Tamara B.
Position statement for skin redundancy
Jun 05, 2007
TREATMENT OF SKIN REDUNDANCY
FOLLOWING MASSIVE WEIGHT LOSS
Recommended Criteria for Third-Party Payer Coverage
Background:
The American Society of Plastic and Reconstructive Surgeons
(ASPRS) is the largest organization of plastic surgeons in the
world. Requirements for membership include certification by
the American Board of Plastic Surgery.
ASPRS represents 97% of the board-certified plastic surgeons
practicing in the United States and Canada. It serves as the
primary educational resource for plastic surgeons and as their
voice on socioeconomic issues. ASPRS is recognized by the
American Medical Association (AMA), the American College of
Surgeons (ACS), and other organizations of specialty societies.
Definitions:
Morbid obesity is defined by a patient weighing at least 100
pounds over the ideal body weight or more than twice the
normal weight for height. It is estimated that as many as nine
million people in the United States suffer from morbid obesity.
The death rate may range up to twelve times that of non-obese
persons of the same age and sex. Associated medical conditions
include coronary heart disease, hypertension, diabetes mellitus,
osteoarthritis, respiratory distress, gall bladder disease and
psychosocial incapacity.
Improvements in the surgical correction of morbid obesity via
gastric partitioning procedures as well as more effective nonsurgical
diet regimens have allowed increasing numbers of
morbidly obese patients to undergo successful and sustained
massive weight loss. While the medical/health benefits of
massive weight loss are obvious, different problems may arise
as a result.
Massive weight loss can lead to extensive redundancy of skin
and fat folds in varied anatomic locations causing functional
problems. These areas include medial upper arms, breasts
(male and female), the abdomen and medial thighs.
Redundant skin folds predispose to areas of intertrigo which
can give rise to infections of the skin (fungal dermatitis,
folliculitis, subcutaneous abscesses). Commonly affected areas
are the overhanging pannus of the lower abdomen and beneath
ptotic breasts. Constant rubbing together of medial thigh folds
can cause areas of chronic irritation and infection as well.
Excessive redundant folds of skin and fat can also cause
difficulty of fitting into clothing, interference with personal
hygiene, impaired ambulation and the potential of
psychosocial concerns of a disfigured appearance. Surgical
procedures to correct skin redundancy include panniculectomy
with or without abdominoplasty (CPT 15831), mastopexy (CPT
19316), upper arm brachiocoplasty (CPT 15836), thighplasty
(CPT 15832) and hip-plasty (CPT 15834).
Cosmetic and Reconstructive Surgery:
For reference, the following definition of cosmetic and
reconstructive surgery was adopted by the American Medical
Association, June, 1989:
Cosmetic surgery is performed to reshape normal structures of
the body in order to improve the patient's appearance and self esteem.
Reconstructive surgery is performed on abnormal structures of
the body, caused by congenital defects, developmental abnormalities, trauma, infection, tumors, or disease. It is generally performed to improve function but may also be done to approximate a normal appearance.
Indications:
Resection of redundant skin and fat folds is medically indicated
if panniculitis (ICD-9 729.39) or uncontrollable intertrigo
(ICD-9 695.89) is present. Chronic or recurrent skin infections
may occur. A large overhanging pannus may cause lower back
pain (ICD-9 724.2) and interfere with ambulation and personal
hygiene. In long standing panniculitis, lymphedema
(ICD-9 457.1) and skin abscesses (ICD-9 682.2) may be present.
Umbilical hernias (ICD-9 553.1) may be associated with a
stretched umbilicus in the panniculus.
Ventral hernias (ICD-9 553.2) from previous abdominal surgery
including gastric partitioning procedures may be present and
require repair at the time of panniculectomy and
abdominoplasty.
In female patients with ptotic breasts after massive weight loss,
macromastia (ICD-9 611.1) may be present and associated with
postural backache (ICD-9 724.2), upper back (ICD-9 724.1), neck
(ICD-9 723.1) and shoulder pain (ICD-9: 719.41). Intertrigo and
related dermatitis may also be present. Reduction
mammoplasty (19318) is indicated in these patients. If ptotic
breasts are not enlarged but consist mostly of redundant skin
and fat, mastopexy (CPT 19316) may be performed for males
and females.
