Your Questions
Your Questions
Q: Dr. Eppley, I am interested in getting a tummy tuck but don’t know too much about it. What type of tummy tuck do I need? Should I try and lose more weight before? Although with my back injury and being on disability I don’t see any significant weight loss happening. I have attached some pictures of my overhanging stomach for your review.
A: Thank you for sending your pictures. What you have is a large abdominal pannus and thick abdominal tissues. What you would ultimately need is really an abdominal panniculectomy rather than a classic tummy yuck. Your abdominal tissues are too thick an your weight is too high to do accomplish anything more than an extended abdominal panniculectomy. While such a procedure would clearly have great benefit, ideally you should lose a lot more weight to have the better abdominal reshaping procedure. But for many patients weight loss is difficult and an abdominal panniculectomy now is better than nothing at all. That would have to be a decision that only you can make and I think with your back injury that decision has already been made.
You should clearly understand that an abdominal panniculectomy is not the same as a tummy tuck. It is a less refined although larger amount of abdominal tissue removal whose main objective is to eliminate the overhanging abdominal tissues.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am wondering if I am a candidate for an abdominal panniculectomy procedure. What I mean by being a good candidate is whether insurance will pay for the procedure. removal. I am not sure if I am a grade 2 or 3 pannus.
A: Only your insurance company can truly answer the question of whether an abdominal panniculectomy would be covered but the basic criteria are:
1) an abdominal pannus that covers the groin crease and hangs onto the thighs,
2) an abdominal pannus that is associated with recurrent groin crease skin infections that has a documented three month history of topical skin treatments (non-surgical therapy) that has failed,
3) a BMI of less than 30 or a body weight that in within 20% of their ideal body weight based on standard height and weight measurements.
If one does not fulfill all three criteria, my experience has been that approval for abdominal panniculectomy surgery will be denied. And in some cases, even if all three criteria are met, a denial will still be given. It is also important to check whether your insurance company has a policy exclusion for panniculectomy surgery, as many companies now do, so this may not be a surgical procedure that is even eligible for coverage.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am interested in a tummy tuck which is needed after my bariatric surgery. After my bariatric surgery I’ve had this horrible itching and burning under my skin flap over my c-section scars. Do you thing my insurance would help pay for me to get a tummy tuck? I am too embarrassed by my body to swim or dress in front of anybody. It really is horrific on my life.
A: For the sake of clarification, you are specifically asking about an abdominal panniculectomy not a tummy tuck. An abdominal panniculectomy is a potentially medically indicated procedure to treat a flap of overhanging skin that causes dermatologic problems underneath it due to chronic moisture. A tummy tuck is a purely cosmetic procedure that removes loose abdominal skin and fat that may or may not have some waistline overhang.
Only your health insurance company can truly answer the question of whether an abdominal panniculectomy would be a covered procedure. That needs to be obtained through what is known as a predetermination process. This involves a consultation from a plastic surgeon from which a predetermination letter with picture and medical documentation would be submitted. From this information, your health insurance company will then determine whether they authorize coverage.
While only the insurance company can make that decision, there are very specific criteria that they look for in determining that eligibility. Without all of them, it will most assuredly be denied. They include photographic documentation of an abdominal pannus that hangs over the groin crease onto the upper thighs, photographic documentation of redness/skin irritation under the abdominal pannus, and medical records that demonstrate there has been a history of skin infections that have been treated by topical methods that have recurred despite these treatments.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am interested in getting a body lift. I have had bariatric surgery two years ago and I need to get rid of excess skin. This excess skin around my waistline is causing severe chafing. My insurance won’t cover ‘cosmetic’ surgery. My question is this: can we get insurance to cover it if it is a medical necessity?
