New national body contouring surgery guide launched to promote equality in provision and improved care for weight loss patients
First framework to help people denied access to life changing NHS plastic surgery treatment
Today (11 March 2014) a new body contouring commissioning guide, which aims to address variation across England in provision and quality of body contouring surgery for patients who have undergone massive weight loss, is launched by the British Association of Plastic, Reconstructive and Aesthetic Surgeons (BAPRAS) and the Royal College of Surgeons (RCS).
Body contouring surgery is reconstructive surgery following major weight loss to remove excessive skin. It is the first time a standardised guide, which has been developed following a rigorous NICE accredited process, has been developed to inform the issue.
The guide was developed in response to research which shows inconsistency in the provision of body contouring surgery across the country. A study(1) of 67 primary care trusts(2) in England showed that 23 excluded any reference to body contouring procedures.
Even where guidance is in place, recommendations can vary dramatically. It has been revealed(3) that 38% of patients who were approved in Scotland for body contouring surgery would not have fulfilled the criteria used in Leeds.
The studies reveal that patients who have already received NHS funding for a gastric band or other form of bariatric surgery then find it very difficult to get body contouring surgery after their weight loss. In addition, access to body contouring surgery is even harder for patients who have lost the weight naturally, through diet/exercise alone (10-30%). This is because they do not have the support of bariatric multi-disciplinary teams(4).
The new guide addresses variation in provision and quality of care – whilst also helping to make most appropriate use of resources – by providing clear criteria for commissioning body contouring surgery and best practice information for healthcare professionals. This includes a quality checklist for multidisciplinary teams to follow through every step of the procedure. The guide concludes with future recommendations, including the development of a compulsory register of operations and complications to enable the best outcomes for patients.
Research has shown that patients who undergo reconstructive body contouring plastic surgery following massive weight loss experience significant improvements in their physical function, emotional wellbeing, body image satisfaction, physical wellbeing and quality of life(5).
Conversely, patients who aren’t able to access body contouring surgery following massive weight loss can suffer from a range of physical and psychological problems. In a recent study, 92% of bariatric surgeons reported that patients experience functional problems relating to excess skin(6). Psychological problems include stress, depression and low-self esteem. Patients unable to access body contouring surgery are also significantly more likely to regain weight, which can lead to health problems, such as diabetes, heart disease and mobility issues, with a resulting burden to the NHS(7).
Mark Soldin, BAPRAS specialist in body contouring surgery and consultant plastic surgeon said:
“I’ve seen many patients whose lives have been transformed through receiving body contouring reconstructive plastic surgery. However, there are many other people who, simply due to their postcode, are denied this procedure and are left to deal with the huge physical and psychological problems caused by excess skin.
“To qualify for this surgery patients need to demonstrate incredible weight loss and to show they have kept the weight off for a considerable period. However, the current ‘postcode lottery’ is unfair for the many patients up and down the country who have worked hard to change their lifestyles in order to meet the strict criteria. We are calling on commissioners and GPs to use this carefully researched, NICE accredited guidance to put an end to people living in limbo, and enable them to live healthy, happy lives.”
It is also hoped the guidance will be used to support GP referrals for patients requesting body contouring surgery by outlining clear criteria for patient assessment.
Paul O’ Flynn, Consultant ENT surgeon and Council Lead for commissioning at the Royal College of Surgeons, said:
“Research demonstrates significant improvements in patients’ emotional wellbeing and quality of life once they have undergone body contouring surgery, which is why it is critical that this guide is used by both commissioners and GPs to inform their referral decisions.
“We hope that this guide will help to create equality in provision of body contouring surgery for patients across England and stop unfair postcode lotteries which are denying patients desperately in need of treatment.”
The full guides is available from www.bapras.org.uk and www.rcseng.ac.uk
Information about available case studies:
• Kerry Trotter, 39
Kerry received a gastric bypass procedure in September 2011 at the Sunderland Royal Hospital, when she weighed 22 stone. Within a year of surgery she had lost a further eight stone, taking her down to 14 stone.
Kerry has been left with lots of excess skin, which is extremely uncomfortable. She made an initial request for a body contouring surgery NHS referral at Durham Hospital in August 2013. After no response for some time, Kerry learned that her appointment had been cancelled without her knowledge, as the medical team had decided that she didn’t fit the eligible criteria for surgery.
