Summary of PICO/PPICO criteria to define the question(s ...
Application 1546:Abdominoplasty with repair of rectus diastasis (also known as rectus divarication) following pregnancy Ratified PICO Confirmation(To guide a new application to MSAC)(Version 1.0)Summary of PICO/PPICO criteria to define the question(s) to be addressed in an Assessment Report to the Medical Services Advisory Committee (MSAC)ComponentDescriptionPatientsPatients with an anterior abdominal wall defect that is a consequence of pregnancy. Additionally, the patient must also:be at least 12 months post-partum; have a diastasis of at least 3cm (as measured by appropriate diagnostic imaging); andhave documented evidence (in case notes) of functional symptoms of low back pain and daily abdominal discomfort on functional use. InterventionAbdominoplasty, with surgical repair of the rectus diastasisComparatorBest supportive care, which may include symptomatic management with pain medication, lower back braces, lifestyle changes, physiotherapy and/or exercise.OutcomesPatient-relevant: Reduction in back pain and urinary incontinence; Improvements in health-related quality of life and general daily functioning;Improved abdominal muscle strength; Recurrence; Quality-adjusted life years; andAdverse events following surgery, as such as seroma, infections, haematomas and nerve damage. Healthcare systemNumber of patients treated each year;Total cost of abdominoplasty per patient; Anaesthesia and hospital costs;Number of additional surgical consults, ultrasounds and associated diagnostic testing;Costs related to adverse events following surgery; as such as seroma, infections, haematomas and nerve damage; andNumber of patients requiring revision surgery due to recurrent mittee-In-Confidence REDACTED TEXTTABLE: REDACTEDREDACTED TEXTTABLE: REDACTEDREDACTED TEXTREDACTED TEXTEND Committee-In-Confidence PICO or PICO rationale for therapeutic and investigative medical services onlyPopulationThe proposed population for abdominoplasty with repair of the rectus diastasis are women who developed symptomatic rectus diastasis following pregnancy. The proposed patient population would also be at least 12 months post-partum, have a diastasis of at least 3cm (as measured by appropriate diagnostic imaging); and have documented evidence of functional symptoms of low back pain and daily abdominal discomfort on functional use in the case notes. Patients would likely be referred to a surgeon by their general practitioner or obstetrician.RationaleIn 2016 this patient group was removed from the MBS item: 30177, due to concerns that the surgery was performed for largely cosmetic reasons and had no significant morbidity or mortality benefit. The removal of these patients resulted in a 32% reduction in the numbers of MBS item 30177 services claimed in 2016 compared to 2015 and produced approximately $1 million in cost savings to the MBS each year (see REF _Ref526592737 \h \* MERGEFORMAT Table 7 in Appendix). Item 30177 now exclusively serves patients who have had massive weight loss and are suffering from the sequelae of this. The applicant requested that patients with postpartum rectus diastasis be reinstated as an eligible patient population for abdominoplasty with repair of the rectus diastasis under item 30176 (which serves patients with rectus diastasis due to surgical removal of large intra-abdominal or pelvic tumours). However, PASC considered that a separate MBS item may be required as abdominoplasty for patients with pregnancy-acquired rectus diastasis would require more complicated clinical restrictions and surgeons are no longer required to seek Medicare Claims Review Panel (MCRP) pre-approval under item 30176. Further, PASC considered a separate MBS item would make it easier to monitor usage and would also distinguish the service from other lipectomy items, which may not require surgical repair of the rectus diastasis. For reference, the relevant current MBS items for abdominoplasty with repair of the rectus diastasis are presented in REF _Ref527558869 \h \* MERGEFORMAT Table 5 and REF _Ref527559052 \h \* MERGEFORMAT Table 6 in REF _Ref526923843 \h \* MERGEFORMAT Appendix. Background Rectus diastasis is defined as an abnormal increase in the width of the linea alba, as measured by the IRD between the two rectus muscles PEVuZE5vdGU+PENpdGU+PEF1dGhvcj5Ic2lhPC9BdXRob3I+PFllYXI+MjAwMDwvWWVhcj48UmVj
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ADDIN EN.CITE.DATA [18, 19]. The function of the linea alba is to maintain the abdominal muscles at a certain proximity to each other PEVuZE5vdGU+PENpdGU+PEF1dGhvcj5CZWVyPC9BdXRob3I+PFllYXI+MjAwOTwvWWVhcj48UmVj
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ADDIN EN.CITE.DATA [20]. However, intra-abdominal pressure can cause the linea alba to stretch and widen, which results in a midline abdominal budge without a fascial defect ADDIN EN.CITE <EndNote><Cite><Author>Nahabedian</Author><Year>2018</Year><RecNum>45</RecNum><DisplayText>[21]</DisplayText><record><rec-number>45</rec-number><foreign-keys><key app="EN" db-id="dzdeaarzbt5r08ew2sbxav03ffxesxv25spp" timestamp="1535943532">45</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Nahabedian, M. Y.</author></authors></contributors><auth-address>National Center for Plastic Surgery, McLean, Virginia.</auth-address><titles><title>Management Strategies for Diastasis Recti</title><secondary-title>Semin Plast Surg</secondary-title><alt-title>Seminars in plastic surgery</alt-title></titles><periodical><full-title>Semin Plast Surg</full-title><abbr-1>Seminars in plastic surgery</abbr-1></periodical><alt-periodical><full-title>Semin Plast Surg</full-title><abbr-1>Seminars in plastic surgery</abbr-1></alt-periodical><pages>147-154</pages><volume>32</volume><number>3</number><edition>2018/07/27</edition><keywords><keyword>Diastasis recti</keyword><keyword>abdominal bulge</keyword><keyword>abdominal hernia</keyword><keyword>pregnancy</keyword><keyword>rectus diastasis</keyword></keywords><dates><year>2018</year><pub-dates><date>Aug</date></pub-dates></dates><isbn>1535-2188 (Print)
