Body Mass Index is Not an Independent Risk Factor for Complications in Facial Feminization Surgery: An Institutional Cohort and NSQIP Analysis

BACKGROUND: Most research on body mass index (BMI) in plastic surgery focuses on general reconstructive procedures, with limited data available on its impact on facial aesthetics and gender-affirming surgeries. Facial feminization surgery (FFS) is a set of procedures designed to modify facial features to appear more feminine. Given that obesity is a well-established risk factor for complications in various surgical fields, this study investigates whether similar risks apply to FFS to better inform surgical decision-making and reduce unnecessary barriers to care. METHODS: A retrospective analysis was conducted on transfeminine patients who underwent FFS at our institution to evaluate the relationship between BMI and postoperative complications. A parallel analysis was performed using the National Surgical Quality Improvement (NSQIP) database from 2009 to 2023, identifying patients with International Classification of Diseases-10 (ICD-10) codes for gender dysphoria and Concurrent Procedural Terminology (CPT) codes related to FFS. In both cohorts, BMI was classified as normal weight (18.5 to 24.9 kg/m2), overweight (25.0-29.9 kg/m2), and obese (≥30.0 kg/m2). Multivariate logistic regression, with comorbidities as covariates, was used to assess associations between BMI category, overall postoperative complications, and specific complication types. RESULTS: Our institutional cohort included 350 FFS patients with the following BMI distribution: 72 obese (20.6%), 119 overweight (34.0%), and 135 normal weight (38.6%). The overall postoperative complication rate was 10.0%. Multivariable logistic regression showed no significant association between BMI category and overall complications or specific complications, including infection, dehiscence, and hematoma. To validate these findings, we analyzed an NSQIP cohort of 597 FFS patients with a similar BMI distribution: 150 obese (25.1%), 175 overweight (29.3%), and 247 normal weight (41.4%). The overall complication rate was low at 3.11%. Consistent with our institutional data, multivariate analysis of the NSQIP cohort found no significant association between BMI and any postoperative complication, including superficial surgical site infection (SSI), deep incisional SSI, or dehiscence. CONCLUSION: Our findings provide robust, multi-institutional evidence that BMI should not be a contraindication for FFS, and that FFS is safe in each category of BMI. Reducing BMI-related barriers can improve access to gender-affirming care. Further research is needed to explore additional factors influencing postoperative outcomes in this population.