Kerry and her GP were subsequently told that this was because the referral notice had been incorrectly logged as a request for breast reduction surgery, when in fact it is major reconstructive plastic surgery that Kerry needs. She will be making another referral request in the near future, with the view to having breast reconstructive surgery and skin removal from her stomach. Kerry now weighs 11 stone
“It’s a big mental challenge getting used to losing so much weight. Having lots of excess skin is very painful – my muscles are stretched and it hurts when my skin is touched.
“Before I had a gastric bypass I knew that I’d be left with lots of excess skin and that this would be uncomfortable – at the moment I can’t wear the clothes I’d like or do all the activities I want to – but I made the decision because I want to be healthy.
“It’s been really problematic trying to secure a proper and fair assessment. I’ve had trouble communicating the fact that I need serious reconstructive plastic surgery, not a breast reduction. I think the assessment process needs to be improved and made more consistent.”
• Wayne Horridge, 33
Wayne weighed 33 stone before receiving a gastric sleeve operation in November 2008, after three years of trying to secure funding support for bariatric surgery.
Wayne lost weight very rapidly and it was difficult for him psychologically to get used to his new body and excess skin. He tried to receive support from the Kings College Mental Health Trust, but this wasn’t effective.
In 2010, Wayne discussed the possibility of body contouring surgery with his GP. However, during his assessment, his reasons for wanting the surgery were deemed as cosmetic, which meant he was denied NHS funded reconstructive body contouring surgery.
Wayne now weighs 16 stone and is yet to receive NHS funded body contouring surgery.
“It’s been a continual struggle trying to receive funding for having excess skin removal, and I’ve just been told to keep waiting.
“Having the surgery would boost my confidence right back up – I visited Australia a couple of years ago and was sitting in a t-shirt on a beach in 40 degree heat. I’d go swimming first thing in the morning or last thing at night, when no-one else was around.
“People need to realise that weight loss surgery alone isn’t an easy way out – the after effects of having so much excess skin are enormous and it’s really uncomfortable.
“Those who have been consistent in losing weight should have fair access to body contouring surgery on the NHS. It shouldn’t only go to bariatric patients either – those who have lost weight naturally and got their lives back on track should be given the same support.”
BAPRAS, the British Association of Plastic, Reconstructive and Aesthetic Surgeons, is the voice of plastic surgery in the UK. It aims to increase the understanding of the professional specialty and scope of plastic surgery, promoting innovation in teaching, learning and research.
Founded in 1946 (originally as the British Association of Plastic Surgeons), today BAPRAS has over 800 members and is the professional representative body for reconstructive and aesthetic plastic surgeons providing services to patients on the NHS and privately in the UK.
Members of the public can find a member plastic surgeon in their area by logging on to www.bapras.org.uk. Anyone can check the GMC to find out if a surgeon is on the plastic surgery specialist register; http://www.gmc-uk.org/register/search/index.asp
1 Mukherjee S, Adegbola S, Kamat S, Agrawal S. Bariplastic (post bariatric body-contouring) surgery in England: a ‘postcode’ lottery. Presented at: 5th Congress of the International Federation for the Surgery of Obesity and Metabolic Disorders European Chapter; April 2012; Barcelona.
2 PCTs no longer exist
3 Shermak MA, Chang D, Magnuson TH, Schweitzer MA. An outcomes analysis of patients undergoing body contouring surgery after massive weight loss. Plast Reconstr Surg 2006; 118: 1,026–1,031.
4 Panniculectomy and Redundant Skin Surgery in Massive Weight Loss Patients- Current Guidelines and Recommendations for Medical Necessity Determination Gurunluoglu R. Ann Plas Surg 2008: 61(6);654-7
5 Gilmartin, J. Long, A,F. Soldin, M. 2013. Identity transformation and a changed lifestyle following dramatic weight loss and body-contouring surgery: An exploratory study. Journal Health Psychology 1359105313511838, first published on December 1, 2013
6 Highton L, Ekwobi C, Rose V. Post-bariatric surgery body contouring in the NHS: a survey of UK bariatric surgeons. J Plast Reconstr Aesthet Surg. 2012 Apr; 65(4): 426-32. Epub 2011 Oct 20.
7 Plastic Surgery Improves Long-Term Weight Control after Bariatric Surgery. Plastic and Reconstructive Surgery, 2013; 132 (4): 826 Nicolas Balagu, Christophe Combescure, Olivier Huber, Brigitte Pittet-Cunod, Ali Modarressi