1535-2188 (Linking)</isbn><accession-num>30046291</accession-num><urls><related-urls><url>;[21]. Pregnancy and obesity are the most frequent causes of rectus diastasis ADDIN EN.CITE <EndNote><Cite><Author>Akram</Author><Year>2014</Year><RecNum>4</RecNum><DisplayText>[4]</DisplayText><record><rec-number>4</rec-number><foreign-keys><key app="EN" db-id="dzdeaarzbt5r08ew2sbxav03ffxesxv25spp" timestamp="1535517226">4</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Akram, J.</author><author>Matzen, S. H.</author></authors></contributors><auth-address>Department of Plastic Surgery, Roskilde University Hospital , Roskilde , Denmark.</auth-address><titles><title>Rectus abdominis diastasis</title><secondary-title>J Plast Surg Hand Surg</secondary-title><alt-title>Journal of plastic surgery and hand surgery</alt-title></titles><periodical><full-title>J Plast Surg Hand Surg</full-title><abbr-1>Journal of plastic surgery and hand surgery</abbr-1></periodical><alt-periodical><full-title>J Plast Surg Hand Surg</full-title><abbr-1>Journal of plastic surgery and hand surgery</abbr-1></alt-periodical><pages>163-9</pages><volume>48</volume><number>3</number><edition>2013/11/22</edition><keywords><keyword>Abdominoplasty</keyword><keyword>Humans</keyword><keyword>*Muscular Diseases/diagnosis/etiology/surgery</keyword><keyword>*Rectus Abdominis/surgery</keyword><keyword>Rectus abdominis diastasis</keyword><keyword>abdominal wall</keyword><keyword>conservative management</keyword><keyword>diastasis recti</keyword><keyword>divarication recti</keyword><keyword>linea alba</keyword><keyword>physiotherapy</keyword><keyword>pregnancy</keyword></keywords><dates><year>2014</year><pub-dates><date>Jun</date></pub-dates></dates><isbn>2000-6764 (Electronic)
2000-6764 (Linking)</isbn><accession-num>24256310</accession-num><urls><related-urls><url>;[4]. However, the condition can also result from prior abdominal operations and large abdominal and pelvic tumours ADDIN EN.CITE <EndNote><Cite><Author>Akram</Author><Year>2014</Year><RecNum>4</RecNum><DisplayText>[4]</DisplayText><record><rec-number>4</rec-number><foreign-keys><key app="EN" db-id="dzdeaarzbt5r08ew2sbxav03ffxesxv25spp" timestamp="1535517226">4</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Akram, J.</author><author>Matzen, S. H.</author></authors></contributors><auth-address>Department of Plastic Surgery, Roskilde University Hospital , Roskilde , Denmark.</auth-address><titles><title>Rectus abdominis diastasis</title><secondary-title>J Plast Surg Hand Surg</secondary-title><alt-title>Journal of plastic surgery and hand surgery</alt-title></titles><periodical><full-title>J Plast Surg Hand Surg</full-title><abbr-1>Journal of plastic surgery and hand surgery</abbr-1></periodical><alt-periodical><full-title>J Plast Surg Hand Surg</full-title><abbr-1>Journal of plastic surgery and hand surgery</abbr-1></alt-periodical><pages>163-9</pages><volume>48</volume><number>3</number><edition>2013/11/22</edition><keywords><keyword>Abdominoplasty</keyword><keyword>Humans</keyword><keyword>*Muscular Diseases/diagnosis/etiology/surgery</keyword><keyword>*Rectus Abdominis/surgery</keyword><keyword>Rectus abdominis diastasis</keyword><keyword>abdominal wall</keyword><keyword>conservative management</keyword><keyword>diastasis recti</keyword><keyword>divarication recti</keyword><keyword>linea alba</keyword><keyword>physiotherapy</keyword><keyword>pregnancy</keyword></keywords><dates><year>2014</year><pub-dates><date>Jun</date></pub-dates></dates><isbn>2000-6764 (Electronic)
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ADDIN EN.CITE.DATA [3]. Another similar prospective cohort study found that that postpartum women with higher IRD values had significantly reduced abdominal muscle function than women with lower values ADDIN EN.CITE <EndNote><Cite><Author>Liaw</Author><Year>2011</Year><RecNum>42</RecNum><DisplayText>[2]</DisplayText><record><rec-number>42</rec-number><foreign-keys><key app="EN" db-id="dzdeaarzbt5r08ew2sbxav03ffxesxv25spp" timestamp="1535940908">42</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Liaw, L. J.</author><author>Hsu, M. J.</author><author>Liao, C. F.</author><author>Liu, M. F.</author><author>Hsu, A. T.</author></authors></contributors><auth-address>Institute of Allied Health Sciences, College of Medicine, National Cheng Kung University, Taiwan.</auth-address><titles><title>The relationships between inter-recti distance measured by ultrasound imaging and abdominal muscle function in postpartum women: a 6-month follow-up study</title><secondary-title>J Orthop Sports Phys Ther</secondary-title></titles><periodical><full-title>J Orthop Sports Phys Ther</full-title><abbr-1>The Journal of orthopaedic and sports physical therapy</abbr-1></periodical><pages>435-43</pages><volume>41</volume><number>6</number><keywords><keyword>Abdominal Muscles/*anatomy & histology/diagnostic imaging/*physiology</keyword><keyword>Adult</keyword><keyword>Female</keyword><keyword>Follow-Up Studies</keyword><keyword>Humans</keyword><keyword>Muscle Strength/physiology</keyword><keyword>Organ Size</keyword><keyword>Physical Endurance/physiology</keyword><keyword>Postpartum Period/*physiology</keyword><keyword>Prospective Studies</keyword><keyword>Ultrasonography</keyword></keywords><dates><year>2011</year><pub-dates><date>Jun</date></pub-dates></dates><isbn>1938-1344 (Electronic)
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ADDIN EN.CITE.DATA [3] ADDIN EN.CITE <EndNote><Cite><Author>Braga</Author><Year>2014</Year><RecNum>92</RecNum><DisplayText>[15]</DisplayText><record><rec-number>92</rec-number><foreign-keys><key app="EN" db-id="dzdeaarzbt5r08ew2sbxav03ffxesxv25spp" timestamp="1538704296">92</key></foreign-keys><ref-type name="Conference Proceedings">10</ref-type><contributors><authors><author>Braga, Andrea</author><author>Sorice, Paola</author><author>Furiga, Serena</author><author>Cantaluppi, Simona</author><author>Cromi, Antonella</author><author>Ghezzi, Fabio</author><author>Serati, Maurizio</author></authors></contributors><titles><title>Diastasis recti abdominis: correlation with parity and stress urinary incontinence</title><secondary-title>Neurourology and Urodynamics</secondary-title></titles><periodical><full-title>Neurourol Urodyn</full-title><abbr-1>Neurourology and urodynamics</abbr-1></periodical><pages>S8-S9</pages><volume>33</volume><dates><year>2014</year></dates><publisher>Wiley-Blackwell 111 River St, Hoboken 07030-5774, NJ USA</publisher><isbn>0733-2467</isbn><urls></urls></record></Cite></EndNote>[15]. Studies also find that patients with rectus diastasis who undergo abdominoplasty find symptomatic relief from low back pain PEVuZE5vdGU+PENpdGU+PEF1dGhvcj5Ub3JhbnRvPC9BdXRob3I+PFllYXI+MTk5MDwvWWVhcj48
