Treatment of early stage breast cancer with lumpectomy, axillary dissection, and radiation therapy is considered by many to be relatively contraindicated in heavy women or women with large or pendulous breasts. To quantitatively analyze this, we reviewed the cosmetic outcome in 257 patients. These patients were divided into "large" (89) and "average" (168) groups by one or more of the following criteria: weight greater than or equal to 80 kg, bra size greater than or equal to 40 in., cup size greater than or equal to D, and tangent separation greater than or equal to 23 cm. All patients were given cosmetic scores on a 1-10 scale by an independent observer for each of 8 cosmetic indices. These scores were analyzed at 1, 3, and 5 years follow-up (median 3 years). The average group scored higher than the large group on overall cosmesis (8.01 vs 7.34, p = 0.0004) and on 5 of 7 subindices (p = 0.0001 to 0.05) at 1 year. At 3 and 5 year follow-up only symmetry and retraction remained significantly different, favoring the average group. The largest difference noted at any point between the groups was 1.27 (retraction at 5 years, 8.54 vs 7.27, p = 0.0148). Therefore, although an inferior cosmetic result has been documented in the large group, we do not feel the magnitude of the difference mandates a change in our policy of offering all of these women breast-conserving therapy.