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Photographic Measurements in 301 Cases of Liposuction and Abdominoplasty Reveal Fat Reduction without Redistribution

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					                                                                                      COSMETIC

Photographic Measurements in 301 Cases of
Liposuction and Abdominoplasty Reveal Fat
Reduction without Redistribution
         Eric Swanson, M.D.
                                   Background: There are no published studies of liposuction or abdominoplasty
                  Leawood, Kans.   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 proce-
                                   dures 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 dif-
                                   ference in upper body measurements when comparing patients who had si-
                                   multaneous 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.




A
        lack of rigorous study limits our present              regarding postoperative fat distribution, includ-
       understanding of fat distribution after lipo-           ing the concept of “fat return.”2,4,5 One recent
       suction. The effect of liposuction on the               study claims that fat redistributes after liposuction,
thickness of the lower body subcutaneous fat layer             leaving treated areas of the lower body but reac-
has only recently been determined.1 Surveys doc-               cumulating in untreated areas of the upper body,5
ument patient satisfaction and a subjective aware-             including the upper abdomen, shoulders, and
ness of a reduction in body size in treated areas.2,3          triceps.6 A report in The New York Times 6 featuring
There is, however, no published objective analysis             an artist’s caricature of this idea (Fig. 1) has been
of this popular technique in a large number of                 widely publicized on the Internet.7,8
patients using measurements. Consequently, lipo-
suction’s validity as a body-shaping instrument re-                     PATIENTS AND METHODS
mains untested.
    This deficiency in our knowledge base has al-              Patients
lowed for the promulgation of different opinions                   A prospective measurement study evaluated
                                                               301 consecutive cases (294 patients) performed
 From the Swanson Center.
 Received for publication January 18, 2012; accepted Febru-
 ary 29, 2012.                                                  Disclosure: The author has no financial interests
 Copyright ©2012 by the American Society of Plastic Surgeons    to disclose. This study received no outside funding.
 DOI: 10.1097/PRS.0b013e3182589ef7

                                               www.PRSJournal.com                                               311e
                                                                     Plastic and Reconstructive Surgery • August 2012

                                                                        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 ab-
                                                                        dominoplasty 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
Fig. 1. The New York Times artist’s caricature of body shape
changes after liposuction (With liposuction, the belly finds what
                                                                        (Mentor Corp., Santa Barbara, Calif.) ultrasonic
the thighs lose. Available at: http://www.nytimes.com/2011/05/
                                                                        system were used for all liposuction procedures.
01/weekinreview/01kolata.html?_r 2. Accessed September 27,
                                                                        Commonly, “lower body” liposuction was per-
2011), as proposed by Hernandez et al (Hernandez TL, Kittelson
                                                                        formed, treating the abdomen, flanks, thighs, and
JM, Law CK, et al. Fat redistribution following suction lipectomy:      knees (Fig. 2). All abdominoplasties included um-
Defense of body fat and patterns of restoration. Obesity 2011;19:       bilical transposition, and all except one (99 per-
1388 –1395). This concept recognizes a lasting effect of liposuc-       cent) were primary abdominoplasties (Fig. 3).
tion on the thighs but postulates compensatory regrowth in the          Mini-abdominoplasties were excluded. Rectus
abdomen, shoulders, and arms; artwork by Jonathon Rosen.                abdominis fascial plication was performed in all
                                                                        abdominoplasties using two layers of monofila-
                                                                        ment polypropylene sutures. Most abdomino-
between September of 2003 and November of                               plasties (89 percent) were performed with si-
2006 that met the inclusion criteria, which in-                         multaneous liposuction of the abdomen and
cluded (1) liposuction or abdominoplasty, with no                       flanks—“lipoabdominoplasty.” All surgery was
simultaneous thigh lift; (2) photographs at least 3                     performed by the author in a state-licensed am-
months after surgery; and (3) no subsequent sur-                        bulatory surgery center.




                    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 aug-
                    mentation. 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 mea-
                    surements of this patient are provided in Figure 8.


