There has been a recent transition in the way women seeking abdominoplasty have been treated in the Australian public healthcare system. The decision to offer publicly funded abdominoplasty used to relate solely to the judgement of the referring general practitioner (GP) and the assessment of the plastic surgeon. More recently, the discretion of individual specialists has been replaced by state governments and criteria-based policies in most Australian public hospitals. In 2009, Pearson and colleagues published a systematic review of policy on exclusions, and exemptions from exclusion, for those seeking abdominoplasty.1 At that time they noted there were no qualitative studies in this field. There has been little published in the literature about how the imposition of a criteria-based system has affected those seeking and undergoing treatment, over and above the effect of the surgery itself. While there have been previous qualitative studies on abdominoplasty,2–4 they have not examined the influence of the process of care associated with Australian restrictions in the public healthcare setting. The aim of this study was to understand the experiences of women undergoing abdominoplasty in the Australian public healthcare setting and how these experiences differ from the findings of previous studies. Furthermore, this study aimed to explore the evidence for the association between physical symptoms and rectus diastasis, and the effect of abdominoplasty on physical and mental health.
Model of care
Flinders Medical Centre is a teaching hospital with onsite outpatient services. Initial consultation for patients requesting abdominoplasty is by a specialist plastic surgeon. As well as conducting a history and examination, the surgeon is required to assess the patient against the criteria of the SA Health elective surgery exclusion and restrictions policy (Table 1) and only place on the waiting list those who meet the criteria. At the time these participants were listed for surgery, the criteria were disabling or persistent physical discomfort or intertrigo (2011 version of the policy). Psychological distress is not a criterion on which selection for surgery can be made, but patients commonly have psychological problems associated with their physical presentations. The service has a close relationship with a liaison psychiatrist (RL) and refers appropriate patients. There are elective surgery officers employed in the hospital whose role is to ensure that patients meet the SA Health elective surgery policy5 and to monitor waiting list patients, over and above the usual admissions office processes. Surgery for these patients is carried out under the care of a named specialist, but parts or all of the procedure may be performed by a trainee under supervision. Postoperative care is by a mixture of trainees, junior doctors and consultants.
Research design and recruitment
This was a qualitative cohort study, with participants being recruited from the surgical waiting list and outpatient lists. Potential participants were provided with a participant information sheet inviting them to contact the qualitative interviewer (KF) directly for interview. This direct communication ensured that surgeons could not influence participation. Participants were treated as a single group and not divided up by their physical indication for surgery. Participants who were preoperative at the time of recruitment, whose surgery date fell in the early part of the study period, and who expressed an interest in further participation were re-interviewed following their surgery. Interviews were conducted either face-to-face or via telephone and transcribed. The interview schedule used to guide the conversation is available as a supplementary file (Appendix 1).
The study was approved by the Southern Adelaide Local Health Network human research ethics committee [approval no. 206.17].
Transcripts were de-identified by replacing interviewee names with pseudonyms. Coding was completed inductively (ie codes were developed from scratch, rather than having a pre-formed list of topics) by one researcher. Co-coding was undertaken on three transcripts to cross-check emerging codes and support the development of themes. Once all 20 interviews were coded using NVIVO 11 software (QSR International, Level 5, Suite 5.11, 737 Burwood Road Hawthorn East, Victoria, Australia 3123), key themes were identified.
Twenty interviews were completed between 2017 and 2020 with 16 women participating. Four were interviewed both pre- and postoperatively, nine in the postoperative period only and three in the preoperative period only. Women had typically waited 2.5–6.5 years to access surgery, meaning that most were subject to the 2011 version of SA Health restrictions and prior to the stricter 2018 version (Table 1).
Interview summaries are shown in Table 2. Key messages arising from the interviews were that motivations for surgery were diverse and complex, there were major hurdles to accessing treatment, waiting on the surgical waiting list was variably burdensome, treatment in the public system may differ from that in the private system, abdominoplasty can be beneficial in terms of both physical and psychological outcomes and that satisfaction with results is variable. These messages are expanded upon under the theme headings below (patient names have been replaced with pseudonyms).
