Research

Aesthetic Surgery Journal

2022, Vol 42(7) 795–807
The Impact of Obesity on Plastic Surgery © The Author(s) 2021. Published
by Oxford University Press on behalf
Outcomes: A Systematic Review and of The Aesthetic Society. All rights
reserved. For permissions, please
Meta-Analysis e-mail: journals.permissions@oup.com
https://doi.org/10.1093/asj/sjab397
www.aestheticsurgeryjournal.com

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Lucas Goldmann Bigarella ; Ana Carolina Ballardin; Luísa Serafini Couto;
Ana Carolina Porciuncula de Ávila; Vinícius Remus Ballotin;
Anderson Ricardo Ingracio, MD, MSc; and Matheus Piccoli Martini, MD

Abstract
Background: Obesity is a potential risk factor for complications in plastic surgeries. However, the data presented by pri-
mary studies are contradictory.
Objectives: The aim of this study was to summarize and clarify the divergences in the literature to provide a better under-
standing of the impact of obesity in different plastic surgery procedures.
Methods: We conducted a systematic review and meta-analysis of the impact of obesity on plastic surgery outcomes.
Searches were conducted in MEDLINE, LILACS, SciELO, Scopus, Embase, Web of Science, Opengrey.eu, and the Cochrane
Database of Systematic Reviews. The primary outcomes assessed were surgical complications, medical complications,
and reoperation rates. The secondary outcome assessed was patient satisfaction. Subgroup analysis was performed to
investigate the impact of each BMI category on the outcomes.
Results: Ninety-three articles were included in the qualitative synthesis, and 91 were used in the meta-analysis. Obese partici-
pants were 1.62 times more likely to present any of the primary outcomes (95% CI, 1.48-1.77; P < 0.00001). The highest increase
in risk among plastic surgery types was observed in cosmetic procedures (risk ratio [RR], 1.80; 95% CI, 1.43-2.32; P < 0.00001).
Compared with normal-weight participants, overweight participants presented a significantly increased RR for complications
(RR, 1.16; 95% CI, 1.07-1.27; P = 0.0004). Most authors found no relation between BMI and overall patient satisfaction.
Conclusions: Obesity leads to more complications and greater incidence of reoperation compared with nonobese pa-
tients undergoing plastic surgeries. However, this effect is not evident in reconstructive surgeries in areas of the body
other than the breast.
Resumen
Antecedentes: La obesidad es un factor de riesgo potencial de complicaciones en las cirugías plásticas. No obstante, los
datos presentados por los estudios primarios son contradictorios.
Objetivos: El objetivo de este estudio fue resumir y aclarar las divergencias en la literatura a fin de ofrecer una mejor
comprensión del impacto que tiene la obesidad en diferentes procedimientos de cirugía plástica.

From the School of Medicine, Universidade de Caxias do Sul (UCS),

Caxias do Sul, Brazil.

Corresponding Author:
Mr Lucas Goldmann Bigarella, School of Medicine, Universidade de
Caxias do Sul (UCS), Av. Bento Gonçalves, 2460/504, Caxias do Sul
95020-412, Brazil.
E-mail: lucasbigarella@gmail.com; Instagram: @lucasbigarella
796 Aesthetic Surgery Journal 42(7)

Métodos: Realizamos una revisión sistemática y un metanálisis del impacto de la obesidad en los resultados de la cirugía
plástica. Se realizaron búsquedas en MEDLINE, LILACS, SciELO, Scopus, Embase, Web of Science, Opengrey.eu y la Base
de Datos Cochrane de Revisiones Sistemáticas (Cochrane Database of Systematic Reviews). Los resultados primarios
que se evaluaron fueron las complicaciones quirúrgicas, las complicaciones médicas y las tasas de reintervención. El
resultado secundario que se evaluó fue la satisfacción del paciente. Se realizó un análisis de subgrupos con objeto de
investigar el impacto de cada categoría de IMC en los resultados.
Resultados: Se incluyeron noventa y tres artículos en la síntesis cualitativa, y se utilizaron 91 en el metanálisis. Los participantes
obesos tuvieron 1.62 veces más probabilidades de presentar cualquiera de los resultados primarios (IC del 95%, 1.48-1.77;
P < 0.00001). El mayor aumento de riesgo entre los tipos de cirugía plástica se observó en los procedimientos cosméticos
(cociente de riesgos [CR], 1.80; IC del 95%, 1.43-2.32; P < 0.00001). Comparados con los participantes de peso normal, los
participantes con sobrepeso presentaron un CR significativamente mayor para las complicaciones (CR, 1.16; IC del 95%,
1.07-1.27; P = 0.0004). La mayoría de los autores no encontraron relación entre el IMC y la satisfacción general del paciente.
Conclusiones: La obesidad conduce a más complicaciones y una mayor incidencia de reintervención en comparación

