Semaglutide and Postoperative Outcomes in Nondiabetic Patients Following Body Contouring Surgery

Abstract

Background

Semaglutide is a medication for weight loss in obese patients. Recently, many plastic surgeons have recommended semaglutide following bariatric surgery to increase weight loss. However, postoperative complications such as wound dehiscence, delayed healing, and infection pose significant risks.

Objectives

In this study we aimed to examine the relationship between preoperative semaglutide and postoperative complications in nondiabetic obese patients undergoing body contouring surgery. We hypothesized that semaglutide would increase the risk of postoperative complications.

Methods

In this retrospective cohort study we utilized the TriNetX Research database. Nondiabetic patients who underwent body contouring surgery between 2021 and 2024 after bariatric procedures were included. Patients were divided into 2 cohorts: Cohort A (4215 patients), which received semaglutide for ≥6 months before surgery, and Cohort B (104,927 patients), without semaglutide. Propensity score matching was employed to create comparable cohorts based on age, gender, race, and BMI. The primary outcomes included postoperative complications within 30 days of surgery.

Results

Significant differences were found between the cohorts. Semaglutide patients had higher rates of wound dehiscence (5.19% vs 2.78%, P < .0001); delayed wound healing (2.58% vs 1.21%, P < .0001); surgical site infections (5.37% vs 2.87%, P < .0001); nausea, vomiting, and diarrhea (11.27% vs 5.34%, P < .0001); hypertrophic scar formation (5.53% vs 3.86%, P = .0011); and surgical site pain (6.05% vs 3.29%, P < .0001).

Conclusions

Preoperative semaglutide in nondiabetic patients undergoing body contouring surgery following bariatric procedures is associated with higher rates of adverse postoperative outcomes. These findings highlight the need for enhanced preoperative counseling and surgical planning to minimize risks and improve patient outcomes.

Level of Evidence: 3 (Therapeutic)

Body contouring surgery following bariatric procedures is often advised by surgeons to address functional limitations and aesthetic issues caused by loose skin following substantial weight loss.¹ Procedures such as abdominoplasty and brachioplasty aim to improve patients' well-being by relieving physical discomfort and minimizing risks such as skin infections and mobility issues.^2,3 Body-contouring surgery after bariatric procedures presents unique challenges, particularly concerning postoperative complications.^4,5 Approximately 46,577 body contouring procedures are performed after massive weight loss surgeries each year, underscoring the rising necessity for strategic approaches to manage postoperative complexities and achieve favorable patient results.⁶ Patients undergoing these surgeries frequently face risks such as wound dehiscence, delayed healing, and infections, which can significantly affect recovery and overall outcomes.⁵ Addressing these complications is crucial for enhancing patient care and the success of surgical interventions in this population.⁷ Optimizing preoperative conditions through effective weight management and metabolic health improvement is a key area of investigation that may help mitigate these risks.⁸

Semaglutide, a GLP-1 receptor agonist, has demonstrated effectiveness in promoting weight loss and improving metabolic health in obese patients.⁹ Semaglutide was approved by the US Food and Drug Administration (FDA) in 2017 for treating type 2 diabetes; however, recently semaglutide has increased in popularity for its effect on significant weight loss in diabetic and nondiabetic patients.¹⁰ Although the benefits of semaglutide in weight management are well-documented, there remains a gap in understanding its potential impact on surgical recovery and complication rates in patients undergoing surgery. Additionally, its effects on postoperative outcomes in nondiabetic patients undergoing body contouring surgery have not been extensively studied.

In this study we aimed to address this gap by examining the relationship between preoperative semaglutide and postoperative complications in nondiabetic, obese patients undergoing body-contouring surgery. We sought to determine whether semaglutide can enhance surgical outcomes and reduce complications. The objectives of this study were (1) to assess the incidence of adverse postoperative outcomes, including wound dehiscence, delayed wound healing, infection, nausea, vomiting, diarrhea, hypertrophic scar formation, and surgical site pain; and (2) to compare these complications between patients who received semaglutide and those who did not. Understanding these dynamics may lead to improved preoperative care protocols and better patient outcomes in plastic surgery following bariatric procedures.