A: Insurance in some cases will cover an abdominal panniculectomy but it depends if the abdominal pannus meets several criteria established by the insurance industry. for such coverage. The abdominal pannus must of a certain size as seen in multiple view pictures (hangs down onto the upper thighs), have a medically documented history by a physician of skin rashes/infections that failed to be resolved by topical therapies and one must be of appropriate weight based on their height. (within 20% of their ideal body weight) Fulfilling these criteria is what constitutes ‘medically necessary’ and such information must be submitted to the insurance company for them to pass judgment on whether it is covered or not.
Even if determined medically necessary, insurance will only cover the front half of the trunk (abdominal panniculectomy) and to the back half or the full body lift.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I honestly need an abdominal panniculectomy and need a price. I do have Medicare and Medicaid. I live in Indiana. How much do they cover and how much would it cost out of pocket. I get rashes and yeast infections because of it. It hangs down to lower pelvic area.
A: There are two options to consider regarding an abdominal panniculectomy. It can be done through my private practice on a self pay basis as an outpatient procedure. This is the most efficient method to have the procedure performed, as surgery could be done in a matter of weeks at an outpatient facility. All follow up care is done at one of my private offices. The other route is to use Medicare for the procedure. Medicare is primary over Medicaid so it needs to be approved through Medicare. This would need to be done at my downtown Indianapolis office, where you would be evaluated, photographs would be taken and medical records obtained to document the time and number of treatments done to treat the skin infections. To qualify for Medicare coverage the abdominal pannus must be of a certain size (hanging down onto the thighs), rashes must be present underneath it and there must have been a course of at least 3 months of care provided for the skin infections/rash from your doctor. It would take a few months to determine if you qualify.
I would need to see some pictures of your abdominal pannus to determine if Medicare is even an option and I also need some information about your general medical history.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I have been trying to get an abdominal panniculectomy since I lost so much weight. My insurance company denied me but I plan to appeal. I have infections and skin ulcers. It makes it hard to do my job. I heard about the Patriot Plastic Surgery Program and wondered if you can help. PLEASE!!! I wanted to get this done before my husband got home from his latest deployment and I was wanting to get this done before he got home and I’ve run into roadblock after roadblock. Can you help? I have attached some pictures of my abdominal problem.
A: While there is little doubt that you would benefit from an abdominal panniculectomy, I am not surprised that you have been denied by your insurance company. By insurance requirements you do not meet the very basic criteria of the size of the pannus, it must reach down and overlap onto the thighs. Plus there must be a 6 month history of medically documented skin infections that have failed to respond to topical therapies and there must also be current photographic evidence of active skin infections. Failure to meet all of these criteria will result in denial of coverage for an abdominal panniculectomy. This is a very common occurrence and can be difficult to appeal without providing documentation of their established criteria.
The Patriot Plastic Surgery program is where some reduction in fees is offered for a variety of cosmetic surgery procedures, including tummy tuck and abdominal panniculectomy.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I have attached some pictures of my stomach pannus. Please let me know if I would be a good candidate for an abdominal panniculectomy. It is the most troubled part of my body. I have backaches and some times irritation underneath due to my jeans. I wear a size16 in pants but that is underneath my pannus. If I got pants to go over my pannus they would not fit my legs and hips properly. I hate this stomach!! 🙁