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con los pacientes no obesos sometidos a cirugías plásticas. Sin embargo, este efecto no es evidente en cirugías
reconstructivas de áreas del cuerpo que no sean el seno.

Level of Evidence: 2  

Editorial Decision date: November 2, 2021; online publish-ahead-of-print November 20, 2021. Risk

Obesity is a well-known public health issue defined by the METHODS

World Health Organization (WHO) as a BMI of ≥30 kg/m².1
Since 1975, the world’s population has become on average
more than 1.5 kg heavier each decade.2 In 2015, over 600
million adults were obese, representing 12% of the world’s
adult population, and the condition contributed to 4 mil-
lion deaths that year.3 If the growth trend continues, global
obesity prevalence will reach 18% in men and surpass 21%
in women by 2025.2
Obesity is directly associated with metabolic syndrome,
which encompasses hypertension, blood lipid disorders,
inflammation, insulin resistance, type 2 diabetes, and an
increased risk of developing cardiovascular diseases.4
Regarding surgery, obesity has been shown to increase
the risk of postoperative complications, especially throm-
botic events, such as pulmonary embolism and deep vein
thrombosis.2
Numerous primary studies assessing the effects of
obesity on postoperative complications in the scenario of
plastic surgery have been published.5 However, secondary
research on this topic has evaluated only breast surgery,
with no published meta-analyses on the effects of obe-
sity on reconstructive/cosmetic surgeries on areas of the
body other than the breast.5-7 Data presented by primary
studies are contradictory, with some studies showing that
obesity should not be considered as a risk factor for some
plastic surgery outcomes,8-10 opposing most of the existing
literature. The purpose of this systematic review and meta-
analysis is to summarize and clarify the divergences in the
literature to provide a better understanding of the impact
of obesity on different plastic surgery procedures.
Protocol and Registration
This study was conducted from May 2020 to September
2021 under the recommendations contained in the
Preferred Reporting Items for Systematic Reviews and Meta-
Analysis (PRISMA).11 The ethical principles guiding this re-
search were based on the items under “General Principles,”
“Scientific Requirements and Research Protocols,” and
“Research Registration and Publication and Dissemination
of Results” contained in the Declaration of Helsinki. The sys-
tematic review protocol was registered on the International
Prospective Register of Systematic Reviews (PROSPERO),
maintained by York University (CRD42020202878).
Search Strategy and Study Selection
A systematic literature search from inception to May 2020
was conducted by one researcher (A.R.I.) of MEDLINE
(PubMed, United States National Library of Medicine,
Bethesda, MD), LILACS (Latin American and Caribbean
Health Sciences Literature; Latin American and Caribbean
Center on Health Sciences Information, São Paulo, Brazil),
SciELO (Scientific Electronic Library Online; Latin American
and Caribbean Center on Health Sciences Information),
Scopus (Elsevier, Amsterdam, the Netherlands, Embase
(Elsevier), Web of Science (Clarivate Analytics, London, UK,
Opengrey.eu, and the Cochrane Database of Systematic
Reviews Wiley, Hoboken, NJ). In addition, Google Scholar
(Google, Mountain View, CA) and specialized registers
Bigarella et al797
were searched for relevant literature (see Appendix A,
available online at www.aestheticsurgeryjournal.com,
which presents the full search strategy). Studies retrieved
from the databases were systematically reviewed by 2 in-
dependent researchers (L.S.C., A.C.B.) and the reference
lists of the retrieved studies were submitted to manual
search. Divergences in the study selection process were
cleared by a third researcher (A.R.I.) when required.
Eligibility Criteria
The inclusion criteria were human cohort studies, case
series, randomized controlled trials, and case-control
studies reporting surgical complications, medical complica-
tions, reoperation rates, or patient satisfaction in obese pa-
tients compared to nonobese patients undergoing plastic
surgery. BMI categories were classified according to the
WHO classification,1 which considers a BMI <18.5 kg/m²
as underweight, between 18.5 and 24.9 kg/m² as normal
weight, between 25 and 29.9 kg/m² as overweight, be-
tween 30 and 34.9 kg/m² as obesity class 1, between
35 and 39.9 kg/m² as obesity class 2, and ≥40 kg/m² as
obesity class 3. Studies were excluded if: (1) the patients
were under 18 years old, (2) the BMI or bodyweight of the
patients was not clear, (3) there was no nonobese control
group (BMI <30 kg/m²), (4) data on complications were in-
sufficient, or (5) they were not written in English, Spanish,
or Portuguese. If 2 or more studies assessed the same