312e
Volume 130, Number 2 • Body Dimensions after Liposuction




                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 includ-
                ing 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                                     gery. Although these photographs were not orig-
    To ensure standardization,9 all digital photo-               inally taken for this purpose (they were taken to
graphs were taken in the same room, using the                    document changes in breast measurements),
same background, lighting, body positioning, fo-                 these images were used to measure changes in
cal distance, and 60-mm camera lens. All preop-                  upper body (not breast) dimensions and to com-
erative photographs were taken on the day of sur-                pare these measurements with a separate group of
gery. Measurements were made at the same level                   78 consecutive women who underwent cosmetic
of the upper abdomen (narrowest level, just below                breast surgery alone during the same study period.
the costal margin), mid-abdomen (umbilical                       Measurements included: (1) shoulder width, mea-
level), hip (iliac crests), outer thighs (greatest               sured at the level of the preaxillary crease; (2)
width), knees (medial femoral epicondyles), and                  mid-humeral width; and (3) upper abdominal
calves (greatest width), using Canfield Mirror                   width (Fig. 5).
7.1.1 (Canfield Scientific, Fairfield, N.J.) imaging
software. Arms were measured at the level of the                 Facial Measurements
deltoid insertion (Fig. 4). Anatomic boundaries                      Preoperative and at least 3-month postopera-
were labeled on size- and orientation-matched im-                tive facial photographs (n 83) were compared
ages (Figs. 2 through 5), and the computer pro-                  and tested for reliability among study patients who
gram calculated widths. All patient weights were                 had simultaneous facial procedures, usually sub-
recorded on the day of surgery and at follow-up                  mental lipectomies, excluding patients treated
appointments using the same hospital scales.                     with facial fillers and face lifts (i.e., no procedures
                                                                 affecting facial volume).
Upper Body Measurements
    Upper body dimensions were measured to in-                   Statistical Analysis
vestigate whether an increase in upper body size                      Statistical analyses were performed using SPSS
occurs after liposuction.5 Among the 245 women                   for Windows version 20.0 (SPSS, Inc., Chicago,
who underwent liposuction and/or abdomino-                       Ill.). Independent t tests were used to assess mean
plasty, a subset of 67 women underwent simulta-                  differences between continuously measured vari-
neous cosmetic breast surgery and had upper body                 ables for two independent groups. One-way anal-
photographs available at least 3 months after sur-               ysis of variance was used to assess mean differences

                                                                                                                  313e
                                                             Plastic and Reconstructive Surgery • August 2012




                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 publi-
                cation, 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                     pairs. Because of multiple comparisons, a p value
there were more than two independent groups.                     of less than 0.01 was considered significant.
Categorical variables were compared with Pear-                       An a priori power analysis was performed. To
son’s chi-square test of independence. Paired t                  achieve 80 percent power, with an alpha level of 0.05,
tests were used to assess mean differences between               using matched pairs to compare pre- and postoper-
continuously measured variables for matched                      ative measurements sufficient to detect a medium-

