Page 20 - When surgery alone won’t cut it - Valerie Maureen Monpellier

Chapter 1 - Introduction
The aim of the first part of this thesis is to unravel whether physical activity, eating style/disorders, depressive disorders, HRQoL and body image are related to weight change after bariatric surgery.
EXCESS SKIN AFTER BARIATRIC SURGERY
As stated in the beginning, excess skin is a very important negative consequence of bariatric surgery. Up to 90% of the population experiences problems with overhang- ing skin as a consequence of the massive weight loss 8-11. Excess skin negatively affects patient’s wellbeing by causing medical, physical and psychological problems 8-11. Patients describe having trouble finding suitable clothing, limitation in daily activ- ities and sports 8,10,11,98. Psychological issues are usually related to a negative body image; patients feel ashamed and unattractive 11,99,100.
Excess skin can only be treated by BCS, a type of surgery in which the excess skin is surgically removed. As expected, BCS generally has a positive effect on the patients’ wellbeing. Several studies showed an improvement of HRQoL, even up to 8 years after the body contouring procedure 101-105. Three small studies have also shown a positive effect of BCS on body image 9,105,106. Moreover, post-bariatric patients who undergo BCS show better weight loss maintenance 107,108. This is especially important, since weight loss and (long-term) maintenance is the primary goal of bariatric surgery. Better weight loss maintenance after BCS have might be caused by an improvement of body image, which improves depressive symptoms and thereby weight loss main- tenance.
Reimbursement of body contouring surgery
Despite the positive effects of BCS only a small percentage (18-33%) of patients seem to undergo one or more body contouring procedures 10,11,109,110. This is at least partly caused by the fact that BCS is not a standard part of bariatric treatment pro- grams and often not reimbursed by health insurance companies. Patients report that the high costs for BCS are the main reason for not undergoing any procedure 10,109. This is a worldwide issue 10,11 109,110.
In the Netherlands there are restrictions for reimbursement of post bariatric body con- touring surgical procedures. In order to qualify for reimbursement by health insurance companies in our country patients first have to meet the following qualifications: (a) have to be at least 18 months past bariatric surgery, (b) should have a stable weight for at least 12 months, (c) should have a BMI < 35 kg/m2. Second, they should have a skin excess grade 3 according to the Pittsburgh Rating Scale (PRS) or an untreatable skin condition caused by the excess skin 111,112.
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