Leigh Aiple was self-conscious and bullied because of his weight - so he made the fatal decision of having cut-price surgery in Asia.
The 31-year-old Australian's death has sparked a call for a clampdown on medical tourism on both sides of the Tasman.
A Victoria coroner's investigation has faulted the standard of care the Melbourne man received after arranging the operation through New Zealand company Gorgeous Getaways.
President of the Australian Society of Plastic Surgeons Mark Ashton was asked by the coroner to investigate whether it was up to Australian standards.
He said the whole industry needed to be investigated and botched medical tourism operations had left people with gaping wounds and necrotising nipples which had to be fixed through public healthcare systems once the patient returned home.
"These people who are bundling these high-risk procedures without adequately disclosing to their clients what the risks of those procedures are need to be looked at by Canberra and Wellington," he said.
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Aiple, who weighed about 124kg, died within a day of arriving home in from the Beverly Wilshire Medical Centre in Kuala Lumpur, Malaysia, in 2014.
His quick-turnaround surgery included a 360-degree tummy tuck, liposuction, upper-eye lift, chin tuck, thigh lift, chest sculpting and lip filler.
Professor Ashton said there were some major concerns, including that he was wrongly rated as a medium risk patient in Malaysia when he was in fact high risk.
Mr Aiple also only saw the surgeon once before the surgery instead of several times, as would be the norm in Australia or New Zealand.
He had two major surgeries just days apart, instead of several months, and his post-operative care was poor.
Mr Aiple's mother found him collapsed in his Melbourne bedroom a day after he returned home.
Professor Ashton told RNZ the pulmonary embolism that killed Mr Aiple was his second - the first had been misdiagnosed in Malaysia and he'd been allowed on a plane home.
Pulmonary embolisms are associated with deep-vein thrombosis, which long-haul air travel can make worse.
John Kenealy, president of the New Zealand Association of Plastic Surgeons, said that people should not fly six weeks either side of a major operation for this reason.
Complications such as infections were also extremely difficult to manage if the patient was not in the same area as the surgeon.
"It's actually problematic even if you've got a patient coming from the South Island to the North Island ... let alone New Zealand to Malaysia, Thailand, India," Mr Kenealy said.
"People look at the upfront costs of the operation and not the ongoing cost should something go wrong."
Despite the death, the Malaysian surgeon Nasir Zahari defended the standard of Mr Aiple's care to the coroner in Victoria.
Gorgeous Getaways has suspended links with the Beverley Wilshire while the clinic did an audit.
The company's international manager Paula Vernon, who is based in Levin, said the clinic had successfully improved their services.
She said the company had also worked to support Mr Aiple's family.
Ms Vernon said she was unaware if her company warned customers about long-haul travel after surgery, or needing to allow for the risk of complications post- surgery.
If the website does carry such warnings, they are hard to find.
She could not say if a New Zealander would get the same standard of care in the clinics they used in Kualu Lumpur, Phuket and Bangkok, as they would back home because it was "such a generalised question".
Gorgeous Getaways - owned by a Silicon valley start-up Taqtik Health - says on its website that "for the price of a treatment at home, you can get a wonderful tropical holiday as well".
Read the Ministry of Foreign Affairs and Trade's advice on medical tourism here.