database, only the study with the largest population or
reporting the largest number of outcomes was included.
Studies published only as abstracts were included, as long
as the data available made data collection possible.
Methodologic Quality Assessment
The quality of the included studies was assessed by
two researchers (A.R.I., M.P.M.) according to the Grading
of Recommendation Assessment, Development, and
Evaluation (GRADE) guidelines.12
Data Extraction
Qualitative and quantitative data were independently
collected by two researchers (A.C.B., L.S.C.) using a pre-
defined form. Divergences were reviewed by a third re-
searcher (M.P.M.). The extracted qualitative data included:
(1) year of publication, (2) country, (3) type of study, (4) type
of surgery, and (5) outcomes measured. The quantitative
data extracted included: (1) characteristics of the popula-
tions (eg, number of participants, number of obese and
nonobese patients, and number of patients in each BMI
category), and (2) number of complications in obese and
nonobese groups, and in each BMI category for each
of the primary outcomes of interest (eg, surgical compli-
cations, medical complications, and reoperation rates).
Surgical complications extracted were seroma formation,
hematoma formation, wound infection, necrosis, hernia,
wound dehiscence, delayed wound healing, partial flap
failure, and total flap failure. Medical complications ex-
tracted were pneumonia, stroke, renal insufficiency, renal
failure, urinary tract infection, sepsis, septic shock, deep
vein thrombosis (DVT), pulmonary embolism (PE), more
than 48 hours on ventilator, and blood transfusion. For the
secondary outcome of interest (eg, patient satisfaction) we
also extracted the type of questionnaire used. When the
total number of events was not presented by the authors,
we used the sum of all extracted complications to estimate
the overall number of complications for each group.
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Data Analysis
Data analysis was performed with Review Manager
(Cochrane, Wiley) version 5.4.1. The Mantel-Haenszel
method with a random-effects model was used to measure
risk ratio (RR), and the results were considered significant
when P < 0.05. Heterogeneity was calculated using the
tau-squared, chi-squared, and I² statistics with their corres-
ponding P values. Publication bias was assessed with visual
evaluation of funnel plots with a triangular 95% confidence
region. The absolute risk increase was calculated by sub-
tracting the incidence of complications in the obese group
from the incidence of complications in the nonobese group.
Subgroup analysis was performed to investigate the impact
that each BMI category, as defined by the WHO,1 had on the
outcomes. We performed a sensitivity analysis to evaluate
the impact of study quality on our results.
RESULTS
Study Selection
Database searching identified 5604 records. After the
removal of duplicates, 2595 records were screened and
2343 were excluded based on title and abstract. Finally,
253 full-text articles were assessed, and 160 did not meet
the eligibility criteria. The 93 remaining articles were in-
cluded in the qualitative synthesis, and 91 in the quanti-
tative synthesis. Figure 1 presents the PRISMA flowchart
for the study selection process and the reasons for the
exclusion of articles based on the inclusion criteria. The
list of excluded references and the reasons for their exclu-
sion are presented in Appendix B, available online at www.
aestheticsurgeryjournal.com.
Characteristics and Quality Assessment
of Included Studies
The 93 included studies presented data on a total of
76,142 participants10,13-104 with an average age range of 17.1
to 62.48 years (range, 13-81 years). The population was
798
Figure 1. Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) flowchart.
composed exclusively of female participants in 59 studies,
ranging from 32.8% to 100% female participants among all
included studies. The average follow-up time was 585 days
(range, 30 to 2190 days). Data on outcomes were presented
separately for at least 1 BMI class in 39 (41.9%) studies. All the
included studies were cohorts, and 77 (82.8%) of them were
retrospective. The year of publication ranged from 1990 to
2020, with 32 (34.4%) being published in the last 5 years.
The majority of the included cohorts were conducted in the
United States (66.7%), Brazil (5.4%), and Germany (4.3%). All
included studies used weight and height measurements to
classify participants into BMI categories. The most frequent
surgeries studied were breast reconstruction in 45 (48.4%)
studies, followed by abdominoplasty and breast reduction in
13 (14%) studies each. Sample sizes varied from 21 to 15,937
participants with a mean of 819 participants. The main out-
come measured was surgical complications in 88 (94.7%)
