis of this popular technique in a large number of patients using measurements. Consequently, liposuctions validity as a body-shaping instrument remains untested. This deficiency in our knowledge base has allowed for the promulgation of different opinions
From the Swanson Center. Received for publication January 18, 2012; accepted February 29, 2012. Copyright 2012 by the American Society of Plastic Surgeons DOI: 10.1097/PRS.0b013e3182589ef7

regarding postoperative fat distribution, including the concept of fat return.2,4,5 One recent study claims that fat redistributes after liposuction, leaving treated areas of the lower body but reaccumulating in untreated areas of the upper body,5 including the upper abdomen, shoulders, and triceps.6 A report in The New York Times 6 featuring an artists caricature of this idea (Fig. 1) has been widely publicized on the Internet.7,8

PATIENTS AND METHODS


Patients A prospective measurement study evaluated 301 consecutive cases (294 patients) performed

Disclosure: The author has no financial interests to disclose. This study received no outside funding.

www.PRSJournal.com

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gery between the surgery date and the date of the postoperative photographs. The usual reason for exclusion was no follow-up visit 3 months or more after surgery. There were 426 liposuction and abdominoplasty procedures performed during this time period, for an inclusion rate of 70.7 percent. This study was approved by the institutional review board of the Surgery Center of Leawood. Surgery The superwet technique and the Lysonix 3000 (Mentor Corp., Santa Barbara, Calif.) ultrasonic system were used for all liposuction procedures. Commonly, lower body liposuction was performed, treating the abdomen, flanks, thighs, and knees (Fig. 2). All abdominoplasties included umbilical transposition, and all except one (99 percent) were primary abdominoplasties (Fig. 3). Mini-abdominoplasties were excluded. Rectus abdominis fascial plication was performed in all abdominoplasties using two layers of monofilament polypropylene sutures. Most abdominoplasties (89 percent) were performed with simultaneous liposuction of the abdomen and flankslipoabdominoplasty. All surgery was performed by the author in a state-licensed ambulatory surgery center.

Fig. 1. The New York Times artists caricature of body shape changes after liposuction (With liposuction, the belly finds what the thighs lose. Available at: http://www.nytimes.com/2011/05/ 01/weekinreview/01kolata.html?_r 2. Accessed September 27, 2011), as proposed by Hernandez et al (Hernandez TL, Kittelson JM, Law CK, et al. Fat redistribution following suction lipectomy: Defense of body fat and patterns of restoration. Obesity 2011;19: 1388 1395). This concept recognizes a lasting effect of liposuction on the thighs but postulates compensatory regrowth in the abdomen, shoulders, and arms; artwork by Jonathon Rosen.

between September of 2003 and November of 2006 that met the inclusion criteria, which included (1) liposuction or abdominoplasty, with no simultaneous thigh lift; (2) photographs at least 3 months after surgery; and (3) no subsequent sur-

Fig. 2. Patient 1. Size- and orientation-matched photographs of a 24-year-old woman before (left) and 1 year after (right) liposuction of her lower body, arms, and axillae and a breast augmentation. The total aspirate volume was 3250 cc. Measurements show a decrease in widths at each of the treated levels. The calves were not treated. Magnetic resonance imaging measurements of this patient are provided in Figure 8.

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Fig. 3. Patient 2. Size- and orientation-matched photographs of a 32-year-old woman before (left) and 5 months after (right) abdominoplasty and liposuction of the lower body, not including calves. The aspirate volume was 1725 cc and the flap weight 2.0 pounds. Measurements show a reduction for each of the treated areas.

Photographs and Measurements To ensure standardization,9 all digital photographs were taken in the same room, using the same background, lighting, body positioning, focal distance, and 60-mm camera lens. All preoperative photographs were taken on the day of surgery. Measurements were made at the same level of the upper abdomen (narrowest level, just below the costal margin), mid-abdomen (umbilical level), hip (iliac crests), outer thighs (greatest width), knees (medial femoral epicondyles), and calves (greatest width), using Canfield Mirror 7.1.1 (Canfield Scientific, Fairfield, N.J.) imaging software. Arms were measured at the level of the deltoid insertion (Fig. 4). Anatomic boundaries were labeled on size- and orientation-matched images (Figs. 2 through 5), and the computer program calculated widths. All patient weights were recorded on the day of surgery and at follow-up appointments using the same hospital scales. Upper Body Measurements Upper body dimensions were measured to investigate whether an increase in upper body size occurs after liposuction.5 Among the 245 women who underwent liposuction and/or abdominoplasty, a subset of 67 women underwent simultaneous cosmetic breast surgery and had upper body photographs available at least 3 months after sur-