314e
Volume 130, Number 2 • Body Dimensions after Liposuction

sized treatment effect (Cohen’s d 0.50),10 34 sub-      Facial Width Measurements
jects would be needed for each group.11                     The mean postoperative facial width (13.35
                                                        cm) was slightly less than mean preoperative width
                                                        (13.41 cm, p      0.01). The intraclass correlation
                    RESULTS                             coefficient was 0.98.
    Patient data are presented in Table 1. The
proportion of obese study patients (body mass
index 30 kg/m2) was 19.3 percent, significantly         1-Year Follow-Up Group
less than the obesity rate for the American adult           Among a subset of 46 patients with measure-
population (33.8 percent; p 0.001).12 The mean          ments 1 year or more after surgery (mean fol-
change in weight after liposuction of the lower         low-up time, 27.6 months; range, 12.2 to 85.5
body was a loss of 2.20 pounds (p 0.01) and 4.58        months), there was a significant reduction in hip
pounds when combined with an abdominoplasty             measurements for patients treated with liposuc-
(p 0.001). There was no significant difference in       tion alone (n 22; p 0.01) and for both mid-
age, sex, body mass index, change in weight, as-        abdominal and hip measurements in lipoabdomi-
pirate volume, or flap weight when comparing            noplasty patients (n 22, p 0.001).
study patients with excluded patients.
                                                        Patients Who Gained Weight after Surgery
                                                            Patients who gained at least 5 pounds after
Lower Body Dimensions after Surgery                     surgery (n 34, 11.6 percent) had a mean weight
     The combined data revealed significant reduc-      gain of 9.3 pounds and a range of 5 to 19 pounds.
tions at all three trunk levels after liposuction and   Hip measurements were reduced after both li-
abdominoplasty in women (Figs. 6 and 7), with sig-      posuction (n     24, p    0.01) and lipoabdomi-
nificantly greater decreases at the mid-abdominal       noplasty (n 10, p 0.01) despite weight gain;
and hip levels for women treated with lipoabdomi-       other trunk measurements were not signifi-
noplasty than women treated with liposuction alone      cantly changed.
(p 0.001; Table 2). Thigh and knee measurements
were reduced in patients who had liposuction (Table                       DISCUSSION
3) and in patients who did not have liposuction of
these areas. The magnitude of the reduction, how-       Study Design
ever, was significantly greater when the thighs and          This study examined a large prospective group
knees were treated (p 0.01). Although the reduc-        of patients measured before and after liposuction
tion in calf measurements was slightly greater for      and/or abdominoplasty to determine the effects
treated patients than untreated patients, the much      of surgery on lower body (i.e., inferior to the costal
smaller sample size for treated patients (n       18)   margins) dimensions—the original therapeutic
precluded a finding of significance. Arm measure-       question. To specifically address the questions of
ments were significantly reduced after liposuction (p   possible changes in upper body dimensions that
   0.001). No photographs were available for un-        may or may not be influenced by simultaneous
treated arms. Men experienced significant reduc-        liposuction,5 a separate contemporaneous cohort
tions at the mid-abdominal and hip levels after li-     of 78 women treated with cosmetic breast surgery
posuction (p         0.001) but not at the upper        alone served as a control group. Although retro-
abdominal level (Table 4), and there was no signif-     spective, these added comparisons benefit from
icant change for untreated thighs in men.               the consistency of the same surgeon, photo-
                                                        graphic standards, minimum 3-month follow-up,
                                                        and the same study period.
Upper Body Measurements                                      This study makes the presumption that upper
    Chest width measurements in men were min-           body width measurements (that do not include
imally affected by liposuction or direct excision of    breast margins) in women having cosmetic breast
breast tissue. Male untreated chests showed a small     surgery are not influenced by changes in breast size.
but significant reduction (p 0.01). There were          Although not specific, shoulder and mid-humeral
no significant changes for any of the three upper       measurements are expected to be sufficiently sensi-
body dimensions among women, whether or not             tive over a large number of patients to detect an
they were treated with liposuction and/or abdomi-       increase in subcutaneous fat volume of the arms,
noplasty at the time of their cosmetic breast sur-      triceps, and mid-axillary areas—sites where Hernan-
gery (Table 5).                                         dez et al. reported “trends for increases.”5

                                                                                                        315e
       Table 1. Data for 301 Liposuction, Liposuction/Abdominoplasty, and Abdominoplasty Procedures*