studies, followed by medical complications in 39 (41.9%)
studies, and reoperations in 22 (23.7%) studies. Quality of
evidence was considered very low in 46 studies, low in
26 studies, and moderate in 21 studies (see Supplemental
Table 1, available online at www.aestheticsurgeryjournal.
com, which presents a summary of the characteristics and
quality assessment of included studies).
Aesthetic Surgery Journal 42(7)
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Obesity and Risk of Complications
A total of 91 studies including 72,935 participants (20,873
in the obese group) were used in the meta-analysis.
Obese participants presented an increased RR for the
development of the overall primary outcomes of interest
(RR, 1.62; 95% CI, 1.48-1.77; P < 0.00001), which included
overall surgical complications (RR, 1.67; 95% CI, 1.46-1.90;
P < 0.00001), overall medical complications (RR, 1.54; 95%
CI, 1.16-2.03; P = 0.003), and reoperation (RR, 1.31; 95% CI,
1.07-1.61; P = 0.008).
Obese participants undergoing cosmetic procedures
presented the highest RR for the development of the overall
primary outcomes of interest among the included types of
surgery (RR, 1.80; 95% CI, 1.43-2.32; P < 0.00001) (Figure 2).
Among cosmetic procedures, pooling of data was pos-
sible for abdominoplasty (RR, 1.80; 95% CI, 1.33-2.45;
P < 0.00001), breast reduction (RR, 1.55; 95% CI, 1.00-2.40; P =
0.05), and body contouring (RR, 2.11; 95% CI, 1.62-2.75;
P < 0.00001). Obesity was associated with a higher RR for
complications in participants undergoing breast recon-
struction (RR, 1.73 95% CI, 1.55-1.92; P < 0.0001) (Figure 3).
However, this effect was not observed in other reconstruc-
tive surgeries (RR, 1.09; 95% CI, 0.91-1.31; P = 0.47) (Figure 4),
Bigarella et al799
Figure 2. Forest plot for the development of the overall primary outcomes of interest in obese vs nonobese participants
undergoing cosmetic procedures. M-H, Mantel-Haenszel method.
which included head and neck reconstruction (RR, 0.93;
95% CI, 0.82-1.05; P = 0.22), lower extremity reconstruction
(RR, 0.93; 95% CI, 0.61-1.41; P = 0.72), and abdominal wall
reconstruction (RR, 1.53; 95% CI, 1.32-1.77; P < 0.00001).
Pooling of data was possible for 9 of the prede-
fined surgical complications. Obese participants pre-
sented an increased and statistically significant RR for
the development of all surgical complications except
for hematoma formation (RR, 1.23; 95% CI, 0.78-1.93;
P = 0.37). The highest RR in surgical complications
was observed in delayed wound healing (RR, 2.34;
95% CI, 1.67-3.27; P < 0.00001), followed by seroma
formation (RR, 2.31; 95% CI, 1.71-3.10; P < 0.00001),
and total flap failure (RR, 2.05; 95% CI, 1.52-2.76;
P < 0.00001). Wound infection was the most reported
surgical complication in 44 studies and obese partici-
pants presented a RR of 1.89 for its development (95%
CI, 1.56-2.29; P < 0.00001). Regarding medical com-
plications, pooling of data was possible for 7 of the
predefined outcomes, and in 3 of them, data used in
the analysis came from only 2 studies. Obese partici-
pants presented an increased RR for the development
of all medical outcomes. However, only DVT (RR, 2.33;
95% CI, 1.49-3.66; P = 0.0002) and PE (RR, 3.23; 95%
CI, 1.77-5.89; P = 0.0001) were statistically significant.
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Figure 5 presents the results of the meta-analysis for
the primary outcomes of interest.
Patient Satisfaction
Of the 12 studies evaluating patient satisfaction,13,16
,22,37,57,66,79,87,88,92,101,102 7 included breast reconstruc-
tion.22,57,66,79,92,101,102 Other types of surgery evaluating
patient satisfaction were breast reduction,13,88 abdomin-
oplasty,16,87 and other body contouring procedures.37 The
most common satisfaction assessment tool used was
the BREAST-Q questionnaire in 6 studies,22,57,66,79,92,102
followed by customized surveys in 3 studies; 13,88,101 the
Likert scale was often used to measure the responses.
Most authors found no relation between BMI and overall
patient satisfaction.1,22,57,89,92,101,105 Lower preoperative
satisfaction with breasts in obese participants was re-
ported by 3 authors, but in the postoperative period, this
difference was no longer present.57,79,90 Srinivasa et al66
conducted the largest of the included studies assessing
patient satisfaction and found that class I obesity partici-
pants undergoing breast reconstruction with implants had
a significantly lower postoperative mean change in satis-
faction with breasts compared with underweight/normal-
weight participants. However, these results were not
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Figure 3. Forest plot for the development of the overall primary outcomes of interest in obese vs nonobese participants
undergoing breast reconstruction. M-H, Mantel-Haenszel method.