A: Thank you for sending your pictures. I do believe you are a good candidate now for an abdominal panniculectomy. The size of overhang of your pannus is significant and much functional improvement would come from its removal. You are not going to have a flat stomach from the procedure, however, and of this you should be aware. It will still be round due to the amount of intra-abdominal fat but there will be no overhang. In preparation for an abdominal panniculectomy, hopefully in the near future, I would still continue to make efforts to lose weight no matter how slight it may be. That will only enable as much stomach tissue to be removed as possible.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am a 44 year old female. I weigh somewhere between 350 and 370lbs. I have spent many years with multiple medical problems. I currently have Crohn’s Disease, Diabetes (Insulin Pump), Fibromyalgia, Asthma, Underactive Thyroid, Pernicious anemia, CVID and Sleep apnea. Through the years, a strong use of steroids resulted in my right femur breaking. On my first surgery for the femur (Sep 2003), I developed MRSA. I spent the next 4 years constantly having surgeries and receiving vancomycin. In April 2007, the MRSA went dormant. This required removing all hardware from my leg. I currently have a lame right leg. I am wheel chair bound. It was after I permanently moved to a wheelchair that I began to gain weight. I am currently prednisone dependent and I must constantly watch for adrenal crisis. The steroids have greatly added to my weight. Since 2007, my weight has managed to stay around 350 – 360lbs. My skin in so thin and damaged from the steroid use that I have developed an extremely large pannicula. It is very large. On the right side of my body it hangs below the knee. On the left it hangs below the genital area. I develop ulcers in my stomach area. The ulcers often become large, oozy, painful and infected. I have had to take vancomycin to cure the infections. I have a location (at the end on the longest piece of pannicula) that receives inadequate blood flow and it has become hard like a rock. Additionally, I develop fungal infections. I had a C-section in 1999. The fungal infection seems to form on the scar and the infection spreads out. I develop open places along the C-section scar. These places itch and bleed. I am currently treating the fungal infection with a mixture of ketoconazole cream and Diaper rash cream. I also sprinkle a nyoxin powder on the fungal infection. The fungal infection is very difficult to treat. My Infection Disease Doctor and my Rheumatologist has suggested a Panniculectomy. Each doctor feels that it is important that I receive a Panniculectomy. The doctors said they feel a Panniuclectomy should be performed first and I should look at the gastric sleeve after I have healed. I have been unable to find a Doctor willing to perform this surgery. I know it is a high risk surgery. I am inquiring to find out if anyone in your facility has any experience with this surgery.
A: Thank you for your inquiry. You are literally between a rock and a hard place. Your needed abdominal panniculectomy procedure is more than just high risk…it is virtually certain to have a 100% complication rate when it comes to wound healing. And that is not to mention your general medical condition which will require considerable after surgery management and is certain to have its own set of complications that could even include severe infection and death. Between the wound and your health complications I could easily see you sending a long time in the hospital. Whomever decides to take on your surgery has to do it with a team approach and be expectant of what is going to ensue. Your best bet is to have this done at a university-based hospital where there is a plastic surgery training program due to the need for a lot of doctors caring for you both during surgery and afterwards.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I believe I need a pubic lift. I have lost 100 lbs and am still over weight by a lot. But I had an abscess removed from one side of the upper pubic area and I’m also uneven on both sides. If you type in pubic lift blog on yahoo and under images there is pictures I believe of one you did that is quite large like mine little different I presume. My question is cost and what would be the steps and healing?
A: When
one has lost 100lbs, I would have no doubt that a pubic lift is needed. But I am suspicious that you may need much more than that. Usually such weight loss causes a lot of abdominal tissue overhang which is most commonly called a pannus or apron. This is a hip to hip removal of the abdominal overhang that would include a pubic lift. It is possible that an isolated pubic lift may suffice, or be partially helpful, but I would have to see pictures of your abdominal area to make a visual evaluation. There is a big difference in the cost and recovery of a pubic lift vs. abdominal panniculectomy so knowing what you look like is essential to answer your questions with any accuracy.
Dr. Barry Eppley
Indianapolis,Indiana
Q: Dr. Eppley, I have an “apron” that hangs below my pelvic bone due to 3 c-sections. I have had this for 20 years. It is my dream to wear a wedding dress and not see the hang over through the dress. Would I have time to heal before wedding date of late October 2013?
