Fri, Dec-22-06, 14:01
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Senior Member
Posts: 1,902
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Plan: IF/Keto OMAD
Stats: 236.9/214.1/199
BF:Why yes/it/is !!!
Progress: 60%
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For what it's worth (if you ever want to have the apron removed)....if you have insurance and you get these infections often you might want to go see a doctor for this...several times. Most insurances do not cover "cosmetic surgery" and some insurance companies like to that that pannectomy surgery is "cosmetic". However if you get frequent infection in the folds that have been seen several times by your doctor it can be considered "medically necessary".
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Start now to document the rashes and infections now with a digital camera with a date stamp. Get a home photo printer so that you can print each of the photos at home yourself. (commercial photo labs won't print these kinds of photos). Keep a photo diary so that your doctor can see what you have to deal with, the frequency and the severity of the problem. Once you have a solid photo documentation, you can have your doctor write a letter for you supporting your application to have a pannilectomy(removal of large pannus((apron of fat and skin)).
Any and all kinds of documentation including treatments you have tried, that didn't work, current treatments you are using, and any other supporting reasons why it is necessary to have the surgery as reconstructive rather than cosmetic. (Hygeine, infections, strain on musko-skeletal system etc.
The reason i'm saying this is because i'm in the exact same boat you are. This is what i'm planning to do next time i get an infection.
Here's an article i saved that you might find helpful....pieced together bits of info you may want to consider.
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CRITERIA FOR ABDOMINOPLASTY TO BE MEDICALLY NECESSARY
Abdominoplasty is considered reconstructive when performed to correct or relieve structural defects of the abdominal wall (ICD-9: 701.8/708.9) and/or chronic low back pain (ICD-9:724.1) due to functional incompetence of the anterior abdominal wall. These conditions may be caused by:
1. Permanent overstretching of the anterior abdominal wall following one or more
pregnancies; (ICD-9: 701.8.701.9).
2. Permanent overstretching (with or without diastasis recti (ICD-9: 928.84) of the anterior abdominal wall with a large or long abdominal panniculus (ICD-9: 278.1) following weight loss in the treatment of morbid obesity and resulting in the uncontrollable intertrigo (crease dermatitis, ICD-9: 692.9) and/or difficult ambulation (ICD-9 724.8).
3. Trauma or surgery to the anterior wall of the abdomen resulting in loss of muscle of fascial integrity or pain from scar contracture (ICD-9: 709.2).
4. Abdominal hernia following previous abdominal surgery (ICD-9: 553.201, 553.21).
Redundant abdominal tissue is called a pannus or panniculus. A pannus can be so large that it hangs like an apron, covering the hips and extending around to the lower back. This large flap of skin can cause disabling rashes, cellulitis, pain, physical limitation, back strain, as well as cosmetic deformity. The larger the pannus, the more extreme symptoms tend to be. endured chronic joint pain and osteoarthritis, especially in the thoracic and lumbar spine areas secondary to a history of obesity. “I also could not sleep comfortably in any position. I had medical reasons for having an abdominoplasty with panniculectomy, which took the extra weight off my spine and helped resolve the back pain.”
The medical reasons cited were recurring rash (yeast infection) under the folds of skin, weakened abdominal muscles due to pregnancy, c-section and previous morbid obesity, and severe breast ptosis (droopiness)
performed for medical and functional reasons, such as for hygiene and mobility, and is then considered a reconstructive procedure and covered by insurance.
INDICATIONS FOR SURGERY
Surgical excision of excess abdominal skin dates to the early 1900s. In 1910, Kelly reported positive outcomes including weight loss, improved comfort, increased activity, and improved hygiene following surgery.1 Anterior abdominal wall laxity is the primary medical indication for an abdominoplasty, since it is responsible for structural defects of the abdominal wall and chronic low back pain (Figures 1 and 2). Abdominal wall laxity can increase the work support of the lumbar dorsal fascia, resulting in lower back pain. Ten extra pounds of adipose tissue in the abdominal wall adds 100 lb of strain on the disks of the lower back by exaggerating the normal “S” curve of the spine. Diastasis recti, congenital or secondary to pregnancy, decrease the efficiency of the abdominal musculature, contributing to lower back strain.
Figures 1 and 2. Overweight Patient with hanging abdominal pannus and evidence of diastasis recti with a bulging abdomen. Note flatter, tighter abdominal contour after surgery.
