Disharmonious Obesity After Liposuction — Why the Abdomen Can Look Bigger After Reducing Only the Breasts

In a previous column (Y-Zone Liposuction for Disharmonious Obesity), we looked closely at one region: the mons pubis, pelvis, and inner thighs. Today we will widen the view and look at the number and size of fat cells, energy balance, and where the remaining fat goes, together with research findings. We will then show, step by step, the progress of one patient who first had breast surgery and then went on to have abdominal surgery because the abdomen looked relatively larger afterward.

A Swedish research team tracked the lifespan of adult fat cells by measuring how much carbon-14—released into the atmosphere during nuclear weapons testing—remained in fat cell DNA. They found that the number of fat cells in adults stayed constant in both lean and obese people, and it stayed the same even after major weight loss. About 10% of fat cells are replaced each year, but the total number remains unchanged.[1]

The same is true when you lose weight. During weight loss, each fat cell simply shrinks in volume while the number of cells stays the same, and in people who were previously obese, the fat tissue contains a higher proportion of fibrous tissue, so the result may be less noticeable.[2] Liposuction, on the other hand, removes the fat cells themselves from the treated area. As a result, even within the same body, the "number of fat cells" differs between treated and untreated areas. When weight is gained later, areas with fewer cells tend to enlarge relatively less, and areas where the cell count is unchanged may become noticeably larger first.[3]

Regaining weight after surgery does not mean the surgery went wrong; it happens because energy balance works the same way it always does. That is why diet and exercise after liposuction are an essential part of maintaining results over the long term.

The most striking finding comes from a Dutch research team. Of 48 patients who had abdominal liposuction, 19 (40%) were found to have an increase of at least one bra cup size. In the control group, who had abdominoplasty only, the figure was 11%. And 47% of those whose cup size increased had experienced a small weight gain of about 4% as measured by body mass index (BMI), compared with 3% among those whose cup size did not increase.[4] In other words, the remaining areas may respond first even to a slight weight gain, without a large weight increase. Earlier, a U.S. study found that 34% of 73 patients who had power-assisted liposuction reported that their breasts felt larger, and this was associated with suction of the abdomen and buttocks.[5] This phenomenon is explained as one form of disharmonious obesity, in which untreated areas such as the breasts look relatively larger compared with areas where the number of fat cells has been reduced.[3]

This has also been examined in a randomized controlled trial. When 32 non-obese women (14 in the surgery group, 18 in the control group) were followed for one year, the difference in body fat percentage between the two groups was 1.82 percentage points at 6 weeks, but after one year the difference was no longer statistically significant. The thighs remained reduced, but fat reaccumulated in the abdomen. Keep in mind that the participants in this study had agreed not to change their lifestyle during the study period.[6] In a study of 36 normal-weight women who had small-volume abdominal liposuction, the group that did not exercise after surgery showed about a 10% increase in visceral fat and a decrease in energy expenditure after 6 months, while these changes did not appear in the group that exercised for 4 months. The reduction in subcutaneous abdominal fat was maintained in both groups.[7] The decrease in energy expenditure mentioned earlier was actually observed in research.

Now let us look at one patient's progress. Because the breasts were large, this patient first had breast liposuction. Once the breasts became smaller, an imbalance in which the abdomen looked relatively larger became noticeable, so the patient went on to have liposuction of the abdomen, flanks, waist, and back. According to the surgical records, the interval between the breast surgery and the abdominal surgery was 16 days. To explain how disharmonious obesity looks, we have separated the results into the stages below.

Before surgery, we explain these possibilities in advance. We also emphasize the importance of managing weight and exercising regularly. For cases in which disharmonious obesity developed after liposuction, an approach combining corrective liposuction, if needed, with aerobic exercise and a low-glycemic-index diet has been reported.[3] Research showing that post-surgery exercise prevented an increase in visceral fat points in the same direction.[7]

A systematic review of 11 studies involving 271 people that examined the effects of surgery removing abdominal fat (abdominal lipectomy) on metabolic syndrome markers and insulin sensitivity found no significant metabolic effect in most of the studies.[9] Liposuction is body contouring surgery that refines the body's outline and proportions; it is not surgery to treat diabetes or metabolic disease.

Below are photos of two patients who had breast liposuction at Venus Clinic, followed by liposuction of the abdomen, flanks, waist, and back, divided by surgical stage. In both patients, the breast surgery was done first; the surgery of the abdomen, flanks, waist, and back followed 16 days later in the first case and 139 days later in the second case. In the first case, the after photos were taken about 5 weeks after breast surgery (about 3 weeks after abdominal surgery) and about 3 months after abdominal surgery. In the second case, the after photo for the breast surgery was taken about 9 days after breast surgery, and the after photo for the abdominal surgery was taken about 10 days after abdominal surgery. Swelling may still be present at these points, so these are not final results.

First Pair — Before Breast Surgery and After Both Surgeries

This is a case with large breasts and a prominent abdomen. The left photo was taken on the day of breast surgery, and the right photo about 5 weeks after breast surgery and about 3 weeks after abdominal surgery. The photos still show the measurement lines I drew myself to plan the surgery and check the changes. The distance from the center of the collarbone to the nipple changed from 26 cm and 25.5 cm to 23 cm and 23.5 cm, and the distance from the breast fold to the navel changed from 11.5 cm to 14 cm. Based on these values, the breasts appear to have moved up by about 2.5 cm. This change is the combined result of both the breast surgery and the abdominal surgery, and because the two surgeries were 16 days apart, it also includes the effect of continued skin contraction after the breast surgery. It cannot be described as the result of the breast surgery alone.

Second Pair — Before and After Abdominal Surgery

This is a case in which the abdomen looked relatively larger after the breasts were reduced first. The left photo was taken 9 days after breast surgery and 7 days before abdominal surgery, and bruising is still visible on the breasts. As the breast volume decreased, the abdomen below looked relatively more prominent—this is the imbalance stage described in this column. The right photo was taken about 3 months after liposuction of the abdomen, flanks, waist, and back, and the proportions of the whole torso have come into balance. This point was also one month after thigh surgery.

First Pair — Before and After Breast Surgery

This is a case with large, sagging breasts. The patient had breast liposuction including the underarm area, and the right photos were taken 9 days after breast surgery, when bruising and swelling are still present. As the breast volume decreased, the volume of the abdomen—which had been less visible because the breasts covered it before surgery—begins to stand out relatively more.

Second Pair — Before and After Abdominal Surgery, 139 Days After Breast Surgery

This is a case in which the abdomen looked relatively larger after breast surgery. The left photos were taken 139 days after breast surgery, on the day of abdominal surgery. The breasts have been reduced, but the volume of the abdomen and flanks remains, so the proportions of the torso look weighted toward the lower part. This is the imbalance described in this column. The right photos were taken 10 days after liposuction of the abdomen, flanks, waist, and back. Swelling is still present at this point, but in the front, side, and back views alike, the lines of the torso are coming into proportion with the breasts.

Once you reach adulthood, the number of fat cells does not change easily, and liposuction reduces the number of fat cells in the treated area. That is why, if weight is gained after surgery, untreated areas may become noticeable first. I believe the way to reduce disharmonious obesity is to plan based on the proportions of the whole body rather than a single area, and to manage weight through diet and exercise after surgery as well. Please also keep in mind that results vary between studies and that individual differences are large.

References: What Is Disharmonious Obesity? Y-Zone Liposuction for Disharmonious Obesity Step-Offs: Why We Operate Along Lines