316e
                                       Liposuction of        Liposuction of           Abdominoplasty,               Abdominoplasty,                                       All
                                        Abdomen and           Lower Body          Liposuction of Abdomen             Liposuction of           Abdominoplasty          Procedures
                                       Flanks (n 84)            (n 94)              and Flanks (n 32)             Lower Body (n 66)            Only (n 14)             (n 301)               p
       Age, yr                                                                                                                                                                              NS
         Mean                                42.25                 40.60                      43.50                        43.51                    40.14                 41.83
         SD                                  11.83                 11.07                      13.49                        10.08                    13.95                 11.58
         Range                           15.20–75.20           18.80–64.20                20.70–65.40                  25.10–66.90              20.00–65.40           15.20–75.20
       Follow-up time, mos                                                                                                                                                                 0.01
         Mean                                  5.79                 6.08                       9.04                          9.35                    13.07                 7.54
         SD                                    6.73                 6.10                      11.65                         13.52                    23.26                10.64
         Range                                3–32                 3–29                       3–57                          3–62                     3–86                 3–86
       Sex                                                                                                                                                                                 0.001
         Female                          39 (46.4%)            94 (100%)                  29 (90.6%)                    66 (100%)                13 (92.9%)           252 (83.7%)
         Male                            45 (53.6%)             0 (0%)                     3 (9.4%)                      0 (0%)                   1 (7.1%)             49 (16.3%)
       Liposuction                                                                                                                                                                          NS
         Primary                         75 (89.3%)            84 (89.4%)                 31 (96.9%)                    63 (95.5%)                2 (50.0%)           264 (90.7%)
         Secondary                        5 (6.0%)              5 (5.3%)                   0 (0%)                        3 (4.5%)                 1 (25.0%)            16 (5.5%)
         Both                             4 (4.8%)              5 (5.3%)                   1 (3.1%)                      0 (0%)                   1 (25.0%)            11 (3.8%)
         n                                   84                    94                         32                            66                        4                 291
       Preoperative BMI, kg/m2                                                                                                                                                              NS
         Mean                                26.77                 25.55                      27.26                        27.06                    25.17                 26.31
         SD                                   3.93                  3.77                       5.12                         4.88                     6.29                  4.41
         Range                           19.23–39.36           18.82–35.54                18.89–41.11                  19.66–44.55              15.11–35.43           15.11–44.55
       Preoperative weight, lbs                                                                                                                                                             NS
         Mean                               180.67              154.93                      167.50                       159.68                   145.55                163.58
         SD                                  39.81                24.14                      33.84                         27.78                    31.80                 33.05
         Range                          120.50–300.00        112.00–226.00              108.00–236.00                 115.50–237.00             84.00–198.00          84.00–300.00
       Postoperative weight, lbs                                                                                                                                                            NS
         Mean                               178.91              152.71                      164.72                       155.09                   144.68                160.98
         SD                                  39.76                22.84                      31.63                         25.74                    26.83                 32.06
         Range                          119.00–295.00        108.00–210.00              103.00–218.00                 103.00–223.00             92.00–182.00          92.00–295.00
       Change in weight, lbs                                                                                                                                                                NS
         Mean                                  1.80                 2.20‡                      2.85                         4.58†                    0.91                  2.61†
         SD                                    7.87                 6.69                       7.83                         7.32                    10.15                  7.49
         Range                           29.00 to 16.00        23.00 to 19.00            17.50 to 18.50                28.50 to 12.00           24.00 to 14.00        29.00 to 19.00
       Aspirate volume, cc                                                                                                                                                                 0.01
         Mean                              1806.12              2919.63                     1240.19                      2487.39                   462.50               2201.66
         SD                                 770.57              1075.16                      534.89                       942.24                   378.87               1108.60
         Range                             600–3950             425–6450                    550–2900                    1150–5350                 100–975               100–6450
       Flap weight, lbs                                                                                                                                                                     —
         Mean                                 —                     —                          5.24                          4.25                     3.23                 4.38
         SD                                   —                     —                          2.91                          2.04                     2.38                 2.40
         Range                                —                     —                      1.50–10.50                    1.50–10.50               0.37–8.50            0.37–13.25
       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.
                                                                                                                                                                                                     Plastic and Reconstructive Surgery • August 2012
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             and upper body.5 Of course, strictly speaking, the
    Seeking to validate their a priori hypothesis of       word “return” is incorrect; the concept really implies
body fat redistribution,13 Hernandez et al. con-           “replacement” of lost fat cells, presumably by recruit-
cluded that liposuction removes fat from the thighs        ment of new adipocytes from local precursor cells.
but that this fat returns within 1 year to the abdomen     Their study was randomized and controlled but in-

                                                                                                            317e
                                                                                                                                                                                                                                                                                                                                                                                                            Plastic and Reconstructive Surgery • August 2012




                                                                                                                                                                                                                        *Change score means for the combined liposuction groups were compared with the change score means for the combined lipoabdominoplasty and abdominoplasty groups using independent
                                                                                                                                                                                                0.001


                                                                                                                                                                                                                0.001
                                                                                                                                                                                                                                                                                                                                                                                                               cluded only 14 patients who had surgery. Impor-




                                                                                                                                                                                NS
                                                                                                                                                            p
                                                                                                                                                                                                                                                                                                                                                                                                               tantly, the treated patients did not remain calorically
                                                                                                                                                                                                                                                                                                                                                                                                               neutral. Treated patients experienced an early
                                                                                                                                                                                                                                                                                                                                                                                                               weight reduction after surgery, but their mean
                                                                                                                                                     All Procedures

                                                                                                                                                                                                                                                                                                                                                                                                               weight returned almost to their preoperative weight

                                                                                                                                                                         0.37 (0.96)†



                                                                                                                                                                                         1.67 (1.69)†


                                                                                                                                                                                                         1.48 (1.33)†
                                                                                                                                                                        28.17 (2.15)
                                                                                                                                                                        27.80 (2.24)


                                                                                                                                                                                        32.30 (2.85)
                                                                                                                                                                                        30.62 (2.37)


                                                                                                                                                                                                        34.79 (2.20)
                                                                                                                                                                                                        33.31 (2.05)
                                                                                                                                                        (n 242)

                                                                                                                                                                                                                                                                                                                                                                                                               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 tho-
                                                                                                                                                                                                                                                                                                                                                                                                               racic vertebra to the space between the fourth and
                                                                                                                                                                                                                                                                                                                                                                                                               fifth lumbar vertebrae.5 The umbilicus is usually
 Table 2. Trunk Dimensions in Women before and after Liposuction, Liposuction/Abdominoplasty, and Abdominoplasty*



