Introduction: Gender-affirming surgeries (GAS) are increasingly in demand. Though these procedures are elective, there is a significant morbidity and mortality benefit. Access to GAS is an ongoing discussion and must balance operative risks, individual risk factors, and potential benefit. Many of those offering these procedures list an ideal or inflexible upper limit of body mass index (BMI). The objective of this work is to determine if there is a relationship between BMI and surgical outcomes for GAS, both chest and genital, both masculinizing and feminizing. Additionally, we seek to evaluate whether any such relationship between BMI and outcomes suggests that a cutoff should (or should not) be considered for access to GAS.
Methods: The scientific literature was searched for original articles reporting on any GAS, including chest, genital, masculinizing, and feminizing procedures. Review articles and abstracts were excluded. We extracted BMI cutoff criteria, reported BMI of each cohort, and statistically evaluated outcomes from each article. A similar search was performed for selected analogous soft-tissue surgeries for comparison.
Results: The highest and lowest BMI reported were 54 and 14.6, both for masculinizing chest surgery. 6 groups reported using BMI upper limits of 25-33 or morbid obesity to undergo GAS. 3 recommended or required an alternative surgical approach for BMI greater than 27-30. 2 specified that BMI is not considered a contraindication for GAS at their institution(s). Of those that reported BMI, 77% (n=34/44) did not specify using BMI to qualify for GAS. It was common for reported BMI mean, standard deviation, and/or ranges to suggest that GAS may have been discouraged or considered contraindicated in obese patients (e.g. 24.8 ± 1.84), though this is of limited credibility without known ranges. 48% (n=21/44) evaluated surgical outcomes in relation to BMI. 11 individual criteria were found to be statistically significant; most commonly choice of surgical approach (n=7/11, 64%).
Conclusions: In a comprehensive review of the literature, we found limited evidence that suggests high BMI is associated with higher risk of complications. The available data supports using high BMI as a proxy for more dangerous health conditions (i.e. diabetes, hypertension, cardiac disease) which must be optimized preoperatively for safety, as in any patient. A higher risk of uncommon or non-life threatening complications may not justify BMI limits to GAS, as long as patient and surgeon acknowledge the higher risk of common obesity related complications, as in other elective but indicated surgeries.
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