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ADDIN EN.CITE.DATA [7, 28]. During the PASC meeting, the applicant noted that Toranto (1990) ADDIN EN.CITE <EndNote><Cite><Author>Toranto</Author><Year>1990</Year><RecNum>12</RecNum><DisplayText>[16]</DisplayText><record><rec-number>12</rec-number><foreign-keys><key app="EN" db-id="dzdeaarzbt5r08ew2sbxav03ffxesxv25spp" timestamp="1535518374">12</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Toranto, I. R.</author></authors></contributors><titles><title>The relief of low back pain with the WARP abdominoplasty: a preliminary report</title><secondary-title>Plast Reconstr Surg</secondary-title><alt-title>Plastic and reconstructive surgery</alt-title></titles><periodical><full-title>Plast Reconstr Surg</full-title><abbr-1>Plastic and reconstructive surgery</abbr-1></periodical><alt-periodical><full-title>Plast Reconstr Surg</full-title><abbr-1>Plastic and reconstructive surgery</abbr-1></alt-periodical><pages>545-55</pages><volume>85</volume><number>4</number><edition>1990/04/01</edition><keywords><keyword>Abdominal Muscles/*surgery</keyword><keyword>Adult</keyword><keyword>Aged</keyword><keyword>Back Pain/etiology/pathology/*surgery</keyword><keyword>Female</keyword><keyword>Follow-Up Studies</keyword><keyword>Humans</keyword><keyword>Intervertebral Disc/pathology</keyword><keyword>Lumbar Vertebrae/pathology</keyword><keyword>Magnetic Resonance Imaging</keyword><keyword>Male</keyword><keyword>Methods</keyword><keyword>Middle Aged</keyword><keyword>Sacrum/pathology</keyword></keywords><dates><year>1990</year><pub-dates><date>Apr</date></pub-dates></dates><isbn>0032-1052 (Print)
0032-1052 (Linking)</isbn><accession-num>2138335</accession-num><urls><related-urls><url>;[16], found patients with bulging rectus diastasis with reported symptomatic relief from low back pain following abdominoplasty. PASC noted that the study was unable to identify any structural abnormalities that could explain the patients’ low back pain and was doubtful of the patients’ response. The applicant stated that abdominoplasty can restore core strength, even without other interventions. The applicant also noted that patients usually realise the condition is rectus diastasis because the pain occurs when the abdominal muscles are contracting.Classification There is a lack of consensus in the literature on when rectus diastasis (as measured by the IRD) becomes pathologic and thresholds for surgery are controversial ADDIN EN.CITE <EndNote><Cite><Author>Akram</Author><Year>2014</Year><RecNum>4</RecNum><DisplayText>[4]</DisplayText><record><rec-number>4</rec-number><foreign-keys><key app="EN" db-id="dzdeaarzbt5r08ew2sbxav03ffxesxv25spp" timestamp="1535517226">4</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Akram, J.</author><author>Matzen, S. H.</author></authors></contributors><auth-address>Department of Plastic Surgery, Roskilde University Hospital , Roskilde , Denmark.</auth-address><titles><title>Rectus abdominis diastasis</title><secondary-title>J Plast Surg Hand Surg</secondary-title><alt-title>Journal of plastic surgery and hand surgery</alt-title></titles><periodical><full-title>J Plast Surg Hand Surg</full-title><abbr-1>Journal of plastic surgery and hand surgery</abbr-1></periodical><alt-periodical><full-title>J Plast Surg Hand Surg</full-title><abbr-1>Journal of plastic surgery and hand surgery</abbr-1></alt-periodical><pages>163-9</pages><volume>48</volume><number>3</number><edition>2013/11/22</edition><keywords><keyword>Abdominoplasty</keyword><keyword>Humans</keyword><keyword>*Muscular Diseases/diagnosis/etiology/surgery</keyword><keyword>*Rectus Abdominis/surgery</keyword><keyword>Rectus abdominis diastasis</keyword><keyword>abdominal wall</keyword><keyword>conservative management</keyword><keyword>diastasis recti</keyword><keyword>divarication recti</keyword><keyword>linea alba</keyword><keyword>physiotherapy</keyword><keyword>pregnancy</keyword></keywords><dates><year>2014</year><pub-dates><date>Jun</date></pub-dates></dates><isbn>2000-6764 (Electronic)
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ADDIN EN.CITE.DATA [4, 6].Most studies consider that an IRD (i.e. the width of the linea alba) greater than 22 mm, measured three centimetres above the umbilicus in a relaxed state to be indicative of rectus diastasis PEVuZE5vdGU+PENpdGU+PEF1dGhvcj5Nb21tZXJzPC9BdXRob3I+PFllYXI+MjAxNzwvWWVhcj48
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ADDIN EN.CITE.DATA [20], who measured the IRD by ultrasound in 150 nulliparous women, aged 20 to 45 years with a body mass index less than 30 kg m2. However, other papers have proposed alternative diagnostic criteria’s. For women younger than 45 years an IRD greater than 1 cm at the supra-umbilical level, 2.7 cm at the umbilicus, and 0.9 cm between the pubic symphysis and umbilicus should be considered pathologic. Corresponding values in women older than 45 years were 1.5, 2.7 and 1.4 cm. Another paper by Nahas (2001) ADDIN EN.CITE <EndNote><Cite><Author>Nahas</Author><Year>2001</Year><RecNum>7</RecNum><DisplayText>[32]</DisplayText><record><rec-number>7</rec-number><foreign-keys><key app="EN" db-id="dzdeaarzbt5r08ew2sbxav03ffxesxv25spp" timestamp="1535517977">7</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Nahas, F. X.</author></authors></contributors><auth-address>Plastic Surgery Division, Hospital Jaragua, Sao Paulo, Brazil. fabio-nahas@.br</auth-address><titles><title>An aesthetic classification of the abdomen based on the myoaponeurotic layer</title><secondary-title>Plast Reconstr Surg</secondary-title><alt-title>Plastic and reconstructive surgery</alt-title></titles><periodical><full-title>Plast Reconstr Surg</full-title><abbr-1>Plastic and reconstructive surgery</abbr-1></periodical><alt-periodical><full-title>Plast Reconstr Surg</full-title><abbr-1>Plastic and reconstructive surgery</abbr-1></alt-periodical><pages>1787-95; discussion 1796-7</pages><volume>108</volume><number>6</number><edition>2001/11/17</edition><keywords><keyword>Abdominal Muscles/*pathology/*surgery</keyword><keyword>Adolescent</keyword><keyword>Adult</keyword><keyword>Fascia/pathology</keyword><keyword>Female</keyword><keyword>Humans</keyword><keyword>Lipectomy</keyword><keyword>Middle Aged</keyword><keyword>Reconstructive Surgical Procedures/methods</keyword></keywords><dates><year>2001</year><pub-dates><date>Nov</date></pub-dates></dates><isbn>0032-1052 (Print)
