Worried Your BMI May Bar You From Surgery? A Swansea-Based Clinician Shares Some Advice
Dean Boyce is the Clinical Lead for Plastic Surgery at The Welsh Centre for Plastic Surgery & Burns. He is a Council Member and Chairman of Education and Training for the British Association of Plastic, Reconstructive & Aesthetic Surgeons. He has also beena consultant at Sancta Maria Hospital in Swansea for the last 14 years. Here, he sheds light on the issue of patients being denied surgery due to their Body Mass Index (BMI) – and how people can best prepare themselves for procedures.
The issue of NHS patients being denied surgery because of their Body Mass Index (BMI) has been the focus of much media attention in recent years and months and it is, understandably, making many potential patients anxious.
Weight restrictions have been put in place for elective surgeries, such as breast reductions and removal of excess skin after weight loss, as well as on other non-cosmetic surgeries such as knee and hip replacements and varicose vein surgery. For aesthetic procedures, restrictions have been imposed in Wales on individuals whose BMI is over 25 - BMI is calculated by dividing an individual's weight by their height squared, to place them in a category from underweight through to morbidly obese. However, these restrictions are extreme and may not be applicable for many patients seeking treatment privately at Sancta Maria Hospital.
Clearly, the index is a useful tool for GPs and other clinicians, but some see it as a blunt instrument, since this standard measuring tool cannot take an individual’s body composition into account. Many ‘superfit’ atheletes with a high muscle mass and very little body fat will have a high BMI.
Many believe a BMI of 25 to be far too restrictive. In fact, a cohort *study carried out in 2016 found that a BMI of 27 was linked to the lowest rate of death.It may be the case that the uplift in the optimum BMI level is as a result of improvements in preventative treatments, such as type 2 diabetes, so the study does give some food for thought, regarding any rigid the use of BMI by decision makers in years to come.
While these restrictions for certain surgeries go against the guidance set out by The National Institute for Clinical Excellence (NICE), which says factors such as obesity and smoking "should not be barriers to referral" when it comes to joint surgery, there are, of course, sound clinical reasons why reducing your BMI is a very sensible approach for anyone who is about to go through a surgical procedure.
Private patients do not face the same restrictions as far as BMI and surgery are concerned, but it is important that people do what they can to prepare for surgery – taking certain steps well in advance of your procedure can greatly aid a successful recovery and it can help your surgery be as effective as it can be. Complication rates of many kinds are higher in overweight patients undergoing surgery. It is best therefore that patients are as fit as they possibly can be before undergoing elective surgery. If your BMI is high it is sensible to try to reduce it ahead of any procedure. Similarly, becoming more active and giving up smoking are wise courses of action – the fitter the patient is, the smoother their recovery process is likely to be.
Clearly, there are sound reasons why some people may struggle to reduce their BMI that might be directly related to the condition that needs to be treated via surgery – if you have painful varicose veins or a worn knee joint, or if you feel you need a breast reduction operation, you may find it hard to exercise effectively. These cases all have their nuances that cannot be expressed simply via their BMI number. At a private hospital such as HMT Sancta Maria Hospital, and we are therefore able to discuss the merits of surgery on a more individual basis.
One such complex issue we see regularly in the course of our clinical work as plastic surgeons is body contouring, removing excess skin from patients who have experienced weight loss. This has become a popular procedure at HMT Sancta Maria and it is a procedure that can have a very significant and positive impact upon a patient’s quality of life. It takes a lot of effort, discipline and commitment to lose a great amount of weight, and extreme weight gain and extreme weight loss both bring with them complex underlying emotions. It makes sense for clinicians to do what they can to support someone on this emotional journey - and the emotional and quality of life impact of removing excess loose skin can be significant.
So, when faced with a patient who may still have some way to go in order to bring their weight loss down to below the 25 BMI mark, it makes little sense to bar them from surgery on what is, essentially, in some cases, a technicality. The weight of the excess skin and subcutaneous tissue itself is often significant, so this is a consideration also, and it sees many such patients turned away by NHS hospitals. For body contouring procedures such as these, there are studies showing higher rates of complications for patients with both very high and low BMIs, though again, NICE does not set specific guidelines about whether these readings should be a bar to surgery.
All clinicians have a legal and a moral responsibility to advise their patients and to treat their patients in the patient’s best interests. There can be complex issues, involving very particular circumstances that must be considered on a case by case basis.
If you have any concerns about your BMI and what effect it might have on your ability to have any surgery, you should, in the first instance, speak to your surgeon.