METHODS

Database and Study Design

In our retrospective analysis, we utilized the TriNetX Research database, a database consisting of deidentified electronic health records from 62 different healthcare organizations (HCOs) located in the United States. The US collaborative network comprises 113.5 million patients. Data were collected from June 17, 2021, to June 17, 2024. The authors explored outcomes related to nondiabetic patients undergoing postbariatric body contouring surgery by current procedural terminology (CPT) and International Classification of Diseases 10th edition (ICD-10) codes. TriNetX adheres to patient confidentiality and data security regulations specific to contributing HCOs.

Utilizing CPT codes, we identified individuals who were nondiabetic and obese and who underwent postbariatric body contouring surgery between June 17, 2021, and June 17, 2024. The types of surgeries included procedures such as panniculectomy, abdominoplasty, thighplasty, brachioplasty, excision of excessive skin, mastopexy, and mastectomy for gynecomastia (Table 1). This study was exempt from institutional review board approval because the data set contained only deidentified data.

Cohorts

Within the data set, we identified patients ages 18 years or older with a history of both bariatric surgery and body contouring surgery following significant weight loss. To differentiate these patients from those who achieved weight loss through nonsurgical means, we utilized specific ICD-10 and CPT codes for postbariatic body contouring procedures. This distinction is critical, because patients who undergo bariatric surgery often experience higher complication rates than those who lose weight through diet and exercise.

Cohort A comprised nondiabetic individuals who had a previous history of both bariatric surgery and body contouring surgery and had been prescribed semaglutide for a minimum of 6 months before undergoing their most recent body contouring procedure. Cohort B, the control group, consisted of nondiabetic individuals who also had a history of both bariatric surgery and body contouring surgery but had not been prescribed semaglutide within the 6 months previous to their surgery.

Patients with significant medical comorbidities, such as uncontrolled diabetes, hypertension, hyperlipidemia, obstructive sleep apnea, cardiovascular disease, or chronic kidney disease, which may have prompted the prescription of semaglutide, were excluded from the analysis to ensure a more homogeneous population for comparison. By excluding these patients, we aimed to reduce confounding factors related to the severity of underlying health conditions. Figure 1 outlines the cohort selection process, including the use of bariatric surgery codes to define the patient population. Obesity was classified exclusively through ICD-10 codes, ensuring a consistent method for identifying patients with obesity.

Surgical Variables

In addition to patient demographics and comorbidities, we accounted for the type of surgery and the length of surgery, because both factors can influence postoperative outcomes. With procedural data from the TriNetX database, we extracted the exact duration of surgeries, which allowed us to analyze the impact of operative time on complication rates. The types of body contouring procedures included panniculectomy, abdominoplasty, mastopexy, and thighplasty, among others. Patients who underwent multiple procedures during the same operation were excluded to reduce the potential confounding effects of increased operative time and surgical complexity. By controlling for both the type and duration of surgery, we aimed to reduce confounding factors that might influence postoperative outcomes.

Outcomes of Interest

The primary outcomes of interest were adverse postoperative events following postbariatric body contouring surgery, including wound dehiscence (ICD-10 codes: T81.30XA, T81.31XA, T81.32XA); delayed wound healing (ICD-10 codes: T81.30XS, T81.30XD); surgical site infections (ICD-10 codes: T81.4XXA, T81.4); nausea, vomiting, diarrhea (ICD-10 codes: R11.0, R11.1, R11.2, R19.7, K52.9); hypertrophic scar formation (ICD-10 codes: L91, L91.0); and surgical site pain (ICD-10 code: G89.18).

Complications were monitored within 30 days postoperatively to ensure they were directly related to the surgery, reducing the likelihood of confounding unrelated conditions such as gastrointestinal issues that might arise later. The complications were further classified with the Clavien-Dindo classification system, with most complications falling into Class I, indicating that they were minor and did not require surgical, endoscopic, or radiological intervention. Class I complications are generally considered less significant but can still impact patient recovery and satisfaction. We did not observe a significant number of higher-grade complications (Class II or above) in this data set, ensuring that the majority of recorded complications were less severe and primarily managed conservatively within a 30-day postoperative period. The 30-day time frame is common for assessment of early postoperative complications when minimizing external influences that could affect outcomes.