gery. Although these photographs were not originally taken for this purpose (they were taken to document changes in breast measurements), these images were used to measure changes in upper body (not breast) dimensions and to compare these measurements with a separate group of 78 consecutive women who underwent cosmetic breast surgery alone during the same study period. Measurements included: (1) shoulder width, measured at the level of the preaxillary crease; (2) mid-humeral width; and (3) upper abdominal width (Fig. 5). Facial Measurements Preoperative and at least 3-month postoperative facial photographs (n 83) were compared and tested for reliability among study patients who had simultaneous facial procedures, usually submental lipectomies, excluding patients treated with facial fillers and face lifts (i.e., no procedures affecting facial volume). Statistical Analysis Statistical analyses were performed using SPSS for Windows version 20.0 (SPSS, Inc., Chicago, Ill.). Independent t tests were used to assess mean differences between continuously measured variables for two independent groups. One-way analysis of variance was used to assess mean differences

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Fig. 4. Patient 3. Size- and orientation-matched photographs of the right arm before (left) and 3 months after (right) liposuction of the lower body, arms, and axillae in a 40-year-old woman. The aspirate volume was 150 cc for each arm and 50 cc for each axilla. The total aspirate volume was 2650 cc. The black upper and right border of the postoperative image (right) shows the matching tilt provided by the computer imaging software. (For publication, these areas would ordinarily be cropped.)

Fig. 5. Size- and orientation-matched upper body photographs of patient 1, before (left) and 1 year after (right) liposuction of the lower body, arms, and axillae and a breast augmentation. Width measurements of the upper body were very similar before and after surgery.

between continuously measured variables when there were more than two independent groups. Categorical variables were compared with Pearsons chi-square test of independence. Paired t tests were used to assess mean differences between continuously measured variables for matched

pairs. Because of multiple comparisons, a p value of less than 0.01 was considered significant. An a priori power analysis was performed. To achieve 80 percent power, with an alpha level of 0.05, using matched pairs to compare pre- and postoperative measurements sufficient to detect a medium-

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sized treatment effect (Cohens d 0.50),10 34 subjects would be needed for each group.11 Facial Width Measurements The mean postoperative facial width (13.35 cm) was slightly less than mean preoperative width (13.41 cm, p 0.01). The intraclass correlation coefficient was 0.98. 1-Year Follow-Up Group Among a subset of 46 patients with measurements 1 year or more after surgery (mean follow-up time, 27.6 months; range, 12.2 to 85.5 months), there was a significant reduction in hip measurements for patients treated with liposuction alone (n 22; p 0.01) and for both midabdominal and hip measurements in lipoabdominoplasty patients (n 22, p 0.001). Patients Who Gained Weight after Surgery Patients who gained at least 5 pounds after surgery (n 34, 11.6 percent) had a mean weight gain of 9.3 pounds and a range of 5 to 19 pounds. Hip measurements were reduced after both liposuction (n 24, p 0.01) and lipoabdominoplasty (n 10, p 0.01) despite weight gain; other trunk measurements were not significantly changed.

RESULTS
Patient data are presented in Table 1. The proportion of obese study patients (body mass index 30 kg/m2) was 19.3 percent, significantly less than the obesity rate for the American adult population (33.8 percent; p 0.001).12 The mean change in weight after liposuction of the lower body was a loss of 2.20 pounds (p 0.01) and 4.58 pounds when combined with an abdominoplasty (p 0.001). There was no significant difference in age, sex, body mass index, change in weight, aspirate volume, or flap weight when comparing study patients with excluded patients. Lower Body Dimensions after Surgery The combined data revealed significant reductions at all three trunk levels after liposuction and abdominoplasty in women (Figs. 6 and 7), with significantly greater decreases at the mid-abdominal and hip levels for women treated with lipoabdominoplasty than women treated with liposuction alone (p 0.001; Table 2). Thigh and knee measurements were reduced in patients who had liposuction (Table 3) and in patients who did not have liposuction of these areas. The magnitude of the reduction, however, was significantly greater when the thighs and knees were treated (p 0.01). Although the reduction in calf measurements was slightly greater for treated patients than untreated patients, the much smaller sample size for treated patients (n 18) precluded a finding of significance. Arm measurements were significantly reduced after liposuction (p 0.001). No photographs were available for untreated arms. Men experienced significant reductions at the mid-abdominal and hip levels after liposuction (p 0.001) but not at the upper abdominal level (Table 4), and there was no significant change for untreated thighs in men. Upper Body Measurements Chest width measurements in men were minimally affected by liposuction or direct excision of breast tissue. Male untreated chests showed a small but significant reduction (p 0.01). There were no significant changes for any of the three upper body dimensions among women, whether or not they were treated with liposuction and/or abdominoplasty at the time of their cosmetic breast surgery (Table 5).

