Body mass index and benign breast surgeries: A survey of plastic surgeons’ knowledge and attitudes

Abstract

Background

The academic literature has not arrived at a consensus on the importance of body mass index (BMI) as an indicator of surgical feasibility and risk. This study evaluates board-certified plastic surgeons' and trainees' knowledge, experiences, and concerns around performing benign breast surgeries in high-BMI patients.

Methods

An online survey instrument was developed and shared with plastic surgeons and plastic surgery trainees from December 2021 to January 2022.

Results

There were 30 respondents (18 from Israel, 11 from the United States, and 1 from Turkey). For respondents who had BMI guidelines for performing benign breast surgeries, the median maximum BMI was 35 for all procedures. Most respondents supported or strongly supported their BMI guidelines.

The majority of respondents indicated that they tended to have less training and experience in performing benign breast surgeries on high-BMI patients compared to those with BMI <30. Most respondents indicated that they were less satisfied with the results of these procedures on high-BMI patients compared to those with BMI <30. The median post-operation recovery time was indicated to be similar for high-BMI patients compared to those with BMI <30 across all procedures; however, the postoperative complication rate was indicated as higher.

Conclusions

Respondents indicated that the risks of complication, more frequent need for surgical revisions, and unsatisfactory outcomes were their greatest concerns when conducting chest surgeries among high-BMI patients. Given that most surgeons practice in settings where high-BMI patients are excluded from procedure access, further research is needed to assess the extent to which these concerns reflect actual outcome differences.

Introduction

As of 2022, the World Health Organization (WHO) estimates that more than one billion people experience obesity,¹ defined as having a body mass index (BMI) that is greater than or equal to 30.² The use of BMI for determining patient treatment and access to care has been a topic of debate. Some studies point to the association of high BMI with a range of morbidity^3,4 and higher anesthesia risk profiles during surgical procedures,⁵ which would support the relevance of BMI when determining a patient's course of care. However, many have indicated problems that arise when adhering to BMI cutoffs, calling into question the ethics of using this measurement for clinical decision-making.⁶ BMI, though often used as a proxy for body fat, does not directly measure fat composition.⁷ In addition, BMI does not adequately account for ethnic and racial discrepancies in body composition,⁸ gender- or age-based considerations,^9,10 or the misrepresentation of muscle mass and body fat distribution.¹¹

The academic literature has not arrived at a clear consensus on whether it is beneficial to use BMI to assess surgical outcomes, with some suggesting that the overreliance on BMI as a health indicator has influenced surgeons’ perceptions of elevated risk.¹² While high BMI is associated with increased risks of adverse events and longer operation times, several studies have indicated that the extent of these differences may not justify the perception of high BMI as a major surgical risk factor. These studies demonstrate that certain procedures are safe to perform in high-BMI patients, some approaches have better outcomes in this population, and high-BMI patients do not have inferior long-term survival rates in general surgery.13, 14, 15

Breast surgeries may be performed across the BMI spectrum, and symptoms indicating a need for benign breast surgeries, such as breast reduction, may be more common in higher BMI patients.¹⁶ Studies of breast surgeries among high-BMI patients have indicated mixed effects on these procedures. Some studies have pointed to a significantly higher risk profile for high-BMI patients. A case–control study of 2,403 patients considered to be obese and 5,597 nonobese controls undergoing an array of breast surgeries (breast reduction, breast reconstruction, mastopexy, and augmentation mammoplasty) found the odds of postoperative complication to be approximately 12 times higher for the obese group compared to the control group.¹⁷ Other studies have also pointed to increased risk for high-BMI patients undergoing implant-based and autologous breast reconstruction,¹⁸ augmentation mammoplasty using breast implants,¹⁹ unilateral mastectomies,²⁰ bilateral mastectomy,²¹ and reduction mammoplasty.²² There is a substantial existing literature that has correlated risk of complications in benign breast surgeries with higher BMI; however, even in high-BMI patients, the overall complication rates remain low.²³