“Supra-pubic lift,” which relocates the mons pubis to a higher, more youthful location.
PREPARATION FOR SURGERY
Abdominoplasty is an elective operation; therefore, patients should be otherwise good surgical candidates. Patients should have a recent physical exam, complete blood count, and a negative pregnancy test. In fact, patients who are considering additional pregnancies are strongly advised against abdominoplasty. While it is possible to successfully complete additional pregnancies following abdominoplasty (skin excision and muscle plication), a patient will negate many of the positive results of the operation with additional births. Smoking cigarettes should cease at least 2 weeks prior to surgery. Smoking significantly increases wound-healing complications, including wound dehiscence, skin loss, and infection. Ideal candidates are at an ideal, stable body weight (body mass index [BMI] of 25 or less). Patients who are medically obese (BMI >30) are a higher surgical risk but are considered for surgery following an individual risk-benefit analysis of other pre-existing medical problems of dysfunction secondary to the abdominal pannus or abdominal wall laxity.
SURGICAL TREATMENT
Many techniques have been described over the past decades to accomplish the goal of skin excision. The resultant closures include high to low horizontal or vertical scars. Most common is the excision of the excess abdominal skin between the umbilicus and mons pubis resulting in a low U-shaped abdominal scar extending from one iliac crest to the other. This incision is easily covered by underwear or a bathing suit. The second, a potentially visible scar, is around the umbilicus at its new position where it exits the tightened abdominal skin.
Once the lower abdominal skin is excised, the upper abdominal skin flap is raised toward the sternal notch. The anterior rectus sheath is clearly exposed at this point and the medial edges of the rectus muscle are plicated with permanent sutures. Any abdominal hernia can be repaired at this time as well.
Less severe deformities can be treated with a “mini-abdominoplasty.” This procedure simply removes excess lower abdominal skin without movement of the umbilicus and complete rectus plication.
Operating time for an abdominoplasty is 2 to 4 hours. It can be performed in an ambulatory center or a hospital, generally, on an outpatient basis. Overweight patients with any medical problems should have the surgery performed in a hospital and observed overnight. Most surgeons who perform abdominoplasty use a general anesthetic, but the surgery can be performed safely using local anesthesia with deep sedation or an epidural. Drains are placed and remain for 1 to 2 weeks following surgery. Sequential compression devices are always used. Urinary catheters are not routinely used. Blood loss of less than 100 cc is customary; therefore, transfusion is not anticipated for this procedure.
Panniculectomy Surgery (Abdominoplasty)
Panniculectomy surgery is a reconstructive procedure performed to remove a panniculus, sometimes referred to as a pannus or abdominal apron. The pannus frequently contributes to a number of health concerns, including chronic wounds. Panniculectomy surgery becomes necessary for many patients who have had massive weight loss as a result of successful bariatric weight-loss surgery. Bariatric weight-loss surgery is one of the fastest growing specialties in America, and therefore, nurses can expect to care for increasing numbers of patients who require this reconstructive procedure. Despite the medical necessity of panniculectomy surgery, barriers to reimbursement exist. An update on the demographics of obesity, nationally and worldwide, are presented, especially as this information relates to the growing interest in panniculectomy surgery following massive weight loss. Bariatric weight-loss surgery and panniculectomy surgery are described and barriers to reimbursement are explained. The importance of wound care documentation in making the case for reimbursement is described, and a sample letter of appeal is provided.
Panniculectomy excises the abdominal pannus. In addition to panniculectomy, a reconstructive abdominoplasty, which involves the anterior muscle wall and fascial plication, is usually performed. A suction lipoplasty may improve the reconstructed abdominal wall contour; the patient may also undergo umbilical or ventral hernia repair. In panniculectomy, the incision creates a scar from the xiphoid process to the pubic bone. There it meets a second, horizontal scar, just above the pubic area, to form what looks like an inverted letter “T.” To create this “T,” the surgeon frees up fat and skin from the anterior abdomen. At that point, a large triangularly shaped area of loose skin and excess fat is carefully removed. The remaining tissue is then attached to the anterior abdominal wall and to itself. A number of procedures can be completed at the same time, such as exploratory laporatomy, revision of the primary surgery, or repair of abdominal wall/ventral hernia.
Who are the Best Candidates for a Panniculectomy surgery ?
