Sunday, March 16, 2014

"What can I do about all this extra skin?" A Body Recontouring Primer

Just returned from a nice and warm week to Florida to catch some Spring Training baseball and some Vitamin D and Vitamin C (as in Citrus).  Great week.

Got to thinking about the next topic for this Blog. When I thought of writing on excess skin removal, and body recontouring, I had to look back to see if I had already covered it.  Looks like  really haven't thus far, and yet it's one of those often recurring questions we get from both patients and providers alike, and a great post-op topic to get into.

As I said, one of the most common questions / concerns patients have at sometime along their massive weight loss journey is again in regard to body image.  It may have been at least somewhat of a psychological issue pre op, and now paradoxically can resurface post op in a different light.

Massive weight loss resulting from bariatric surgery can be both exciting and anxiety producing. While patients are essentially universally pleased with their resultant weight loss, new problems of sagging skin, or markedly absent regions of their previous anatomy ("...where did my butt and breasts go?") do get them on edge and frustrated.  Most I see do admit, though, that they would generally trade the weight loss and its attendant health benefits for their new found body makeup and shape.

So, what is there that can be done?  This is well within the domain of the Plastic Surgeon, and the increasingly popular field of Body Recontouring after massive weight loss, usually associated with weight loss surgery.

As may be expected, and it can be argued that it truly is a medical problem, and it results from a procedure that was medically necessary (and approved by the insurance company), playing the "excess skin insurance game" to see what can be covered is a fairly complicated process.  It certainly is not automatic. Much less complicated are the excellent results that patients obtain after the surgery, whether they self-pay or are able to have it covered by their insurance company. Let's see if I can cover this in a way to at least let you in on the process, so you are aware what we and the patient often goes through, and may need from us (you and me) on their way to have their plastic surgery done.

The most common desire our patients have after successful weight loss surgery has to do with their abdominal pannus, or panniculus.  This redundant drape of skin is the result of the 'overstretching' of the abdominal wall skin from prolonged obesity and increased sub cutaneous tissue.  Their may or may not be associated striae, as is seen post pregnancy, and the extent of the excess skin may further extend posteriorly, bilaterally, around to the flanks, depending on the amount of weight lost, as well as the degree of skin elasticity and compliance.  It is well known that persons of color do tend to have better collagen and elasticity, and may show comparatively less redundancy and disfigurement after massive weight loss.  Age is also inversely proportional to elasticity and compliance of the skin, and certainly smoking as well as other disease states and medicines can accelerate skin changes negatively systemically with associated massive weight loss.

In broad terms, a Panniculectomy may be covered by insurance, whereas an Abdomioplasty (Panniculectomy with muscular / fascial tightenting, possibly with some Liposuction for added contouring) is essentially never covered.

The good side of the issue is that if insurance covers it, that's great.  It is a mostly functional procedure, and will go a long way to get rid of the associated recurrent skin fold rash (intertrigo, bacterial +/- fungal), and the cosmetic issues of what to do with the bunch of skin near the belt line that is difficult to hide.  Patients say that the extra abdominal skin acts as a constant reminder of the patient's previous body habitus that they frustratingly still cannot change. Patients are usually very happy with their results, and for the most part tell me, "I'm not looking to get into a bikini at the beach, I just can't get rid of this big wad of extra skin". The weight from the extra skin can go 7-15# or more  depending on the amount that is resected, and whether or not a circumferential (Belt Lipectomy) approach is necessary.

The down side to the insurance issue is that it frequently is not covered by the patient's insurance carrier.

This often stems from their view that the procedure is essentially a cosmetic procedure, and not medically necessary.  Each insurance company has a slightly different view, and it's often difficult from our side of the equation to know how to best play the game in order to try and get it approved. We rely on the Plastic Surgeons and their staff to guide the patient through this as able.  Often at an initial consult, based on the exam, the history, and the known quirks of an individual patient's insurance company, a Plastic Surgeon may advise the patient outright that it won't be covered.

Other instances may require more information and documentation to get it covered.  Usually, the patient must be 15-18 months plus post surgery, in order to be at or near their reasonable goal weight, and demonstrating both weight stability as well as sound nutrition and normal lab work and nutritional parameters (protein, CBC, vitamin levels, Fe, etc.).  They must also be  non-smoking, as this semi-cosmetic procedure is elective, and concomitant smoking greatly increases the risk of unwanted wound complications and healing issues, as well as increasedpulmonary and DVT risks.

The documentation required is often a retrospective look the weight loss history, abdominal skin fold rashes, their treatments, and their recurrences.  This can be from a PCP and/or us at the bariatric surgery office.  As is often the case, the more documentation the better.

We have also found that sending our patients to different Plastic Surgeons in our area can yield different results.  Some Plastic Surgeons participate more easily with certain insurance types, and some honestly have more of an interest in doing the legwork to get the patient to surgery and get the procedure done than others do.  I can understand that the process with some patient's insurance companies is cumbersome, and can demand a lot of effort.   And then the aspect that the extra effort is for a case that may not pay very well, and take their time away from cosmetic specialty cases that may be reimbursed at a better rate for less burden on the staff.  This may just not be a desirable trade off for a busy Plastics practice.

However, as far as the patient goes, a brief investment of time on our part (or yours) to document some needed history for the patient, and get it to the insurance company in an effort to get a panniculectomy reimbursed, they are very appreciative.

So, for part 2 a little more about body recontouring in respect to Breasts, Axillae, and Thighs to complete the primer.

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