Despite the increased risk of complications associated with higher BMI, the benefits of breast surgeries among high-BMI patients must also be considered when determining the best course of action. For instance, a study of patient-reported outcomes following reduction mammoplasty found high satisfaction rates among patients that was not lowered due to the patients’ BMI status.²⁴ Access to reduction mammoplasty or gender-affirming mastectomy may also enable some high-BMI individuals to engage in exercise and other health promotion activities that would otherwise be inaccessible due to limitations imposed by breast size.²⁵

The academic literature on benign breast surgeries among high-BMI patients indicates a need for clearer surgical guidance for this patient population. Understanding current practices, perspectives, and experiences of plastic surgeons who routinely perform these procedures could inform the development of improved, evidence-based guidelines. This study aims to synthesize plastic surgeons’ knowledge and attitudes related to performing a range of benign breast surgeries (reduction mammoplasty, gynecomastia repair, augmentation mammoplasty, feminizing breast augmentation surgery, and masculinizing top surgery) among high-BMI patients in order to facilitate improved decision-making.

Materials and methods

Ethical approval

The study was determined to be exempt from review by the Boston Children's Hospital Institutional Review Board (IRB-P00040972).

Survey development

The authors designed a novel online survey instrument to assess plastic surgeons’ and trainees’ knowledge, attitudes, and experiences with breast surgery in high-BMI patients. The survey instrument also investigated current guidelines on BMI limits and respondents’ perspectives on these guidelines. The initial survey focused on six different breast surgery categories: reduction mammoplasty, gynecomastia repair, augmentation mammoplasty, double mastectomy, feminizing breast augmentation surgery, and masculinizing top surgery; however, this analysis was restricted to the benign breast surgeries as BMI limitations are less salient in the context of cancer treatment. Checks were performed to ensure consistency and completeness of the survey prior to distribution.

Survey distribution and analysis

The survey instrument was built through the Qualtrics survey platform (Qualtrics, Provo, UT) and distributed through an email invitation with a hyperlink. The survey was distributed in English to publicly available email addresses of plastic surgeons who conduct breast surgeries, listservs of plastic surgery associations, and colleagues of the authors. Potential respondents were identified based on demonstrated experience with benign breast surgeries. The authors sought to distribute the survey to a wide array of plastic surgeons and trainees to mitigate responder biases. The survey was made available from December 20, 2021, to January 30, 2022, approximately a 6-week period.

Of the 44 responses that were initiated, 30 were complete (68% completion rate). The survey was administered anonymously and electronically. Since the survey link was distributed through listservs, the exact response rate could not be obtained. The survey involved subsections for respondents depending on which procedures they indicated that they performed within the past year. There was no monetary compensation for completion of the survey. STATA (version 17.0, College Station, TX, USA) was used to analyze survey responses. A full sample survey instrument is provided in Appendix A.

Results

There were 30 respondents (18 from Israel, 11 from the United States, and 1 from Turkey). Fifty-three percent of respondents stated that they practiced in an academic hospital and 60% stated that they practiced in urban areas with more than a million residents. A total of 30 respondents performed reduction mammoplasty (100%), 27 performed gynecomastia repair (90%), 26 performed augmentation mammoplasty (87%), 8 performed feminizing breast augmentation in transgender patients (27%), and 6 performed masculinizing top surgery (20%). Eighty-three percent of respondents were board-certified plastic surgeons, and 17% were trainees.

The majority of respondents performing reduction mammoplasty, gynecomastia repair, and augmentation mammoplasty had been performing the procedures for over ten years. In contrast, 83% of respondents performing masculinizing top surgery had five or fewer years of experience with the procedure, and 75% of respondents performing feminizing breast augmentation surgery had five or fewer years of experience with the procedure (Table 1). This may reflect the growth of interest in gender-affirming surgeries, particularly in the United States, after the implementation of the Affordable Care Act.²⁶

Table 1.

