Page 126 - When surgery alone won’t cut it - Valerie Maureen Monpellier

Chapter 7
The fact that the excess skin impacts several aspects of the patients’ life makes it even more important to include all these aspects in a screening tool for reimburse- ment for BCS.
In our opinion the modified BAPRAS questionnaire can be combined with the Dutch weight criteria, thereby creating the final version of the tool: the Dutch ReBoc tool (Referral and Reimbursement for Body Contouring tool, Appendix 2). In the Dutch Re- boc tool patients, who do not have a stable weight cannot be referred; in the BAPRAS guideline these patients could still apply for reimbursement. Weight fluctuations can negatively impact complication rates and all of the patients who qualified had a stable weight before surgery 37. A recent pregnancy or planning to have children in the future is also an exclusion criterion for referral, because this will negatively influence the post-operative result. Last but not least, all patients with a recent life-event, a history of psychological issues and/or addiction, should be evaluated by the psychologist (of the bariatric team) in order to decide whether these issues can be seen as a contra-in- dication for BCS. This psychologist should also evaluate other aspects, such as body dysmorphic disorder symptoms.
The BODY-Q should be a part of the Dutch Reboc tool, as it is the most suitable in- strument to objectively evaluate the impact of overhanging skin on patients’ well-be- ing 26. Ideally, the BODY-Q should also be evaluated after BCS to evaluate the effect of body contouring procedures.
Like in the BAPRAS guideline, patients with a very high initial BMI (> 50 kg/m2) who want a functional panniculectomy are an exception in the criteria according to the Dutch Reboc tool. In the study population, four patients qualified for referral, but had a BMI > 35 kg/m2. Before bariatric surgery, these four patients all had a BMI > 50 kg/ m2, which implicates that they will never be able reach a BMI < 35 kg/m2 after bariat- ric surgery 38. A panniculectomy will bring these patients to another level of exercise freedom, which subsequently will lead to further lowering of their BMI. Therefore, patients with a starting BMI > 50 kg/m2 should be evaluated separately with regard to an abdominal debulking (panniculectomy) procedure.
A limitation of the current study is that all questionnaires were filled out at home by the patients. Therefore, we were not able to examine the patients and objectify the com- plaints like skin conditions and physical limitations. However, since all patients were informed that the questionnaires were anonymous and that the answers did not have any effect on possible BCS, we think this potential bias has been low.
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