Propensity Matching

To reduce potential biases and control for confounding variables, we employed propensity score matching (PSM), a common statistical method in observational studies. PSM was utilized to match patients in the cohorts based on key individual characteristics, including BMI, comorbidities, age, race, sex, and ethnicity. Given that BMI can significantly influence surgical outcomes, particularly for procedures like mastopexy, it was a critical covariate included in the matching process. This approach allowed us to balance the groups effectively and minimize the influence of factors that might otherwise skew the results. By including these specific demographic variables, we ensured a fair and comparable analysis of outcomes across patients undergoing body contouring surgery. Previous research has shown that age, BMI, comorbidities, sex, race, and ethnicity are important predictors of surgical outcomes, making them key variables for ensuring accurate comparisons between the cohorts.^11-14

Statistical Analysis

The analysis was performed utilizing the TriNetX software platform, which harnesses programming languages such as JAVA, R, and Python for statistical calculations. Various measures of association including risk ratios, risk differences assessed by t tests, and odds ratios were computed, accompanied by their corresponding 95% confidence intervals (CIs). Risk ratios and chi-square analyses were conducted. Statistical significance was established at a threshold of P < .05.

RESULTS

A total of 728,947 patients with a prescription of semaglutide in 64 HCOs were identified, with a mean age of 55 ± 14 years. Two cohorts were created for our study. Cohort A included 4215 patients with preoperative prescription of semaglutide and a previous history of undergoing body contouring surgery across 47 healthcare organizations with a mean age of 55 ± 12 years. Cohort B had 104,927 patients with no prescription of semaglutide and a previous history of undergoing body contouring surgery across 59 healthcare organizations with a mean age of 56 ± 16 years. After matching, Cohort A and Cohort B consisted of 4157 patients per cohort. Demographics of each cohort before and after matching are outlined in Table 2. The age of each cohort ranged from 18 to 99.

Patients with a history of postbariatric body contouring surgery and previous semaglutide use showed significantly higher risks for various complications compared to those without semaglutide use. Specifically, semaglutide patients had a 1.867 times increased risk for wound dehiscence (5.19% vs 2.78%, P < .0001); 2.128 times increased risk for delayed wound healing (2.58% vs 1.21%, P < .0001); 1.868 times increased risk for infection at the surgical site (5.37% vs 2.87%, P < .0001); 2.111 times increased risk for nausea, vomiting, and diarrhea (11.27% vs 5.34%, P < .0001); 1.433 times increased risk for hypertrophic scar formation (5.53% vs 3.86%, P = .0011); and 1.841 times increased risk for surgical site pain (6.05% vs 3.29%, P < .0001) compared to non–semaglutide patients (Table 3).

DISCUSSION

In this study we aimed to assess the impact of preoperative semaglutide on postoperative outcomes in nondiabetic, obese patients undergoing body contouring surgery following bariatric procedures. The results indicate a significant association between semaglutide and increased risk of postoperative complications, underscoring the need for cautious consideration of this medication in preoperative planning for body contouring surgeries.

Complications and Risks

Patients receiving semaglutide preoperatively exhibited a notably higher incidence of several postoperative complications compared to those who did not take the drug. This higher risk raises concerns about the need for semaglutide in nondiabetic patients. Although semaglutide affects metabolic processes and may influence wound healing and immune responses, the observed increased risks suggest negative influences on surgical recovery when these complications are not limited to side effects. For instance, the higher rates of wound dehiscence and delayed healing among semaglutide patients may be linked to the drug's impact on gastrointestinal motility and nutrient absorption, potentially leading to nutritional deficiencies that impair wound healing.¹⁰ This hypothesis aligns with previous studies emphasizing the critical role of nutritional status in surgical recovery.^15-18 Furthermore, the increased infection rates might be related to semaglutide's effects on immune modulation.¹⁹ Further research is needed to explore the physiological and pharmacological mechanisms of semaglutide in relation to surgical outcomes and to refine clinical strategies for patients undergoing body contouring surgery after bariatric procedures. Semaglutide's influence on gastrointestinal motility, nutrient absorption, and immune function may contribute to the increased risks of complications such as wound dehiscence, delayed healing, and infections. These physiological effects warrant further research to understand their impact on surgical recovery and long-term outcomes.