Plastic surgeons’ experiences conducting procedures

	Aug. mammoplasty	Reduction mammoplasty	Feminizing breast aug.	Gynecomastia repair	Masculinizing top surgery
	N=26	N=30	N=8	N=27	N=6
Years conducting procedure
0-5	23%	20%	75%	19%	83%
6-10	23%	23%	0%	26%	0%
11-15	12%	13%	0%	11%	17%
16-20	8%	7%	0%	7%	0%
21-25	12%	10%	12%	15%	0%
>25	23%	27%	12%	22%	0%
Number of patients in past year
<10	42%	7%	88%	48%	83%
11-50	35%	57%	0%	44%	0%
51-100	4%	23%	0%	0%	17%
>100	19%	13%	12%	7%	0%
BMI guidelines for procedure
Currently have BMI guidelines	58%	67%	75%	74%	67%
Previously had BMI guidelines	8%	3%	12%	4%	17%
Never had BMI guidelines	35%	30%	12%	19%	17%
Unsure	0%	0%	0%	4%	0%

The majority of respondents performing the following procedures have BMI guidelines: reduction mammoplasty, gynecomastia repair, augmentation mammoplasty, feminizing breast augmentation, and masculinizing top surgery. The median maximum BMI limit indicated by respondents with BMI guidelines for these procedures was 35 for all procedures where limits were common, and most respondents supported or strongly supported their BMI guidelines (Figure 1).

Figure 1.

Maximum BMI limitations for performing various benign breast surgeries.1

The majority of respondents indicated a tendency to have less training and experience in performing breast and chest surgery procedures on high-BMI patients compared to those with BMI <30. The majority of respondents also indicated that they were less satisfied with the results of these procedures among high-BMI patients compared to those with BMI <30. The median post-operation recovery time was indicated to be similar for high-BMI patients compared to those with BMI <30 across all procedures; however, the postoperative complication rate was indicated as higher (Figure 2).

Figure 2.

Training, experience, satisfaction, and complication risk in performing breast surgeries among high-BMI patients relative to patients with BMI <30.

Across all discussed procedures, the majority of respondents had low to no concern about adequate training, prior experience, or clear guidelines when conducting procedures on patients with high BMIs. However, the majority of respondents did endorse moderate to high concerns about the increased risk of surgical revisions and complications for high-BMI procedures, with the exception of augmentation mammoplasty (Figure 3).

Figure 3.

Plastic surgeons’ concerns surrounding performing benign breast surgeries for high-BMI patients.

Discussion

In situations where there is no clear, ethical insight, research on professional knowledge, attitudes, and practices can improve clarity of direction. This study was designed to synthesize the knowledge and attitudes of plastic surgeons and trainees regarding performing breast surgeries on high-BMI patients in order to improve understanding of how these factors affect procedural decision-making. While guidelines for the management of high-BMI patients in other medical fields—such as primary care,²⁷ pregnancy,²⁸ and metabolic and bariatric surgery^29,30—have been established, standardized guidelines have yet to be developed for plastic surgeons performing benign breast surgeries.

With the exception of augmentation mammoplasty, the majority of study respondents reported using BMI guidelines to restrict access to benign breast surgeries, with the median BMI maximum being 35. The absence of BMI guidelines for augmentation mammoplasty may have been due to the relatively low percentage of high-BMI patients seeking this procedure¹⁷ or similar perceived risks of significant complications across different BMIs.³¹ The respondents indicated that their guidelines came from a diversity of sources, including professional society guidelines, research papers, and hospital policies. Among those respondents who had BMI guidelines, the majority were in strong support of their BMI guidelines. This stands in contrast to some groups who note the barriers that BMI limits impose and call for increased access to benign breast surgeries for high-BMI patients.^32,33

Across many types of benign breast surgery, respondents indicated that they had concerns about operating on high-BMI patients. These concerns included less satisfaction with results, increased risk of complications, and more frequent need for revision. Such concerns indicate a need to assess how to best approach improving surgical care for patients with higher BMI who might still be expected to benefit from benign breast surgeries, such as employing alternative surgical methods associated with lower risk.³⁴ In addition, there is a need to better understand the magnitude of any risks associated with operating on high-BMI patients, a task that is difficult given the relatively small number of surgeons willing to perform benign breast surgeries in this population.

