Q: I have a high BMI, but no diabetes, no high cholesterol, no weight-related illnesses and I exercise six days a week and do two days of strength training. My diet is all vegetarian and mostly plant-based. Would there be a consideration for DIEP with a BMI of over 35 at your practice?

A: As long as you are not much over 35 BMI, and otherwise healthy, it may be possible to operate on you safely. The primary determinate of risk, in my opinion, is what percentage of excess fat is directly under the skin (the higher, the better) and what percentage is buried deep around your intestines (very bad fat).

Fat deep inside your abdomen does several unfavorable things when you have a DIEP flap. Firstly, and by far, most importantly, it increases your risk of blood clots, which can be fatal. I’ve never had anyone die from a DIEP flap, and I very much want to keep it

that way. Secondly, it presses outward on the rectus abdominis muscle, which increases the risk of abdominal wall problems or hernia.

Fat located directly under the skin certainly increases your risk of wound healing problems, but I don’t consider it nearly as dangerous as intra-abdominal fat. It can even be good up to a point, as often it can be readily removed and used for the DIEP flap itself.

The final risk assessment comes down to seeing you in person and pinching (gently) to get a feel for how your extra fat is distributed. As a general rule, if you have a big tummy, the more you can pinch between your fingers, the better.

I would be happy to chat with you or see you via telemedicine or in person to discuss further.

- Richard M. Kline, Jr., MD