Most surgical checklists still work the way a shopping list works: one point for this, one point for that, add them up. A body does not behave like that.
Two health factors that each look small on paper can behave very differently when they sit in the same person. They do not add — they interact, and they amplify one another. The way a body heals after surgery is the result of that interaction, not of a sum. That is why our clinic built its own assessment rather than borrowing a generic score.
Dr. Mehmet Sürmeli, MD, FEBOPRAS · European & Turkish Board-Certified Plastic Surgeon · Member of ISAPS & ASPS · Licensed in Türkiye, Dubai (DHA) and Abu Dhabi (DOH)
What it produces is a picture, not a verdict
What comes out of the assessment is not a label. It shows where your healing is likely to be strong, where it needs support, and what should be prepared or corrected before an operation is even considered — a condition to bring under control, a medication to review with the doctor who prescribed it, a habit worth changing first.
Sometimes the honest conclusion is that a procedure is not the right one for you, or not right yet. You are told that early, and in writing, rather than after a decision has been made.
The model informs. The surgeon decides.
No algorithm makes a decision about your care. Every assessment reaches Dr. Sürmeli personally, with the reasoning behind it visible, and his clinical judgment stands above it. A model can weigh what is written down. It cannot look at you, and it does not carry responsibility for the result.
Why your photographs never travel through a messaging app
Photographs are the most sensitive thing you send us, and messaging apps are the wrong place for them. They are not sent through WhatsApp or any chat service. Instead you receive your own private, encrypted upload link, you agree to a clear consent step before anything is uploaded, and the images stay attached to your medical record rather than sitting in a chat history on somebody’s phone.
Inside the assessment: Surgical Unified Risk, Morbidity & Eligibility Level Index — the SURMELI Index
(Disclaimer: This index is designed to support surgeons in risk assessment and decision-making. It is not a substitute for comprehensive clinical evaluation or individualized case-by-case clearance.)
For patients who want the detail behind the summary above.
Where surgical risk scoring came from
Surgical risk scoring began as paperwork. The systems still in daily use were built to answer narrow questions quickly, usually by a clinician holding a pen, and their design reflects the era that produced them: findings are sorted into boxes, each box is worth a fixed number of points, and the points are added up. They were a genuine advance on nothing at all. They were never intended to describe how one particular person’s body heals after an operation they chose to have.
Each remains excellent at the job it was built for. None of them was built for this one.
| System | Built to answer | How it treats a measurement | How it combines findings | What it does not attempt |
|---|---|---|---|---|
| ASA-PS Physical Status classification | How fit is this patient for anaesthesia, in one word? | Not measured — a clinician assigns one of six descriptive classes1 | It does not. It is a single label. | Any prediction of wound healing, scarring or aesthetic outcome |
| Caprini RAM | How likely is a blood clot after surgery? | Banded. Age 41–60 scores one point; a BMI over 25 scores one point, whether it is 25.1 or 392 | Points are added together2 | Anything other than venous thromboembolism |
| RCRI Revised Cardiac Risk Index | How likely is a cardiac event after non-cardiac surgery? | Binary. Six factors, each present or absent3 | Points are added, zero to six3 | Healing, infection, scarring, recovery |
| POSSUM | Comparing surgical departments fairly, given differing case mixes | Graded physiological and operative variables4 | Combined through a fitted equation4 | Individual counselling — it is an audit instrument |
| The SURMELI Index | How is this body likely to heal after elective surgery? | Continuous. A measurement enters as the number it actually is | Findings interact and amplify one another; they are not summed | It does not replace the surgeon, and does not pretend to |
Caprini deserves particular credit: it has been formally validated in plastic and reconstructive surgery patients5, and it is a genuinely useful instrument. Our disagreement with it is not about quality — it is that clot risk is one channel of harm among several, and that a band is a blunt way to describe a body.
Three design decisions, and why
1. No cliffs. A banded system contains invisible walls. A patient with a body-mass index of 24.9 and a patient at 25.1 are, to that system, two different kinds of person. Biologically they are the same person. We do not accept a model in which someone misses a risk group by a tenth of a unit, so measurements enter the Index as continuous values — age, body-mass index, and the direction and stability of recent weight change — and the curve moves smoothly through them.
2. Risk accelerates — it does not climb in a straight line. The second finding in a patient costs more than the first, and the third costs more than the second. A body compensates well until it is asked to compensate for several things at once. The health term of the Index is therefore built to rise faster as burden increases, rather than adding a fixed amount each time — and it is deliberately bounded, so that no profile runs away into a number that has stopped meaning anything.
3. Findings multiply, they do not add. This is the substantive break with the older systems. Where a checklist records a patient with factor A and factor B as A + B, the Index treats that pair as carrying more than A + B, because that is what happens in tissue. Diabetes and obesity in the same person — each only moderate on paper — are not two moderate problems for an operation that depends entirely on wound healing. They are one large one.
Age is handled the same way: not as a category and not as a penalty, but as a continuous influence that begins to matter gradually from mid-life and then modifies everything else, rather than sitting beside it.
One deliberate separation: the standard medical weight categories are real, and you will be told plainly where you sit within them. They simply do not drive the arithmetic, because a category is a description, not a mechanism.