                                                                                                                                                     Abdominoplasty
                                                                                                                                                      Only (n 13)



                                                                                                                                                                         0.69 (0.61)†



                                                                                                                                                                                         1.37 (1.58)‡

                                                                                                                                                                                                                                                                                                                                                                                                               located at or below the level of the fourth lumbar
                                                                                                                                                                        28.41 (2.59)
                                                                                                                                                                        27.72 (2.58)


                                                                                                                                                                                        32.37 (3.58)
                                                                                                                                                                                        31.01 (2.77)


                                                                                                                                                                                                        34.37 (2.86)
                                                                                                                                                                                                        33.37 (2.39)
                                                                                                                                                                                                         1.00 (1.34)                                                                                                                                                                                           vertebra.14 The fact that liposuction was per-
                                                                                                                                                                                                                                                                                                                                                                                                               formed only below the umbilicus, and the abdo-
                                                                                                                                                                                                                                                                                                                                                                                                               men 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 mea-
                                                                                                                                                                                                                                                                                                                                                                                                               sured fat volume in the abdomen but not the
                                                                                                                                              Lower Body (n 65)




                                                                                                                                                                                                                                                                                                                                                                                                               thighs after liposuction. There is no need to resort
                                                                                                                                                Abdominoplasty,
                                                                                                                                                 Liposuction of




                                                                                                                                                                         0.48 (0.88)†



                                                                                                                                                                                         2.23 (1.88)†


                                                                                                                                                                                                         2.08 (1.49)†




                                                                                                                                                                                                                                                                                                                                                                                                               to redistribution theory—a concept the propo-
                                                                                                                                                                        28.58 (1.89)
                                                                                                                                                                        28.10 (2.03)


                                                                                                                                                                                        32.96 (3.15)
                                                                                                                                                                                        30.73 (2.50)


                                                                                                                                                                                                        35.58 (2.42)
                                                                                                                                                                                                        33.50 (2.06)




                                                                                                                                                                                                                                                                                                                                                                                                               nents admit has not been confirmed by other in-
                                                                                                                                                                                                                                                                                                                                                                                                               vestigators and is without a known physical
                                                                                                                    Mean Dimension (SD), cm




                                                                                                                                                                                                                                                                                                                                                                                                               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
                                                                                                                                              Liposuction of Abdomen
                                                                                                                                                and Flanks (n 29)




                                                                                                                                                                                                                                                                                                                                                                                                               volume increases in untreated areas in patients
                                                                                                                                                  Abdominoplasty,




                                                                                                                                                                         0.56 (0.94)‡



                                                                                                                                                                                         2.55 (1.52)†


                                                                                                                                                                                                         1.92 (1.18)†




                                                                                                                                                                                                                                                                                                                                                                                                               who gained weight.
                                                                                                                                                                        29.20 (2.31)
                                                                                                                                                                        28.64 (2.35)


                                                                                                                                                                                        33.63 (2.79)
                                                                                                                                                                                        31.09 (2.55)


                                                                                                                                                                                                        35.10 (1.96)
                                                                                                                                                                                                        33.18 (1.87)




                                                                                                                                                                                                                                                                                                                                                                                                                    In fact, Hernandez et al. did not actually dem-
                                                                                                                                                                                                                                                                                                                                                                                                               onstrate fat redeposition in the upper body. Citing
                                                                                                                                                                                                                                                                                                                                                                                                               a “trend” based on such limited sample sizes, im-
                                                                                                                                                                                                                                                                                                                                                                                                               precise measurement devices, p values over 0.05,
                                                                                                                                                                                                                        t tests. Before and after measurements were compared using paired t tests.




                                                                                                                                                                                                                                                                                                                                                                                                               and no Bonferroni correction or use of a more
                                                                                                                                                                                                                                                                                                                                                                                                               rigorous alpha level for multiple comparisons is
                                                                                                                                                                                                                                                                                                                                                                                                               statistically indefensible. Another problem is that
                                                                                                                                              Body (n 94)




                                                                                                                                                                                                                                                                                                                                                                                                               a small group of patients who happened to gain
                                                                                                                                                                                         1.06 (1.48)†


                                                                                                                                                                                                         1.16 (1.19)†
                                                                                                                                               Liposuction



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

                                                                                                                                                                                        31.27 (2.44)
                                                                                                                                                                                        30.22 (2.34)


                                                                                                                                                                                                        34.44 (2.08)
                                                                                                                                                                                                        33.28 (2.22)
                                                                                                                                                of Lower




                                                                                                                                                                                                                                                                                                                                                                                                               weight formed the treatment cohort. This con-
                                                                                                                                                                                                                                                                                                                                                                                                               founding influence would be less likely in a larger,
                                                                                                                                                                                                                                                                                                                                                                                                               normally distributed sample.


