Utilization of Body Contouring Procedures Following Weight Loss Surgery: A Study of 37,806 Patients

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1 DOI /s ORIGINAL CONTRIBUTIONS Utilization of Body Contouring Procedures Following Weight Loss Surgery: A Study of 37,806 Patients Maria S. Altieri 1 & Jie Yang 2 & Jihye Park 3 & David Novikov 1 & Lijuan Kang 3 & Konstantinos Spaniolas 1 & Andrew Bates 1 & Mark Talamini 1 & Aurora Pryor 1 # Springer Science+Business Media New York 2017 Abstract Background Bariatric surgery has substantial health benefits; however, some patients desire body contouring (BC) procedures following rapid weight loss. There is a paucity of data regarding the true rate of BC following bariatric procedures. The purpose of our study is to examine the utilization of two common procedures, abdominoplasty, and panniculectomy, following bariatric surgery in New York State. Methods The SPARCS longitudinal administrative database was used to identify bariatric procedures by using ICD-9 and CPT codes between 2004 and Procedures included sleeve gastrectomy, Roux-en-Y gastric bypass, and laparoscopic adjustable gastric banding. Using a unique patient identifier, we tracked those patients who subsequently underwent either abdominoplasty or panniculectomy with at least a 4- year follow-up (until 2014). Multivariable Cox proportional hazard model was used to evaluate predictors of follow-up BC surgery. Results 37,806 patients underwent bariatric surgery between 2004 and Only 5.58% (n = 2112) of these patients subsequently had a BC procedure, with 143 of them (6.8%) This work was presented at the Scientific Forum at the American College of Surgeons, Washington DC * Maria S. Altieri maria.altieri@stonybrookmedicine.edu Division of Bariatric, Foregut and Advanced Gastrointestinal Surgery, Department of Surgery, Stony Brook University Medical Center, 100 Nichols Road, HSC T19, Stony Brook, NY 11794, USA Department of Family, Population and Preventive Medicine, Stony Brook University Medical Center, Stony Brook, NY, USA Department of Applied Mathematics and Statistics, Stony Brook University, Stony Brook, NY, USA having 1 plastic surgery. The average time to plastic surgery after band, bypass, or sleeve was ± , ± , and ± days, respectively (P < ). Following the multivariable Cox proportional hazard model, a female, SG patients, patients with Medicare or Medicaid, and patients in either <20 or >80%ile in yearly income were more likely to have plastic surgery after adjusting for age, race/ethnicity, comorbidities and complications (P values < ). Conclusions This study shows that plastic surgery is completed by only 6% of patients following bariatric procedures. As insurance and income are associated with pursuing surgery, improved access may increase the number of patients who are able to undergo these reconstructive procedures. Keywords bariatric surgery. body contouring procedures Introduction As obesity continues to be a widespread problem in the USA, there is an increasing number of individuals who choose to undergo weight loss procedures [1]. After bariatric procedures, although patients tend to experience a decrease in the severity of obesity related complications [2], most adult patients experience excess redundant skin [3]. Furthermore, among adolescents, 66% of females and 37% of males experience problems directly related to excess skin effectively challenging the current belief that younger people do not suffer from excess skin after massive weight loss surgery to the same extent as adults [4]. This excess skin results in problems with personal hygiene, skin infections, and ulcers, as well as severe personal psychosocial distress [5, 6]. A recent study by Kitzinger et al. discovered that 75% of women and 68% of men were interested in plastic surgery following weight loss,