DISCUSSION
Study Design This study examined a large prospective group of patients measured before and after liposuction and/or abdominoplasty to determine the effects of surgery on lower body (i.e., inferior to the costal margins) dimensionsthe original therapeutic question. To specifically address the questions of possible changes in upper body dimensions that may or may not be influenced by simultaneous liposuction,5 a separate contemporaneous cohort of 78 women treated with cosmetic breast surgery alone served as a control group. Although retrospective, these added comparisons benefit from the consistency of the same surgeon, photographic standards, minimum 3-month follow-up, and the same study period. This study makes the presumption that upper body width measurements (that do not include breast margins) in women having cosmetic breast surgery are not influenced by changes in breast size. Although not specific, shoulder and mid-humeral measurements are expected to be sufficiently sensitive over a large number of patients to detect an increase in subcutaneous fat volume of the arms, triceps, and mid-axillary areassites where Hernandez et al. reported trends for increases.5

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Liposuction of Lower Body (n 94) Abdominoplasty Only (n 14) p NS 40.60 11.07 18.8064.20 6.08 6.10 329 94 (100%) 0 (0%) 84 (89.4%) 5 (5.3%) 5 (5.3%) 94 25.55 3.77 18.8235.54 154.93 24.14 112.00226.00 152.71 22.84 108.00210.00 2.20 6.69 23.00 to 19.00 2919.63 1075.16 4256450 1240.19 534.89 5502900 5.24 2.91 1.5010.50 2.85 7.83 17.50 to 18.50 164.72 31.63 103.00218.00 167.50 33.84 108.00236.00 159.68 27.78 115.50237.00 155.09 25.74 103.00223.00 4.58 7.32 28.50 to 12.00 2487.39 942.24 11505350 4.25 2.04 1.5010.50 27.26 5.12 18.8941.11 27.06 4.88 19.6644.55 31 (96.9%) 0 (0%) 1 (3.1%) 32 63 (95.5%) 3 (4.5%) 0 (0%) 66 2 (50.0%) 1 (25.0%) 1 (25.0%) 4 25.17 6.29 15.1135.43 145.55 31.80 84.00198.00 144.68 26.83 92.00182.00 0.91 10.15 24.00 to 14.00 462.50 378.87 100975 3.23 2.38 0.378.50 29 (90.6%) 3 (9.4%) 66 (100%) 0 (0%) 13 (92.9%) 1 (7.1%) 9.04 11.65 357 9.35 13.52 362 13.07 23.26 386 7.54 10.64 386 0.001 252 (83.7%) 49 (16.3%) NS 264 (90.7%) 16 (5.5%) 11 (3.8%) 291 NS 26.31 4.41 15.1144.55 NS 163.58 33.05 84.00300.00 NS 160.98 32.06 92.00295.00 NS 2.61 7.49 29.00 to 19.00 0.01 2201.66 1108.60 1006450 4.38 2.40 0.3713.25 43.50 13.49 20.7065.40 43.51 10.08 25.1066.90 40.14 13.95 20.0065.40 41.83 11.58 15.2075.20 0.01 Abdominoplasty, Liposuction of Abdomen and Flanks (n 32) Abdominoplasty, Liposuction of Lower Body (n 66) All Procedures (n 301)

Table 1. Data for 301 Liposuction, Liposuction/Abdominoplasty, and Abdominoplasty Procedures*

Liposuction of Abdomen and Flanks (n 84)

42.25 11.83 15.2075.20

5.79 6.73 332

39 (46.4%) 45 (53.6%)

75 (89.3%) 5 (6.0%) 4 (4.8%) 84

26.77 3.93 19.2339.36

180.67 39.81 120.50300.00

178.91 39.76 119.00295.00

1.80 7.87 29.00 to 16.00

Age, yr Mean SD Range Follow-up time, mos Mean SD Range Sex Female Male Liposuction Primary Secondary Both n Preoperative BMI, kg/m2 Mean SD Range Preoperative weight, lbs Mean SD Range Postoperative weight, lbs Mean SD Range Change in weight, lbs Mean SD Range Aspirate volume, cc Mean SD Range Flap weight, lbs Mean SD Range

1806.12 770.57 6003950

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BMI, body mass index; NS, not significant. *Weights were compared across the two test times using a paired t test. Eleven procedures were included in all procedures that had procedure combinations that did not fit in one of the five procedure groups, so that the sum of the procedures in the first five columns is 290 rather than 301. Seven patients had two procedures, so that the total number of patients was 294. Means for the combined liposuction groups were compared with the means for the combined lipoabdominoplasty and abdominoplasty groups using independent t tests. Percentages for the combined liposuction groups were compared with the percentages for the combined lipoabdominoplasty and abdominoplasty groups using the chi-square test of independence. p 0.001. p 0.01.

