When should a patient with significant comorbidities, such as uncontrolled diabetes, severe cardiovascular disease, chronic obstructive pulmonary disease (COPD), history of deep vein thrombosis (DVT) or pulmonary embolism (PE), taking anticoagulant medications like warfarin (coumarin) or novel oral anticoagulants (NOACs), history of abdominal surgery, body mass index (BMI) greater than 40, or a smoker, be excluded from abdominoplasty with liposuction?

Absolute and Relative Contraindications for Abdominoplasty with Liposuction

Patients with BMI >40 kg/m², active smoking, uncontrolled diabetes, severe cardiovascular disease, recent DVT/PE, or inability to safely discontinue anticoagulation should be excluded from abdominoplasty with liposuction due to significantly elevated perioperative risks.

Absolute Contraindications

Severe Obesity (BMI >40 kg/m²)

• BMI >40 kg/m² is an absolute contraindication to elective abdominoplasty with liposuction 1
• Combined procedures in obese individuals significantly increase complication rates, with BMI being an independent predictor of major complications (RR 1.05 per unit increase) 1
• Perioperative complications are associated with extremely high BMI in bariatric surgery populations, with similar risks applicable to body contouring procedures 2
• Patients with BMI >40 should be counseled toward bariatric surgery first if they desire body contouring, as this addresses the underlying obesity and reduces surgical risk 3

Active Cardiovascular Disease

• Severe cardiovascular disease, decompensated heart failure, unstable coronary syndromes, or significant arrhythmias are absolute contraindications 2, 4
• Patients with diagnosed or occult coronary heart disease have substantially higher surgical risk, with cardiac complication rates of 6.8-15.3 per 1000 patients in obese surgical populations 2
• Any patient with functional capacity <4 METs (unable to climb one flight of stairs or walk 2 blocks) has increased perioperative cardiac risk requiring deferral until optimization 4

Recent Thromboembolic Events

• History of DVT or PE within the past 3 months is an absolute contraindication 2
• Confirmed VTE risk increases with combined procedures (0.06% for liposuction alone vs higher rates with combined procedures) 1
• Perioperative DVT/PE rates in surgical populations range from 0.4-1% even with prophylaxis 2

Uncontrolled Diabetes Mellitus

• Uncontrolled diabetes with HbA1c >8% or active diabetic complications is an absolute contraindication 2, 4
• Diabetes is a major clinical predictor requiring immediate evaluation and optimization before elective surgery 4
• COVID-19 data demonstrates that patients with diabetes and undergoing surgery have significantly worse outcomes, a principle applicable to elective procedures 2

Relative Contraindications Requiring Optimization

Active Smoking

• Active smoking within 4-6 weeks of surgery is a strong relative contraindication 1
• Smoking is an independent risk factor for complications and should prompt mandatory cessation before proceeding 4
• Wound infection, dehiscence, and fat necrosis rates are significantly elevated in smokers 5

Anticoagulation Therapy

• Patients on warfarin or NOACs who cannot safely discontinue therapy should not undergo elective abdominoplasty 6
• While DOACs may be as efficacious as warfarin in obese patients (BMI ≥35 kg/m²), the perioperative management requires careful planning 6
• Hematoma rates, though lower with lipoabdominoplasty (0.8% overall), increase significantly when anticoagulation cannot be held 5, 1

Chronic Obstructive Pulmonary Disease (COPD)

• Severe COPD or pulmonary disease requiring home oxygen is a relative contraindication 2
• COPD significantly increases mortality from perioperative complications 2
• Pulmonary complications occur in 0.1% of liposuction cases but increase substantially with underlying lung disease 1

Previous Extensive Abdominal Surgery

• Multiple prior abdominal surgeries with extensive scarring increase complication risk 2
• Previous surgery does not absolutely contraindicate abdominoplasty but requires careful patient selection and counseling about increased risks 5
• Wound complications (infection, dehiscence, fat necrosis) occur in 5.6% of cases and are higher with prior surgery 5

BMI Thresholds and Risk Stratification

Evidence-Based BMI Cutoffs

• BMI 35-40 kg/m² represents a gray zone requiring individualized assessment 3, 1
• Patients with BMI 35-39.9 kg/m² should only proceed if they have no other significant comorbidities 3
• BMI >40 kg/m² is a hard stop - these patients should pursue bariatric surgery first 3, 1

Combined Procedure Considerations

• Combined procedures significantly increase complication rates (RR 4.81) compared to abdominoplasty or liposuction alone 1
• The overall complication rate for abdominoplasty with liposuction is 10.5%, which is actually lower than abdominoplasty alone (13.0%) when performed by experienced surgeons 7
• However, this safety profile only applies to appropriately selected patients without the contraindications listed above 7

Critical Pitfalls to Avoid

Arbitrary Liposuction Volume Restrictions

• Regulations limiting liposuction to 500-1000 ml when combined with abdominoplasty are not evidence-based 7
• Increasing liposuction volume is not independently associated with increased complications when performed by board-certified plastic surgeons 7
• The focus should be on patient selection rather than arbitrary volume limits 7

Underestimating Cardiac Risk

• Physical examination and ECG often underestimate cardiac pathology in obese patients 2
• Body size alone may camouflage jugular venous distention, and heart sounds are often distant 2
• Baseline ECG should be obtained in all patients, as 20% have ischemic changes 4

Inadequate Preoperative Optimization

• Patients with poor functional capacity require cardiac evaluation with stress testing before proceeding 4
• Chronic kidney disease (creatinine ≥2 mg/dL) requires cardiac evaluation 4
• Depression, cognitive impairment, and frailty should not be overlooked as these increase perioperative risk 4

Facility and Surgeon Requirements

• Procedures should be performed by board-certified plastic surgeons with experience in combined procedures 7
• High-volume centers with experienced surgeons optimize outcomes 3
• Hospital settings paradoxically have higher complication rates (RR 1.36), likely reflecting patient selection bias toward higher-risk cases 1