Theme one: motivations for surgery
Although the assessing surgeon was clearly focused on physical symptoms and the potential benefit of surgery to relieve those, the interviews showed broad heterogeneity in the motivations for surgery including physical, medical, emotional and psychosocial. This is illustrated in the following interview excerpts.
“The skin was a reminder of how big I really was and it was almost like I’d been through all this work … Once you get to your desired weight and everything—I actually got down to the weight which was my perfect weight for my height and I looked anorexic, so I actually put some on but, yeah, it was just the psychological side of it all. I basically had a marriage breakdown because of losing all the weight and everything like that as well and then to have the apron of skin was very uncomfortable.” Heather
“I was exercising and was also going to a physio as well to help me to do certain exercises. Then, yeah, it was probably about a year and a half—it was after my son’s first birthday, but I can’t—it’s all a blur now, I can’t remember if it was the physio or the GP but someone was like, ‘Yeah, I can still fit four fingers in there. That’s not going to come together any time soon and probably not without some sort of surgical intervention’.” Prue
Theme two: accessing treatment and waiting on waiting list
In terms of ability to access treatment in the public system, there was wide variation. The following excerpt reflects gratitude for abdominoplasty being available in the public system.
“I’m just amazed that I live in a country where this has been able to happen when financially we would’ve never been able to pay for this probably, or not for a very long time. Who knows how many years I would go on just having this back pain all the time.” Rebecca
Other excerpts cover the challenges of long waiting periods prior to surgery, and the fact that being in limbo is difficult to plan around.
"Twelve months came around and I hadn’t heard anything. "Marielle
“I thought, a couple of years but, yeah, it’s been about four and a half now. I’ve just sort of said to them, ‘I don’t want to be pushy. Hubby’s got to book leave. We’ve got a family holiday in November and I really don’t want it to coincide with that’ … Every now and then I think, ‘Oh gosh, it would be nice to have it done and to put it behind me.’” Prue
Some interviewees were cognisant of the hospital sometimes needing to change surgery dates to accommodate emergency cases.
“I could go on probably a bit longer with the hernia but, you know, I’ve waited my time, to a reasonable amount I think, but if someone showed up ahead of me and was in excruciating pain, whether it be a child or whatever, I would say, well, I’m happy to wait another X amount of time, but it has to come to something in the end.” Loretta
Interviewees knew that there were eligibility guidelines that could approve the surgery, and there were varied levels of acceptance/understanding around this.
“Well, not being approved for the surgery would have an impact on my life because I’d think—I would hold a grudge against the government probably and think well, I’m being victimised.” Val
Theme three: public versus private processes of care
Generally, a high level in trust of public health services was displayed by participants, as the following excerpts illustrate.
“Oh my God, you know, I trust the surgeons with my life, I really do. Women out there that are wanting to have it done, go for it. Go for it, do you know what I mean? Do something for yourself like I did. You’re not going to get a 21-year-old’s body but that is a little bit towards it, you know? Go for it. Put your life in the doctor’s hands because that’s what they study for. That’s why God’s given them that gift, to help us.” Zofia
“If these surgeons couldn’t do their job, they wouldn’t be in a job … I have total trust in their knowledge and their ability.” Kirsty
Participants talked about different expectations in relation to ‘knowing the surgeon’ than if they were paying for the surgery, rather than having it in the public system.
“I mean obviously going through public you’re going to have the trainees as opposed to private whereas you meet the doctor that will be your doctor.” Robyn
“If I was paying for it of course then I’d probably be a bit like, ‘Well, I’ve paid you all this money to do it and now you’re not doing it, someone else is’ but I kind of feel that being a public patient in a very busy public hospital, I was lucky to get what I’ve had done so I’m just grateful for that aspect of it really.” Trudy
Some participants felt that there were more limited options for understanding expected outcomes in a public versus private system when using the internet or social media for research.