2 specifically body contouring (BC) procedures such as abdominoplasty and panniculectomy, to correct this deformity and improve quality of life [3]. Steffen et al., reported that among body regions, 18.3% undergo BC at the waist/abdomen, which is the most commonly contouring site [7]. Another survey showed that the most common procedures were abdominoplasties [8]. Although the health and medical benefits of bariatric surgery leading to massive weight loss are easily noticeable, measurable, and thus universally insured, the benefits of plastic surgery following bariatric surgery are less so. While the American Society of Plastic Surgeons reported abdominoplasty as one of the most common reconstructive procedures in 2015, with 127,967 surgeries performed in the USA, the number of bariatric patients undergoing these procedures is not well-known and probably consist of a small percentage [9].These procedures are considered cosmetic and therefore, in our current health care system, insurance providers deny patients who may be in need of or desire to undergo such procedures. According to the current literature, 40 50% of third-party payers deny authorization for these procedures after massive weight loss and 87.8% of patients desiring BC surgery identify that cost is the major barrier to access [6, 10]. Interestingly, other studies have shown that insurance coverage is not the sole limiting factor influencing whether or not a patient receivesbc surgery. A study showedthat9.8% ofpatientsdesired to lose more weight before considering BC surgery while only 2.8% of patients were fearful of undergoing additional surgery after bariatric surgery [6]. Moreover, a study conducted in Austria found that despite free access to plastic surgery, only 14.9% of patients underwent the procedure in that country, further calling into question whether or not there is more at play than just affordability andcoverage[11]. Therefore, althoughinsurancecoverage and access to these procedures may play a role, other factors can be associated, as well. Although interest is high, the true frequency of reconstruction following weight loss surgery is unknown. The purpose of our study is to examine the utilization of two common body contouring procedures, abdominoplasty and panniculectomy, following bariatric surgery in New York State as well as identify what factors may influence whether a patient does or does not undergo a BC procedure. Methods Through the use ICD-9 code for obesity and overweight and ICD- 9 and CPT procedural codes, the New York SPARCS database was used to identify all patients undergoing bariatric procedures between 2004 and Procedures included Roux-en-Y gastric bypass (RYGB), sleeve gastrectomy (LSG), and laparoscopic adjustable gastric banding (LAGB). We excluded patients who were age <18, had previous bariatric procedures (n = 167), were lost to follow-up following 1 year after bariatric procedure, or had missing data. Through the use of a unique identifier, these patients were followed across the state of New York and patients undergoing either abdominoplasty (ICD-9 and CPT codes) or panniculectomy (ICD-9 and CPT codes) were identified. Chisquare test and Welch s t test were used to compare categorical variable and continuousvariables betweenpatients with and without a plastic surgery, respectively. Kruskal-Wallis test was used to compare the number of plastic surgeries after different types of bariatric surgery. Multivariable Cox proportional hazard (PH) model was used to compare the likelihood of having a followup plastic surgery among patients in different bariatric surgery groups after adjusting for other possible confounding factors. Possible confounding factors include patients age, gender, bariatric surgery year, insurance, health region, complications during bariatric surgery, comorbidities, and the number of comorbidities that are included in a Charlson comorbidity index [12]. Any factors with P value <0.1 in the univariate regression models were further considered in the multivariable Cox PH model. All analysis was performed using SAS 9.4 (SAS Institute Inc., Cary, NC) and significance level was set at Results There were 37, 806 patients who underwent bariatric surgery between 2004 and From these, 13,635 were LAGB, 22,428 were RYBG, and 1743 were LSG (Table 1). Four or more years following their index procedure, there were only 5.58% (n = 2112) of these patients with a subsequent BC procedure, with 93.2% (n = 1969) having one procedure and 143 of them (6.8%) having more than one plastic procedure. In the LAGB group, 434 patients (3.18%) had one BC procedure and 20 (0.14%) had two or more BC procedures; within the bypass patients group, 1376 (6.14%) had one BC procedure and 106 (0.48%) had two or more BC procedures: within the sleeve group, 159 (9.12%) had one BC procedure and 17 (0.98%) had two or more BC procedures. Four hundred and eight out of 2112 (19.31%) patients who had BC procedures changed insurance following