                                                                                                                                                                                                                                                                                                                                                                                                               Limitations of Measurement Devices
                                                                                                                                              Flanks (n 37)
                                                                                                                                              Liposuction of
                                                                                                                                               Abdomen and




                                                                                                                                                                         0.52 (0.84)†



                                                                                                                                                                                         1.85 (1.37)†


                                                                                                                                                                                                         1.19 (0.99)†




                                                                                                                                                                                                                                                                                                                                                                                                                   Measurements of body and limb circumfer-
                                                                                                                                                                        28.98 (1.93)
                                                                                                                                                                        28.46 (2.05)


                                                                                                                                                                                        32.91 (2.19)
                                                                                                                                                                                        31.06 (1.96)


                                                                                                                                                                                                        34.32 (1.73)
                                                                                                                                                                                                        33.13 (1.75)




                                                                                                                                                                                                                                                                                                                                                                                                               ences, skin folds, and other nonradiologic tech-
                                                                                                                                                                                                                                                                                                                                                                                                               niques 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 subcu-
                                                                                                                                                                                                                        NS, not significant.




                                                                                                                                                                                                                                                                                                                                                                                                               taneous fat measurements by magnetic resonance
                                                                                                                                                                       Upper abdomen




                                                                                                                                                                                                                                                                                                                                                                                                               imaging1 has been validated by cadaveric
                                                                                                                                                                       Mid-abdomen




                                                                                                                                                                                                                                                                                                                                                                                                               dissections.19 Area and volume calculations, how-
                                                                                                                                                                                                                        †p 0.001.
                                                                                                                                                                         Change



                                                                                                                                                                         Change


                                                                                                                                                                         Change




                                                                                                                                                                                                                        ‡p 0.01.
                                                                                                                                                                         Before



                                                                                                                                                                         Before



                                                                                                                                                                         Before




                                                                                                                                                                                                                                                                                                                                                                                                               ever, are affected by image artifacts and interob-
                                                                                                                                                                         After



                                                                                                                                                                         After



                                                                                                                                                                         After




                                                                                                                                                                                                                                                                                                                                                                                                               server variation, causing differences in repeated
                                                                                                                                                                       Hip




                                                                                                                                                                                                                                                                                                                                                                                                               measurements in the range of 10 percent.20 Such

318e
Volume 130, Number 2 • Body Dimensions after Liposuction

Table 3. Extremity Measurements in Women before and after Liposuction, and No Treatment*
                                                                     Mean (SD), cm

                   Outer Thigh      Right Knee       Left Knee          Right Calf      Left Calf       Right Arm         Left Arm
Treated with
    liposuction
  Before           37.95 (2.60)    12.10 (1.14)     12.00 (1.17)       11.44 (0.82)    11.36 (1.09)    15.30 (1.50)     14.87 (1.34)
  After            36.24 (2.61)    11.68 (1.08)     11.53 (1.10)       11.23 (0.78)    11.17 (1.03)    14.58 (1.32)     14.04 (1.25)
  Change            1.71 (1.51)†    0.42 (0.54)†     0.47 (0.55)†       0.21 (0.52)     0.19 (0.48)     0.72 (0.66)†     0.82 (0.65)†
  n                    165             169              169                  18              18            132              132
Untreated
  Before           35.81 (2.13)    11.45 (0.85)     11.33 (0.89)       10.60 (0.88)    10.49 (0.90)         —                —
  After            35.30 (2.17)    11.26 (0.87)     11.15 (0.89)       10.45 (0.92)    10.37 (0.89)         —                —
  Change            0.51 (0.82)†    0.19 (0.35)†     0.18 (0.41)†       0.14 (0.37)†    0.13 (0.41)†        —                —
  n                      79              73               73               205             205              —                —
*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          Abdominoplasty, Liposuction of          Abdominoplasty          All Procedures
                         and Flanks (n 45)              Abdomen and Flanks (n 3)                Only (n 1)                (n 49)
Upper abdomen
  Before                      33.86 (2.16)                           31.96 (2.42)                   29.11 (—)           33.65 (2.28)
  After                       33.63 (2.26)                           31.84 (1.81)                   29.11 (—)           33.43 (2.32)
  Change                       0.23 (0.71)                            0.12 (0.73)                       —                0.22 (0.70)
Mid-abdomen
  Before                      36.41 (2.19)                           34.78 (0.85)                   28.52 (—)           36.15 (2.41)
  After                       35.16 (2.29)                           34.15 (0.59)                   31.17 (—)           35.02 (2.28)
  Change                       1.25 (0.99)†                           0.63 (0.56)                       —                1.13 (1.11)†
Hip
  Before                      35.69 (2.42)                           34.93 (1.12)                   31.26 (—)           35.55 (2.41)
  After                       34.91 (2.27)                           34.49 (1.30)                   31.26 (—)           34.81 (2.25)
  Change                       0.78 (1.16)†                           0.44 (0.75)                       —                0.75 (1.13)†
Thigh, untreated
  Before                      38.11 (2.29)                           36.51 (—)                      34.01 (—)           37.86 (2.36)
  After                       38.13 (2.20)                           36.61 (—)                      34.60 (—)           37.91 (2.24)
  Change                       0.02 (0.95)                               —                              —                0.05 (0.91)
  n                                21                                     1                             1                    23
*Before and after measurements were compared using paired t tests.
†p 0.001.