“I joined this Facebook group, because I want to see before and after because you don’t know what it’s going to look like. You just—you’ve got no expectations, so I would trawl through and find someone with a similar tummy to me and see their after photos and think, ‘Wow, that’s amazing, that’s what I could have’ type of thing.” Rachel
“I won’t get the chance, normally, like if you were going and having an abdominoplasty privately you would research your surgeons, find someone with a good reputation. You would want to see before and after pictures of their work, that kind of thing and, you know, get a feel for them, their reputation, what their work is like.” Annette
Theme four: results of surgery
Of those who had undergone surgery, two women were very unhappy with the results. The following is an excerpt from one of them (see also final column in Table 2).
“I was lying down…how [sic] that was sticking out, she said to me, ‘Oh, we could take a little bit more off here’ and I went, ‘Okay, I would really like that’ and she goes, ‘But we’ll wait for the six week check-up.’ That’s when I saw Dr [Name] and she says, ‘I don’t know if we can do any more, if there’s any more funding from the government for that.’ Interviewer: ‘And how did that make you feel?’ Zofia: ‘Very upset because I think to myself, it’s just not right. It’s just not finished off properly.’” Zofia
Two women were uncertain if they were glad that they had undergone surgery (reporting that it would take them a while to get used to the new them), with the following quote illustrating this outcome.
“I still have the same hang-ups. I still don’t like what I see in the mirror regardless and I still think, ‘Oh my God, I don’t look any different.’ People say, ‘Oh God, it’s amazing’, but I don’t feel it.” Jill
Most participants were happy they’d had the abdominoplasty, but some had had to spend time getting used to what the scar looked like. Generally, the scar, or ‘finishing off’, was a key point in determining how women felt about their surgery.
“I’m just happy to have had it done and under the public system, which cost me nothing, because I have tried hard to lose weight, so it was a reward for me to have it done and not to have to pay anything. Of course, we have been in medical benefits and taxes and all that, like everyone, so I thought I sort of deserved it too. Anyway, I was thrilled to have it done but I wasn’t overly happy with the end result of the scar in the middle.” Loretta
“I’ve been back running and walking most days again so best thing I’ve ever done. Best thing ever.” Trudy
For one participant, an improved mental state and completely alleviated back pain were the best parts about the surgery.
“Psychologically, a massive difference,and, despite the pain of surgery and the discomfort in my stomach muscles, not a scrap of back pain since the surgery, like, instantly gone.” Rebecca
The participant interviews revealed that, although the surgeon was essentially focusing on the physical criteria for surgical treatment due to the mandate of the state policy, motivations of women for undergoing abdominoplasty were complex and multidimensional. They included psychological and social motivations as well as physical symptoms. On the theme of accessing surgical treatment, the interviews illustrated the frustrations and fears that patients may have around processes of selection for surgery and not being familiar with their operating surgeon. The issue of ‘knowing your surgeon’ overlapped into the theme of public versus private treatment. Participants perceived one of the benefits of being treated privately as being able to access more information about anticipated surgical outcomes, which would assist them in developing realistic expectations. The feeling of gratitude for being able to access surgery in the public system and faith in the public system was found in several interviews, despite the acknowledged frustrations of waiting and risk of surgery cancellation. Several women showed an understanding of (and even preoccupation with) the criteria around surgery and the possibility of being denied access to abdominoplasty.
In terms of outcomes from surgery, results reported were more varied than might be expected in a group who all had clear physical indications for surgery. Improved back pain, quality of life and ability to exercise were all reported, but so were negative feelings about the aesthetic results of surgery.
This study of a group of women undergoing abdominoplasty in a public hospital setting has shown the heterogeneity of motivations for surgery, expectations and patient reported outcomes. Expectations of patients have been shown to be very varied, not just in terms of medical procedures and outcomes, but also in terms of process of care. In respect of psychosocial outcomes, again there was a broad range, from patients who were happy to those who were clearly distressed. The findings of this study are similar to those of Bragg and colleagues in the English National Health Service.6 In their survey of abdominoplasty patients, they found variations in satisfaction, with most dissatisfaction being expressed around scars, residual abdominal overhang and ‘dog-ears’. This highlights the importance of clarity in informed consent about scarring and expected outcomes.