0032-1052 (Linking)</isbn><accession-num>11711966</accession-num><urls><related-urls><url>;[32] proposed rectus diastasis should be classified according to myofascial deformity and aetiology. These differing diagnostic criteria are summarised in REF _Ref525724188 \h \* MERGEFORMAT Table 1. Table SEQ Table \* ARABIC 1: Three classification systems to diagnose rectus diastasisNahas (2001) ADDIN EN.CITE <EndNote><Cite><Author>Nahas</Author><Year>2001</Year><RecNum>7</RecNum><DisplayText>[32]</DisplayText><record><rec-number>7</rec-number><foreign-keys><key app="EN" db-id="dzdeaarzbt5r08ew2sbxav03ffxesxv25spp" timestamp="1535517977">7</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Nahas, F. X.</author></authors></contributors><auth-address>Plastic Surgery Division, Hospital Jaragua, Sao Paulo, Brazil. fabio-nahas@.br</auth-address><titles><title>An aesthetic classification of the abdomen based on the myoaponeurotic layer</title><secondary-title>Plast Reconstr Surg</secondary-title><alt-title>Plastic and reconstructive surgery</alt-title></titles><periodical><full-title>Plast Reconstr Surg</full-title><abbr-1>Plastic and reconstructive surgery</abbr-1></periodical><alt-periodical><full-title>Plast Reconstr Surg</full-title><abbr-1>Plastic and reconstructive surgery</abbr-1></alt-periodical><pages>1787-95; discussion 1796-7</pages><volume>108</volume><number>6</number><edition>2001/11/17</edition><keywords><keyword>Abdominal Muscles/*pathology/*surgery</keyword><keyword>Adolescent</keyword><keyword>Adult</keyword><keyword>Fascia/pathology</keyword><keyword>Female</keyword><keyword>Humans</keyword><keyword>Lipectomy</keyword><keyword>Middle Aged</keyword><keyword>Reconstructive Surgical Procedures/methods</keyword></keywords><dates><year>2001</year><pub-dates><date>Nov</date></pub-dates></dates><isbn>0032-1052 (Print)
0032-1052 (Linking)</isbn><accession-num>11711966</accession-num><urls><related-urls><url>;[32] classification: based on the myofascial deformity and the aetiologyDeformityType AType BType CType DAetiologyPregnancy Myoaponeurotic laxityCongenitalObesity Correction Anterior sheath plicationExternal oblique plicationRectus abdominis advancementAnterior sheath plication and rectus abdominis advancementRath, Attali et al. (1996) ADDIN EN.CITE <EndNote><Cite><Author>Rath</Author><Year>1996</Year><RecNum>78</RecNum><DisplayText>[33]</DisplayText><record><rec-number>78</rec-number><foreign-keys><key app="EN" db-id="dzdeaarzbt5r08ew2sbxav03ffxesxv25spp" timestamp="1536891433">78</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Rath, A. M.</author><author>Attali, P.</author><author>Dumas, J. L.</author><author>Goldlust, D.</author><author>Zhang, J.</author><author>Chevrel, J. P.</author></authors></contributors><auth-address>Institut d'Anatomie Clinique de l'UFR de Bobigny-Paris XIII, Bobigny, France.</auth-address><titles><title>The abdominal linea alba: an anatomo-radiologic and biomechanical study</title><secondary-title>Surg Radiol Anat</secondary-title><alt-title>Surgical and radiologic anatomy : SRA</alt-title></titles><periodical><full-title>Surg Radiol Anat</full-title><abbr-1>Surgical and radiologic anatomy : SRA</abbr-1></periodical><alt-periodical><full-title>Surg Radiol Anat</full-title><abbr-1>Surgical and radiologic anatomy : SRA</abbr-1></alt-periodical><pages>281-8</pages><volume>18</volume><number>4</number><edition>1996/01/01</edition><keywords><keyword>Abdominal Muscles/*anatomy & histology/diagnostic imaging/physiology</keyword><keyword>Adolescent</keyword><keyword>Adult</keyword><keyword>Age Factors</keyword><keyword>Aged</keyword><keyword>Aged, 80 and over</keyword><keyword>Biomechanical Phenomena</keyword><keyword>Child</keyword><keyword>Female</keyword><keyword>Humans</keyword><keyword>Male</keyword><keyword>Middle Aged</keyword><keyword>Tomography, X-Ray Computed</keyword></keywords><dates><year>1996</year></dates><isbn>0930-1038 (Print)
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ADDIN EN.CITE.DATA [20] classification: based on the normal width of linea alba. LevelAt Xiphoid3 cm above the umbilicus2 cm below the umbilicus Width1.5 cm2.2 cm1.6 cmSource: Collated based on data from Nahabedian (2018) ADDIN EN.CITE <EndNote><Cite><Author>Nahabedian</Author><Year>2018</Year><RecNum>45</RecNum><DisplayText>[21]</DisplayText><record><rec-number>45</rec-number><foreign-keys><key app="EN" db-id="dzdeaarzbt5r08ew2sbxav03ffxesxv25spp" timestamp="1535943532">45</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Nahabedian, M. Y.</author></authors></contributors><auth-address>National Center for Plastic Surgery, McLean, Virginia.</auth-address><titles><title>Management Strategies for Diastasis Recti</title><secondary-title>Semin Plast Surg</secondary-title><alt-title>Seminars in plastic surgery</alt-title></titles><periodical><full-title>Semin Plast Surg</full-title><abbr-1>Seminars in plastic surgery</abbr-1></periodical><alt-periodical><full-title>Semin Plast Surg</full-title><abbr-1>Seminars in plastic surgery</abbr-1></alt-periodical><pages>147-154</pages><volume>32</volume><number>3</number><edition>2018/07/27</edition><keywords><keyword>Diastasis recti</keyword><keyword>abdominal bulge</keyword><keyword>abdominal hernia</keyword><keyword>pregnancy</keyword><keyword>rectus diastasis</keyword></keywords><dates><year>2018</year><pub-dates><date>Aug</date></pub-dates></dates><isbn>1535-2188 (Print)
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ADDIN EN.CITE.DATA [20] and Rath, Attali et al. (1996) ADDIN EN.CITE <EndNote><Cite><Author>Rath</Author><Year>1996</Year><RecNum>78</RecNum><DisplayText>[33]</DisplayText><record><rec-number>78</rec-number><foreign-keys><key app="EN" db-id="dzdeaarzbt5r08ew2sbxav03ffxesxv25spp" timestamp="1536891433">78</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Rath, A. M.</author><author>Attali, P.</author><author>Dumas, J. L.</author><author>Goldlust, D.</author><author>Zhang, J.</author><author>Chevrel, J. P.</author></authors></contributors><auth-address>Institut d'Anatomie Clinique de l'UFR de Bobigny-Paris XIII, Bobigny, France.</auth-address><titles><title>The abdominal linea alba: an anatomo-radiologic and biomechanical study</title><secondary-title>Surg Radiol Anat</secondary-title><alt-title>Surgical and radiologic anatomy : SRA</alt-title></titles><periodical><full-title>Surg Radiol Anat</full-title><abbr-1>Surgical and radiologic anatomy : SRA</abbr-1></periodical><alt-periodical><full-title>Surg Radiol Anat</full-title><abbr-1>Surgical and radiologic anatomy : SRA</abbr-1></alt-periodical><pages>281-8</pages><volume>18</volume><number>4</number><edition>1996/01/01</edition><keywords><keyword>Abdominal Muscles/*anatomy & histology/diagnostic imaging/physiology</keyword><keyword>Adolescent</keyword><keyword>Adult</keyword><keyword>Age Factors</keyword><keyword>Aged</keyword><keyword>Aged, 80 and over</keyword><keyword>Biomechanical Phenomena</keyword><keyword>Child</keyword><keyword>Female</keyword><keyword>Humans</keyword><keyword>Male</keyword><keyword>Middle Aged</keyword><keyword>Tomography, X-Ray Computed</keyword></keywords><dates><year>1996</year></dates><isbn>0930-1038 (Print)
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ADDIN EN.CITE.DATA [25], which compared abdominoplasty to three-months of physiotherapy demonstrated that patients with an IRD ≥ 3 cm had significantly reduced health-related quality of life (as measured by the SF-36 survey) compared to the general population. The study also demonstrated that patients who received abdominoplasty had significantly improved SF36 scores PEVuZE5vdGU+PENpdGU+PEF1dGhvcj5FbWFudWVsc3NvbjwvQXV0aG9yPjxZZWFyPjIwMTY8L1ll
