Some men contemplating chest surgery have been advised by their surgeon that they should lose weight prior to undertaking surgery. In fact some surgeons may even refuse to operate on a person who is extremely overweight or obese.
Some people find the idea of this offensive or even discriminatory. Overweight people have been subject to some pretty nasty harassment and discrimination simply because of their size. Unlike other mobility limiting medical conditions, the issue of ‘fat’ triggers strong emotions in some people, mostly negative. Examination of the reasons for this is outside the scope of this article, however it is totally understandable that some obese people may read more into their surgeon’s reaction than is actually there. I must say I was surprised when my chosen surgeon advised me to lose weight prior to chest surgery because I did not consider myself to be overweight. A little flabby at best but hardly ‘fat’.
I guess the lesson here is not to take the request to lose weight personally and if you’re unsure why you doctor has asked you to lose weight or even refused to operate because of your weight – ask. Many surgeons are very good at what they do, but they are often not effective communicators. They know what they’re talking about and why but many have difficulty in communicating this to their patients. Don’t be afraid to ask them why they want you to lose weight and what problems you or they may face if you are unable to do so. Remember you are hiring them to do a job, presumably because you believe they will give you the best result. You’re not hiring them for their excellent bedside manner.
There are, however, some very good reasons your surgeon might ask you to lose weight prior to any elective surgery. Dr Djinovic of Belgrade outlines these in his fact sheet “FTM surgery Healthy Weight Management”. Like many medical practitioners, he uses the Body Mass Index (BMI) to determine healthy weight ranges in patients. Not all doctors use the BMI. Some also use body fat measurements or ‘pinch test’, as the BMI does not take into account muscle mass.
So what is ‘overweight’ in medical terms? The BMI compares weight (kgs) with height (metres) to come up with a numeric value, with 24 being in the centre of the ‘healthy’ zone, ‘obese’ is above 28 and ‘morbidly obese’ above 35. There are some variances for men and women, so if you are on testosterone make sure you compare yourself against the male ‘norm’. If you are not on testosterone you will need to use the female scale to get a correct reading. The BMI is the dominant measurement used by doctors but it does not take into account muscle mass (so those body builders amongst us may unsuspectingly find themselves in the ‘obese’ category).
In addition to the general health risks of being overweight there are the added physical stresses of surgery and recovery. Obese and morbidly obese people have a far higher chance of suffering life threatening complications under anaesthetic than non-obese people. When a patient is under anaesthetic a machine breathes for them. Their body is not getting the same volume of oxygen that it gets when they are breathing unassisted. This lessening of oxygen in the blood puts a strain on all organs as they are operating on a reduced oxygen level. Put simply, it means your body (including your heart) has to work harder to keep things functioning. When a person is overweight their body is already working harder and being under anaesthetic adds to this burden. There are other serious risks for overweight patients undergoing surgery. These include a greater chance of life threatening breathing difficulties such as the airway closing whist under anaesthetic and an increased risk of cardiac arrest (heart attack).
Just a word about smoking and surgery. An alarming number of men in our community smoke. Oxygen is vital to the recovery process, both in terms of ‘getting back on your feet’ and for the healing of scar tissue. This is why doctors will strongly advise their patients to give up smoking prior to surgery and during the recovery phase. A failure to do so may result in both a longer physical recovery, slower healing of incision sites and an increased risk of grafts dying.
Obese patients also present hospital staff with other, more practical, difficulties. When a patient is unconscious theatre staff have to manually move them from the operating table to the recovery bed. Moving an unconscious person of healthy weight is difficult enough, but moving an unconscious obese person brings with it a higher chance of injury to staff and the patient. During chest surgery, the surgeon will also often prop the patient up to ensure the chest is sculpted correctly. This is made much more difficult if the patient is obese.
Then there is the aesthetic aspect of the surgery. Presumably you have chosen your surgeon because you believe they will give you the best possible result. A good surgeon is like a master craftsman. Most surgeons will not agree to perform chest surgery unless the patient has been on T for at least a year. Ideally, you should be as lean as possible and as muscular as possible prior to chest reconstruction surgery. This is so that the surgeon has a ‘frame’ to work on. It assists with body sculpting and nipple placement. While a surgeon may perform some remedial liposuction to reduce any residual fatty deposits, liposuction is not a weight loss method. Increased body fat may reduce the aesthetic quality of the reconstructive work and lead to patient dissatisfaction. One of Dr. Djinovic’s reasons for not performing phalloplasty on obese men is because the neo-phallus will be too large and will be uncomfortable for the man and for his partner.
In this day and age of lawsuits and ‘risk management’ surgeons are ever mindful of all the things that could go wrong and some are unwilling to take any risk at all. In the United States, doctors in some jurisdictions are refusing to treat overweight patients at all, let alone operate on them. The decision to operate or not is ultimately up to the surgeon. Regardless of how important and life-saving surgery is to us, SRS is considered to be ‘elective’ surgery and therefore the surgeon will not will not risk injury to their patient or expose themselves to financial loss through a law suit if they deem surgery to be risky. The surgeon bears the greatest burden for your safety and therefore has the final say.
Surgery isn’t the only obstacle for overweight men. Obesity may also make starting hormone therapy difficult. Women predominantly store excess weight around their hips but when men (identified ‘female’at birth) start testosterone treatment, most of that fat migrates to the waistline. Excess weight on the hips may be undesirable for aesthetic reasons but in and of itself, will rarely cause major medical issues. However, excess fat on the waist is a precursor to all sorts of medical problems, including coronary heart disease, high blood pressure and stroke. As a result some doctors will not approve testosterone therapy for seriously obese people.
So what are your options if you are obese and find yourself in the situation where your doctor has refused to operate or to start you on hormone therapy? Firstly, don’t take it personally. Your doctors are not out to get you. Secondly, be proactive and take an active role in finding a solution. Find out what you can do to lose weight or minimise the risks of surgery if weight loss is difficult. The causes of obesity are many and varied, as a result there is no one-size-fits-all answer. Finally, be prepared to work with your doctors. They want a good result as much as you do.
 Langer, R.A. “Anaesthesia and the morbidly obese.
 Science Daily. “Obese patients have double the risk of airway problems during an anaesthetic, study shows.
 Freeman, D.W. “Fat-phobic doctors refuse to treat obese patients: Is that fair?”