A: Prepare to have your dream come true. One of the most rewarding of all tummy tucks is the removal of the abdominal apron, also known as a pannus. Its dramatic removal creates not only an instantaneous waistline change but a near lifestyle improvement without a floppy bag of tissue getting in the way of clothes, exercise, personal hygiene and intimate relations. Given that your wedding is over six months away, you will be in good shape for your wedding as long as you have the tummy tuck at least 3 months before the big day. The other good news is that after the tummy tuck there is no chance that this abdominal apron will ever come back unless one has more children (I am assuming after 3 that you are having no more) or unless you gain a tremendous amount of weight (greater than 50 lbs) and lose it again.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, my mother has a grade 5 abdominal pannus that covers her knees and below and 2 years ago developed a lymphedematous mass and hernia through the abdominal wall. It drains fluid off and on chronically and she has been taking antibiotics chronically off and on for years. She is on Medicare and they have denied coverage for the panniculectomy portion of the surgery, stating they will only do the hernia repair and not the panniculectomy which is coming out to 7000 dollars. Is there any advice you can give to help us appeal this? She has been on South Beach diet for 2.5 years, lost 44 pounds on the diet, and been at a stable weight for many years. She can no longer walk due to the herniated pannus. She has atrial fibrillation and a pacemaker and diabetes (although well controlled on oral hypoglycemics) I believe that leaving the pannus in place poses a significant risk to her to develop infection and a clot or other dangerous complications. I would appreciate any advice you can give. We need to fix the hernia and also want the panniculectomy so she can walk again and continue her diet and exercise program as weight loss may also help her atrial fibrillation problem as well. I cannot believe the insurance company considers this cosmetic in a 74 yr old woman. 🙁
A: It certainly sounds like your mother would benefit greatly by a combined abdominal panniculectomy and hernia repair. But I believe you may have a misconception about how Medicare works. Medicare, a federal program, does not preauthorize or preapprove any surgical procedure. They never have. A surgeon must do the procedure and then wait and see if Medicare will actually approve (pay) for the procedure. When it comes to an abdominal panniculectomy, no matter how medically indicated it might be (and your mother certainly fulfills that criteria), Medicare will almost certainly deny it after it is done. This leaves the patient with the benefit but the doctor will rarely ever get paid and if they do it is pennies on the dollar. An abdominal panniculectomy is a lot of work, risk and after care for little if any reimbursement. A patient may say that this is not their problem but the doctor’s…but it influences the options for many prospective patients. This is because very few plastic surgeons are willing anymore to do such procedures under Medicare. Thus the origin of the $7,000 fee to which you refer must be a cosmetic fee quote to do the procedure, allowing Medicare to pay for the hospital, operating room and anesthesia fess which they are obligated to do. Short of doing it under this fee for service basis, you will have to seek a plastic surgeon who accepts Medicare coverage.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I have had three c-sections, gained and lost over 100 lbs at least three times. ( after each pregnancy) I want to know if I need a tummy tuck or some type of pannus removal.
A: The difference between a tummy tuck and an abdominal panniculectomy is really one of magnitude. They are in many ways the same procedure with some different variations to them. A panniculectomy is nothing more than a ‘big’ tummy tuck. It involves a larger amount of abdominal skin and fat removal as a pannus means an apron or overhang of abdominal tissues across the waistline often onto the pubic areas or upper thighs. This means the horizontal incision and resultant scar may be longer and even extend into the back area from that of its smaller cousin, the more traditional tummy tuck. Given your description of recurrent weight loss of that magnitude and pregnancies, I would have no doubt that you have a pannus and your surgery would be a panniculectomy, often called an extended tummy tuck. The recovery from a tummy tuck or an abdominal panniculectomy would be the same. Longer incisions do not really mean a longer or more significant recovery.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I have been fighting my insurance company since last year due to a yeast infection under the pannus of my stomach. The insurance denied the surgery, saying it was cosmetic, but recently these huge purple marks have appeared and are very thin. A nurse friend said they feel like a blister about to pop and are concave. However, these marks keep spreading across the pannus. My question to you, is, would you, or do you know of a surgeon that would be willing to use me as a teaching subject and take me on as a case study and do the surgery as pro bono? I have had this yeast infection for 7 years and now I am at a standstill. Any advice you could offer would be more then generous. Thank you so much for your time.