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ADDIN EN.CITE.DATA [25]. According to epidemiological studies, approximately 33% [23] to 41% [22] of primiparous women have a rectus diastasis of two or more finger widths (IRD ≥ 3cm) at 12-months postpartum. However, only 1% of postpartum women had a rectus diastasis of three or more finger widths (IRD > 4.5 cm). Further, the median IRD of patients in Emanuelsson’s trial was 4 cm PEVuZE5vdGU+PENpdGU+PEF1dGhvcj5FbWFudWVsc3NvbjwvQXV0aG9yPjxZZWFyPjIwMTY8L1ll
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ADDIN EN.CITE.DATA [28].The applicant stated that whilst there were no high-quality studies to correlate an increased IRD with worsening symptoms, expert opinion would suggest that there is a strong correlation. The applicant considered that a clinical cut-off of an IRD ≥ 4 cm would restrict the eligible population significantly but would still allow patients with the greatest severity to receive treatment. However, it would also render a significant proportion of women with genuine disability ineligible for treatment. Clinical assessment Patients presenting at their GPs’ with symptoms of low back pain and abdominal discomfort would have their abdominal muscles assessed for rectus diastasis using the finger-width method. Patients with evident rectus diastasis would then be referred for a diagnostic ultrasound (MBS item: 55812) to measure the diastasis (i.e. IRD). Patients found to have significant rectus diastasis (i.e. IRD ≥ 3 cm) would then be referred to a specialist surgeon. The surgeon would then take a full history and examination of the patient, ensuring the patient meets the proposed MBS criteria.Eligible population In 2016 there was approximately 132,089 parous women (based on 311,104 live births and an adjusted fertility rate of 2.36 children per a parous woman). Of these women, approximately 43,061 have a rectus diastasis of at least 3 cm. According to Sperstad, Tennfjord et al. (2016) PEVuZE5vdGU+PENpdGU+PEF1dGhvcj5TcGVyc3RhZDwvQXV0aG9yPjxZZWFyPjIwMTY8L1llYXI+
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ADDIN EN.CITE.DATA [23] 46% of women with rectus diastasis also experienced lumbopelvic pain. Assuming the number of parous women who have completed having children remains constant at 2016 levels (see REF _Ref526868057 \h \* MERGEFORMAT Table 8), approximately 19,808 of Australian women would have both lumbopelvic pain and rectus distastes and thus would be eligible for surgery under the applicant’s proposed criteria (see REF _Ref525742764 \h \* MERGEFORMAT Table 2). The applicant considered that whilst the eligible population is large, uptake will likely to be very low as most patients would not want to undergo major surgery, particularly those with young children. The applicant estimates that reinstating postpartum patients would result in approximately 1,000 more surgeries being performed each year. This estimate is consistent with the observed 1,200 fewer lipectomies being performed in 2016, after postpartum patients were removed from item 30176 (see Table 12). PASC agreed that this estimate was reasonable. Table SEQ Table \* ARABIC 2: Number of patients eligible for surgery each year: Women with pregnancy acquired rectus diastasis and who experience lumbopelvic pain and that have completed having childrenInputCalculation EstimateANumber parous women who have completed having children in 2016 (ABS) REF _Ref526410923 \h \* MERGEFORMAT Table 8132,089BProportion of women who develop pregnancy acquired rectus diastasis (IRD ≥ 3 cm) PEVuZE5vdGU+PENpdGU+PEF1dGhvcj5TcGVyc3RhZDwvQXV0aG9yPjxZZWFyPjIwMTY8L1llYXI+
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ADDIN EN.CITE.DATA [23]32.6%CNumber of women with pregnancy acquired rectus diastasis A x B43,061DProportion of women with pregnancy acquired rectus diastasis and lumbopelvic pain PEVuZE5vdGU+PENpdGU+PEF1dGhvcj5TcGVyc3RhZDwvQXV0aG9yPjxZZWFyPjIwMTY8L1llYXI+
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NTwvZWxlY3Ryb25pYy1yZXNvdXJjZS1udW0+PC9yZWNvcmQ+PC9DaXRlPjwvRW5kTm90ZT4A
ADDIN EN.CITE PEVuZE5vdGU+PENpdGU+PEF1dGhvcj5TcGVyc3RhZDwvQXV0aG9yPjxZZWFyPjIwMTY8L1llYXI+
PFJlY051bT43MzwvUmVjTnVtPjxEaXNwbGF5VGV4dD5bMjNdPC9EaXNwbGF5VGV4dD48cmVjb3Jk
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aW9sb2d5PC9rZXl3b3JkPjxrZXl3b3JkPlByZWduYW5jeTwva2V5d29yZD48a2V5d29yZD5QcmVn
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ADDIN EN.CITE.DATA [23]46%EEligible patient populationC x D19,808Sensitivity analysis: using an IRD ≥ 4.5 cm (≥ 3 finger widths)FThe proportion of women who develop pregnancy acquired rectus diastasis (IRD ≥ 4.5 cm) [29]1.1%GNumber of women with pregnancy acquired rectus diastasisA x F1,453HThe proportion of women with pregnancy acquired rectus diastasis and lumbopelvic pain PEVuZE5vdGU+PENpdGU+PEF1dGhvcj5TcGVyc3RhZDwvQXV0aG9yPjxZZWFyPjIwMTY8L1llYXI+
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ADDIN EN.CITE.DATA [23]46%IEligible patient populationG x H668InterventionThe medical service proposed by the applicant is the surgical repair of the abdominal wall defect by closing the distance between the rectus muscles. The repair would involve suturing the musculoaponeurotic layer of the abdominal wall and including associated excision of redundant skin and fat and transposition of the umbilicus (radical abdominoplasty). The surgical procedure for postpartum patients would be identical to patients undergoing radical abdominoplasty due to the surgical removal of large intra-abdominal or pelvic tumours (MBS item: 30176). REF _Ref526940987 \h \* MERGEFORMAT Table 3 outlines the MBS items that would likely be claimed by a patient undergoing lipectomy. The service would be performed under general anaesthesia in an accredited hospital and would include a one to four-night inpatient stay. The applicant proposes only accredited hospitals and surgeons would perform the surgery. REF _Ref526940987 \h \* MERGEFORMAT Table 3 outlines the MBS items that would likely be claimed by a patient undergoing lipectomy and REF _Ref527549116 \h \* MERGEFORMAT Table 4 summarises the associated hospital costs. Table SEQ Table \* ARABIC 3: MBS items claimed by a patient undergoing lipectomy MBS ItemDescriptionFeeBenefit55812Diagnostic ultrasound of the patient’s abdominal wall to diagnosis rectus diastasis (IRD ≥ 3 cm)CHEST OR ABDOMINAL WALL, 1 or more areas, ultrasound scan of, where: (a) the service is not associated with a service to which an item in Subgroups 2 or 3 of this Group applies; and (b) the referring practitioner is not a member of a group of practitioners of which the providing practitioner is a member $109.1075% = $81.8585% = $92.75104Initial consultation and discussion of procedure Professional attendance at consulting rooms or hospital by a specialist in the practice of his or her speciality after referral of the patient to him or her-each attendance, other than a second or subsequent attendance, in a single course of treatment, other than a service to which item 106, 109 or 16401 applies$86.8575%?