RAG rating
n/a
Document type
Clinical policy
Place
Hertfordshire and West Essex ICB
Output type
Clinical Policies & Evidence-based Interventions
Document
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Body Contouring

July 2022 v1.0

The aim of body contouring procedures is to improve the functional ability of people with severe loose or sagging skin. Body contouring is not funded for cosmetic or psychological reasons.
The areas where body contouring may be considered are (although this list is not exhaustive):
  • Abdomen
  • Thighs
  • Arms - above the elbow only
  • Breast
Abdominoplasty and apronectomy (body contouring of abdomen) are outside of the scope of this policy. Please refer instead to the national EBI programme criteria at https://ebi.aomrc.org.uk/ 
This policy applies to body contouring at all other sites.

Content 

The body area that contouring is requested for must be made clear in the referral. Medical photography may be requested.
Body contouring should not be commissioned for cosmetic reasons and should be offered only in exceptional cases for those patients evidencing a strong clinical need. 
The following criteria should be fulfilled: 

Age 18 or over 
AND 
Same site body contouring has not already been performed. (A maximum of 1 procedure for each area of the body will be funded.)
AND

Disfiguring scarring following trauma or previous surgery resulting in skin tethering to deep tissues and functional problems or severe pain.
OR
Excessive skin as a result of significant weight loss where:

     o Starting BMI above 40 and current BMI less than 25 with a stable weight maintained for at least 2 years.

OR
    o Starting BMI above 50 and current BMI at least 20 points lower, or 50% of excess body weight lost, whichever is greater. Stable weight maintained for at least 2 years.

AND 

Significant functional problems

     o Experience of severe difficulty with activities of daily living as documented on the Barthel scale.

OR 
     o Significant recurrent infections beneath the skin fold, panniculitis or skin ulceration that has not responded to optimal medical therapy (typically for at least 12 months, requiring systemic antibiotics or antifungals)

All patients with excessive skin as a result of significant weight loss need a full assessment of their functional problems by an appropriate professional (e.g., Occupational Therapist) prior to an application, and the report must be included with the application. It is incumbent on the referring clinician only to refer for an assessment for patients who do have severe functional issues. 
All funding for body contouring will be for a single stage procedure. Contour irregularities and moderate asymmetry are predictable following surgery. Any post-surgical cosmetic irregularities (including dog ears or unequal fat distribution) will not be funded by the ICB for revision surgery.

Definitions

"Severe functional problems”: The following are examples of severe functional issues, but this list is not exhaustive:
  • Documented evidence of recurrent infections beneath the skin folds
  • Experiencing severe difficulties with daily living e.g., ambulatory restrictions, hygiene,ulcerations etc
"Stable weight”: Refers to weight with no greater fluctuation than +/- 5kg around the weight at the start of the two years. There must be evidence that weight independently assessed (e.g., through GP or weight management provider e.g., Weight Watchers/Slimming World) every 6 months during this time (i.e., 4 assessments taken over the 2 years).

"Excess body weight” is the weight loss required to reduce an individual to the maximum ‘normal’ BMI of 25kg/m2.

"Disfiguring scarring” – disfigurement is the state of having one’s appearance deeply and persistently harmed. 

Rationale

Procedures for aesthetic reasons are not routinely funded. Approval of body contouring is only for problems with severe functional problems and experiencing severe difficulties with the activities of daily living.
To make this procedure clinically effective, it is important that patients undergoing BCS procedures have achieved and maintained a stable weight so that the risks of recurrent obesity are reduced and risks relating to surgery are kept to a minimum.

Patients who are not eligible for treatment under this policy may be considered on an individual basis where their GP or consultant believes exceptional circumstances exist that warrant deviation from the rule of this policy. Individual cases will be reviewed as per the ICB policy.

References

British Association of Plastic, Reconstructive and Aesthetic Surgeons, "UK Commissioning guide: Massive Weight Loss Body Contouring,” 2017. http://www.bapras.org.uk/docs/defaultsource/commissioning-and-policy/2017--draft-for-consultation--body-contouring-surgerycommissioning.pdf?sfvrsn=0 (Accessed 19/10/18)
http://www.bmj.com/company/wp-content/uploads/2016/05/NHS-weight-loss-surgery.pdf
Al-Hadithy, H. Aditya, & K. Stewart, "Does the Degree of Ptosis Predict the Degree of Psychological Morbidity in Bariatric Patients Undergoing Reconstruction?” Plastic and Reconstructive Surgery, pp. 942-950, 2014.
Gilmartin, SJ, Long, A and Soldin, M, "Identity transformation and a changed lifestyle following dramatic weight loss and body-contouring surgery: An exploratory study,” Journal of Health Psychology, vol. 20, no. 10, pp. 1318 - 1327, 2015.
van der Beek et al., "The impact of reconstructive procedures following bariatric surgery on patient wellbeing and quality of life,” Obesity Surgery, vol. 2, no. 1, pp. 36-41, 2010.
de Zwaan et al., "Body image and quality of life in patients with and without body contouring surgery following bariatric surgery: a comparison of pre- and post- surgery groups,” Frontiers in Psychology, vol. 5, pp. 1-10, 2014.
 
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