Volume 130, Number 2 Body Dimensions after Liposuction

Fig. 6. Upper abdomen, mid-abdomen, and hip measurements before and after liposuction in women. Data are presented as means SD.

Fig. 7. Upper abdomen, mid-abdomen, and hip measurements before and after lipoabdominoplasty in women. Data are presented as means SD.

Theory of Fat Redistribution after Liposuction Seeking to validate their a priori hypothesis of body fat redistribution,13 Hernandez et al. concluded that liposuction removes fat from the thighs but that this fat returns within 1 year to the abdomen

and upper body.5 Of course, strictly speaking, the word return is incorrect; the concept really implies replacement of lost fat cells, presumably by recruitment of new adipocytes from local precursor cells. Their study was randomized and controlled but in-

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NS, not significant. *Change score means for the combined liposuction groups were compared with the change score means for the combined lipoabdominoplasty and abdominoplasty groups using independent t tests. Before and after measurements were compared using paired t tests. p 0.001. p 0.01.

0.001

0.001

Table 2. Trunk Dimensions in Women before and after Liposuction, Liposuction/Abdominoplasty, and Abdominoplasty*

Liposuction of Lower Body (n 94)

27.32 (1.95) 27.17 (2.21) 0.16 (1.07)

31.27 (2.44) 30.22 (2.34) 1.06 (1.48)

34.44 (2.08) 33.28 (2.22) 1.16 (1.19)

cluded only 14 patients who had surgery. Importantly, the treated patients did not remain calorically neutral. Treated patients experienced an early weight reduction after surgery, but their mean weight returned almost to their preoperative weight at 1 year. In the study by Hernandez et al., abdominal fat volume calculations were based on axial magnetic resonance images from the level of the 12th thoracic vertebra to the space between the fourth and fifth lumbar vertebrae.5 The umbilicus is usually located at or below the level of the fourth lumbar vertebra.14 The fact that liposuction was performed only below the umbilicus, and the abdomen was not treated at all in three patients, in the context of a substantial postoperative weight gain, may explain why there was an increase in measured fat volume in the abdomen but not the thighs after liposuction. There is no need to resort to redistribution theorya concept the proponents admit has not been confirmed by other investigators and is without a known physical explanation.5 Furthermore, new fat deposition without a positive energy balance, as claimed by the authors (relying on food surveys), contradicts the first law of thermodynamics.15 It is much more likely that these investigators simply observed fat volume increases in untreated areas in patients who gained weight. In fact, Hernandez et al. did not actually demonstrate fat redeposition in the upper body. Citing a trend based on such limited sample sizes, imprecise measurement devices, p values over 0.05, and no Bonferroni correction or use of a more rigorous alpha level for multiple comparisons is statistically indefensible. Another problem is that a small group of patients who happened to gain weight formed the treatment cohort. This confounding influence would be less likely in a larger, normally distributed sample. Limitations of Measurement Devices Measurements of body and limb circumferences, skin folds, and other nonradiologic techniques have overall errors in the range of 3 to 15 percent.16 Dual-energy x-ray absorptiometry may be affected by factors such as age, body cell mass,17 and state of hydration.18 The accuracy of subcutaneous fat measurements by magnetic resonance imaging1 has been validated by cadaveric dissections.19 Area and volume calculations, however, are affected by image artifacts and interobserver variation, causing differences in repeated measurements in the range of 10 percent.20 Such

All Procedures (n 242)

NS

Abdominoplasty Only (n 13)

28.17 (2.15) 27.80 (2.24) 0.37 (0.96)

28.41 (2.59) 27.72 (2.58) 0.69 (0.61)

32.37 (3.58) 31.01 (2.77) 1.37 (1.58) 32.96 (3.15) 30.73 (2.50) 2.23 (1.88) 33.63 (2.79) 31.09 (2.55) 2.55 (1.52) 32.91 (2.19) 31.06 (1.96) 1.85 (1.37)

32.30 (2.85) 30.62 (2.37) 1.67 (1.69)

Abdominoplasty, Liposuction of Lower Body (n 65)

Mean Dimension (SD), cm

Abdominoplasty, Liposuction of Abdomen and Flanks (n 29)

28.58 (1.89) 28.10 (2.03) 0.48 (0.88)

Liposuction of Abdomen and Flanks (n 37)

29.20 (2.31) 28.64 (2.35) 0.56 (0.94)

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Upper abdomen Before After Change Mid-abdomen Before After Change Hip Before After Change