A: Battling insurance companies to get coverage for abdominal panniculectomies is standard and the denials and appeals can go on for years. But this is fight you must continue and eventually you should win because you have a real medical necessity condition that justifies an abdominal panniculectomy. It is also a fight you must continue because you are not going to find a plastic surgeon to do it at their own expense. There are also numerous other expenses of surgery (OR, anesthesia, etc) that must be paid that go way beyond whatever a surgeon’s fee is.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I have had five pregnancies and my muscles are separated as well as I have a skin flap that hangs down. My back hurts all the time since my stomach muscles are so weak. My skin flap hangs down and rubs on my thighs. I have done physical therapy but it doesn’t help. My insurance says they won’t cover it and I can’t afford to get it fixed on my own. Being in this plight, how can I get my insurance company to pay? It seems like they should but they just don’t understand. What do you suggest?
A: The reality of medical insurance today is that coverage will not be provided for ‘muscle separation’, medically known as a rectus diastasis. While this is a common occurrence after multiple pregnancies, it is not interpreted as medically necessary to repair by the insurance industry. There is no getting around this ruling nor do such symptoms as muscle weakness make it possible for insurance to pay for surgery. It is different if an umbilical hernia is present as this is a true defect in the abdominal wall. The same consideration applies to abdominal skin flap surgery, known as an abdominal panniculectomy. Only in large abdominal pannuses that hang way down onto the thigh and have associated chronic skin infections underneath will insurance consider coverage for its removal.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I had gastric bypass surgery in 2005 and I would love to have a tummy tuck. I’m sure this surgery would help me feel better due to other health conditions I have. I have severe depression, lower back bulging disc with nerve blocks and other health issues that have caused me to become disabled and last year I was approved for S.S.D.I benefits. A tummy tuck is a surgery that I have wanted for years because I have lost a lot of weight. But with the way my tummy looks it makes me feel incomplete and sad. I have pain with the sagging skin with my back and extreme rashes underneath the lower flabby skin around the panty line. Please help. I’m so unhappy with the way I look and feel. Thank you for your time.
A: Your abdominal situation with your weight loss after bariatric surgery is a common one. The weight loss has been great but the abdominal overhang (pannus) is now a ‘new’ problem. Your description of symptoms is classic and I would have no doubt that a tummy tuck would be of great benefit. Your biggest challenge is getting a tummy tuck is an economic one. By being on disability I would assume that your health insurance is through Medicare or Medicaid. This would require you finding a plastic surgeon who participates in those programs which I do not. Even with private health insurance, there are fewer and fewer plastic surgeons today who will perform this surgery through insurance anymore. In addition, there is also the issue of whether you would qualify for an abdominal panniculectomy/tummy tuck which is an insurance determination not a plastic surgery one.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am a 54 year old female with an overlying abdominal apron. I have had three c-sections with some prominent scarring where they did this surgery. This c-section scar pulls in and the weight of the overhanging apron on it makes it chronically sore and irritated. I am also a diabetic and have high pressure. Do you think removing the fat with liposuction will help me. I am interested in something like Smartlipo since it appears to be the least invasive. Will my diabetes and high blood pressure get better after surgery?
A: When anyone describes having an abdominal apron, also known as a pannus, they are by definition talking about a large amount of skin that hangs over the waistline. In treating an abdominal apron the consideration of liposuction is immediately excluded. While it does remove fat, it will actually make the overhang of the apron worse. What you need is an abdominal panniculectomy, also known as a ‘simple’ tummy tuck. It is the cutoff of the abdominal apron without any manipulation of the underlying abdominal muscles. This will provide both an immediate and effective cure of your problem. Given your age and health conditions, you will need to get medical clearance from your doctor. It is very possible, although not assured, that this surgery may help reduce some of your medication requirements for your blood pressure and diabetes if the apron is big enough.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am a 35 years old and I am 5’ 7 “and weigh 246 pounds. I am been married for eight years I have three girls. I feel that I’m now really fat because around five years ago I was a size 16. Now I am a size 24 and I exercise and diet and have tried mesotherapy with very little results. I have skin that hanghs over the sides which really bothers me. Can you help me?
