Page 119 - When surgery alone won’t cut it - Valerie Maureen Monpellier

INTRODUCTION
Body contouring surgery (BCS) is the only available treatment for overhanging skin after massive weight loss. Numerous studies have shown that post-bariatric patients who undergo BCS have significant improvements in quality of life (QoL), body im- age and psychological status 1-8. In addition, these patients have better long-term weight loss maintenance, thus BCS seems to prolong the effect of bariatric surgery 9-11. However, reimbursement of BCS is a worldwide issue, because of the absence of an instrument to objectively decide which patients should qualify for reimbursement 12-15. Ideally, such an instrument would include all aspects of patients’ well-being that are affected by the overhanging skin.
In the Netherlands, BCS is only reimbursed when there is “mutilation” or a “serious impairment of bodily function in daily life” 16. According to the Dutch guidelines mu- tilation is defined as a grade 3 excess skin on the Pittsburgh Rating Scale (PRS) and impairment of bodily function as a chronic skin condition, or a specific, measured amount of overhanging skin 17. However, the PRS was only created to visually evaluate excess skin on photographs and it has been proven to be an unreliable tool for this purpose 18,19. Resulting in inconsistent qualification for reimbursement and unfair de- cision making: patients with the most complaints are not always reimbursed. Unfortu- nately, a good tool to physically measure and calculate skin excess (in cm2) instead of photographs is not available so far. An additional item missing in the current guideline is the evaluation of QoL and psychological items.
In Great Britain, decisions regarding reimbursement for BCS were compared to a winning a lottery 20. Therefore, the British Association of Plastic, Reconstructive and Aesthetic Surgeons (BAPRAS) developed a screening tool which includes weight loss, the medical, physical and psychological problems caused by excess skin and medical history 21. In addition, a patient reported outcome measure (PROM) was added. How- ever, this tool has never been tested in daily practice, nor really been implemented 22. The goal of this study is to evaluate a modified version of the BAPRAS screening tool in a post-bariatric population. We will also study QoL and its relationship with the screening tool scores. The results will be used to further improve the questionnaire and develop an improved screening tool to select post-bariatric patients for referral and reimbursement of BCS.
METHODS
Standard treatment
All patients were recruited at the Nederlandse Obesitas Kliniek (NOK, Dutch Obesity Clinic). The NOK is the largest, outpatient clinic for treatment of patients with morbid obesity in the Netherlands. Treatment program consists of bariatric surgery with clear- ly protocolled pre- and postoperative group counselling by a multidisciplinary team up
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