Figure 4. Forest plot for the development of the overall primary outcomes of interest in obese vs nonobese participants
undergoing other reconstructive surgeries. M-H, Mantel-Haenszel method.

observed in other obesity classes or autologous breast Subgroup Analysis

reconstruction participants. Similar results were observed
by Atisha et al,101 who reported that obese women under-
going expander/implant breast reconstructions were less
satisfied than normal-weight women with their aesthetic
results.
The analysis of complications for each BMI category in-
cluded 31 studies for nonobese subgroups and 17 to 19
studies for obesity classes because some authors did
not present individual data for all of the obesity classes.
Bigarella et al801

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Figure 5. Results of the meta-analysis for the primary outcomes of interest in obese vs nonobese participants. DVT, deep vein
thrombosis; PE, pulmonary embolism; PFF, partial flap failure; TFF, total flap failure; UTI, urinary tract infection.

Figure 6. Results of the subgroup analysis for the primary outcomes of interest in each BMI category.

Normal-weight (RR, 0.65; 95% CI, 0.57-0.75; P < 0.00001)
and overweight (RR, 0.77; 95% CI, 0.70-0.85; P < 0.00001)
participants presented a reduced relative risk for compli-
cations compared with the obese. Compared with normal-
weight participants, overweight participants presented a
significantly increased RR for complications (RR, 1.16; 95%
CI, 1.07-1.27; P = 0.0004). Obese class I (RR, 1.58; 95%
CI, 1.37-1.83; P < 0.00001), class II (RR, 1.65; 95% CI, 1.45-
1.88; P < 0.00001), and class III (RR, 1.95; 95% CI, 1.74-2.19;
P < 0.00001) participants were more likely to develop com-
plications compared with nonobese participants, and the
RR increased with weight. Figure 6 presents the results of
the subgroup analysis for each BMI category.
Sensitivity Analysis and Publication Bias
The analysis including only the 21 studies considered
as moderate quality found an increased RR for the
development of the overall primary outcomes of interest
in obese participants undergoing any plastic surgery (RR,
1.64; 95% CI, 1.35-1.99; P < 0.00001), similar to the findings
of the analysis including all studies. Results presented a
small possibility of publication bias as funnel plots of all
analyses had symmetric distributions.
DISCUSSION
Obesity is a public health problem that has been increasing
over time.106 Parallel to the increase in the obese popula-
tion, we are witnessing a growing demand for plastic sur-
geries. In 2019, over 11 million cosmetic surgeries were
performed worldwide, which represents a 20% increase
compared with 2015.107 In surgery, obesity repercus-
sions extend from the preoperative to the postoperative
period.5,6 This is due to physiological changes caused by
obesity, which include altered tissue irrigation, smaller
802
collagen deposition, overlapping of risk factors associated
with obesity, and increased inflammatory activity, which
contributes to healing difficulties and the need to use
larger flaps.6,108 Such factors lead to a higher risk of devel-
oping surgical and medical complications, and a greater
chance of reoperation as seen in our meta-analysis and
previous studies.5,6
The relative risk and the absolute risk of any complica-
tions occurring in the obese group were increased by 62%
and 11.13%, respectively. Regarding surgical complications,
the highest effects were seen in delayed wound healing,
seroma formation, and total flap failure, which were respec-
tively 2.34, 2.31, and 2.05 times more likely to occur in obese
participants. However, the risk of hematoma formation was
not associated with a higher BMI. These findings are com-
patible with a previous meta-analysis evaluating only breast
reconstruction.5 Due to the higher rate of complications,
reoperations were 1.31 times more likely to occur in partici-
pants with BMI ≥30 kg/m2, which was smaller than the effect
found by Panayi et al.5 The increased risk for reoperation in
obese participants is not exclusive to plastic surgery, being
previously reported in participants undergoing myocardial
revascularization, gastroplasty, and knee arthroplasty.109-111
Obesity was also associated with an increase of 54%