Concerns for justice and respect for patient autonomy dominate many discussions on the appropriateness of imposing BMI limitations on care, and these concerns may disproportionately affect certain population groups. For example, BMI limits may pose additional, unnecessary barriers to gender-affirming surgeries given the disproportionately high impact of high BMI on transgender and gender-diverse populations.³² Several studies have demonstrated that gender-affirming breast surgeries can be safely conducted on high-BMI transgender and gender-diverse patients with complication rates comparable to low-BMI patients and high levels of patient satisfaction, although results vary.^21,35, 36, 37 Future guidelines must consequently account for the benefits that breast surgeries can have for high-BMI patients, such as alleviating gender dysphoria and improving overall quality of life in the case of transgender and gender-diverse patients,³⁸ while being realistic about any associated risks.

While some practices use BMI guidelines as a way to minimize the risks associated with benign breast surgeries, the absolute increase in risk seen in high-BMI patients is low.²³ An emphasis on informed consent—by discussing differences in outcomes and complications for high-BMI patients—could improve transparency and improve patients’ understanding of their risk profile. Informed consent has played an important role in other surgeries performed on high-BMI patients, such as weight loss surgery, and this approach may best manifest the principle of respect for persons.³⁹

Strengths and limitations

There are multiple strengths of this study. The novel survey instrument is the first to our knowledge that captures plastic surgeons’ knowledge, attitudes, and practices around conducting a range of breast surgeries among high-BMI patients. The inclusion of surgeons from multiple countries and different settings also improves the generalizability of the results.

There are also several limitations to our study. While a substantial number of respondents completed the survey, the respondents are not necessarily representative of the broader population of surgeons offering benign breast surgeries. The majority of respondents practiced in academic hospitals and urban settings. These settings are likely systematically different from community-based hospitals in more rural environments. For example, hospitals in urban settings will likely see higher patient volumes and consequently have better protocols in place for treating high-BMI patients compared to a more rural context where volumes are lower. Similarly, the respondents all come from upper-middle- to high-income countries according to World Bank country income group classifications.⁴⁰ The geographical distribution of respondents may also affect respondents’ exposure to high-BMI patients, which may bias the results. In light of these demographic considerations and the relatively limited total sample size, there are limitations in the extent to which these results are generalizable, particularly in lower-income settings. Nevertheless, this study's approach could serve as a starting point for continued investigation in broader socioeconomic and demographic contexts.

Conclusions

The widespread reliance on BMI restrictions and the negative perceptions of operating on high-BMI patients challenge surgeons’ ability to provide quality care across the BMI spectrum. The lack of clear, consistent data regarding the magnitude of any increase in risk for performing benign breast surgery in high-BMI populations leads to a reliance on surgeon opinion and experience. While that may be reasonable in some situations, the fact that the majority of respondents performing benign breast surgeries do so in environments that intentionally limit access to these procedures for individuals with high BMI may challenge the reliability of their intuitions.

Many plastic surgeons report significant concerns around performing benign breast surgeries in high-BMI patients, including an increased risk of complications and revisions and decreased satisfaction with outcomes. With increasing rates of high-BMI patients seeking breast surgeries, there is a need to understand both the magnitude of any increased risks associated with these procedures and how such risks can and should be balanced with potential benefits. Meanwhile, surgeons with BMI limitations for benign breast surgeries may wish to consider how to address the needs of patients who cannot currently access these procedures, including through the implementation of informed consent-based protocols rather than strict BMI guidelines.

Declaration of Competing Interest

None declared.