variability is too high to allow reliable conclusions                  mensions correlates closely with expansion or re-
when expected therapeutic changes are in this                          duction of subcutaneous fat volume. Of course,
range and sample sizes are small. Type I false                         change in external body dimensions is the rele-
positive (e.g., fat redistribution5) and type II false                 vant issue from the patient’s perspective. Linear
negative (e.g., no metabolic effect of liposuc-                        measurements on standardized and size-matched
tion5,21) statistical errors are inevitable.                           photographs have an intraclass correlation of 0.98
                                                                       on repeated measurements, sufficiently precise to
                                                                       be clinically useful.
Photographic Study of Body Dimensions
    Photographs are inexpensive, require only a
few minutes of patient time, and maximize patient                      Effect of Liposuction on Fat Distribution
participation. Large sample sizes are feasible, and                        The traditional “adipocyte theory,” described
permit statistical analyses with a very low risk of                    by Fournier and Illouz, and Illouz and de
type I or II errors, ensuring a high degree of                         Villers,24,25 holds that fat cells are permanently
reliability.22 Because an increase in fat volume ac-                   removed by liposuction. The present photo-
counts for about 80 percent of increased body                          graphic study supports this concept. Linear mea-
mass in nonobese adults,23 change in physical di-                      surements on magnetic resonance images in three

                                                                                                                               319e
                                                                  Plastic and Reconstructive Surgery • August 2012

