Ideal Weight

Weight is so important for whole body health and healing.

Reasons to lose weight prior:

Losing weight after surgery can ruin some results, particularly for any surgery which is tightening the skin- breast lift, breast reductions, and abdominoplasties. If you lose weight after the lift, your breast will droop again. Or your tummy will hang again.
Where your weight comes off varies. Proportion is important. We need to know the size and ratio of your breast, abdomen, and hip to each other. If you lose 20 pounds does it come 10 off the breast and 10 off the belly? Or 20 off the belly?
Higher BMI = higher complications. Wound healing, infections, blood clots, tissue death, and more.
If your BMI is high, you may have sleep apnea and an obstructed airway. Please take this test to see if you may have unknown sleep issues HERE. Why do I care about apnea? First, it makes your airway and intubation for surgery harder and riskier. Second, apnea affects oxygenation to your tissue. This impairs healing, scarring, infection risk. And last, most pain medications cause respiratory depression. Apnea already has respiratory issues. The most dangerous time is when sleeping at night. This can be made better by weight loss and/or CPAP.

Our outpatient surgery center has a cut off of 34 for BMI.

Normal BMI is up to 24.
If above 27 with an additional medical issue (diabetes, high blood pressure) or a BMI over 30, Dr. Greenberg strongly urges you to lose weight prior to surgery to improve SAFETY & OUTCOME. A BMI over 30 is considered obese.
If above 34, weight loss is mandatory if possible, and your surgery must be done at an inpatient hospital for safety reasons.

THERE ARE MANY CHOICES TO HELP.

general advice for weight loss

I get how hard losing weight is. I am a post menopausal woman who has had three kids. My recommendations stem from years of seeing what is successful, reading good advice books like the Obesity Code, by Dr. Fung, and also reading the scientifically documented benefits of the GLP-1 medications for those who have fought the fight to lose weight, doing those things listed below, and just need a little more help.

Generally higher protein diet/lower carbohydrate diet.
Keep your calorie count STEADY. Do not cut calories too much- this leads to slowing of metabolism and the weight rebounds when you eat normally again.
Look for easy ways to improve- sugary drinks or juices, that dessert before bed, a daily glass of wine.
If you are in perimenopause or menopause, hormone therapy may help. I recommend going to www.joinmidi.com It is covered by insurance and they are great at advising on hormone issues around menopause.
Do not weigh yourself daily. Healthy weight loss takes time.
Intermittent fasting. I love this. It really addresses insulin insensitivity and can lower your HBA1c in addition to helping you lose weight. The baseline is 16/8, where you eat for 8 hours, fast for 16 hours. Some people extend the window to 18/6 or 20/4. For a great synopsis of this, I recommend the Obesity Code book by Dr. Fung
Be active. Take the stairs. Clean up the house. Studies show doing 2-5 minutes of walking after meals significantly improves blood sugar levels.
Metformin. This is a diabetes medication- it is cheap, has been around for 40 years, and has few side effects (mostly GI stuff like nausea, diarrhea). In some patients it may help with weight loss (and blood sugar control). Check your HbA1C. If over 5.0, talk to your doctor about it. If you have polycystic ovary disease PCO, many doctors recommend Metformin.
Continuous Glucose Monitor. I love these. It tells you what makes YOUR blood sugar spike. If your HBA1c is below 5.5, you likely don’t need to evaluate it yet. But if you are above 5.5, find out how to control your blood sugar better. Not only will it improve your risk for dementia, heart disease, diabetes, and more, it will help fight insulin resistance which leads to fat deposition.
Semaglutide and tirzepatide. These GLP-1 agonists are the workhorse of weight loss. They are super effective and safe. There can be side effects- GI symptoms/muscle loss/pancreatitis- and we strongly recommend doing these medications under the care of a physician and team who understand the medications. We offer GLP agonist injections here in our office as part of our physician supported weight management program. We will help you determine the best approach for you based on your unique health profile.

What do studies show?

Study after study shows higher BMI correlates with higher complications in almost every area: nausea, DVT, pulmonary embolus, infection, fat necrosis, tissue loss, wound healing issues, need for reoperation, and poorer scarring.

I just did a blog about breast reconstruction, and they showed a clear correlation with BMI, starting at a BMI over 25. The complications went up as the BMI went up.

They found a BMI of 32 or more was as risky as operating on a current smoker.
They found BMI was more predictive of complications than age, history of diabetes, or smoking. (!!!) And the numbers were not small percentages of issues. Many were 20% or higher.
They found there were distinct levels of complication increases:
- BMI 25 infection requiring oral antibiotics
- BMI 30 any breast complication
- BMI 30 any infection
- BMI 35 unplanned reoperation for wound breakdown
- BMI 35 infection requiring IV antibiotics
- BMI 35 mastectomy flap necrosis (tissue death)
- BMI 35 unplanned reoperation
- BMI 40 fat necrosis (tissue death)

This is one study which echoes the findings of tons of prior studies. Higher BMI= higher complications.

GLP-1 medications

What are GLP-1 agonists?

GLP-1 agonists are a once-weekly injectable dual glucagon-like peptide 1 (GLP-1) receptor agonists. In newer GLP medications there is also a glucose-dependent and insulinotropic polypeptide (GIP) receptor agonist. It works by

increasing insulin production
lowering glucagon secretion
targeting areas in the brain that regulate appetite and food intake, ie reducing cravings and “food noise”.

A small change in the molecule allows the drug to last weeks in our bodies rather than the natural version our bodies make, which lasts minutes.

The newer GLP medications act in the following ways:

Delays food digestion, keeping you feeling full longer with smaller meal sizes.
Slows intestinal motility so you will feel fuller longer after meals.
Dual action receptors allow for lower blood sugars, in part by reducing the production of sugar in the liver.
Stimulates insulin secretion by the pancreas.
GIP increases energy expenditure, resulting in weight loss reductions

Our program tries to optimize your results and safety in a multifaceted way. We will help determine the best clinically guided weight management approach for you based on your unique health profile.

Lab Work
Weigh in with body muscle and fat percentages
BRI- Body roundness index, looking at waist to hip ratios (a more accurate predictor of health risks.)
Ancillary services to help with the weight loss and provide an offramp, such as – NAD, Creatine, Continuous Glucose monitors, and a custom probiotic to help with glucose control and bowel regularity.

last thoughts on weight

Other considerations:

Realistic weight loss is 5-7 pounds/month. When planning for timelines, take this into account.
I do not support dieting with severe caloric restriction. These tend to fail (read the Obesity Code book) and send you into surgery depleted of the protein and nutrients critical to help you heal and fight infection. It has been shown patients who protein load one month prior to and one month after surgery have STATISTICALLY lower infection rates and prettier scars.
Protein is important. You do not want to go into a surgery being depleted nutritionally.
Weight should be STABLE. If your weight is yo-yoing or is increasing, you do not have good systems in place. You must be stable to do surgery.
Even if you do not end up with a big complication from higher BMI, for sure you will have higher rates of healing issues– little infections along the suture line, fat necrosis, spitting sutures, uglier scars, widened scars, etc

SAFETY and RESULT should be your focus when doing elective surgery. The science is clear. BMI of 30 or higher is considered obese, 35 or higher severe obesity. Weigh yourself (I will weigh you, the operating room will weigh you), so get on that scale to see your number. For a calculator, click BMI CALCULATOR