28.98 (1.93) 28.46 (2.05) 0.52 (0.84)

34.32 (1.73) 33.13 (1.75) 1.19 (0.99)

35.10 (1.96) 33.18 (1.87) 1.92 (1.18)

35.58 (2.42) 33.50 (2.06) 2.08 (1.49)

34.37 (2.86) 33.37 (2.39) 1.00 (1.34)

34.79 (2.20) 33.31 (2.05) 1.48 (1.33)

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Table 3. Extremity Measurements in Women before and after Liposuction, and No Treatment*
Mean (SD), cm Outer Thigh Treated with liposuction Before After Change n Untreated Before After Change n Right Knee Left Knee Right Calf Left Calf Right Arm Left Arm

37.95 (2.60) 36.24 (2.61) 1.71 (1.51) 165 35.81 (2.13) 35.30 (2.17) 0.51 (0.82) 79

12.10 (1.14) 11.68 (1.08) 0.42 (0.54) 169 11.45 (0.85) 11.26 (0.87) 0.19 (0.35) 73

12.00 (1.17) 11.53 (1.10) 0.47 (0.55) 169 11.33 (0.89) 11.15 (0.89) 0.18 (0.41) 73

11.44 (0.82) 11.23 (0.78) 0.21 (0.52) 18 10.60 (0.88) 10.45 (0.92) 0.14 (0.37) 205

11.36 (1.09) 11.17 (1.03) 0.19 (0.48) 18 10.49 (0.90) 10.37 (0.89) 0.13 (0.41) 205

15.30 (1.50) 14.58 (1.32) 0.72 (0.66) 132

14.87 (1.34) 14.04 (1.25) 0.82 (0.65) 132

*Before and after measurements were compared using paired t tests. Photographs were unavailable for untreated arms. p 0.001.

Table 4. Trunk and Thigh Dimensions in 49 Men Treated with Liposuction, Liposuction/Abdominoplasty, or Abdominoplasty, or No Treatment*
Mean Dimension (SD), cm Liposuction of Abdomen and Flanks (n 45) Upper abdomen Before After Change Mid-abdomen Before After Change Hip Before After Change Thigh, untreated Before After Change n 33.86 (2.16) 33.63 (2.26) 0.23 (0.71) 36.41 (2.19) 35.16 (2.29) 1.25 (0.99) 35.69 (2.42) 34.91 (2.27) 0.78 (1.16) 38.11 (2.29) 38.13 (2.20) 0.02 (0.95) 21 Abdominoplasty, Liposuction of Abdomen and Flanks (n 3) 31.96 (2.42) 31.84 (1.81) 0.12 (0.73) 34.78 (0.85) 34.15 (0.59) 0.63 (0.56) 34.93 (1.12) 34.49 (1.30) 0.44 (0.75) 36.51 () 36.61 () 1 Abdominoplasty Only (n 1) 29.11 () 29.11 () 28.52 () 31.17 () 31.26 () 31.26 () 34.01 () 34.60 () 1 All Procedures (n 49) 33.65 (2.28) 33.43 (2.32) 0.22 (0.70) 36.15 (2.41) 35.02 (2.28) 1.13 (1.11) 35.55 (2.41) 34.81 (2.25) 0.75 (1.13) 37.86 (2.36) 37.91 (2.24) 0.05 (0.91) 23

*Before and after measurements were compared using paired t tests. p 0.001.

variability is too high to allow reliable conclusions when expected therapeutic changes are in this range and sample sizes are small. Type I false positive (e.g., fat redistribution5) and type II false negative (e.g., no metabolic effect of liposuction5,21) statistical errors are inevitable. Photographic Study of Body Dimensions Photographs are inexpensive, require only a few minutes of patient time, and maximize patient participation. Large sample sizes are feasible, and permit statistical analyses with a very low risk of type I or II errors, ensuring a high degree of reliability.22 Because an increase in fat volume accounts for about 80 percent of increased body mass in nonobese adults,23 change in physical di-

mensions correlates closely with expansion or reduction of subcutaneous fat volume. Of course, change in external body dimensions is the relevant issue from the patients perspective. Linear measurements on standardized and size-matched photographs have an intraclass correlation of 0.98 on repeated measurements, sufficiently precise to be clinically useful. Effect of Liposuction on Fat Distribution The traditional adipocyte theory, described by Fournier and Illouz, and Illouz and de Villers,24,25 holds that fat cells are permanently removed by liposuction. The present photographic study supports this concept. Linear measurements on magnetic resonance images in three