in the risk of developing medical complications relative to
nonobese participants. However, the risk of development of
only 2 (DVT and PE) of the 7 medical complications analyzed
had a statistically significant association with obesity, which
could be explained by the small number of studies used in
the analysis of these other 5 outcomes. An increased risk
for DVT and PE in obese participants was observed and al-
ready expected, considering that obesity is associated with
higher plasma concentrations of prothrombotic factors,
such as fibrinogen, von Willebrand factor, and factor VII.112
In addition, surgery is also a well-known risk factor of DVT
due to the trauma and immobilization to which patients are
submitted in the operative and perioperative periods.113 It
is recommended that obese patients undergoing plastic
surgery receive appropriate venous thromboembolic pro-
phylaxis with early mobilization, sequential compression
devices, and perioperative anticoagulant medication.114
The highest increase in risk among plastic surgery types
was observed in cosmetic procedures. Obese participants
were 1.8 times more likely to develop any complication than
nonobese, with an absolute risk increase of 12.28%. Among
cosmetic procedures, obese participants undergoing body
contouring procedures presented an increase in relative
and absolute risk for any complications of 111% and 16%, re-
spectively. In addition to the metabolic disorders inherent
to obesity, a large proportion of body contouring surgeries
are performed in bariatric patients, who have been exposed
for long periods to the metabolic disorders of obesity and
are considered as a high-risk group for nutritional defi-
ciencies.115 However, further prospective and randomized
studies are required to evaluate the clinical significance of
nutritional deficiencies in plastic surgery outcomes.
Aesthetic Surgery Journal 42(7)
Obesity was not associated with a higher RR for devel-
oping complications in participants undergoing head and
neck reconstruction and lower extremity reconstruction.
Furthermore, we found that obese participants undergoing
breast reconstruction presented a smaller RR than obese
participants undergoing cosmetic procedures, which dif-
fers from previous findings in the literature.5 This result
could be explained by the oncological population of these
studies. Cancer patients who present with lower weight
tend to have a worse prognosis because they will have
lower nutritional reserves to support treatments.58 Also,
patients with more advanced forms of the disease tend
to have lower BMI and may even present cancer-induced
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cachexia.116 In addition, head and neck cancer patients
are more likely to present dysphagia and odynophagia,
increasing the risk of nutritional problems, making the
prognosis of nonobese patients worse.
Obese participants presented smaller preoperative sat-
isfaction than nonobese participants. The probable con-
tributing factor is the distortion of normal aesthetic breast
subunits, more commonly observed in the obese.57,79,90
Despite the higher surgical complication rates and the
often lower aesthetic results among obese participants,102
satisfaction with outcomes tends to be the same between
groups after plastic surgery. The only exception was seen
in breast reconstructions with implants or expanders, in
which obese women were less satisfied with the results,
which could be explained by the challenges of achieving
acceptable symmetry with unilateral breast reconstruc-
tions in larger patients.101
Implications for Clinical Practice and
Future Research
Although plastic surgery can benefit the obese popula-
tion, their higher risk for medical and surgical complications
and higher reoperation rates should be considered when
indicating plastic surgery for these patients. Also, the at-
tending physician must be able to manage the operative
technique, and to recognize the potential pre-, peri-, and post-
operative risks, as well as their respective management.117
Obesity also increases the risk of hypertension, myocardial
ischemia, and diabetes mellitus,7 requiring attention from the
clinical-surgical team in this regard as well.117 Furthermore,
physicians should evaluate the risks and benefits of cos-
