Why Lipo and Elevated BMI Don't Mix

I recently responded to a question posted on RealSelf asking if the person was a candidate for liposuction with an elevated BMI. Most of my colleagues will say: No. While I generally agree, let’s explore why we advise against liposuction in these circumstances.

Describing BMI

BMI, or Body Mass Index, is a ratio of one’s height and weight, and there are plenty of website calculators that can help people calculate their BMI. This number is used to stratify patients as underweight, normal, overweight, obese, and morbidly obese. For the vast majority of people, numbers don’t lie. However, there are always exceptions: for example, I don’t think anyone would consider Dwayne “The Rock” Johnson overweight even though his BMI is over 30: he is 6’5” and weighs about 260 pounds. The scale breaks down for bodybuilders who have very high muscle mass and low body fat.

Physicians use the BMI number as one component of overall health, and surgeons in particular rely on this number as an important risk assessment tool before elective (including cosmetic) surgery. We know that as the BMI increases, so do the risks for complications after surgery. Plastic surgeons may deny elective cosmetic procedures to patients with high BMI ( greater than 35 or 40) due to these risks.

High BMI Contraindication for Surgery

So, why do my colleagues say that patients with high BMI are not candidates for liposuction? Three key reasons:

1. As mentioned above, there are increased risks with any surgery for patients with significantly elevated BMI, including wound healing complications, blood clots in the legs, and anesthesia risks. Since liposuction is an elective medical procedure (even if patients may feel that it is an emergency....), we, as surgeons, are reluctant to expose patients to these risks, unlike for a medical emergency where we don’t have a choice.
2. To achieve excellent and dramatic results from liposuction in patients who are (morbidly) obese, we would need to remove a tremendous amount of fat—perhaps 8, 10, 12, or more liters. Current guidelines caution against performing this in one sitting due to the risks from fluid shifts, medication overload, and potential bleeding. Therefore, if we were to perform liposuction in this patient group, we would likely need to break it up into two, three, or even four separate surgical procedures. Most patients would not want to undertake such a process and the associated costs. Unfortunately, social media and pop culture have imbued us with “one-and-done” expectations.
3. Even if we were to undertake staged, high-volume liposuction, we must then ask: “what will happen with the skin?” In most cases, the patient will be left with loose hanging skin that will require excision (tummy tuck, body lift, thigh lift, arm lift). And now we are back to more surgeries. One might ask: “can I just do a tummy tuck?” Now we are back to my first point: surgical risks are unacceptably high for these major procedures.

This is why, before cosmetic body contouring surgery, most practitioners will recommend medically supervised or surgically assisted weight loss for patients with a BMI greater than 35 or 40. There are exceptions: on occasion, we may offer treating small areas, such as the neck, where a small amount of fat would be removed to reduce the risk profile.

Have questions?

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