=?$65.1585% = $75.85105Further pre-operative discussion and consenting process (60% of patients may require a second discussion) Professional attendance by a specialist in the practice of his or her speciality following referral of the patient to him or her-an attendance after the first in a single course of treatment, if that attendance is at consulting rooms or hospital, other than a service to which item 16404 applies$43.6575% = $32.7585% = $37.1520803INITIATION OF MANAGEMENT OF ANAESTHESIA for all procedures on the nerves, muscles, tendons and fascia of the lower abdominal wall, not being a service to which another item in this Subgroup applies$79.2075% = 59.4085% = $67.3523083Anaesthesia for a 2 hour procedure.$158.4075%?=?$118.8085% = $134.6530176Lipectomy, radical abdominoplasty (Pitanguy type or similar), with excision of skin and subcutaneous tissue, repair of musculoaponeurotic layer and transposition of umbilicus, not being a service associated with a service to which item 30165, 30168, 30171, 30172, 30177, 30179, 45530, 45564 or 45565 applies, if it can be demonstrated that there is an anterior abdominal wall defect that is a consequence of the surgical removal of large intra-abdominal or pelvic tumours$985.70 75% = $739.30105Post-surgical consultation (on average patients require 5 consults)Professional attendance by a specialist in the practice of his or her speciality following referral of the patient to him or her-an attendance after the first in a single course of treatment, if that attendance is at consulting rooms or hospital, other than a service to which item 16404 applies$43.6575% = $32.7585% = $37.15Table SEQ Table \* ARABIC 4: Hospital costs associated with lipectomy AR-DRGAverage CostG10A: Hernia procedures, major$11,337Cost for a one to four-night stay in hospital $2,179 to $8715Source: NHCDC Round 20AR-DRG = Australian Refined Diagnosis Related Group; NHCDC = National Hospital Cost Data CollectionComparator‘Best supportive care’ was nominated as the main comparator. Best supportive care can include symptomatic treatment with pain killers, lower back braces and lifestyle changes. The doctor may also recommend the patient continues with their physiotherapy or exercise program. The applicant stated that whilst physiotherapy and/or exercise is commonly used to treat rectus diastasis PEVuZE5vdGU+PENpdGU+PEF1dGhvcj5FbWFudWVsc3NvbjwvQXV0aG9yPjxZZWFyPjIwMTY8L1ll
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ADDIN EN.CITE.DATA [5, 22, 25, 30], it is used much earlier in treatment than abdominoplasty. The applicant reiterated patients generally only consider surgery after they have exhausted all other treatment options (i.e. patients have already tried and failed multiple exercise/physiotherapy programs). OutcomesPatient-relevantThe applicant stated that abdominoplasty in the postpartum patients with a rectus diastasis of at least 3 cm improves health-related quality of life and reduces urinary incontinence symptoms, and lower back and abdominal pain. In support of this clinical claim, the applicant provided a list of studies of that showed patients who underwent abdominoplasty experienced a multitude of health benefits (see REF _Ref527123244 \h \* MERGEFORMAT Table 9). Therefore, the following patient relevant outcomes have been identified: Reduction in back pain and urinary incontinence; Improvements in health-related quality of life and general daily functioning;Improved abdominal muscle strength; Recurrence; Quality-adjusted life years; andAdverse events following surgery, as such as seroma, infections, haematomas and nerve damage. Healthcare systemIf abdominoplasty, with surgical repair of the rectus diastasis was to become available to postpartum patients, the resulting healthcare resources and costs will relate to:Number of patients treated each year;Total cost of abdominoplasty per patient; Anaesthesia and hospital costs;Number of additional surgical consults, ultrasounds and associated diagnostic testing;Costs related to adverse events following surgery; as such as seroma, infections, haematomas and nerve damage; andNumber of patients requiring revision surgery due to recurrent diastasis.Current clinical management algorithm for identified populationCurrently, there are no MBS-funded treatment options for postpartum patients with rectus diastasis. Therefore, these patients would likely present at their GP’s (usually multiple times) with complaints of low back pain and abdominal discomfort. These patients would then be clinically assessed by their GP and referred for diagnostic imaging if it was clinically appropriate. If the ultrasound indicated the patient had rectus diastasis, the GP would then recommend the patient trial conservative treatments, such as physiotherapy, exercise, lifestyle changes and painkillers. Patients who do not respond to conservative treatment would be recommended ‘best supportive care’, which may include symptomatic treatment with pain medication, lower back braces and lifestyle changes or the patient may be recommended they continue treatment with physiotherapy and/or exercise program. See REF _Ref527547203 \h \* MERGEFORMAT Figure 1. Figure SEQ Figure \* ARABIC 1: Available treatment options for patients with postpartum rectus diastasisGP = general practitioner; RD = rectus diastasis Proposed clinical management algorithm for identified population REF _Ref527548577 \h \* MERGEFORMAT Figure 2 presents the proposed treatment options available for postpartum women with rectus diastasis (who failed to respond to conservative treatment) if abdominoplasty is reinstated for this patient group. Patients who fail to respond to conservative treatment would be given the option to either manage symptoms with ‘best supportive care’ or surgery. Patients who opt for surgery would be referred by their GP to a general or plastic surgeon, who would then assess the patient for suitability and eligibility for abdominoplasty.Figure SEQ Figure \* ARABIC 2: Available treatment options for patients with postpartum rectus diastasis if this patient group is reinstated for abdominoplasty GP = general practitioner; RD = rectus diastasis Proposed economic evaluationThe overall clinical claim proposed by the applicant is superiority to best supportive care. The appropriate type of