Page 165 - When surgery alone won’t cut it - Valerie Maureen Monpellier

Mutilation
In the post-bariatric population, mutilation is defined as an excess skin grade 3 ac- cording to the Pittsburgh Rating Scale (PRS) 20, 21. The PRS consists of a grading scale for excess skin on ten anatomically defined areas, ranging from 0 (indicating normal) to 3 (indicating the most severe deformity). For each of the scores there is also an explanation available, for example excess skin grade 3 for the breasts is explained as: severe lateral roll and/or severe volume loss with loose skin. Grade 3 on the PRS scale does not always mean the most excess skin: grade 2 excess skin on the abdomen is defined as overhanging pannus and grade 3 as multiple rolls or epigastric fullness. An abdominal panniculus can be more serious than multiple rolls, however grade 3 needs more extensive surgery and is thus (in that way) a more severe deformity.
The PRS was developed by Song et al. to provide a systematic approach for selection of the appropriate body contouring procedure for post-bariatric patients 21. The PRS provides a good overview of the deformities seen in the post-bariatric population and was validated by the developers. It was, however, not designed as a method to evaluate whether patients should be reimbursed for BCS. Therefore, van der Beek et al. tested the PRS in Netherlands. A total of 13 observers, plastic surgeons, nurses and students, rated photographs of 10 areas of 25 patients 22. The results showed a moderate interobserver validity, meaning that the PRS is not an objective scale to rate the amount of overhanging skin. In daily practice this results in differences in rating of excess skin by plastic surgeons and insurance companies. Thus, some patients will be considered a grade 2 by the insurance company; while the plastic surgeon rates the overhanging skin as grade 3. But, there will also be patients who will get reimbursement while the plastic surgeon does not rate the overhanging skin as grade 3. This makes the current system used to define mutilation unreliable and subjective.
Impairment of bodily function
A serious impairment of bodily function in daily life is defined as a significant restric- tion of movement and/or a chronic skin condition that cannot be treated with con- servative measures 20. Only for the abdominal overhanging skin there is an objective measurement of a significant restriction of movement: the abdominal skin surplus should cover at least 25% of the length of the femur.
However, this “objective” measurement was never tested in a post-bariatric popula- tion. It is unknown if this cut-off point correlates with complaints of the patient and if this measurement is reliable. And although we showed that overhanging skin on the abdomen is most prevalent, patients also complain of excess skin on breast, flanks, arms and legs. For these areas, there are not objective criteria to define restriction of movement. The guideline does provide examples, like when walking is restricted by
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