When a patient loses large amounts of weight, the skin does not retain its shape, leaving the patient with a large hanging apron of excess skin and fat below the stomach area, otherwise known as a pannus," said Ernest Manders, MD, ASPS member. "By focusing on patients who undergo a panniculectomy to remove the pannus, we found significantly fewer complications in patients who had the procedure one year after bariatric surgery rather than during the initial surgery
Are you still planning to lose a lot of weight?
Waiting one year and allowing an interval for weight loss after the surgery, has a number of benefits over the simultaneous procedure. There were significantly fewer complications for patients who waited one year, including fewer wound infections and less wound reopening. Of the 123 patients studied, there was no respiratory disease or deaths among patients who waited after bariatric surgery. In addition, 20 percent of patients who had a panniculectomy during bariatric surgery had the surgery repeated later due to additional weight loss.
Patients who waited fared much better than those who did not because their bodies were healthier going into the panniculectomy, according to Dr. Manders. Many of the patients studied had lost about 100 pounds, gotten their diabetes under control, reduced their hypertension and lowered the stress on their hearts, making the surgery much safer and decreasing the risk of complications.
How is a Panniculectomy Surgery Done?
This surgery is similar to a tummy tuck but is more complex. Panniculectomy cuts out the large abdominal apron of fat that hangs down in obese people or those who have lost a great deal of weight.
Home Care After Panniculectomy
Please follow these instructions in addition to those listed on the General Home
Care After Plastic Surgery sheet you received. Abdominoplasty / Panniculectomy
If you have steri strips (butterfly tapes) on your incision, leave them in place until your first doctor’s visit after the surgery.If you have drains, empty them as instructed. Record the amount of drainage and reapply the suction 2 times a day. Sponge bathe daily until the drains are removed, then you can shower. Wash your wound with soap and water and pat it dry once a day. Clean around the drains once a day and replace the dressings. If the dressings are soiled, they can be replaced more often. Do not lift anything over 10 pounds for 6 weeks. This includes children and pets. Do not put pressure or weight on your abdomen for 6 weeks. Wear an abdominal binder, if provided, 24 hours a day until you return for your first doctor’s visit after surgery. You may remove it to clean your wound.
As expected, you will have pain and swelling in the days following surgery. Your doctor can prescribe a painkiller if needed, and will instruct you on how to best handle the pain.
Soreness may last for several weeks or months. You may also experience numbness, bruising and overall tiredness for that same time period.
As with any surgery, there are risks. Remember, this surgery affects a very crucial part of your body. Though they’re rare, complications can include infection, bleeding under the skin flap, or blood clots. You may carry an increased risk of complications if you have poor circulation, diabetes, or heart, lung or liver disease.
You may experience insufficient healing, which can cause more significant scarring or loss of skin. If you do heal poorly, you may require a second surgery. As we mentioned before, the scars from a tummy tuck are fairly prominent, and though they may fade slightly, they will never completely disappear. Your surgeon may recommend certain creams or ointments to use after you’ve completely healed to help with the scars.
Return to Living
Generally, most people love the new look after they’ve undergone this procedure; however, you may not feel like your normal self for months after the surgery. You’ve gone through a tremendous amount to make this happen, both emotionally and spiritually, and it’s very important that you follow proper diet and exercise to maintain your new look.
Does Insurance Cover a Panniculectomy Surgery?
Be warned: Insurance carriers generally do not cover elective, cosmetic surgery. But, your carrier may cover a certain percentage if you have a hernia that will be corrected through the procedure, or your anterior muscles are abnormally spread. It’s extremely important that you begin communicating with your insurance company early on, and that you discuss your insurance concerns with your surgeon. In most cases, your surgeon will write a letter to your insurance carrier, making the case for medical necessity, if it applies to you. It’s also very important to realize that insurance may only cover certain portions of the surgery, so make sure you get details. With any cosmetic surgery, this may affect future insurance coverage for you and your premiums may increase.
