Excess Skin Removal Surgery FAQ When is excess skin removal considered reconstructive vs cosmetic? Under California s Reconstructive Statute, Health & Safety Code section 1367.63: Surgery EITHER to improve function OR to restore an abnormal structure to normal appearance to the extent possible is considered reconstructive. Surgery to alter or reshape a normal structure to improve appearance is considered cosmetic. Excess skin surgery is only considered reconstructive if your Permanente physician or surgeon determines that it is reconstructive and not cosmetic. The Permanente physician may exercise professional judgment, clinical experience, and/or specialty expertise to determine whether a patient s excess skin falls within either definition Defining Reconstructive Surgery: How do physicians interpret improve function? Permanente physicians and surgeons generally will consider a recommendation of excess skin removal surgery to improve function when a patient s ability to perform essential tasks like walking or maintaining basic personal hygiene is impaired. When excess skin impairs function to this degree, the excess skin may also be considered an abnormal structure that can be restored to normal appearance. Patients do not need to have functional impairments to qualify for surgery. In general, the abnormal appearance standard is an easier and lower threshold to meet. Simply put, functional impairment often occurs in more severe cases of abnormally excessive skin. A rash in and of itself is not an indication for surgery. pg. 1
Defining Reconstructive Surgery: How do physicians determine if excess skin is an abnormal structure? Here are some examples of when excess skin may be considered an abnormal structure: Lower Abdomen: The Permanente physician may consider an abdominal skin fold (known as a panniculus or pannus ) to be an abnormal structure if it: completely covers the pubic hair above the genitalia, or pubic mound, and reaches the genitals or upper thighs; the overhang covers the entire region of the pubic mound on either side even if it doesn t fully cover the pubic mound itself; would completely cover the pubic mound if the mound itself was not hanging down below the genitalia area. Upper arms: When stretching arms straight out, like an airplane, the excess skin hangs to the same level as the breast fold or the lowest point of the breastbone (flat bone running down the middle of the chest) A rough guide is if it hangs below your bra level Other areas: Wherever the degree of excess skin overhang would be similar to the degree of overhang seen in abnormal lower abdominal skin. This could include excess skin where the overhang measures between 2.5-3 inches, depending on a person s height. An example would be a significant skin fold in the upper part of the abdomen. pg. 2
If a Permanente physician concludes that my excess skin is an abnormal structure or impairs function, will I automatically qualify for reconstructive surgery? If the Permanente physician or surgeon determines that: Any health risk that you have does not outweigh the surgical benefits, Your skin fits the abnormal criteria assessment, The surgery will either restore function or more than minimally improve appearance, and You understand and consent to the rigors of excess skin surgery, You should qualify for reconstructive surgery. Health conditions that would exclude you from being able to have surgery despite having an abnormal structure include high BMI and smoking. When considering whether to recommend any surgery, physicians always weigh the risks of surgery versus any potential benefits. Excess skin surgery bears significant risk, such as difficulty in wound healing, infection, other major complications, and even death. Permanente physicians may recommend weight loss and other health management measures to reduce the risks of excess skin surgery. What is the difference between a reconstructive surgery and a cosmetic surgery for excess skin removal? Generally, a reconstructive surgery focuses only on addressing the deformity by removing the abnormal excess skin or excess skin that impairs function. Cosmetic surgery goes further, removing excess skin that is considered normal and otherwise improving appearance. pg. 3
Take the example of a panniculectomy, which is a reconstructive procedure to remove severe, excess skin, versus an abdominoplasty, also known as tummy tuck, which is a common cosmetic procedure that can be performed when the degree of excess skin can vary from mild to severe. In general, a panniculectomy only removes a significant skin fold below the belt line (around the level of the hips). A full abdominoplasty will also remove a skin fold (even if it is small), while also addressing sagging skin of the upper abdomen, stretching skin from above the navel, tightening of abdominal wall muscles, and re-insetting the belly button. Does Kaiser offer cosmetic surgery for excess skin removal? If patients are eligible for reconstructive surgery, plastic surgeons can offer a patient cosmetic enhancements for an additional fee (click here for difference between reconstructive and cosmetic surgery). Availability of cosmetic surgery may vary based on capacity and access. How much does excess skin surgery cost? Reconstructive surgery is generally covered under insurance and cosmetic surgery is self-pay. Check with membership services to determine what your co-pay or deductible would be for a hospitalization. Make sure you ask if the co-pay applies per day or per hospitalization. Any office visits or lab tests you must complete prior to surgery would also involve your normal co-pay or deductible. pg. 4
