Following significant weight loss, many individuals are left with excess skin. This article explores the options for skin removal surgery, particularly focusing on Kaiser Permanente's coverage policies and the various aspects of these procedures.
Understanding Weight Loss Surgery
Weight-loss surgery encompasses several procedures designed to help individuals struggling with obesity. It's important to recognize that weight-loss surgery is not cosmetic surgery. It will not remove fatty tissue. After a lot of weight loss, you may have excess skin. These surgeries aim to reduce the size of the stomach or alter the digestive process, leading to decreased food intake and absorption. Common types of weight-loss surgery include:
- Adjustable Gastric Banding: A band is placed around the upper part of the stomach, creating a pouch.
- Gastric Sleeve: More than half of your stomach is removed, leaving a thin sleeve, or tube, that is about the size of a banana.
- Roux-en-Y Gastric Bypass: A small part of the stomach is used to create a new stomach pouch, roughly the size of an egg. The smaller stomach is connected to the middle portion of the small intestine, bypassing the rest of the stomach and the upper portion of the small intestine. This reduces the amount of food you can eat at one time. Bypassing part of the intestine reduces how much food and nutrients are absorbed.
- Biliopancreatic Diversion: Part of the stomach is removed. The remaining part of the stomach is connected to the lower part of the small intestine. The food you eat then bypasses much of the small intestine.
- Biliopancreatic Diversion with Duodenal Switch: A portion of the stomach is removed, but the pylorus remains intact. The pylorus controls food drainage from the stomach. The pylorus is connected to a lower segment of the intestine. The duodenum is connected to the lower part of the small intestine. The food you eat then bypasses much of the small intestine.
These surgeries can be performed through open surgery or laparoscopically. Laparoscopic surgery involves several small cuts and uses small tools and a camera to guide the surgery. You recover sooner and may be less likely to have pain or problems after surgery.
After surgery, you will need to make big, lifelong changes in how you eat-including smaller portions and different foods. Regular exercise is also important for losing weight and keeping it off. Weight-loss surgery has risks, including a risk of death. Each type of surgery also has its own risks. Gastric bypass and gastric sleeve surgeries can cause a leak from the stomach into the belly area. With gastric bypass, the connection between the stomach and the small intestine can get narrow. After adjustable gastric banding, you are more likely to need another surgery to fix problems than you would after gastric bypass. For example, some people need a second operation because the band slips or it works its way from the outside of the stomach to the inside.
The Challenge of Excess Skin
A common consequence of massive weight loss following bariatric surgery is the presence of excess, hanging skin. This excess skin can lead to several issues, including:
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- Physical Discomfort: The excess skin can cause chafing, irritation, and skin breakdown.
- Hygiene Problems: It can be difficult to keep the areas under the excess skin clean and dry, leading to infections.
- Mobility Issues: In some cases, the excess skin can restrict movement and make exercise difficult.
- Psychological Distress: Many individuals feel self-conscious and unhappy with their appearance due to the excess skin.
Kaiser Permanente's Coverage Policies on Skin Removal
A significant legal case, Wendy Gallimore, et al. v. Kaiser Permanente, shed light on Kaiser Permanente's policies regarding skin removal surgery after bariatric weight loss. The court ruled that Kaiser cannot systematically classify removal of excess skin following bariatric weight loss surgery as a cosmetic procedure. California law requires insurance companies to pay for reconstructive surgery to repair disfigurement caused by trauma or disease. Judge Carvill rejected Kaiser’s position that excess skin is not a disease, and he ruled that the insurer’s policy of only providing referrals to plastic surgeons for patients whose excess skin presented a functional problem ignored the California Health & Safety Code’s requirement that reconstructive surgery also must be covered if it will help restore a patient’s normal appearance.
However he declined to grant the declaratory relief requested by the plaintiffs, which asked the court to rule that referral denials for each class member violated the statute, finding that in some instances the denial could be medically appropriate. “While not all members of the class may qualify for excess skin removal surgery and many who do may choose not to undergo such a procedure, they all have a common interest in being correctly advised as to the availability of coverage for such procedures and to have their physicians evaluating any request they might make do so under legally correct criteria,” Judge Carvill wrote.
The ruling emphasizes that Kaiser must correctly advise patients about coverage availability and ensure that physicians evaluate requests under legally correct criteria. It acknowledged that not all members of the class may qualify for excess skin removal surgery and many who do may choose not to undergo such a procedure.