Reconstructive surgery
Abdominoplasty is a reconstructive surgical procedure intended to correct a problematic abdominal pannus and the associated co-morbidities. A large abdominal pannus (abdominal apron) can be very troublesome after extensive weight loss. It may be associated with cutaneous inflammation, such as panniculitis, cellulitis, intertriginous dermatitis, skin abscesses, gangrene, excoriation, or folliculitis. Other related concerns include lymphedema, ambulatory difficulty, toileting trouble, and hygiene problems that can lead to unpleasant odors. Urinary stress incontinence can be aggravated by extra lower abdominal weight.14 A large abdominal pannus often poses a barrier to sexual activity. Patients frequently complain of debilitating low back and extremity pain. Physical activity can be uncomfortable. Clothes fit improperly, and patients report body image concerns. A large abdominal pannus can interfere with respiratory function and lead to diminished abdominal wall integrity from attenuated fascia and muscles; umbilical and ventral hernias are not uncommon.15 Abdominal panniculectomy and reconstructive abdominal surgery may be performed to alleviate these conditions. However, some thirdparty payers are reluctant to provide reimbursement, and most patients are unable to afford the procedure without some financial assistance.
Documentation for reimbursement
Some authors contend that postbariatric, surgical, co-morbidity issues are similar to those following radical mastectomy, where breast reconstruction has become recognized as a humane necessity. Like individuals treated for breast cancer, people experiencing profound weight loss often require corrective surgery. Such surgery should be an accepted part of the surgical package or at least available on a reasonably permissive, as required basis.15 Regardless, the indications for panniculectomy require documentation, which serves as a basis for appeal in the event that corrective surgery is initially denied. Third party payers have been known to refuse payment for abdominal panniculectomy for many reasons, one being a lack of photographic evidence, coupled with a lack of clinical evidence. Therefore, it is prudent to document all observed and reported clinical symptoms that are associated with a large abdominal pannus, along with dated photographs. Some payers require that the pannus hang down far enough to obscure the pubic area. Others reportedly look for intertrigo or other signs of inflammation under the pannus. Photographs that best serve the patient’s needs include front, side, and under surface views.15 When all else fails, some patients have asked attorneys who specialize in reimbursement for bariatric needs to assist them in obtaining third party payment.16
Panniculectomy
Panniculectomy excises the abdominal pannus. In addition to panniculectomy, a reconstructive abdominoplasty, which involves the anterior muscle wall and fascial plication, is usually performed. A suction lipoplasty may improve the reconstructed abdominal wall contour; the patient may also undergo umbilical or ventral hernia repair. In panniculectomy, the incision creates a scar from the xiphoid process to the pubic bone. There it meets a second, horizontal scar, just above the pubic area, to form what looks like an inverted letter “T.” To create this “T,” the surgeon frees up fat and skin from the anterior abdomen. At that point, a large triangularly shaped area of loose skin and excess fat is carefully removed. The remaining tissue is then attached to the anterior abdominal wall and to itself. A number of procedures can be completed at the same time, such as exploratory laporatomy, revision of the primary surgery, or repair of abdominal wall/ventral hernia.
Operative management
In addition to the usual preoperative workup, some authors suggest endoscopic or radiographic studies of the primary weight loss surgery, because if revisions of the initial surgery are needed, this is thought to be the best time to make them.15
From 13% to 47% of patients who have abdominoplasty experience perioperative complications. The literature suggests that elderly patients, those who smoke, and those who have hypertension have a greater incidence of postoperative complications.17
A number of conditions influence the postoperative course of patients who have surgery. Some patients have lost considerable weight prior to panniculectomy surgery, while others may still be large enough to develop weight related postoperative complications. Early mobilization is criti cal in the recovery period. Many larger pa tients are able to turn, ambulate, and trans fer soon after surgery, while others may have difficulty because of pain or sedation.18 A physical therapist can assess the postop erative strength and endurance needs of patients.
Patients who weigh more than 300 pounds generally require some level of special accommodation. Often, the only special accommodations that patients need are a bed that is wide enough to allow them to turn independently, a walker to support their weight for the first few postoperative days, and an overhead trapeze to help them to reposition themselves. These three items are thought to help patients to maintain their strength and independence. Clinicians report that independent patients who have adequate supportive equipment are less likely to injure themselves or caregivers during the early postoperative period.19
At this time, patients may have a higher morbidity from surgery and anesthesia due to atelectasis, deep vein thrombosis, and pulmonary embolism.15 Sequential compres sion devices are available to accommodate larger legs. Foot “squeezers” are useful in that they better accommodate larger patients. Full body rotation therapy may control the risk of atelectasis in postoperative patients with limited mobility. Abdominal binders can help promote postop activity by encouraging deep breathing, turning and coughing.
