Everybody arrives with a number. Mine is under 35, ideally under 30. The number is a proxy. Here is what it stands for.
The Line
“The plastic surgery literature has shown that complications go up the higher the BMI. The most likely complications in higher BMIs are seromas, infection, blood clots, and longer surgical times.”
“BMI above 35 is regarded as class II obesity, and at this point we see risks significantly increase.”
The studies back it. Gupta and colleagues (Aesthetic Surgery Journal, 2016), 127,961 patients: major complications 1.6 percent at normal weight, 4.2 percent at BMI 40 and above, worst in abdominoplasty and lower body lift. Brito and colleagues (Aesthetic Plastic Surgery, 2020): 74.1 percent complications in obese tummy tuck patients, mostly seroma. Their data, not mine.
Mine, to a patient in 2018:
“Your current BMI is at 37, which in my experience puts you at high risk for complications. Ideally your BMI should be under 30, which means you should weigh 190 pounds or less. I am willing to work with patients with a BMI under 35, which means you should weigh 220 pounds or less. I have not seen increased complications with BMIs under 35.”
What the Number Stands For
“For example, in higher BMIs, the abdominal plication cannot be performed as tight, because with higher BMI there is more visceral fat, and when we tighten the abdominal muscles, the visceral fat presses up against the diaphragm and the lungs. Therefore, if we plicate too tight in the presence of visceral fat, it can compromise breathing after surgery.”
That is the whole thing. The internal corset has to leave room to breathe.
“Also, the five liter limit on liposuction for safety applies to all BMIs, so in higher BMIs that five liter reduction is proportionally much less than in a normal weight patient.”
“Remember that the amount of liposuction is limited to about 5 L which translates to just under 5 pounds. The size reduction is often larger than the weight reduction.”
The Exception
“These decisions occur on a case-by-case basis, and there are exceptions. During consultation, if the patient mostly has external subcutaneous fat and excess skin, then these areas can be targeted. The exception is when most of the fat is visceral and lives inside the abdominal cavity. This fat cannot be targeted with plastic surgery and increases risks.”
“But the fact of the matter is that some patients have just plateaued and are no longer able to lose more weight. They continue to diet and exercise and use GLP-1s, or they may have already had a bariatric procedure. But the fact that they are not moving the scale is frustrating and sometimes causes psychological distress, resulting in bounce backs and weight gain, almost a vicious cycle of a yo-yo effect.”
“At this point, if the patient agrees that the benefits will outweigh the risks, and it gets them motivated to a healthier weight and lifestyle, I agree to proceed.”
One in three of my consults now arrives after a GLP-1; I wrote that up here, and the body contouring side here.
Staging
“At high BMIs, we also consider staging. The ideal is to keep a surgery under six hours, and at higher BMIs each procedure can take longer than usual. Many times we will opt to perform liposuction first and the excisional surgeries later. Sometimes we elect to remove the tissues, like in a panniculectomy, to improve quality of life, hygiene, and mobility, without emphasizing the cosmetic result.”
And at the far end of the scale, honesty:
“I recommend a BMI less than 35, although some exceptions can be made. To get to this BMI, your weight should be 190 or less. At your current weight you are at very high risk for complications. Your current BMI is 50, which makes you a candidate for a bariatric weight loss procedure.”
| What the patient asks | What I am actually deciding |
|---|---|
| Is my BMI too high? | How much visceral fat is in the way |
| Can I have it all at once? | Whether it fits under six hours |
| Should I lose more first? | Whether the scale is still moving |
| Will it be flat? | Whether the fat is under the skin or under the muscle |
The surgical read, with the full table and the literature, is on agulloplasticsurgery.com. The plateau conversation is on the Southwest Plastic Surgery post. Tomorrow: the panniculectomy.
Why Choose Dr. Agullo
Double board-certified, by the American Board of Plastic Surgery and the American Board of Surgery. Mayo Clinic plastic surgery fellowship. Clinical Associate Professor of Plastic Surgery at Texas Tech University Health Sciences Center. Castle Connolly Top Doctor for 13 consecutive years.
Ready to Talk?
Bring the number. I will tell you what it is standing in for. (915) 590-7900, text 1-866-814-0038, or book at agulloplasticsurgery.com/appointments. #StayBeautiful
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