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Table 5. Upper Body Dimensions in 67 Women Treated with Liposuction, Liposuction/Abdominoplasty, or Abdominoplasty and Simultaneous Cosmetic Breast Surgery, and 78 Women Treated with Cosmetic Breast Surgery Alone*
Mean Dimension (SD), cm Liposuction with Simultaneous Cosmetic Breast Surgery (n 35) Shoulder width Before After Change n Bihumeral width Before After Change n Upper abdominal width Before After Change n 48.65 (3.34) 48.36 (3.13) 0.28 (1.16) 35 50.97 (3.95) 50.65 (3.78) 0.31 (1.33) 35 30.74 (3.07) 29.71 (5.48) 1.03 (4.91) 35 Liposuction/ Abdominoplasty with Simultaneous Cosmetic Breast Surgery (n 27) 48.81 (2.98) 48.54 (3.28) 0.27 (1.00) 27 51.17 (3.62) 50.93 (3.66) 0.25 (1.17) 27 31.55 (2.87) 31.14 (2.70) 0.41 (1.10) 26 Abdominoplasty with Simultaneous Cosmetic Breast Surgery (n 5) 46.75 (4.46) 46.33 (3.53) 0.43 (1.21) 5 47.24 (4.97) 47.06 (4.21) 0.18 (1.79) 5 29.62 (2.65) 29.60 (2.39) 0.02 (0.67) 5 Cosmetic Breast Surgery Alone (n 78) 46.82 (3.14) 46.72 (2.93) 0.10 (0.87) 78 48.18 (3.54) 48.21 (3.52) 0.03 (1.08) 78 28.82 (2.91) 29.02 (2.78) 0.20 (0.86) 76 All Procedures (n 145) 47.63 (3.31) 47.44 (3.15) 0.19 (0.98) 145 49.38 (3.95) 49.27 (3.83) 0.11 (1.18) 145 29.82 (3.12) 29.60 (3.67) 0.22 (2.59) 142

NS

NS

NS

*Before and after measurements were compared using paired t tests. No changes from before to after were significant. Means for the change scores for the liposuction group, the combined lipoabdominoplasty and abdominoplasty groups, and the breast surgery alone group were compared by one-way analyses of variance. None of the comparisons detected a significant difference.

weight-stable study patients reveal an average reduction of 45.6 percent in subcutaneous fat thickness in the abdomen, flanks, and thighs (p 0.001), with no sign of subsequent fat accumulation up to 1 year (Fig. 8).26 Imaging data corroborate the study findings; both photographs (Fig. 2 and 5) and nuclear magnetic resonance images (Fig. 8) reveal fat reduction in treated areas without evidence of redistribution. It is not surprising that abdominoplasty reduces the mid-abdominal and hip measurements more than liposuction alone, in view of this techniques full-thickness excision of lower abdominal skin and fat and the expected contribution of the muscle repair. This finding is also consistent with higher patient-reported result ratings for lipoabdominoplasty than liposuction alone.3 The reductions in measurements in untreated areas (thighs, knees, and calves in women; chest in men; and face in both sexes) were unexpected. Although small, these differences are likely to be reliable, owing to the statistical power provided by large sample sizes. These findings may reflect a psychological boost provided by improved body proportions; 91.0 percent of surveyed patients reported a greater motivation to stay in shape after surgery.3 Such decreases in untreated areas provide further evidence against the notion of a compensatory positive caloric shift or fat redistribution after liposuction. In conditions of marked weight loss, fat cells shrink, but the absolute number tends to remain

the same.2729 Physical removal, by liposuction or lipectomy, offers the only option for reducing the absolute number of fat cells30 and changing body proportions. In moderate obesity, increase in fat mass is caused by fat cell hypertrophy rather than hyperplasia.3133 Spalding et al. determined that a constant 10 percent of fat cells are renewed annually and this rate does not vary among adult ages and body mass indices.34 Reduction in the number and mass of subcutaneous fat cells is the most likely explanation for the significant decrease in plasma triglyceride levels observed after liposuction in patients with elevated preoperative levels.35 Metabolic Effects of Liposuction It has been postulated that liposuction may induce a metabolic imbalance, causing the body to gain weight to compensate for the fat that has been removed.5,13 This measurement study and other clinical studies, however, reveal no compensatory weight gain 3 to 12 months after liposuction.3538 There is no reliable evidence to suggest that liposuction induces a positive caloric state to drive the fat volume back to its original level. Because the total number of fat cells is tightly controlled in adulthoodwhether that number is normal or increased by excessive production during childhood34it makes sense that a surgical reduction will not alter this regulatory control and that the fat cell number will reach a new plateau, balanced by adipocyte pro-

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Volume 130, Number 2 Body Dimensions after Liposuction