Clinical Implications

These findings have significant clinical implications, highlighting the importance of a balanced approach to managing obesity and metabolic syndrome in patients preparing for body contouring surgery. Surgeons and healthcare providers must carefully weigh the benefits of semaglutide in weight management against its potential risks for postoperative complications.

The decision to utilize a 6-month period for semaglutide administration is supported by clinical data and literature indicating sufficient time to achieve meaningful improvements in metabolism and weight loss.^20,21 However, it is crucial to consider whether a 6-month course of semaglutide offers greater benefits than lifestyle modifications, such as regular exercise. Exercise is well-established for its positive effects on cardiovascular health, insulin sensitivity, and overall metabolic function, potentially mitigating surgical risks without the specific side effects associated with semaglutide.^22-24 Comparative studies are needed to evaluate the effectiveness of these 2 approaches and establish optimal preoperative weight management strategies. However, obesity is not solely the result of individual lifestyle choices but is influenced by broader societal factors, including modes of transport, occupational demands, and environmental accessibility to physical activity.^25-27 For instance, walking, cycling, stair climbing, and other forms of incidental movement throughout the day may play a significant role in managing weight, yet these aspects are often overlooked in discussions of physical activity. Further research should not only compare semaglutide and structured exercise programs but also explore how routine movement and environmental factors contribute to preoperative weight management. Understanding these dynamics could inform more holistic approaches that account for societal predispositions to obesity and help establish optimal preoperative strategies tailored to individual patient contexts. Comparative studies that incorporate these elements are needed to provide a more comprehensive assessment of weight management interventions.

To aid surgeons in informed decision-making regarding semaglutide, a risk assessment tool such as a scorecard or composite score could be developed. This tool would integrate factors such as initial metabolic status, nutritional health, and specific risks associated with semaglutide. By calculating overall risk, surgeons could better assess whether the benefits of semaglutide outweigh its potential risks for each patient. Comprehensive preoperative assessments, including evaluations of nutritional and metabolic status, are critical.^28,29 Adjustments to semaglutide timing or dosage, along with increased perioperative monitoring, may be necessary to mitigate risks.³⁰ Exploring alternative strategies to semaglutide or additional measures to counteract its potential negative impacts on surgical outcomes also could be beneficial.³¹ Patient education is essential; nondiabetic, obese patients considering body contouring surgery should be informed about the potential complications associated with semaglutide, helping them make informed decisions about their preoperative weight management strategies and setting realistic expectations for surgical outcomes.^32,33

Recommendations and Clinical Considerations

Although in our study we could not determine the optimal timing for holding semaglutide before surgery, a cautious approach is warranted. Based on emerging clinical practices, we suggest considering discontinuation of semaglutide at least 1 to 4 weeks before surgery, allowing sufficient time for its effects on gastrointestinal motility and nutrient absorption to resolve.³⁴ Resumption of semaglutide postoperatively should be guided by individual patient recovery and nutritional status, ideally under close monitoring by both surgical and medical teams.

In addition to perioperative semaglutide management, other strategies to reduce surgical risks should be emphasized. Operative staging, particularly for patients with significant comorbidities or those undergoing complex body contouring procedures, may help reduce overall stress on the body and lower the risk of complications.⁵ This approach involves dividing the surgical plan into multiple, smaller procedures to allow adequate recovery time between stages. For example, prioritizing high-risk areas for contouring in initial procedures while deferring less critical areas to subsequent stages may provide a safer and more effective pathway for these patients.

Nutritional optimization is also paramount in mitigating risks.^35,36 Comprehensive preoperative nutritional assessments, including screening for deficiencies in vitamins and minerals essential for wound healing (eg, vitamins A, C, and D, zinc, and iron), should be standard practice. For patients at risk of deficiencies, targeted supplementation protocols should be initiated well in advance of surgery.³⁷ Additionally, lifestyle modifications such as adopting a balanced diet and engaging in consistent physical activity tailored to the patient's capabilities can enhance metabolic health and reduce perioperative risks.^38,39 Practical recommendations may include incorporating daily walking, low-impact exercises, or resistance training, which are accessible and effective ways to promote weight management and improve cardiovascular health.