A: Based on your height and weight now, you are close to be over 100lbs from your ideal body weight. I suspect that you were never near your ideal body weight by the numbers so that it is not a realistic goal. While weight is just a number, getting you somewhere between 170 and 190lbs ir probably an achieveable weight target. That being said, you are not a candidate for liposuction or any form of excisional body contouring, such as an abdominal panniculectomy, until you reach the 200lb mark. You are simply too big now to get the best benefits out of any form of plastic surgery. You need to consult with a weight loss clinic or specialist as the first step in your potential body metamorphosis begins with a non-surgical weight loss appproach not plastic surgery.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I need to have a pannciuectomy. I had weight loss surgery in November 2010. I was originally 375lbs and I lost over a hundred pounds. I have had this overhang since I was in my teens and it now hangs to touch my upper legs. Will my insurance pay for it? My out of pocket expense is met for this year so surgery should be paid in full. Please please can you help me?
A: Many overweight people have a large abdominal overhang initially that is then aggravated by their weight loss. As the weight comes off and the ‘balloon deflates’ so to speak, this skin overhangs worsens and sags lower as it has lost volume. This creates complete obliteration of the groin creases and their pubic and genital regions creating the well known hygiene and skin irritation issues. As you have described, your abdominal pannus now hangs down completely into your thighs. By definition, this is one of the criteria that insurance uses to determine coverage.
While I would agree that it sounds like your panniculectomy would be covered by insurance, my opinion is irrelevant and is meaningless from the insurance coverage perspective. This is why we always file a predetermination so the insurance company has enough information for them to make a decision. It is their decision not mine. As a plastic surgeon, I am merely a vehicle by which I can help the patient be put in a position so their insurance company can make an accurate review and determination. This predetermination involves a written letter by me describing your condition, the problems that it is causing and photographs which show the size of the abdominal pannus. That is mailed to them and then you await a written response as to their decision about coverage for your abdominal panniculectomy.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I have poor elasticity and a pannus that is causing problems sitting and walking. However I’m not that obese at 175. My skin is just weird after years of battling anorexia and bulimia. I’m in recovery now and off weight causing meds (depakote and seroquel). I don’t like liposuction outcomes and want to avoid that. I am hoping you can tell me that this is just from atrophy and break down of muscle from my disorders, and healthy work with weights and aerobic exercise and good meal plan can get rid of my thin skinned pannus covering mainly groin and hips (not over pubis). It’s causing pinching pain when I walk or sit and sweat related problems like chaffing. It’s getting worse even though I’m losing weight to hopefully go back to my previous set-point of about 133. I should add that I’m an apple with a lot of adipose fat in relation to my hips. Also, I am wondering if my insurance might cover a panniculectomy, and if that is an option for me. Thanks for you time.
A: No abdominal pannus can ever be removed short of excisional surgery. Skin excess will not disappear with exercise, diet or even any form laser or ‘skin-tightening’ liposuction. Only a panniculectomy or amputational abdominoplasty will work. This is a surgical problem. When it comes to potential insurance coverage, your description of your pannus sounds like it would not qualify. One of the clear insurance coverage criteria for an abdominal panniculectomy is that the pannus hangs over the groin crease onto the thighs.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Hello, I’m writing because I am in need of a tummy tuck. I have had four c-sections and I would like to know if I will be able to get a tummy tuck. I have a very large stomach pouch that I dislike and would like for it to be removed before I get too old. If not, it will be sitting in my lap. Will having these c-section scars interfere with having a tummy tuck? Can the entire stomach pouch be removed or can only some of it come off? Thanks for answering my questions!