Fig. 8. Patient 1. This 24-year-old womans clinical photographs are shown in Figures 2 and 5. Axial abdominal (above) and coronal lower body (below) magnetic resonance imaging scans were taken before (left), 6 months after (center), and 1 year after (right) liposuction of her lower body, arms, and axillae, and a breast augmentation. The subcutaneous fat appears white in these T1-weighted images. Measurements are indicated at the level of the abdomen, left flank, and thigh. One year after surgery (above, right), there is no evidence of compensatory fat deposition in the abdomen on the axial view. The coronal image at 1 year (below, right) also shows the abdomen and lower torso, with no evidence of fat redistribution.

duction and loss. Indeed, the study findings suggest that the lipostat,39 a theoretical homeostatic system thought to maintain fat deposits at a constant level, is reset after liposuction. It has been proposed that subcutaneous fat removal may cause untoward effects by upsetting the balance of visceral and subcutaneous fat volumes.5,40 Recent evidence, however, reveals that removal of excess subcutaneous fat can have favorable metabolic and inflammatory consequences, and that excess subcutaneous fat may be just as important, and potentially unhealthy, as excess visceral fat.35

concept of fat reaccumulation in treated or untreated areas of the body. Extraordinary claims require extraordinary evidence. Carl Sagan
Eric Swanson, M.D. Swanson Center 11413 Ash Street Leawood, Kans. 66211 eswanson@swansoncenter.com

ACKNOWLEDGMENTS

The author thanks Jane Zagorski, Ph.D., for statistical analyses, Lindsey Kroenke, B.S.N., for data collection, and Gwendolyn Godfrey for illustrations.
REFERENCES
1. Swanson E. Assessment of reduction in subcutaneous fat thickness after liposuction using magnetic resonance imaging. J Plast Reconstr Aesthet Surg. 2012;65:128130.

CONCLUSIONS
Removal of excess fat cells by liposuction and abdominoplasty provides a long-term reduction in treated areas. Measurements do not support the

