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Body Mass Index, or BMI, has been historically used in surgery as a tool to determine things such as risk stratification with surgical procedures. In the world of Plastic Surgery, however, it is often used as a screening mechanism to exclude patients who are “bad candidates” for cosmetic procedures. While there is good evidence to show that higher BMIs can correlate to safety outcomes and complication rates, I have found it to be a useful guide in my practice but not a hard stop for turning patients away. At the end of the day, the most important factors to consider are the individual patient’s anatomy, their goals, and what realistic expectations can be achieved. The bottom line is women of all shapes and sizes deserve to feel beautiful and confident. We have come a long way in our society to redefine what exactly the “ideal” body image is, but I don’t think we are totally there yet in realizing the sheer diversity of its forms.
In my practice, I have found that with good patient counseling and good patient selection, happy patients with life-changing results are achievable. There are, however, a couple of key factors to take into consideration in order to determine who exactly is that good candidate and how exactly we get to that great result.
AS ALWAYS, SAFETY FIRST
I think it goes without saying that safety is always a surgeon’s number one consideration and priority in their surgical decision making. The reality is we have good evidence to support that higher BMIs are associated with poorer surgical outcomes, increased post-surgical risks of potentially life-threatening issues such as a Deep Venous Thromboembolism, and a higher risk of anesthesia complications. In certain cases, it might be safe to perform the surgery but only in a hospital setting with more access to specialists and longer-term monitoring post-operatively. Thus, a patient’s entire health history, surgical history and individual anatomy must ALL be considered when making the decision of candidacy for an elective cosmetic procedure. This is a non-negotiable.
INTRA-ABDOMINAL VS EXTRA-ABDOMINAL FAT
To better understand who will get the best results in a higher BMI Tummy Tuck, it's important to review the distinction between intra-abdominal fat and extra-abdominal fat. Intra-abdominal fat is fat that is inside the abdominal cavity, surrounding your abdominal organs. This fat contributes to the protuberance of the abdomen, even when the outer skin and tissue is trimmed and tightened. There is no surgical treatment for this fat– only diet and exercise will address it. On the other hand, extra-abdominal fat is the fat that can be addressed and removed with a tummy tuck and liposuction. This is the fat that you can pinch with your fingers. So why do we care about distinguishing between these types of fat accumulation? Well, how much fat a person holds intra-abdominally can have a huge impact on the results we hope to achieve with a Tummy Tuck. Even with the most aggressive liposuction and skin tightening, intra-abdominal fat will leave a patient with a rounder, more protuberant abdomen after surgery. Despite this limitation, many patients are still incredibly satisfied and happy. What’s most important is to be clear and transparent with patients before proceeding with surgery. However, for that patient with a higher BMI and lots of intra-abdominal fat that dreams of a snatched waist and flat abs, they will most certainly be disappointed with the discrepancy between what can realistically be achieved with surgery versus what they desire to be achieved.
LIPOABDOMINOPLASTY VS A TRADITIONAL TUMMY TUCK
Oftentimes, higher BMI Tummy Tucks are candidates for what is referred to as a ‘Lipoabdominoplasty’. This technique varies slightly from a traditional Tummy Tuck in several key ways. A simple way to think about all Tummy Tucks is that the skin below the belly button is removed, and the skin above the belly button is stretched down to meet the lower, final incision. In a traditional Tummy Tuck, the mechanism by which the skin above the belly button is loosened enough to eventually stretch downward is to surgically lift it off of the underlying muscle layer. Once elevated, this skin has now been detached from its blood vessels on its undersurface and, as a consequence, cannot be liposuctioned without significant risk to the skin’s blood supply. Basically, in a traditional Tummy tuck, you can’t also do liposuction of the skin above the belly button. But what if you have loose skin AND a significant layer of fat that needs to be removed? If you perform only a traditional Tummy Tuck, then you only treat one of these problems. It’s these patients who are best suited for a Lipoabdominoplasty. Using this technique, the excess skin below the belly button is removed (just like in a traditional TT) but liposuction is used to thin out and loosen the skin above the belly button until it can stretch down and reach the lower abdominal incision. It is kind of a two-for-one in that a single procedure will address both the excess fat and skin of the central abdominal wall. The drawback, however, is that liposuction cannot be as aggressive (i.e. we cannot remove as much fat) when pairing it with a Tummy Tuck as would be if doing liposuction on its own. Ultimately, I think most patients would choose to combine the procedures in a Lipoabdominoplasty despite its limitations, as the alternative would be a staged, two-surgery approach.
A STALLED WEIGHT LOSS JOURNEY
Another important factor to consider is whether a patient is in the midst of a weight loss journey and, if so, what is their motivation for surgery. Traditionally, patients have been counseled to fully achieve their weight loss goals prior to undergoing elective cosmetic procedures. In the case of a tummy tuck, the worry is that if you undergo the procedure and then go on to lose a significant amount of weight, you will be left with residual loose skin that will require a revision surgery. From a recovery standpoint and a financial standpoint, it makes the most sense to try and consolidate everything into a single surgery and avoid the risk of future surgeries. However, some of the happiest patients I have treated have been smack in the middle of their weight loss journey. These patients are motivated and dedicated. However, the sheer physical discomfort of their excess abdominal skin coupled with the profound negative impact it has on their self-image has caused them to stall out in their weight loss journey. In these cases, patients are well aware that a revision may be necessary down the road, and they feel that the benefits they will gain from having the procedure done now outweigh the risks of a revision later.
SCAR PATTERNS MAY VARY
One of the most steadfast concepts in plastic surgery is the more skin laxity a person has, the longer their incisions will be. A traditional Tummy Tuck places a single, low-lying scar just above the pubic bone. However, in some higher BMI patients who seek Tummy Tucks, they have loose skin that extends beyond the front side of the abdomen and onto the waist or flank area. In these cases, a Tummy Tuck that extends the incision around the waist or even a Full Body Lift (extending the incision circumferentially) will be best to address all the loose skin. Even more, some patients are best suited for what is called a fleur-de-lis abdominoplasty which places one scar low on the abdomen and one vertically in the abdominal midline. Ultimately, which type of Tummy Tuck is best for which patient will be based on a good physical examination and a thorough understanding of the patient’s goals and expectations.
Taking into consideration all of the key points that I’ve outlined above, what they all underscore are the importance of understanding individualized anatomy, unique patient goals, and setting realistic expectations. The more your expectations can align with realistic surgical results, the more successful the surgery and the relationship you have with your surgeon will be.
To schedule your consultation with Dr. Megan today, call 206.860.5582. If you have comments or questions you would like answered in future blog posts, leave them in the comments section below.