economic evaluation is likely to be a cost-utility analysis, with best supportive care used as the comparator. PASC advised that the use of imaging would help prevent leakage to people wanting the procedure for cosmetic reasons, and consideration should be given to adding a requirement in the descriptor for pre-procedure imaging (to rule out cosmetic use). PASC advised that the cost of this requirement should be analysed for Budget impact during the assessment phase.Proposed item descriptorAs discussed previously, the application originally requested that Item 30176 be expanded to include patients with an anterior abdominal wall defect due to pregnancy. However, PASC considered a separate item number may be more appropriate. PASC also considered that the procedure should be restricted to ‘once in a lifetime’. The proposed item descriptor was updated to reflect PASC’s proposed changes.Proposed updated wording to existing Item 30176 – Category 3 – Therapeutic ProceduresGroup T – surgical operationsSubgroup 1 – general Lipectomy, radical abdominoplasty (Pitanguy type or similar), with excision of skin and subcutaneous tissue, repair of musculoaponeurotic layer and transposition of umbilicus, not being a service associated with a service to which item 30165, 30168, 30171, 30172, 30177, 30179, 45530, 45564 or 45565 applies, and where it can be demonstrated that one of the following conditions is present: anterior abdominal wall defect that is a consequence of the surgical removal of large intra-abdominal or pelvic tumours; oranterior abdominal wall defect that is a consequence of pregnancy and the patient must: not be receiving this service within 12 months after the end of a pregnancy (once in a lifetime);have a diastasis of at least 3 cm (measured by appropriate pre-procedure diagnostic imaging); andhave documented functional symptoms (in the case notes) of lower back pain, combined with daily pain or discomfort at the site of the diastasis in the abdominal wall during functional use (H)Multiple Operation Rule (Anaes.) (Assist.)Fee: $985.70 Benefit: 75% = $739.30Proposed item descriptor: Category 301XX – Category 3 – Therapeutic ProceduresGroup T – surgical operationsSubgroup 1 – general Lipectomy, radical abdominoplasty (Pitanguy type or similar), with excision of skin and subcutaneous tissue, repair of musculoaponeurotic layer and transposition of umbilicus, not being a service associated with a service to which item 30165, 30168, 30171, 30172, 30176, 30177, 30179, 45530, 45564 or 45565 applies, and where it can be demonstrated, by pre-procedure imaging, that the patient has an abdominal wall defect as a consequence of pregnancy and must: not be receiving this service within 12 months after the end of a pregnancy (once in a lifetime);have a diastasis of at least 3cm (measured by appropriate diagnostic imaging); andhave documented functional symptoms (in the case notes) of lower back pain, combined with daily pain or discomfort at the site of the diastasis in the abdominal wall during functional use (H)Multiple Operation Rule (Anaes.) (Assist.)Fee: $985.70 Benefit: 75% = $739.30Claims for item 301XX should be lodged with the Department of Human Services for referral to the National Office of the Department of Human Services for assessment by the Medicare Claims Review Panel (MCRP). Claims should be accompanied by full clinical details, including pre-operative colour photographs. Where digital photographs are supplied, the practitioner must sign each photograph to certify that the digital photograph has not been altered. Practitioners may also apply to the Department of Human Services for prospective approval for proposed surgery. AppendixTable SEQ Table \* ARABIC 5: Related MBS item descriptorsMBS Item Description 30176Lipectomy, radical abdominoplasty (Pitanguy type or similar), with excision of skin and subcutaneous tissue, repair of musculoaponeurotic layer and transposition of umbilicus, not being a service associated with a service to which item 30165, 30168, 30171, 30172, 30177, 30179, 45530, 45564 or 45565 applies, if it can be demonstrated that there is an anterior abdominal wall defect that is a consequence of the surgical removal of large intra-abdominal or pelvic tumoursFee: $985.70 Benefit: 75% = $739.3030177Lipectomy, excision of skin and subcutaneous tissue associated with redundant abdominal skin and fat that is a direct consequence of significant weight loss, in conjunction with a radical abdominoplasty (Pitanguy type or similar), with or without repair of musculoaponeurotic layer and transposition of umbilicus, not being a service associated with a service to which item 30165, 30168, 30171, 30172, 30176, 30179, 45530, 45564 or 45565 applies, if:(a) there is intertrigo or another skin condition that risks loss of skin integrity and has failed 3 months of conventional (or non-surgical) treatment; and(b) the redundant skin and fat interferes with the activities of daily living; and(c) the weight has been stable for at least 6 months following significant weight loss prior to the lipectomyFee: $985.70 Benefit: 75% = $739.30Source: MBS websiteClaims for item 30177 should be lodged with the Department of Human Services for referral to the National Office of the Department of Human Services for assessment by the Medicare Claims Review Panel (MCRP). Claims should be accompanied by full clinical details, including pre-operative colour photographs. Where digital photographs are supplied, the practitioner must sign each photograph to certify that the digital photograph has not been altered. Practitioners may also apply to the Department of Human Services for prospective approval for proposed surgery. As of 1st November 2018, claims for item 30176 no longer require MCRP pre-approval. Table SEQ Table \* ARABIC 6: MBS item history for abdominoplasty with repair of the rectus diastasis in postpartum womenMBS Item Description 30177 (prior to 1 November 2015)LIPECTOMY radical abdominoplasty (Pitanguy type or similar), with excision of skin and subcutaneous tissue, repair of musculoaponeurotic layer and transposition of umbilicus, not being a service performed within 12 months after the end of a pregnancy and not being a service associated with a service to which item 45564, 45565 or 45530 applies (Anaes.) (Assist.)