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2. Broughton G, Horton B, Lipschitz A, Kenkel JM, Brown SA, Rohrich RJ. Lifestyle outcomes, satisfaction, and attitudes of patients after liposuction: A Dallas experience. Plast Reconstr Surg. 2006;117:17381749. 3. Swanson E. Prospective outcome study of 360 patients treated with liposuction, lipoabdominoplasty, and abdominoplasty. Plast Reconstr Surg. 2012;129:965978. 4. Dillerud E, Haheim LL. Long-term results of blunt suction lipectomy assessed by a patient questionnaire survey. Plast Reconstr Surg. 1993;92:3542. 5. Hernandez TL, Kittelson JM, Law CK, et al. Fat redistribution following suction lipectomy: Defense of body fat and patterns of restoration. Obesity 2011;19:13881395. 6. Kolata G. With liposuction, the belly finds what the thighs lose. The New York Times. May 1, 2011. Available at: http:// www.nytimes.com/2011/05/01/weekinreview/01kolata. html?_r 2. Accessed September 27, 2011. 7. Paddock C. Fat liposuctioned from hips returns to belly within 12 months. Medical News Today. May 2, 2011. Available at: http://www.medicalnewstoday.com/articles/223917.php. Accessed September 29, 2011. 8. Doheny K. Study: Fat may return after liposuction. WebMd Health News. May 3, 2011. Available at: http://www.webmd. com/healthy-beauty/news/20110503/study-fat-may-returnafter-liposuction. Accessed September 29, 2011. 9. DiBernardo BE, Adams RL, Krause J, Fiorillo MA, Gheradini G. Photographic standards in plastic surgery. Plast Reconstr Surg. 1998;102:559568. 10. Cohen J. Statistical Power Analysis for the Behavioral Sciences. 2nd ed. Hillsdale, NJ: Lawrence Erlbaum Associates; 1988:26. 11. Faul F, Erdfelder E, Lang AG, Buchner A. G*Power 3: A flexible statistical power analysis program for the social, behavioral, and biomedical sciences. Behav Res Methods 2007; 39:175191. 12. Flegal KM, Carroll MD, Ogden CL, Curtin LR. Prevalence and trends in obesity among US adults, 1999 2008. JAMA 2010;303:235241. 13. Yost TJ, Rodgers CM, Eckel RH. Suction lipectomy: Outcome relates to region-specific lipoprotein lipase activity and interval weight change. Plast Reconstr Surg. 1993;92:11011108; discussion 1109 1111. 14. Kuhns LR, Borlaza GS, Seigel R, Thornbury JR. External anatomic landmarks of the abdomen related to vertebral segments: Applications in cross-sectional imaging. Am J Roentgenol. 1978;131:115117. 15. Rosenbaum M, Leibel RL, Hirsch J. Obesity. N Engl J Med. 1997;337:396407. 16. Sjostrom L, Kvist H, Cederblad A, Tylen U. Determination of total adipose tissue and body fat in women by computed tomography, 40K, and tritium. Am J Physiol. 1986;250:E736 E745. 17. St-Onge M-P, Wang J, Shen W, et al. Dual-energy x-ray absorptiometry-measured lean soft tissue mass: Differing relation to body cell mass across the adult life span. J Gerontol. 2004;59A:796800. 18. Pietrobelli A, Wang Z, Formica C, Heymsfield SB. Dualenergy X-ray absorptiometry: Fat estimation errors due to variation in soft-tissue hydration. Am J Physiol. 1998;274: E808E816. 19. Abate N, Burns D, Peshock RM, Garg A, Grundy SM. Estimation of adipose tissue mass by magnetic resonance imaging: Validation against dissection in human cadavers. J Lipid Res. 1994;35:14901496. 20. Ross R, Shaw KD, Martel Y, de Guise J, Avruch L. Adipose tissue distribution measured by magnetic resonance imaging in obese women. Am J Clin Nutr. 1993;57:470475. 21. Klein S, Fontana L, Young VL, et al. Absence of an effect of liposuction on insulin action and risk factors for coronary heart disease. N Engl J Med. 2004;350:25492557. 22. Chung KC, Kalliainen LK, Spilson SV, Walters MR, Kim HM. The prevalence of negative studies with inadequate statistical power: An analysis of the plastic surgery literature. Plast Reconstr Surg. 2002;109:16; discussion 78. 23. Leibel RL, Rosenbaum M, Hirsch J. Changes in energy expenditure resulting from altered body weight. N Engl J Med. 1995;332:621628. 24. Fournier PF, Illouz Y-G. Collapsing surgery and body sculpturing. In: Regnault P, Daniel RK, eds. Aesthetic Plastic Surgery Principles and Techniques. Boston: Little, Brown; 1984:686 687. 25. Illouz Y-G, de Villers YT. eds. Body Sculpturing by Lipoplasty. Edinburgh: Churchill Livingstone; 1989:27. 26. Swanson E. Assessment of reduction in subcutaneous fat thickness after liposuction using magnetic resonance imaging. Paper presented at: Scientific Meeting of the American Society of Plastic Surgeons; September 24, 2011; Denver, Colo. 27. Fried S, Kral JG. Adipose tissue morphology, metabolism, and growth. In: Teimourian B, ed. Suction Lipectomy and Body Sculpturing. St. Louis: Mosby; 1986:1532. 28. Hirsch J, Knittle J. Cellularity of obese and nonobese human adipose tissue. Fed Proc. 1970;29:15161521. 29. Hirsch J. Adipose cellularity in relation to human obesity. Adv Intern Med. 1971;17:289300. 30. Kral JG. Surgical reduction of adipose tissue hypercellularity in man. Scand J Plast Reconstr Surg. 1975;9:140143. 31. Hirsch J, Gallian E. Methods for the determination of adipose cell size in man and animals. J Lipid Res. 1968;9:110119. 32. Bjorntorp P, Hood B, Martinsson A, Persson B. The com position of human subcutaneous adipose tissue in obesity. Acta Med Scand. 1966;180:117121. 33. Bjorntorp P, Sjostrom L. Number and size of adipose tissue fat cells in relation to metabolism in human obesity. Metabolism 1971;20:703713. 34. Spalding KL, Arner K, Westermark PO, et al. Dynamics of fat cell turnover in humans. Nature 2008;453:783787. 35. Swanson E. Prospective clinical study reveals significant reduction in triglyceride level and white cell count after liposuction and abdominoplasty and no change in cholesterol levels. Plast Reconstr Surg. 2011;128:182e197e. 36. Giese SY, Bulan EJ, Commons GW, Spear SL, Yanovski JA. Improvements in cardiovascular risk profile with large-volume liposuction: A pilot study. Plast Reconstr Surg. 2001;108: 510519. 37. Giese SY, Neborsky R, Bulan EJ, Spear SL, Yanovski JA. Improvements in cardiovascular risk profile after large-volume lipoplasty: A 1-year follow-up study. Aesthet Surg J. 2001;21: 527531. 38. Montoya T, Monereo S, Olivar J, Iglesias P, Diaz P. Effects of orlistat on visceral fat after liposuction. Dermatol Surg. 2009; 35:469474. 39. Mayer J. Regulation of energy intake and the body weight: The glucostatic theory and the lipostatic hypothesis. Ann NY Acad Sci. 1955;63:1543. 40. Matarasso A, Kim RW, Kral JG. The impact of liposuction on body fat. Plast Reconstr Surg. 1998;102:16861689.

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