A: The large stomach pouch to which you refer is a pannus, otherwise known as an apron of skin. (and fat) Between multiple children, c-sections and weight gain, the excessive abdominal skin and fat falls over the waistline. The scarred and indented c-section location accentuates this pannus by pulling in tightly underneath it. The solution to this pannus problem is a modification of a traditional tummy tuck known as an abdominal panniculectomy. It differs from the tummy tuck because the amount of tissue that is removed is larger. This makes for a longer low horizontal incision, often extending into the back area. The final result is often not as refined as that of a tummy tuck given the type of body on which it is performed. In its simplest form, an abdominal panniculectomy is an amputation of the pannus from along the waistline.
Dr. Barry Eppley
Indianapolis, Indiana
Q: I am in need of an abdominal panniculectomy but my insurance has denied me saying it is cosmetic. They denied me saying it is not medically necessary because it is not preventing me from being functional. I have plenty of documentation with all my medical care providers in support of this need. What can I do?
A: The request for abdominal panniculectomies , or an amputation of overhanging abdominal skin and fat, from insurance companies is very common. As a result, they have a very specific set of criteria to be eligible for coverage. These typically include the following; a pannus that hangs down onto the thighs (photographs are required), a documented history of recurrent skin infections underneath the pannus that requires topical medications, and a six month history of these recurring skin infections that has failed non-surgical treatments.
If a proper predetermination has been done and the insurance company has denied it, then there is nothing you can do. You are legally entitled to an appeal of which they tell you how to do it on their denial paperwork. But once an appeal has been denied then that debate is over. The insurance company controls what they will pay for or won’t pay for. Their determination is based on their policy requirements and the determination of their medical director. They obviously have determined, no matter how unfair you think it may be, that your abdominal pannus does not qualify. Your only option is to have the procedure done on a cosmetic fee basis.
Dr. Barry Eppley
Indianapolis, Indiana
Q: My daughter has grown in the past two years a strange looking abdominal growth. It doesn’t look like any abdominal pannus picture I have ever seen. She is very obese but has a normal looking white abdomen which hangs down a little. However, directly under (and separate from) this normal looking abdomen is a huge purple/red hanging balloon which is ulcerated and infected. It grows out from under the abdomen right above the pubis. She is scheduled for surgery in a month and the surgeon is acting like he doesn’t know for sure what it is. It is estimated to weigh about 50 pounds. Have you ever run across anything like this in your plastic surgery practice?
A: While it is unusual, I am certain it is not a mystery per se. There are only a certain number of conditions that it could be. Possibilities include a granulomatous reaction from a ulcerated wound in the skin fold, an area of lymphedema with resultant ulceration, ballooning subcutaneous fat necrosis or benign growths such as large lipomas, hemangiomas or even a teratoma. Whatever the final pathologic diagnosis, it will be removed by wide excision down to the underlying abdominal wall with a modified abdominal panniculectomy. It does not sound anything like a hernia of which it is in an unlikely location and a CT scan would easily rule that out. A CT scan would also rule out any tumor growths from deeper structures, such as the ovaries.
With a weight of 50 lbs, however, it is much more likely that this is a benign tumor growth of solid tissue rather than any reactive mass.
Dr. Barry Eppley
Indianapolis Indiana
Q: I have a large pannus that hangs down to my knees. My insurance will not pay to have it removed even though my doctor and a specialist has written that it is medically necessary due to the health problems that it is causing me. How much would something like this cost or do you know any doctor that would do this probono. I have also lost a little over a 100lbs. (used to weight 550 lbs and now weigh 450 lbs) but my abdomen still keeps growing to the point it is down my knees. This has greatly affected my life to the point I have sores, I can’t bend, I have a hard time walking,and taking care of myself. I have to depend on my wife and daughter for the stuff I used to do for myself. I am desperate and need help and guidance.
A: What you are in need of is an abdominal panniculectomy. This should not be confused with a more simple tummy tuck or abdominoplasty in the cosmetic patient. Removing a large pannus in a man of your size is a complicated procedure with significant medical risks. In addition, that type of abdominal panniculectomy is associated with a 100% incidence of postoperative complications such as wound breakdowns, fluid collection, and infections This is not said to deter you from having this operation…as you need it…but it must be done in the right medical setting. This means in a hospital with good medical supervision afterwards and at least a few days of hospital time for recovery. This is why it should not be economically viewed as a cosmetic procedure. There are just too many potential expenses that are likely to occur that go beyond just the cost of the operation. Because of this operation’s complexity, there is not going to be any doctor who will do it for free…there is just too much work and risks to be taken for that approach.