Although hematoma formation rarely occurs, wound dehiscence, seroma formation, and wound infection are common problems. 14 Drains are routinely placed after surgery, and it is important to look for drain clotting or the unintentional removal of drains by patients, who are often discharged with drains still in place. To prevent accidental dislodgement of the drainage bulbs, the clinician may choose to secure the suction reservoirs with a commercially available holders with an elastic waistband and Velcro closure (fig. 1). The holder may discourage patients from pulling out or tampering with the drainage bulbs. Patients or their caregivers will need to learn how to empty and care for tubes as well as to develop an emergency plan in case clots form or the tube falls out.
Infection can be a problem, because many morbidly obese patients have other medical problems, particularly type II diabetes mellitus. It contributes to delayed wound healing. Additionally, unexcised fatty tissue can become devitalized, leading to fat necrosis and subsequent infection.
Care should be taken when assessing the low midpoint of the “T” in the abdominal incision, as this is where a wound separation is most likely to occur.14 All wounds should be kept clean and dry, especially those in skin folds. It is important to contain any drainage, clean the area frequently with a nontoxic cleanser, and secure dry dressings to absorb excess moisture. In the event of wound separation, patients can be taught to cleanse the opened area gently with a nontoxic wound cleanser. They should avoid cytotoxic cleansers, such as betadine and Dakin’s solution, unless specifically indicated for bacterial invasion. Irregular body contours present a challenge for securing dressings. Flexible cloth tapes can mold to the contours as necessary to ensure that dressings are fixed securely to the intended area.
Freiberg explains that some wound complications can be avoided or at least minimized by the use of abdominal binders and, later, girdle supports with gapfree stitching in widths up to 15’ and lengths up to 94” (such as the Dale Abdominal Binder). Abdominal binders should be worn for the first 4 weeks after surgery. Binders not only provide a degree of comfort, they minimize shearing forces between the abdominal skin and wall. Binders are designed to control unnecessary edema and to reduce ecchymosis.14 If the patient has lost considerable weight, then special oversized binders may not be necessary. However, if some binders do not fit properly, they can lead to skin breakdown or failure to comply with the care plan. The binder with a Velcro closure with limitless sizing can accommodate a wide range of body shapes (Fig. 2). As the patient loses weight, the binder can be closed at different points and/or panels can be removed. A clinical nurse specialist, as a member of the interdisciplinary team, can ensure that properly sized equipment is available.
Pain is thought to interfere with mobility and must be considered as part of the recovery plan. Excess body fat can alter drug absorption, depending on the medication. For example, drugs such as diazepam and carbamazepine are highly soluble in fat and therefore absorbed mostly in adipose tissue. Dosages of these drugs must be calculated by using the patient’s actual body weight. Drugs that are absorbed mainly into lean tissue, such as acetaminophen, should be calculated using the patient’s ideal body weight – what the patient should weigh.20 Trying to remember which drugs fall into which category is almost impossible. A clinical pharmacist can be an important resource to ensure that drug dosages are accurate.
Standardized 1 to 1.5 inch needles may not be able to penetrate adipose tissue in a patient with especially thick hips. In this case, either a longer needle or a drug that uses another route should be considered.
Sometimes, veins in a larger person’s arm are deeply buried and starting an IV can be difficult. The use of a bendable armboard which can be custom shaped to each individual patient and secured with Velcro straps can help protect the IV site and prevent the cather from being dislodged. If it takes more than two tries, consider using a peripherally inserted, central catheter (PICC) or a midline catheter instead of a standard peripheral catheter. Both will stay in place for weeks or months, thereby eliminating the need to stick the patient repeatedly.21
Postoperative care is essential at the beginning of the recovery period. Early ambulation, appropriate use of specialized equipment, attention to the risks of wound and pulmonary complications, IV access, and pain management work together to achieve that end.
Summary
It is important for consumers to realize that weight loss surgery is a tool to help them lose weight – but only a tool. Once weight loss is achieved, they may continue to battle with quality of life issues, one of which is a large abdominal pannus, which often contributes to a functional deficit as well as hygiene and wound care problems. Panniculectomy is thought to control some of these co-morbidities and to provide patients with an opportunity to move forward with daily living activities
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best wishes
Last edited by deb34 : Fri, Dec-22-06 at 14:14.
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I thought that even when I was thin.
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