the index bariatric procedure. The average time to plastic surgery after band, bypass, or sleeve was ± , ± , and ± days, respectively (P < ). For 143 patients with >1 plastic surgery, the average time (days) from patients index bariatric procedure to their first plastic surgery dates is ± days and from patients first plastic surgery dates to their second plastic surgery dates is ± days. Table 2 shows the descriptive characteristics of patients who are undergoing BC procedures in terms of time. The mean time to first plastic surgery was significantly different (P value <0.05) with respect to bariatric procedure type, age, race/ethnicity, insurance, and yearly income level, but not significantly different among different gender (P value =0.0542). It took longer for young patients

3 Table 1 Frequency table for (#) of plastic surgeries by patients first bariatric surgery type # of plastic surgery Overall patient N (%) Band patient N (%) Bypass patient N (%) Sleeve patient N (%) 0 35,694 (94.41%) 13,181 (96.67%) 20,946 (93.39%) 1567 (89.9%) (5.21%) 434 (3.18%) 1376 (6.14%) 159 (9.12%) (0.33%) 17 (0.12%) 91 (0.41%) 15 (0.86%) 3 15 (0.04%) 2 (0.01%) 13 (0.06%) 0 (0%) 4 3 (0.01%) 0 (0%) 2 (0.01%) 1 (0.06%) 6 2 (0.01%) 1 (0.01%) 0 (0%) 1 (0.06%) Total 37,806 (100%) 13,635 (100%) 22,428 (100%) 1743 (100%) whose age was years old to have plastic surgery than older patients (age >30). Sleeve patients had plastic surgery sooner than band patients. When looking at patients characteristics, comorbidities, and complications at the initial bariatric surgery, records between patients who ever had a plastic surgery and who did not have one up to 2014, marginally bariatric type, age group, gender, race/ethnicity, payment, yearly income level and some of the comorbidities and complications were significantly associated with having plastic surgery or not (all P values <0.05). In terms of gender, more female patients (6.27%) had plastic surgery than male patients (2.92%) (P value <0.0001) (Table 3). Table 2 Descriptive table of the time from bariatric surgery to first plastic surgery (days) by patients characteristics and first bariatric surgery types Variable Level N Mean Std Minimum Median Maximum IQR P-value* Bariatric type Band <.0001 Bypass Sleeve Age group > Gender Female Male Race/ethnicity White < Black Asian Hispanic Other Payment Medicaid < Medicare Commercial Other Unknown Yearly income level ($) Unknown <46, ,254 50, ,145 55, ,330 81, , , *P value was based on Welch s t test NY counties median yearly incomes were based on 2009 US census bureau data and were classified into five levels, i.e., yearly income level. Unknown income level means patients residential counties were unknown or out of NY

4 Table 3 Descriptive table of patients characteristics, comorbidities and complications by having a follow-up plastic surgery or not Variable Level Total Patients who never had plastic surgery Patients who had plastic surgery P value* Bariatric type Band 13,634 13,180 (96.67%) 454 (3.33%) < Bypass 22,425 20,943 (93.39%) 1482 (6.61%) Sleeve (89.90%) 176 (10.10%) Age group (94.15%) 336 (5.85%) < , (93.90%) 625 (6.10%) ,111 10,427 (93.84%) 684 (6.16%) (95.40%) 382 (4.60%) (96.46%) 81 (3.54%) > (96.58%) 4 (3.42%) Gender Female 30,130 28,242 (93.73%) 1888 (6.27%) < Male (97.08%) 224 (2.92%) Race/ethnicity White 23,208 22,013 (94.85%) 1195 (5.15%) < Black (95.35%) 232 (4.65%) Asian (93.22%) 8 (6.78%) Hispanic (90.32%) 426 (9.68%) Other (95.06%) 251 (4.94%) Payment Medicaid (91.60%) 141 (8.40%) < Medicare (94.44%) 152 (5.56%) Commercial 32,261 30,472 (94.45%) 1789 (5.55%) Other (95.06%) 13 (4.94%) Unknown (98.03%) 17 (1.97%) Yearly income level ($) # Unknown (94.35%) 79 (5.65%) < <46, (92.04%) 476 (7.96%) 46,254 50, (96.38%) 232 (3.62%) 50,145 55, (94.63%) 169 (5.37%) 55,330 81, (94.97%) 212 (5.03%) 81, ,197 16,645 15,701 (94.33%) 944 (5.67%) Congestive heart failure (98.20%) 3 (1.80%) Hypertension 19,181 18,204 (94.91%) 977 (5.09%) < Chronic pulmonary disease (93.95%) 479 (6.05%) Weight loss (98.29%) 10 (1.71%) < Depression (95.55%) 317 (4.45%) < Anastomotic (84.62%) 4 (15.38%) Respiratory arrest 3 2 (66.67%) 1 (33.33%) Hypertension 3 2 (66.67%) 1 (33.33%) Intestinal (89.76%) 30 (10.24%) Digestive (91.52%) 28 (8.48%) *P value was based on chi-squared test # NY counties median yearly incomes were based on 2009 US census bureau data and were classified into five levels, i.e., yearly