The court did not mandate that Kaiser pay for evaluations and possible surgery for all class members initially denied a referral. “When it comes to post-bariatric excess skin conditions, there is no bright line between what would constitute reconstructive versus plastic surgery,” Judge Carvill wrote, finding a ruling that skin removal is covered doesn’t automatically mean plaintiffs are entitled to the procedure. He said those determinations would require a level of scrutiny of clinical decisions beyond the court’s abilities. “Each class member’s circumstance would have to be examined at a level of detail that would be impossible on a class basis and was never even attempted in this trial,” the ruling states.
Types of Skin Removal Procedures
Several surgical procedures can address excess skin after weight loss. The specific procedure recommended will depend on the location and amount of excess skin.
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- Panniculectomy: A panniculectomy is surgery to remove fat and skin that hangs down from your belly. The doctor makes one or more cuts (incisions) in your belly. Extra fat and skin are removed. Then the skin is brought together and closed with stitches, staples, or skin glue. The surgery leaves one or more scars. You may go home the same day, or you may spend a day or longer in the hospital.
- Tummy Tuck (Abdominoplasty): This procedure removes excess skin and fat from the abdomen and tightens the abdominal muscles.
- Brachioplasty (Arm Lift): Removes excess skin and fat from the upper arms.
- Thigh Lift: Removes excess skin and fat from the thighs.
- Breast Lift (Mastopexy): Reshapes and lifts sagging breasts.
- Lower Body Lift: Addresses excess skin on the abdomen, hips, thighs, and buttocks.
What to Expect After a Panniculectomy
Recovery from a panniculectomy, a common skin removal procedure, involves several stages. Your belly will be sore and swollen for the first week after surgery. The skin on your belly will probably be mostly numb for several weeks to months. Feeling will come back slowly. But you may have small areas around the incisions that are always numb. Don't use a heating pad on your stomach while it's still numb, or you could have severe burns. It's normal to feel tired while you heal. You won't be able to stand up straight when you get home. To regain your normal movement, you'll need to get up and walk every day. The surgery leaves one or more scars that will fade with time.
- Initial Recovery: Allow the area to heal. Be active. Walking is a good choice. You will probably need to take 2 to 3 weeks off from work.
- Pain Management: Hold a pillow over your incisions when you cough or take deep breaths.
- Diet: You can eat your normal diet. If your bowel movements are not regular right after surgery, try to avoid constipation and straining. Drink plenty of water.
- Medications: Be safe with medicines. Read and follow all instructions on the label. Your doctor will tell you if and when you can restart your medicines. If you take aspirin or some other blood thinner, be sure to talk to your doctor. He or she will tell you if and when to start taking this medicine again.
- Wound Care: You will have a dressing over the cut (incision). A dressing helps the incision heal and protects it. Wash the area daily with warm water, and pat it dry. Don't use hydrogen peroxide or alcohol. You may need to wait a few days before you can take a shower. You will likely have several drains near your incision. You may have a special girdle, called a binder, placed around the area where you had surgery. This binder will help ease swelling and pain. Your doctor may have you sleep in a recliner, or propped up in bed, with pillows under your knees.
- Follow-up Care: Follow-up care is a key part of your treatment and safety. Be sure to make and go to all appointments, and call your doctor if you are having problems. Call 911 anytime you think you may need emergency care. You have symptoms of a blood clot in your lung (called a pulmonary embolism).
Important Considerations
- Timing: Wait until your weight stabilizes. For the best results, you should wait until your weight stabilizes at your new size for several months (usually about 18 months after surgery). Otherwise, as you continue to lose weight, you are likely to develop more excess skin.
- Realistic Expectations: Excess skin removal surgery is not cosmetic surgery. Even if you follow all the recommendations, it’s realistic to expect that you will still have some excess skin after surgery.
- Recovery: Recovery can be painful. Many people who have had body contouring surgery say that the recovery is worse than from metabolic and bariatric surgery.
- Individual Assessment: Each class member’s circumstance would have to be examined at a level of detail that would be impossible on a class basis and was never even attempted in this trial,” the ruling states.
Making an Informed Decision
Deciding whether to undergo skin removal surgery after significant weight loss is a personal one. It's crucial to:
- Consult with Your Doctor: Discuss your goals, expectations, and medical history with your doctor to determine if you are a suitable candidate for surgery.
- Understand Kaiser Permanente's Coverage: Inquire about Kaiser Permanente's specific coverage policies for skin removal procedures and the criteria for approval.
- Research Different Procedures: Learn about the various types of skin removal surgeries, their risks, and their benefits.
- Consider the Recovery Process: Be prepared for a potentially lengthy and challenging recovery period.
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