Resection of redundant upper arm and thigh tissue is
performed to improve the patient's comfort and appearance.
Redundant thigh tissue may extend posteriorly and involve the
buttocks and inferior gluteal regions.
ASPRS SOCIOECONOMIC AND POLICY DEVELOPMENT DEPARTMENT • 444 EAST ALGONQUIN ROAD • ARLINGTON HEIGHTS, IL 60005 • (847) 228-9900 • FAX: (847) 228-9432
POSITION PAPER
AMERICAN SOCIETY OF
PLASTIC AND RECONSTRUCTIVE
SURGEONS
®
POSITION PAPER TREATMENT OF SKIN REDUNDANCY FOLLOWING MASSIVE WEIGHT LOSS PAGE 2
PREPARED BY THE SOCIOECONOMIC COMMITTEE
APPROVED BY AMERICAN SOCIETY OF PLASTIC AND RECONSTRUCTIVE SURGEONS BOARD OF DIRECTORS, JUNE, 1996
Procedures:
Panniculectomy is the surgical resection of the overhanging
"apron" of redundant skin and fat in the lower abdominal area.
The redundant skin and fat may continue laterally across the
hips and lower back. If this is symptomatic, correction by
excision of excess tissue in these regions may be medically
necessary (CPT 15834). Umbilical or other abdominal hernias
may also be present and should be repaired. If significant folds
of redundant skin in fat are present in the upper abdomen and
signs and symptoms of functional abnormalities are present, an
abdominoplasty (CPT 15831) may be indicated with the
panniculectomy. Massive weight loss can cause significant
ptosis of the breast (ICD-9 611.8). If medically indicated
symptoms and signs of breast enlargement are present in the
female patient, a bilateral reduction mammoplasty (CPT 19318)
is indicated. Ptosis of the breast in male patient requires
correction by subcutaneous mastectomy (CPT 19140) with skin
resection and nipple areolar repositioning. Ptosis of the female
breast without breast enlargement can be corrected by
mastopexy (CPT 19316).
In the thigh regions, excessive skin and fat is excised using
various incisions to provide for direct removal of the redundant
tissue with longitudinal or diagonal incisions extending to and
sometimes including the inguinal region. The thighplasties
(CPT 15832) are usually performed on the medical surface of
the thighs, however, can be continued to the posterior inferior
gluteal and buttock regions if indicated. In the arms, a
brachioplasty (CPT 15836) is performed via an elliptical
excision along the medial border of the upper arm.
Documentation:
Justification for the resection of skin and fat redundancy
following massive weight loss should be documented by the
surgeon in the history and the physical, and should be included
in the operative note. In the abdomen, this consists of the
probability of relieving the clinical signs and symptoms
associated with the abdominal panniculus, diminished
abdominal wall integrity, including back pain, recurrent
intertriginous dermatitis, poor hygiene and pressure of hernias.
For the breast, it should be based on the presence of
macromastia or ptosis in females. For the male patient, the
presence of ptotic breast skin and nipples should be
documented.
Photographs:
Photographs are usually taken to document pre-operative
conditions and aid the surgeon in planning surgery. In some
cases, they may record physical signs. However, photos do not
substantiate symptoms and should only be used by third-party
payers in conjunction with the patient's history and physical
examination. It is the recommendation of ASPRS that
photographs be taken when the patient is in an upright
position. The patient, however, must sign a specific
photographic release form and strict confidentiality must be
honored. It is the opinion of ASPRS that a board-certified
plastic surgeon should evaluate all submitted photographs.
Position Statement:
It is the position of the American Society of Plastic and
Reconstructive Surgeons that resection of redundant of skin
and fatty tissue following massive weight loss is reconstructive
when performed to relieve specific clinical signs and
symptoms. Surgery to resect redundant skin is performed to
relieve clinical signs and symptoms related to abdominal wall
weakness and panniculitis; to relieve signs and symptoms
when macromastia and/or ptosis is associated with this in
female patients; and for male patients with signs and
symptoms of ptotic breast skin. The resection of other areas of
redundant skin and fat, specifically of the upper arm and
thighs, may be indicated for cosmetic reasons.