These strategies highlight the importance of individualized preoperative planning and multidisciplinary collaboration. Future studies should aim to validate specific recommendations for semaglutide and further investigate the role of these adjunct interventions in reducing complications associated with body contouring surgery in this population.

Limitations and Future Research

This study possesses several strengths, notably the use of real-world data, which enhances the external validity of its findings. The large patient sample size further strengthens the statistical power and generalizability of the results, providing a more comprehensive understanding of how semaglutide may influence postoperative complications in body contouring bariatric surgery. The breadth and depth of data available through TriNetX allow for robust analyses of clinical outcomes, even across diverse surgical populations. Additionally, the multicenter and multiregion design ensures that the study captures a wide range of patient demographics, healthcare practices, and geographical variations, further increasing the applicability of the findings across diverse populations and healthcare settings. Despite certain limitations, the aggregation of large volumes of real-world patient information makes TriNetX a valuable tool for assessing trends and outcomes associated with semaglutide in surgical populations.

Nevertheless, this study has several limitations that should be acknowledged. First, the lack of granular information on patient characteristics such as insurance type and provider characteristics such as surgeon experience introduces potential sources of bias and limits the generalizability of the results. Additionally, the study lacks data on drug dosage, including the specific dosage, duration of use, and timing of discontinuation or resumption in the perioperative period. This absence of detailed drug information prevents a comprehensive analysis of dose-response relationships and the effects of varying regimens on postoperative outcomes. Investigating the effects of varying dosages and durations of semaglutide use as well as the potential benefits of nutritional supplementation or alternative medications could provide valuable insights. Furthermore, the reliance on electronic health records introduces challenges related to data accuracy and completeness, which could affect outcome assessments, particularly in identifying patients with multiple diagnoses. Another limitation is that the type of bariatric surgery previously undergone by the patients is not specified in the data set. Different bariatric procedures, such as gastric bypass or sleeve gastrectomy, may carry variable risks of postoperative complications, which could influence the findings. Investigating these procedure-specific risks in future studies would provide more nuanced insights. Finally, the reliance on electronic health records introduces challenges related to data accuracy and completeness, which could affect outcome assessments, particularly when identifying patients with multiple diagnoses or incomplete follow-up data. Finally, the study's retrospective nature and reliance on observational data mean that, although associations between semaglutide and surgical outcomes were identified, causality cannot be inferred. Prospective cohort studies and more controlled research designs will be essential to elucidating causal mechanisms and validating these findings across diverse populations and extended durations of semaglutide use.

CONCLUSIONS

This study sheds light on the nuanced relationship between semaglutide and postoperative outcomes following postbariatric body-contouring surgery. Through meticulous analysis, it becomes evident that patients utilizing semaglutide are at a substantially elevated risk for various adverse outcomes compared to their non-semaglutide counterparts. These risks span wound-related complications like dehiscence and delayed healing to gastrointestinal issues and surgical site pain. These findings not only deepen our understanding of the impact of semaglutide on surgical outcomes but also emphasize the critical importance of tailored monitoring and adjusted perioperative management strategies for this specific patient population. Moving forward, clinicians should consider these insights when crafting individualized care plans for patients undergoing body contouring surgery while utilizing semaglutide, ultimately striving to optimize postoperative recovery and mitigate potential complications.

Acknowledgments

The authors want to thank Christen Walcher, MPAff, for assistance with manuscript preparation. Additionally, the authors thank BioRender (Toronto, Canada) for assistance with Figure 1. The data supporting the findings of this study are available from the TriNetX Research database (Cambridge, MA), which is a proprietary data source. The authors are committed to sharing data with qualified researchers upon reasonable request, provided that such requests comply with TriNetX's data use agreements and privacy regulations.

Disclosures

The authors declared no potential conflicts of interest with respect to the research, authorship, and publication of this article.

Funding

This research was supported in part by a Clinical and Translational Science Award (UL1 TR001439) from the National Center for Advancing Translational Sciences. The content is solely the responsibility of the authors and does not necessarily represent the official views of the NIH (Bethesda, Maryland).

REFERENCES

Author notes