BMI and Top Surgery: Understanding the Clinical Framework

I was recently contacted by a prospective patient asking about BMI (Body Mass Index) cutoffs for top surgery. This is an important question that deserves a transparent and thorough explanation.

What is BMI and why does it matter?

BMI is a screening tool used by healthcare professionals to estimate body composition using height and weight. While it has well-documented limitations (it doesn't account for muscle mass, fat distribution, or individual health variations) it remains a widely used metric for assessing certain surgical risks.

The UK Context

In the UK, BMI cutoffs for elective surgery vary by setting and procedure. The NHS typically sets limits around BMI 30-35 for many elective procedures, though this varies by region and clinical commissioning group. Private facilities have more flexibility, with some able to support patients up to BMI 40 or higher, but only if they have the appropriate medical infrastructure in place.

This is the crucial point: BMI cutoffs are not about a surgeon's personal beliefs about who "deserves" surgery. They are determined by the clinical capabilities and safety equipment available at each specific facility.

Why Do These Limits Exist?

Higher BMI is associated with increased surgical and anaesthetic risks, including:

• Anaesthetic challenges: Airway management, proper medication dosing, and monitoring can be more complex

• Higher risk of sleep apnoea: This condition, more common in patients with elevated BMI, significantly increases anaesthetic risk

• Wound healing: Increased risk of infection and wound complications

• Technical factors: Longer surgery times and increased surgical complexity

• Post-operative care: Greater need for specialist monitoring and equipment

Research shows that these risks become substantially more significant in patients with a BMI higher than 40. Importantly, recent studies specific to top surgery suggest that while minor complications may increase, the procedure is generally safe across BMI ranges when appropriate precautions are taken and proper facilities are available.

My UK Practice: BMI 40

At my UK facility, I can safely operate on patients with BMI up to 40 because we have:

• Appropriate anaesthetic expertise and equipment

• Specialist monitoring capabilities

• Access to enhanced recovery facilities if needed

• Protocols for managing higher-risk patients

This limit is not a reflection of my surgical philosophy, rather it reflects the maximum BMI I can safely support given the specific resources available at this facility.

Greece: No BMI Limit

In Greece, I work with facilities that have different capabilities and regulatory frameworks. These hospitals are equipped to safely manage patients across all BMI ranges, which is why I'm able to offer surgery without BMI restrictions there.

My Philosophy on Access to Care

I want to be absolutely clear: I believe everyone who needs gender-affirming care should be able to access it, regardless of body size. Throughout my career, I have successfully performed top surgery on many patients with elevated BMIs.

My commitment is to provide care safely and ethically. This means:

• Being honest about facility limitations

• Never using BMI as a gatekeeping tool based on personal bias

• Continuously working to expand access where possible

• Treating every patient with dignity and respect

The Fatphobia Conversation

I understand the frustration when patients encounter BMI restrictions. Medical fatphobia is real and it manifests in dismissive attitudes, assumptions about lifestyle, and barriers to care that aren't evidence-based. I recognise this reality and actively work against it in my practice.

However, it's also true that some BMI considerations in surgery are rooted in genuine safety concerns and facility limitations rather than bias. The challenge is distinguishing between the two. My goal is always to maximise access while ensuring patient safety.

Looking Forward

I recognise that travel to Greece isn't feasible for everyone. While I wish I could offer the same flexibility in my UK practice, patient safety must be my first priority, and that means working within the capabilities of each facility.

If you're a prospective patient concerned about BMI requirements, I encourage you to:

• Have an open conversation during consultation about your individual health profile

• Understand that BMI is one factor among many we consider

• Know that optimising other health factors (managing sleep apnoea, blood sugar control if diabetic, etc.) can significantly reduce surgical risk regardless of BMI

• Feel empowered to ask questions and seek clarity

In Summary

BMI cutoffs in surgery exist primarily due to facility capabilities and genuine safety considerations, not as a tool to exclude people from care. While I'm constrained by BMI 40 in my UK practice, I remain committed to expanding access to gender-affirming surgery for all patients. This is why the same cut offs do not apply in my Greek practice.

Everyone deserves a chest that allows them to live authentically and comfortably.