income level. Unknown income level means patients residential counties were unknown or out of NY Following multivariable Cox PH model, female (HR of female vs. male: 2.11, 95% CI: , P value <0.0001), SG patients (P < ), patients with Medicare or Medicaid, and patients with either <20 or >80%ile in yearly income were more likely to have plastic surgery after adjusting for age, race/ethnicity, comorbidities that considered in a Charleson index and complications (P values <0.0001) (Table 4). Discussion This study shows that less than 6% of patients who had bariatric procedures between 2004 and 2010 had a subsequent body contouring procedure though 2014, although 143 of them (6.8%) had more than one procedure. Body contouring procedures usually occur within 2 years following the index bariatric procedures and the time from first body contouring

5 Table 4 Hazard ratio of predictors and their 95% confidence intervals for predicting the likelihood of having a plastic surgery based on a multivariable Cox PH model Variable Levels Hazard Ratio 95% CI P value* Bariatric type Band vs. bypass < Sleeve vs. bypass Age group vs < vs vs vs >70 vs Gender Female vs. Male < Race/ethnicity Black vs. White < Other vs. White Asian vs. White Hispanic vs. White Payment Medicaid vs. commercial Medicare vs. commercial Unknown vs. commercial Other vs commercial Yearly income level ($) # <46,254 vs. 81, , < ,254 50,145 vs. 81, , ,145 55,330 vs. 81, , ,330 81,936 vs. 81, , Unknown vs. 81, , Anastomotic No vs. Yes Depression No vs. Yes < Hypertension No vs. Yes Weight loss No vs. Yes Digestive No vs. Yes intestinal No vs. Yes # of specific comorbidities in a Charlson comorbidity index 1 vs vs vs *P value was based on Wald test from multivariable Cox PH model # NY counties median yearly incomes were based on 2009 US census bureau data and were classified into five levels, i.e., yearly income level. Unknown income level means patients residential counties were unknown or out of NY procedure to second body contouring procedure was about a year. When examining which patients will undergo body contouring procedures more quickly, patients >30 years of age and/or patients who had undergone a LSG were found to undergo them sooner (Table 2). Univariate analysis showed that bariatric procedure type, age group, gender, race/ethnicity, payment source, yearly income level, and some of the comorbidities and complications were significantly associated with having plastic surgery (all P values <0.05). Following multivariate analysis, after adjusting for all other factors, gender, having sleeve gastrectomy, patients with Medicare or Medicaid, and with either <20 or >80%ile in yearly income were more likely to have body contouring surgery (P values <0.0001). Studies have showed that bariatric patients have expressed dissatisfaction with the excess skin at the wait/abdomen and greater satisfaction if BC is performed. This highlights the importance of educating patients and recommending BC surgery in case of redundant skin [7]. The exact predictors of who may desire BC surgery are not well-known. Steffen et al. showed a relationship between current BMI and increased patient dissatisfaction [7]. However, body image plays an important role in desire for BC [13]. Preoperative discussion regarding expectations and the possibility of requiring further procedures due to excess skin is vital. A big disparity exists between patients who desire BC and those who undergo the procedure. Others have

6 examined the incidence of these procedures and similarly to this study have shown that the incidence of BC procedures following bariatric surgery is relatively small. Mitchell et al. surveyed patients 6 10 years after undergoing RYGB via a questionnaire in order to obtain information regarding patients experience as well as desire for BC surgery. Seventy patients answered the questionnaire as abdominoplasties (24.3%) were the most commonly performed BC procedures. Majority of patients, at least to some extent, desired BC surgery, most notably in the waist/abdomen [8]. In a study surveying patients who have undergone gastric bypass surgery between 2003 and 2009, 74% desired BC surgery, while only 21% of these patients actively pursued BC procedures [3]. In another study, only 3.6% of patients undergoing LSG between 2006 and 2014 underwent subsequent BC procedures postoperatively, although there was a strong