metic procedures in obese patients even more carefully be-
cause these are elective surgeries that present a higher risk
of complications than other types of plastic surgery.
Our study showed that obese patients undergoing any
plastic surgery present an absolute increase in the risk of
developing any complication by 11.13%, which means that
for every 100 obese patients, there will be 11 additional
complications that were not expected in a similar nonobese
group of patients. For class III obesity patients, the abso-
lute increase in the risk of developing any complication
reaches 20.20%, representing 20 additional complications
Bigarella et al803
for every 100 patients. Regarding medical complications,
obese patients present an absolute increase in the risk for
its occurrence of 1.25%, with 5 additional cases of PE and 4
of DVT occurring for every 1000 obese patients. Therefore,
preoperative weight management and postponing surgery
until weight reduction is achieved should be considered to
reduce the risks associated with the procedure, especially
in cosmetic cases. Despite being assessed as a categoric
variable, the risk associated with BMI probably increases
continuously. Therefore, future research should evaluate
BMI as a continuous variable to determine the threshold at
which overweight begins to significantly increase the risk
of complications.
Although obesity was evaluated in the included studies
as a relation between weight and height, methods that as-
sess the percentage of body fat tend to be more accurate
and precise.118 In addition, new classifications of obesity
have been proposed based on metabolic profile rather
than body composition because body measurements fail
to consider the impact of adiposity on metabolic processes
and the occurrence of unmeasured confounders.118,119
Future research should also investigate the impact of met-
abolic markers on plastic surgery outcomes.
Strengths and Limitations
We provide a systematic review with meta-analysis of the
risks for complications and wellbeing impact of obesity
in different types of plastic surgery, gathering the current
knowledge on the topic to inform patients and facilitate
decision-making for healthcare professionals. Our re-
view covered a vast number of studies, including a total
of 76,142 participants. Although previous reviews have
assessed the impact of obesity on breast reconstruction
and breast reduction, this is the first systematic review with
meta-analysis to evaluate this impact on abdominoplasty,
body contouring, and other reconstructive surgeries such
as head and neck, lower extremity, and abdominal wall
reconstruction. Furthermore, we assessed the risk for
each BMI category, including the risk for overweight pa-
tients, which was not reported in the previous studies on
this topic. Our sensitivity analysis showed a small impact
of study quality on the results and the analyses of funnel
plots indicated that it is unlikely that publication bias influ-
enced the results.
However, the quality of most of the included studies
was very low or low, mainly because they consisted of co-
hort studies, which carry inherent biases. The majority of
them were composed of small and nonsimilar samples.
Selection biases were also noticed in the sample composi-
tion, such as the presence of bariatric patients and patients
undergoing multiple procedures. Also, a small number of
studies measured medical complications, and data on BMI
categories were frequently not reported.
CONCLUSIONS
Obesity influences peri- and postoperative conditions,
leading to more surgical and medical complications, and a
greater incidence of reoperation compared with nonobese
patients undergoing plastic surgeries. However, this effect
is not evident in patient satisfaction or reconstructive sur-
geries in areas of the body other than the breast.
Supplemental Material
This article contains supplemental material located online at
www.aestheticsurgeryjournal.com.
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Disclosures
The authors declared no potential conflicts of interest with re-
spect to the research, authorship, and publication of this article.
Funding
The authors received no financial support for the research,
authorship, and publication of this article.
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