For these reasons, you and your doctor should continue to work on getting it approved through your insurance carrier. This is your best bet to eventually getting this important operation for you done.
Dr. Barry Eppley
Indianapolis Indiana
Q: I have a prominent ‘apron’ and it’s getting difficult to navigate. I had twin girls last year and would just like to have a lap to hold them in. I am not expecting to be a size six overnite but I just need to get rid of this extra baggage. I have read about the operation ‘abdominal panniculectomy’ and it sounds exactly like what I need. I would like to have that operation but just want to be sure it it safe since I have a young set of twins. What complications have you seen with this operation and how quickly does one recover?
A: The abdominal panniculectomy is essentially an amputation operation of the overhanging apron. It should not be confused with its cousin, an abdominoplasty or tummy tuck. While they are seemingly similar procedures as they do recontour the abdominal wall, how it is done and what the final result looks like is different. The goal of a panniculectomy is to get rid of the overhang, not to create a slim waist or flat stomach. That simply is not possible given the large anatomy of the abdominal pannus. Getting rid of the pannus will improve back and knee pain as well as skin hygiene underneath the skin flap. In most panniculectomies, it is best to eliminate the belly button (umbilicus) so there is less potential for wound healing problems after surgery.
The most common complications after abdominal panniculectomies are fluid collections (seromas) and wound healing problems of the incision. They are so common it is fair to say that 100% of panniculectomy patients will experience them. Most of them they don’t require further surgery to solve but sometimes they do. Major medical problems, such as blood clots, pneumonia or heart problems, are not common. But most panniculectomy patients are often overweight and may have other accompanying medical problems. This is why a good medical work-up before surgery with approved clearance by your doctor is very important.
It is best to think of complete recovery after a panniculectomy as taking up to four to six weeks.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Hopefully someone there can fill me in even though I have no insurance! I want to know the approximate cost for an abdominal panniculectomy. I am very obese, weigh 360 lbs and am 5′ 2″. The majority of my weight is in my abdomen. This apron is like a catch 22, It is getting harder to walk and then I don’t so I eat and don’t walk and gain weight. I fell and hurt my knees 4 years ago, gained 100 lbs since then. Thanks for providing an outlet for me to vent. I liked the idea that you have had experience with this surgery for obese people. I still want to know what the surgery would cost. I maintained a weight of 250 to 260 lbs for over 25 years before the knee injury that never got fixed. Fat never stopped me before and it won’t now. My health history is otherwise remarkably good. My blood pressure is 115/60, fasting blood sugar 70 to 80 and the rest of my blood work is normal.
A: The abdominal panniculectomy procedure provides great physical benefits to those patients such as yourself. By the removal of overhanging weights that often approximate 30 to 40 bs, if not more, the strain on one’s back and knees is significantly reduced. This is in addition to the improvement in groin and genital hygiene.Most medical insurances will cover this procedure as ythey should given the medical benefits that it provides. The abdominal panniculectomy can not really be compared to the more common tummy tuck which is performed in more weight appropriate patients and is smaller in surgical magnitude and recovery.
Unlike a tummy tuck, the cost of an abdominal panniculectomy is out of reach for most patients. Costs could easily approach $10,000 to $15,000. It takes longer to do and will almost always require an overnight stay and often several days in the hospital. Complications rates are high and secondary problems such as fluid collections and wound breakdowns are common. Secondary surgical revision for wound closure is not rare ane exposes one to even greater expense. For these reasons, one should attempt this procedure under insurance for the really large type pannuses that you appear to have.
Dr. Barry Eppley
Indianapolis, Indiana