References:
Davis, T. S. "Morbid Obesity." Clinics in Plastic Surgery,
11(3):517, 1984. Guerrero-Santos, J. "Brachioplasty." Aesthetic Plastic Surgery, 3:1,
1979. Hallock, G. G. "Simultaneous Brachioplasty, Thorachoplasty, and Mammaplasty." Aesthetic Plastic Surgery, 9(3):233, 1985.
Hauben, D. J. "One Stage Body Contouring." Annals of Plastic
Surgery, 21(5):472, 1988.
Palmer, B. "Skin Reduction Plasties Following Intestinal Shunt Operations for Treatment of Obesity." Scandinavian Journal of
Plastic and Reconstructive Surgery, 9:47, 1975.
Savage, R.C. "Abdominoplasty Following Gastrointestinal Bypass Surgery." Plastic and Reconstructive Surgery, 71(4): 500,
1993. Zook, E.G. "The Massive Weight Loss Patient." Clinics in Plastic
Surgery, 2(3):457, 1975.
posting helpful info
May 23, 2007
If you have any questions, feel free to ask.
Tami
Request for plastics
May 23, 2007
This letter is a request for coverage by Blue Cross of California for a circumferencial lower body lift (which would alleviate many issues as detailed below) with lipo-plasty of the upper and lateral abdomen and hips to contour the reconstructed abdominal wall and breast augmentation to be performed by Dr. Charles Price. (or the alternative of an abdominoplasty, thigh lift, and buttocks lift and breast augmentation)It is the position of the American Society of Plastic and reconstructive Surgeons that resection of skin and fatty tissue following massive weight loss is "reconstructive" when performed to relieve specific clinical signs and symptoms.
To explain, I did have Roux-en-Y surgery done on April 26th, 2004. I have lost 115 pounds and my weight has been stable for six months. I have also made positive changes, not only in my diet, but with exercise, as well. I started walking regularly shortly after surgery and have continued to do so, even in the winter. Last March, I added stretching and resistance training 3-4 times a week at CURVES. I began to notice a couple of changes. I developed some nagging low back pain. I have implemented pilates work outs at home with videos to try strengthening my "core". The nagging back pain has not gone away and I regularly take over the counter pain killers to deal with the pain. In the past several months I have also experienced several vaginal yeast and bacterial infections, I attribute to the excess skin and increased exercise, as the symptoms are mostly on the outside, not internal. My OBGYN records document this. I had not had any trouble with this prior to all the weightloss.
-----ommitted breast appeal info here----most ins. will NOT cover augmentation for ANY reason, but many have gotten lifts covered-----
When I sit in a chair, I can feel folds of skin under my tail bone. I have tried numerous undergarments and still find I have this very uncomfortable and painful problem. This is especially noticeable while riding a bike, or sitting on any hard seat, or even a cushioned but bumpy seat as in a car ride. My job is a "sit-down" job and I find that if I do not sit with my legs crossed this skin under my tailbone becomes very painful. By crossing my legs, I get a lift on one side of the buttocks which brings relief there, but also causes more discomfort to my back, knees, and legs after long periods of time. It is very difficult to sit with correct posture with this excess skin folding under my buttocks. The circumferencial lower body lift would eliminate this problem.I had two full term pregnancies both ending with normal vaginal deliveries. My first baby was 8 lbs., 2 oz.; the second was 8 lbs., 15oz. Dr. Price estimates he could remove 8" of skin vertically in the front and 4-6" on the sides and back. My posture has changed due to the changes in my form, (extremely noticeable in the pictures taken in Dr. Price’s office)and that is the cause of my back pain. I also experienced a prolapsed uterus and had to have a hysterectomy 2 1/2yrs ago due to a weekened muscular system. I also had bladder and rectal repairs done due to the prolapsed uterus and am now again experiencing a fallen bladder due to weakened muscles from obesity. Surgical excision of excessive abdominal tissue dates back to the early 1900s. In 1910, Kelly (Kelly, HA. Excision of fat of the abdominal wall - lipectomy. Surgical Gynecology and Obstetrics. 1910;10:229) reported positive outcomes, including weight loss, improved comfort, increased activity, and improved hygiene following surgery. Anterior abdominal wall laxity is the primary medical reason for abdominoplasty, since it is responsible for structural defects of the abdominal wall and chronic low back pain. Abdominal wall laxity can increase the work support of the lumbar dorsal fascia, resulting in low back pain. Ten extra pounds of adipose tissue on the abdominal wall adds 100lbs of strain on the discs of the lower back by exaggerating the "S" curve of the spine. Diastasis recti, whether congenital or secondary to pregnancy, decreases the efficiency of the abdominal musculature, contributing to lower back pain, )Giese, Sharon, MD, FACS. Consultation on Abdominoplasty. The Female Patient. 2002.)