desire for abdominoplasty. The authors attributed the disparity to insurance coverage, as 25.6% of patients could not afford the costs and lack of insurance affected 12% of the patients [14]. Insurance and income can play a role, as in this study patients with Medicare or Medicaid and those with either <20 or >80%ile in yearly income were more likely to have a subsequent procedure. In addition, one in every five people has changed insurance prior to obtaining BC procedure, which further implies that insurance plays a significant role. While some insurance companies may cover the cost of these procedures, others will not. To complicate this issues, companies can have different criteria for coverage. Coverage policies can impact an individual s ability to undergo surgery, as patients may not have the financial recourses. However, as Mitchell points out, broad coverage can lead to decrease in reimbursement for providers from such procedures, thus leading to decreased access [15]. However, insurance may not be the only determining factor. Felberbaur et al. reported only 14.9% of bariatric patients choose to undergo plastic surgery despite having free access [16]. The authors attributed the low number of patients to the unfavorable view of plastic surgery in Austria and the lack of desire of patients to undergo more procedures [16]. Another study showed that the rate of complications following BC procedures is relatively high (up to 50%), although the rate of severe complications is lower, but still significant (10.5%). In addition, these complications were associated with higher costs [3]. This study has several limitations, which can be attributed to the use of a retrospective database, such as the potential for coding errors and lack of clinically rich information including specific weight loss following bariatric surgery, which may play a role in the decision to seek BC procedures. The SPARCs database also only captures procedures performed in a hospital setting, and could miss BC operations that were performed in office-based operative facilities. In addition, procedures performed outside of the state of New York are not accounted in this analysis. However, patients who were lost to follow-up were excluded from the study. In addition, since it is a retrospective data, we cannot determine the specific reasons why the majority of the patients have not undergone BC surgery. While we were able to examine if the number of comorbidities included in a Charleson score played any significant effect on subsequent bariatric surgery, we were not able to determine the Charleson score since an administrative database could not provide the level of severity of these comorbidities. Although there are limitations, this is the first study to follow such a large cohort of patients and determine the incidence of BC procedures with at least 4 years of follow-up. Conclusion Our study shows that plastic surgery is completed by only 6% of patients following bariatric procedures. Insurance and income make body contouring surgery affordable for these patients. Additional studies are required to examine patient attitudes toward body contouring surgery and possible barriers to utilization. Acknowledgements We would like to thank the statistical support from the Biostatistical Consulting Core, School of Medicine, Stony Brook University. Compliance with Ethical Standards Conflict of Interest Author 1, Author 2, Author 3, Author 4, Author 5, Author 6, Author 7, and Author 8 have nothing to disclose. Author 9 reports honoraria for speaking for Ethicon, Medtronic, Stryker, and Gore; and is a consultant for Medicines Company and Merck. Ethical Approval All procedures performed in studies involving human participants were in accordance with the ethical standards of the institutional and/or national research committee and with the 1964 Helsinki declaration and its later amendments or comparable ethical standards. Informed Consent Does not apply to this study. Funding No industry or other external funding was used for this research. Dr. Pryor receives honoraria for speaking for Ethicon, Medtronic, and Gore; is a consultant for Freehold Medical and Intuitive, and has ownership interest in Transenterix. References 1. Ogden CL, Carroll MD, Fryar CD, Flegal KM. Prevalence of Obesity Among Adults and Youth: United States, NCHS Data Brief,

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