Purpose: Following bariatric surgery, a proportion of patients will seek body contouring procedures.  While bariatric surgeries have increased, the number of patients undergoing post-bariatric body contouring (PBBC) has remained relatively stable.  We hypothesize that socioeconomic factors, including primary payer source, play a major role in determining which patients obtain PBBC procedures.

Methods:  PART 1:  Patients having undergone bariatric surgery at our institution between January 2005 and December 2005 were contacted with IRB approval and asked to participate in a questionnaire.  The questionnaire addressed demographics, medical factors, complaints associated with excess skin, prior PBBC procedures and insurance status on the decision to undergo body contouring. 

PART 2: To determine the frequency of post-bariatric body contouring surgery performed in the United States, a cross sectional analysis of the 2006 Healthcare Cost and Utilization Project - Nationwide Inpatient Sample was performed.  Entries with the ICD-9-CW code V45.86, indicating prior bariatric surgery status were identified.  Next, ICD-9 procedure codes 86.83 (abdominoplasty / panniculectomy) and 85.6 (mastopexy) were used to identify PBBC procedures within this patient group.  Admission and discharge status, patient demographics, expected payment source, total charges, length of stay and hospital characteristics were examined. To assess region variability, US states were grouped into 1 of 4 regions based on US census data.

Results:  PART 1: Responders were more commonly female (83%) and married (67%).  The mean pre-op BMI was 48.8 while the mean post-op BMI was 29.8.  Eighty three percent of patients stated that they had overhanging abdominal skin that impacted on quality of life such that they would seek PBBC.  The most common reasons patients had not yet undergone body contouring surgery were; 1) concerns over inability to pay and 2) waiting for weight loss plateau.  

PART 2: Within the NIS population, 4,500 patients were identified as bariatric surgery patients.  Of these, 261 underwent a PBBC procedure.  Compared to non-PBBC patients, PBBC patients were more likely to be female (87.4 vs 82.4%, p<0.05) and to be self paying (18.4 vs 3.6%, p<0.05).  Age and race did not differ in the 2 groups.  The most common payer for PBBC and non-PBBC procedures was private insurance (59 and 61%).  For non-PBBC procedures, Medicare was the second most common payer source (22.5%). Yet, for PBBC, self-pay was the second most common payer source (18.4%), while Medicare was third (11.1%).  Comparing trends across the 4 US regions, the expected primary payer distribution differed significantly for those patients undergoing PBBC (Figure 1).

Conclusion: Following bariatric surgery, many patients will consider body contouring to help manage symptoms related to excess soft tissue.  However, pursuing these procedures is closely related to the ability to pay.  Private insurance appears to pay for non-PBBC and PBBC surgery at a similar rate across the US.  However, relative to non-PBBC procedures, a greater (and regionally variable) percentage of patients must pay for PBBC surgery out of pocket.  This inequality coincides with a decreased rate of Medicare payment as primary payer for PBBC in all regions.