The AMA supports the following definitions of "cosmetic" and ‘reconstructive" surgery in a statement released in June, 1989: Cosmetic surgery is performed to reshape normal structures of the body in order to improve the patient’s appearance and self-esteem. Reconstructive surgery is performed on abnormal structures of the body, caused by congenital defects, developmental abnormalities, trauma, infection, tumors or disease. It is generally performed to improve function, but may also be done to approximate a normal appearance. The AMA encourages third-party payers to use these definitions in determining services for coverage under plans they offer or administer. Abdominoplasty is considered reconstructive when performed to correct or relieve structural defects of the abdominal wall and/or chronic low back pain due to functional incompetence of the anterior abdominal wall.
In the Combined Evidence of Coverage and Disclosure Form, PartVI What is Not Covered, pg 41, it states: We will not furnish benefits for: Cosmetic Surgery: Cosmetic Surgery or other services that are performed to alter or reshape normal structures of the body in order to improve appearance. I would interpret this to mean that these procedures are not covered after weight loss surgery for the sake of appearance, I am not requesting coverage of surgery for the sake of appearance, but to relieve pain from a change in structure, and to alleviate repeated yeast infections due to excess skin. Furthermore, under PartXXII Definitions, it states: Cosmetic Surgery is surgery that is performed to alter or reshape normal structure of the body in order to improve appearance. Reconstructive Surgery is surgery that is Medically Necessary and appropriate and is performed to correct or repair abnormal structure of the body caused by congenital defects, developmental abnormalities, trauma, tumors or disease to do either of the following: (1)to improve function or (2) recreate a normal appearance, to the extent possible. NOTE:Cosmetic Surgery does not become Reconstructive Surgery because of a psychological or psychiatric reasons.
With the cicumferencial body lift, Dr. Price could eliminate the excess skin folds under my buttocks, the 8"inches of excess skin hanging on the front of my abdomen, and the 4-6" of skin on my sides and back while at the same time reduce the excess pubis area skin that is causing reoccurring yeast infections. The breast augmentation would place my breast tissue back in the appropriate area of my chest, rather than letting that tissue hang to my abdomen. This would certainly improve the functionality of my core body by eliminating the force of pull on my back caused by this excess hanging skin. I would be able to sit with correct posture without experiencing pain.
I would prefer to have the cause of this lower back pain corrected, rather than treat the symptoms. I have tried exercises to strengthen my back and abdomen. I am limited by the gastric bypass surgery to the amount of ibuprofen and other types of medications I can take for relief, which is short lived at that. I have also invested in some support garments, which, quite honestly, didn’t help at all.
I realize that a circumferencial body lift and breast augmentation are major surgeries and carry with them all the risks of any other surgical procedure. It involves one or more large abdominal incisions, drains, pain, and time away from work. I am willing to do this so that I can maintain the healthier lifestyle I have developed. I also want to be able to do projects around my home that involve lifting and moving, without the prospect of having even worse back pain. This is not a consequence of gastric bypass surgery that I expected, but I do feel that a circumferencial lower body lift and breast augmentation are necessary in my case.
I respectfully request that a circumferencial body lift and breast augmentation be approved and paid at the usual rates for covered procedures.The following ICD-9 Codes are applicable in my case: Lower back pain and postural back ache, 724.2 Upper back pain 724.1 Neck Pain 723.1 Shoulder pain 719.41 yeast infection 112.9
About Me
Before & After
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