Gender-affirming chest surgery in adults with extreme BMI: a multi-center retrospective analysis of clinical outcomes

Transgender and gender-diverse (TGD) patients face multifactorial barriers to accessing medically-necessary interventions, including gender-affirming chest surgery (GACS). Surgeons may exacerbate this inequity by imposing preoperative body mass index (BMI) requirements on their patients. Recent studies present conflicting evidence regarding the association between BMI and postoperative complications following GACS; however, no studies have assessed these outcomes in cases of extremely high BMI (>40 kg/m2). Assigned female at birth patients ≥ 18 years old undergoing GACS at three institutions were reviewed. Demographic and clinical characteristics were analyzed descriptively between patients with BMI ≤40 and >40 kg/m2. A multivariable logistic model was used to determine the effect of BMI on complications. 647 patients were included, of these, 82 (12.7%) had BMI >40 kg/m2. Among patients with BMI >40 kg/m2, 21.9% had at least one complication. A significant association was observed between BMI and overall complications (p=0.0026). Adjusted analyses suggested that patients with BMI >40 kg/m2 were 2.34 times more likely to experience at least one complication (95% CI 1.153, 4.733). Overall complications, incisional dehiscence, and major complications (requiring unplanned readmission and/or reoperation) were significantly higher in patients with BMI >40 kg/m2. This multi-institutional retrospective review demonstrates a higher frequency of adverse outcomes in patients with BMI >40 kg/m2. GACS can be performed safely in patients with extreme BMI, however appropriate informed consent is necessary. These data will facilitate evidence-based counseling on the risks and benefits of GACS in this patient population.