If I don t qualify now because I need to work on quitting smoking/losing weight to have the surgery, who should I call when I do become a candidate in the future? Call the Bariatric Reconstructive Surgery information line at (626) 405-6752. What are the hours/location/phone number to call for plastic surgery consultation? Call the Bariatric Reconstructive Surgery information line at (626) 405-6752. Am I eligible for Reconstructive Skin Removal Surgery (RSRS)? Take the RSRS eligibility questionnaire: STAGE 1 1. Are you in fairly good health (meaning pre-existing medical conditions under good control like diabetes, blood pressure, heart condition, cancer) to undergo a surgery? Yes/No 2. Has it been 12 months or more since your bariatric surgery? Yes/No 3. Is your Body Mass Index (BMI) at or below 30? Yes/No 4. Has your weight been stable (within 10lb range) for the last 6 months? Yes/No 5. Have you avoided smoking or using nicotine within the last 3 months? Yes/No If all responses to above questions were Yes, click here If any of the responses to the above questions were No, see below: pg. 5
It is unlikely a plastic surgeon would consider you for reconstructive excess skin removal at this time due to the following: Question 1: Any surgery, including excess skin removal, carries risks: infection, bleeding, or death of tissue with open wounds, to name a few. If you have chronic health conditions that are poorly managed, or you are in poor general health, a surgeon would likely determine that the risks of doing surgery outweigh the benefits. Significant hypertension or high hemoglobin A1C are examples of conditions that should be improved prior to surgery. What you can do: Follow up with your primary care doctor to get poorly controlled issues addressed. Once your primary care doctor states you are stable, you can try re-engaging in this process. Questions 2 and 4: Within the first 24 months after surgery, people will get to their lowest post-op weight, and then gain some weight back, before they plateau. This is normal. If it has been less than 12 months since your surgery, it is possible that you may still lose more weight or regain some weight in the near future. It is best that your weight is stable (within a 10lb range for 6 months) before considering excess skin removal because the amount of skin needing removal changes along with changes in weight. What you can do: Once you are 12 months post-op, wait until your weight has stabilized (within a 10lb range) for 6 month period. Additionally, please note, to be considered eligible for surgery, plastic surgeons want your Body Mass Index (BMI) to be 30 or lower. BMI higher than 30 has a high risk of complications, up to 12 times higher than when BMI is below 30. Question 3: A BMI higher than 30 has a high risk of complications, up to 12 times higher than when BMI is below 30. Plastic surgeons prefer that the BMI be 30 or below to ensure an optimal outcome and patient safety. What you can do: If your BMI is higher than 30: Kaiser Permanente offers several weight management programs. To find the program that is right for you, go online to kp.org/healthybalance pg. 6
Question 5: Apart from being bad for your health, smokers and nicotine users have poor wound healing. These surgeries often involve very large incisions, and poor wound healing increases the risk of infection and other complications. What you can do: Sign up for a stop smoking program by calling (866) 862-4295, or go online to kp.org/breathe STAGE 2 Where is the excess skin you wish to have removed? Lower Abdomen: Does your excess skin match the following example? Yes/No Skin fold overhang completely covers the pubic hair above the genitals (this area is also known as the pubic mound or mons pubis) and reaches the genitals or upper thighs. Upper arms: When stretching arms straight out on the sides away from the body, like an airplane, does the excess skin hang to same level as the breast fold or the lowest point of the breastbone (flat bone running down the middle of the chest). A rough guide is if it hangs below the lowest edge of the bra. Yes/No Other areas Is the degree of excess skin overhang similar to the degree of overhang seen in abnormal lower abdominal skin? This could include excess skin where the overhang measures between 2.5-3 inches, depending on a person s height. An example would be a significant skin fold in the upper part of the abdomen. Yes/No pg. 7
If you answered Yes to all questions in stage 1 and Yes to any question in stage 2, you may be eligible to receive reconstructive skin removal surgery. Your next step is to call the Bariatric Reconstructive Surgery information line at (626) 405-6752 Monday through Thursday, 9 a.m. to 5 p.m. You will have an opportunity to submit photos to help determine your eligibility, if you wish. This is offered as a convenience for you. The final step would be an in-person consultation with a plastic surgeon based on eligibility. If you answered No to question 3, you may be eligible to receive reconstructive skin removal surgery once your BMI is 30 or lower. BMI higher than 30 has a high risk of complications, up to 12 times higher than when BMI is below 30. Plastic surgeons prefer that the BMI be 30 or below to ensure an optimal outcome and patient safety. For patients with BMI under 35, initial consultations can be arranged to prepare the patients for the safest outcomes. To help you get your BMI to 30 or below, Kaiser Permanente offers several weight management programs. To find the program that is right for you, go online to kp.org/healthybalance Print the results of your excess skin removal eligibility questionnaire for your own records pg. 8
Contact us If you have further questions regarding excess skin removal, please call the Bariatric Reconstructive Skin Surgery information line at (626) 405-6752 Monday through Thursday, 9 a.m. to 5 p.m. regarding reconstructive skin removal surgery. Please have the responses from your eligibility questionnaire available when you call. For questions regarding Health Plan benefits, please contact Membership Services at 1-800-777-1370 or 1-800-464-4000 pg. 9