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           Liposuction/             Abdominoplasty
                       Simultaneous          Abdominoplasty with         with Simultaneous          Cosmetic             All
                      Cosmetic Breast       Simultaneous Cosmetic         Cosmetic Breast        Breast Surgery      Procedures
                      Surgery (n 35)        Breast Surgery (n 27)         Surgery (n 5)          Alone (n 78)         (n 145)         p
Shoulder width
  Before                 48.65 (3.34)              48.81 (2.98)              46.75 (4.46)          46.82 (3.14)      47.63 (3.31)
  After                  48.36 (3.13)              48.54 (3.28)              46.33 (3.53)          46.72 (2.93)      47.44 (3.15)
  Change                  0.28 (1.16)               0.27 (1.00)               0.43 (1.21)           0.10 (0.87)       0.19 (0.98)    NS
  n                          35                        27                         5                    78                145
Bihumeral width
  Before                 50.97 (3.95)              51.17 (3.62)              47.24 (4.97)          48.18 (3.54)      49.38 (3.95)
  After                  50.65 (3.78)              50.93 (3.66)              47.06 (4.21)          48.21 (3.52)      49.27 (3.83)
  Change                  0.31 (1.33)               0.25 (1.17)               0.18 (1.79)           0.03 (1.08)       0.11 (1.18)    NS
  n                          35                        27                         5                    78                145
Upper abdominal
    width
  Before                 30.74 (3.07)              31.55 (2.87)              29.62 (2.65)          28.82 (2.91)      29.82 (3.12)
  After                  29.71 (5.48)              31.14 (2.70)              29.60 (2.39)          29.02 (2.78)      29.60 (3.67)
  Change                  1.03 (4.91)               0.41 (1.10)               0.02 (0.67)           0.20 (0.86)       0.22 (2.59)    NS
  n                          35                        26                         5                    76                142
*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 re-                     the same.27–29 Physical removal, by liposuction or
duction of 45.6 percent in subcutaneous fat thick-                     lipectomy, offers the only option for reducing the
ness in the abdomen, flanks, and thighs (p                             absolute number of fat cells30 and changing body
0.001), with no sign of subsequent fat accumula-                       proportions. In moderate obesity, increase in fat
tion up to 1 year (Fig. 8).26 Imaging data corrob-                     mass is caused by fat cell hypertrophy rather than
orate the study findings; both photographs (Fig. 2                     hyperplasia.31–33 Spalding et al. determined that a
and 5) and nuclear magnetic resonance images                           constant 10 percent of fat cells are renewed an-
(Fig. 8) reveal fat reduction in treated areas with-                   nually and this rate does not vary among adult ages
out evidence of redistribution.                                        and body mass indices.34 Reduction in the number
    It is not surprising that abdominoplasty re-                       and mass of subcutaneous fat cells is the most
duces the mid-abdominal and hip measurements                           likely explanation for the significant decrease in
more than liposuction alone, in view of this tech-                     plasma triglyceride levels observed after liposuc-
nique’s full-thickness excision of lower abdominal                     tion in patients with elevated preoperative levels.35
skin and fat and the expected contribution of the
muscle repair. This finding is also consistent with
higher patient-reported result ratings for lipoab-                     Metabolic Effects of Liposuction
dominoplasty than liposuction alone.3 The reduc-                            It has been postulated that liposuction may in-
tions in measurements in untreated areas (thighs,                      duce a metabolic imbalance, causing the body to
knees, and calves in women; chest in men; and face                     gain weight to compensate for the fat that has been
in both sexes) were unexpected. Although small,                        removed.5,13 This measurement study and other clin-
these differences are likely to be reliable, owing to                  ical studies, however, reveal no compensatory weight
the statistical power provided by large sample sizes.                  gain 3 to 12 months after liposuction.35–38 There is no
These findings may reflect a psychological boost pro-                  reliable evidence to suggest that liposuction induces
vided by improved body proportions; 91.0 percent of                    a positive caloric state to drive the fat volume back
surveyed patients reported a greater motivation to                     to its original level. Because the total number of fat
stay in shape after surgery.3 Such decreases in un-                    cells is tightly controlled in adulthood—whether
treated areas provide further evidence against the                     that number is normal or increased by excessive
notion of a compensatory positive caloric shift or fat                 production during childhood34—it makes sense
redistribution after liposuction.                                      that a surgical reduction will not alter this regu-
    In conditions of marked weight loss, fat cells                     latory control and that the fat cell number will
shrink, but the absolute number tends to remain                        reach a new plateau, balanced by adipocyte pro-

320e
Volume 130, Number 2 • Body Dimensions after Liposuction




      Fig. 8. Patient 1. This 24-year-old woman’s 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 subcu-
      taneous 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 sug-                  concept of fat reaccumulation in treated or un-
gest that the “lipostat,”39 a theoretical homeostatic              treated areas of the body.
system thought to maintain fat deposits at a con-
stant level, is reset after liposuction.                              Extraordinary claims require extraordinary evidence.
    It has been proposed that subcutaneous fat                                                                —Carl Sagan
removal may cause untoward effects by upsetting                                                            Eric Swanson, M.D.
the balance of visceral and subcutaneous fat                                                                  Swanson Center
volumes.5,40 Recent evidence, however, reveals                                                              11413 Ash Street
that removal of excess subcutaneous fat can have                                                        Leawood, Kans. 66211
favorable metabolic and inflammatory conse-                                                      eswanson@swansoncenter.com
quences, and that excess subcutaneous fat may be                                    ACKNOWLEDGMENTS
just as important, and potentially unhealthy, as                       The author thanks Jane Zagorski, Ph.D., for statistical
excess visceral fat.35                                             analyses, Lindsey Kroenke, B.S.N., for data collection, and
                                                                   Gwendolyn Godfrey for illustrations.
                  CONCLUSIONS                                                             REFERENCES
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abdominoplasty provides a long-term reduction in                       thickness after liposuction using magnetic resonance imag-
treated areas. Measurements do not support the                         ing. J Plast Reconstr Aesthet Surg. 2012;65:128–130.


                                                                                                                               321e
                                                                           Plastic and Reconstructive Surgery • August 2012

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                    ˚
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Description: 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.