From this study, the hurdles to accessing surgery provided delays for patients and seemingly affected quality of life, over and above the actual impairment due to the condition. It is difficult to quantify how much this factor may be compounding the distress and reduced mental wellbeing of these women. There is evidence to support that the waiting itself (for any type of elective surgery) can contribute to anxiety and depression.7,8
In regard to the value of abdominoplasty for improving mental health, the comments of participants like ‘Trudy’ seem to validate this. Other studies also support the proposition that abdominoplasty improves mental health and wellbeing.9 A Finnish study of 64 women undergoing abdominoplasty found significant levels of preoperative psychopathology, and significant improvements in mental health following surgery.10 This is concordant with reports from participants like ‘Heather’ who had experienced suicidality and depression in the past and found abdominoplasty ‘psychologically effective’.
However, the effect of abdominoplasty on mental health is not always predictable. The literature indicates that the effect is different between patients with no formal psychopathology, those with common psychopathologies (such as depression) and different again in those with severe psychopathologies such as body dysmorphic disorder.11,12
It seems clear from the literature that it is important for plastic surgeons to understand the level of psychopathology in those seeking abdominoplasty at the preoperative assessment stage.13 This is further supported by Pearson and colleagues’ study on public sector abdominoplasty, which concluded that a psychiatrist could have a useful role for public patients with psychological distress.1
In terms of physical and quality of life benefits from surgery, several participants in our study confirmed this benefit, none as clearly as ‘Rebecca’ in her report of complete resolution of her back pain. Despite the lack of consensus in defining pathology, in terms of effectiveness of abdominoplasty for treating established symptomatic rectus diastasis, there is now good evidence. Measures such as the Oswestry disability index(ODI) and other patient reported outcomes measures (PROMs) have been used to demonstrate relief of back pain and improved quality of life in several patient cohorts.14–17
Several interviews highlighted the role of abdominoplasty in resolving skin infections and rashes. This is consistent with evidence in the literature demonstrating that the excess abdominal skin following massive weight loss and consequent rashes beneath the residual pannus is associated with health impairment18 and that abdominoplasty is an effective treatment.19–21
It should be noted that since the enrolment of some of the patients to this study, increased policy restrictions on abdominoplasty would now exclude some of the women who participated.5 Health funders worldwide are under pressure to curb spending, and as plastic surgery is often perceived as equating to aesthetic/cosmetic surgery, it is a target for restrictions. The basis for restrictions is not always centred on the wellbeing of patients or equity of access. This is articulated well in articles from the UK on the ‘postcode lottery’ of elective surgery.22
The limitations of this study are that the participants were not a homogenous group and only a few of the participants were interviewed both before and after surgery. Those interviewed only after surgery had to rely on the recollection of their motivation for surgery and how they experienced preoperative health care processes. In addition, women were not classified according to current restriction criteria, so it is not possible to know how many would meet criteria if they were assessed today. The strength of this study is that it is the first qualitative study on the experiences of women in an Australian public hospital setting undergoing abdominoplasty.
Women undergoing abdominoplasty in the public sector are not a homogenous group, neither in their motivations for surgery nor in their reported outcomes. This qualitative study found evidence for improvement in physical symptoms and psychological wellbeing in women undergoing abdominoplasty, which supports existing quantitative studies, but also highlights a need for liaison psychiatry and clear information for public sector patients, especially relating to scars. Criteria-based assessment contributes an additional burden for these patients.
Patients/guardians have given informed consent to the publication of data.
Conflict of interest
Nicola Dean is the breast section editor for the Australasian Journal of Plastic Surgery and was removed from the editorial process due to this conflict of interest. There are no other conflicts of interest to disclose for any authors.
The authors received no financial support for the research, authorship, and/or publication of this article