What the Index deliberately scores as zero
A risk model that penalises everything is not careful — it is lazy, and it frightens people for no clinical reason. Each finding below was examined against the evidence and ruled to carry no independent weight. Every one is still recorded in your file, still read by the surgeon, and several still change how your anaesthesia or medication is managed on the day. None of them changes your risk assessment.
| Finding | Why it scores zero | What still happens |
|---|---|---|
| Methotrexate and similar disease-modifying drugs | A randomised trial in 388 patients undergoing elective surgery found complications in 2% of those who continued methotrexate versus 15% of those who stopped it. Continuing is the safer course6 | Continued, in consultation with your rheumatologist |
| MTHFR gene variant | Current haematology guidance states this test should not be ordered at all, because the association with clotting is null7 | Noted; a genuine clotting history is weighed heavily and separately |
| GLP-1 weight-loss medication | Anaesthetic guidance treats this as a stomach-emptying and airway matter managed by fasting, not as a wound-healing risk8 | A specific pre-operative fasting protocol |
| Hashimoto’s thyroiditis, stable on levothyroxine | Compared with euthyroid patients, treated patients show no difference in wound healing, tissue integrity, blood loss, recovery from anaesthesia or length of stay9 | Thyroid status confirmed before surgery |
| Isolated food allergy, including egg and soy | Propofol is safe in the large majority of egg-allergic patients who have no history of anaphylaxis — the labelling warning is not supported by the outcomes10 | Recorded as a medication and anaesthesia alert. Food anaphylaxis raises a prominent alert — and still scores zero |
| Well-controlled high blood pressure | It does not appear as an independent predictor in surgical-site-infection risk models, which repeatedly identify diabetes, smoking, body-mass index and operative duration instead11 | Managed perioperatively; still relevant to bruising and bleeding |
We would rather explain why something does not count than quietly add a point to look thorough.
References
- American Society of Anesthesiologists. ASA Physical Status Classification System.
- Caprini JA. Thrombosis risk assessment as a guide to quality patient care. Disease-a-Month 2005;51(2–3):70–8.
- Lee TH, Marcantonio ER, Mangione CM, et al. Derivation and prospective validation of a simple index for prediction of cardiac risk of major noncardiac surgery. Circulation 1999;100(10):1043–9.
- Copeland GP, Jones D, Walters M. POSSUM: a scoring system for surgical audit. British Journal of Surgery 1991;78(3):355–60.
- Pannucci CJ, Bailey SH, Dreszer G, et al. Validation of the Caprini risk assessment model in plastic and reconstructive surgery patients. J Am Coll Surg 2011;212(1):105–12.
- Grennan DM, Gray J, Loudon J, Fear S. Methotrexate and early postoperative complications in patients with rheumatoid arthritis undergoing elective orthopaedic surgery. Ann Rheum Dis 2001;60(3):214–7.
- Middeldorp S, Nieuwlaat R, Baumann Kreuziger L, et al. American Society of Hematology 2023 guidelines for management of venous thromboembolism: thrombophilia testing. Blood Advances 2023;7(22):7101–38.
- American Society of Anesthesiologists. Consensus-based guidance on preoperative management of patients on GLP-1 receptor agonists, 2023; multisociety clinical practice guidance, 2024.
- Palace MR. Perioperative management of thyroid dysfunction. Clin Med Insights Endocrinol Diabetes 2017;10:1–5.
- Murphy A, Campbell DE, Baines D, Mehr S. Allergic reactions to propofol in egg-allergic children. Anesth Analg 2011;113(1):140–4.
- Risk-factor analyses of surgical-site infection consistently identify diabetes, smoking, body-mass index, wound contamination and operative duration as independent predictors; controlled hypertension is not among them. Stated as absence from multivariate models, not as proof of no effect.
Patient Safety FAQ
No. The assessment evaluates the information you have provided and presents it, along with its reasoning, to Dr. Sürmeli. He personally makes every decision regarding your care. The purpose of the system is to ensure risk assessment is as objective as possible: to quantify and grade relevant risks, and to make sure nothing you have shared is overlooked. It is designed to support—not replace—the surgeon.
Because your safety comes first, and surprises are what we are trying to prevent. If something in your health could raise the risk of an operation, it needs to be known early — while there is still time to act on it: to optimise the plan, to postpone until your health is in a better condition, or, when it is the right decision, not to operate. This is elective surgery. If a full assessment shows that an operation would place you at serious risk, we change the plan or advise against a cosmetic procedure altogether. That judgement is only possible once your health history is complete: an operation that suits one person may be the wrong choice for another with the same wishes.
You are told, in writing, and early. In most cases it is something that can be prepared or corrected first — a condition to bring under control, a medication to review with your own doctor, a habit to change well before and after surgery. In some cases the honest answer is that the operation is not advisable, and you will be told that too.
Your photographs are seen only by Dr. Sürmeli and his surgical nurse. They are never exposed to non-medical staff — never. They are uploaded through your own private, encrypted link after a clear consent step, and they are used solely for your medical assessment. They are not published, and they are not part of any chat conversation.
Yes — that is exactly what it is designed for. The pre-evaluation, your photographs, the assessment and the surgeon’s own answer all happen before you book anything.
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