(See para T8.8 of explanatory notes to this Category)Fee: $985.70 Benefit: 75% = $739.3030178 (proposed by the RWG, not supported by the DoH)LIPECTOMY, radical abdominoplasty (Pitanguy type or similar), with excision of skin and subcutaneous tissue, repair of musculoaponeurotic layer and transposition of umbilicus, not being a service associated with a service to which item 30165, 30168, 30171, 30172, 30177, 30179, 45564, 45565 or 45530 applies, and where it can be demonstrated that one of the following conditions is present: ?anterior abdominal wall defect that is a consequence of the surgical removal of large intra-abdominal or pelvic tumours; oranterior abdominal wall defect that is a consequence of pregnancy that has had no response to at least 6 months of conservative non-surgical treatment such as physiotherapy, and, is causing physical impairment, when performed not less than 1 year, after the end of most recent pregnancy. Once in a lifetime.Not describedSource: MBS websiteDoH = Department of Health; RWG = review working groupTable SEQ Table \* ARABIC 7: Number of MBS items 30176 and 30177 processed and benefits paid by Medicare from 2013 to 2017 Items20132014201520162017Item: 30176Number of items processed24Total Benefits Paid $1,479$2,957Item: 30177 1Number of items processed3,3873,5943,7032,5042,488Change in the number of items processed due to the removal of postpartum patients-1,199-1,215Total Benefits Paid $2,386,903$2,524,435$2,601,030$1,757,590$1,750,998Estimated cost savings due to the removal of postpartum patients $843,440$850,032Source: Medicare Statistics 1 Patients with postpartum rectus diastasis were removed as an eligible patient group in 2016 Table SEQ Table \* ARABIC 8: Method for calculating the number of parous women who have completed having children in Australia in 2016InputCalculationEstimatedAAverage number of births per an Australian woman1.79BProportion of women who never give birth24%CAverage number of children per a parous Australian womanA / (1-B) 2.36DNumber of births311,104 ENumber parous women who have completed having children in 2016D?/?C132,089Source: Australian Bureau of Statistics Table SEQ Table \* ARABIC 9: Review of the literature for abdominoplasty’s impact on urinary incontinenceStudyStudy type Measurements Improvements in key outcomes (pain, reoccurrence, and AE following lipectomy Taylor, Merten et al. 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ADDIN EN.CITE.DATA [28] A prospective cohort study of 214 PP Australian patients who underwent abdominoplasty. The study included all presenting patients. Mean (SD) IRD = 4.5 cm (1.4)IRD range = 0 to 9 cmMean parity = 2.5Patients filled out questionnaires at pre-opt, 6 weeks post-op and 6 months post-op.The study used validated questionaries: ODI for back pain and the ICIQ-UI for UI symptoms.Back pain ODI mean (SD): -pre-op = 10.9 (7.31)-6-week post-op = 3.97 (5.64) -6 months 1.58 (3.49)UI symptoms ICIQ: -pre-op 6.22 (5.36) -6 week post-op = 1.63 (2.87);- 6-months post-op = 1.60 (2.92)Increased IRD was not a predictor of UI or back pain.Carruthers, Kocak et al. (2014) PEVuZE5vdGU+PENpdGU+PEF1dGhvcj5DYXJydXRoZXJzPC9BdXRob3I+PFllYXI+MjAxNDwvWWVh
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ADDIN EN.CITE.DATA [7]*Retrospective analysis of 100 women who underwent abdominoplasty, consisting of 50 patients had preoperative urinary incontinence (cases) and 50 patients with no preoperative urinary incontinence (controls). Response rate = 40%. Mean age = 40.8 yrs. Parous women = 92% The questionnaire collected information on symptoms related to stress or urgency incontinence, the severity of incontinence, and any changes in incontinence symptoms following abdominoplasty. The publication only reported results for SUIOf the 100 subjects who responded, 50 subjects reported preoperative symptoms of SUI. Of these, 30 subjects (60%) noted improvement in their symptoms following abdominoplasty. 13 subjects (26%) reported no change in SUI symptoms and 7 (14%) reported worsening of SUI symptoms.Solanki, Duffield et al. (2010) ADDIN EN.CITE <EndNote><Cite><Author>Solanki</Author><Year>2010</Year><RecNum>88</RecNum><DisplayText>[14]</DisplayText><record><rec-number>88</rec-number><foreign-keys><key app="EN" db-id="dzdeaarzbt5r08ew2sbxav03ffxesxv25spp" timestamp="1538700317">88</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Solanki, N. S.</author><author>Duffield, J. A.</author><author>Dean, N. R.</author><author>Morgan, R. G.</author></authors></contributors><auth-address>Department of Plastic and Reconstructive Surgery, Flinders Medical Centre, Bedford Park, South Australia, Australia. nicholas.solanki@health..au</auth-address><titles><title>The effect of abdominoplasty on urinary incontinence in women</title><secondary-title>Plast Reconstr Surg</secondary-title></titles><periodical><full-title>Plast Reconstr Surg</full-title><abbr-1>Plastic and reconstructive surgery</abbr-1></periodical><pages>206e-209e</pages><volume>126</volume><number>4</number><keywords><keyword>Abdominal Fat/surgery</keyword><keyword>Abdominal Muscles/*surgery</keyword><keyword>Age Distribution</keyword><keyword>Aged</keyword><keyword>Australia</keyword><keyword>Body Mass Index</keyword><keyword>Female</keyword><keyword>Humans</keyword><keyword>Incidence</keyword><keyword>Middle Aged</keyword><keyword>Patient Satisfaction</keyword><keyword>*Quality of Life</keyword><keyword>Retrospective Studies</keyword><keyword>Risk Assessment</keyword><keyword>Surgery, Plastic/*methods</keyword><keyword>Surveys and Questionnaires</keyword><keyword>Urinary Incontinence/*epidemiology/physiopathology/prevention & control</keyword></keywords><dates><year>2010</year><pub-dates><date>Oct</date></pub-dates></dates><isbn>1529-4242 (Electronic)
0032-1052 (Linking)</isbn><accession-num>20885227</accession-num><urls><related-urls><url>;[14]*Retrospective analysis of 46 Australian women who underwent abdominoplasty, consisting of 27 (59%) patients had preoperative urinary incontinence (cases) and 19 (41%) without preoperative urinary incontinence (controls).Most patients were parous. Median age = 42.7 yearsSelf-reported questionnaire used a Likert scale to assess symptoms of urinary incontinence. No description of incontinence type (stress vs urgency) Of the 27 patients with preoperative urinary incontinence, 26% noted improvements following surgery; 70.4% reported no change and 3.7% reported worsening of symptoms.AE = adverse events; IRD = inter rectus distance; LA = linea alba; M = months; post-op = post-operation; PP = post-partum; SF-36 = 36-item Short Form Survey; RD = rectus diastasis; UI = urinary incontinence, VAS = visual analogue scale; VHPQ = Ventral Hernia Pain Questionnaire* Presented previously to the Department of Health by the Lipectomy ReviewTable SEQ Table \* ARABIC 10: Review of the literature for abdominoplasty’s impact on health-related quality of life and abdominal strengthStudyStudy type Measurements Improvements in key outcomes (pain, reoccurrence, and AE following lipectomy Emanuelsson, Gunnarsson et al. (2014) PEVuZE5vdGU+PENpdGU+PEF1dGhvcj5FbWFudWVsc3NvbjwvQXV0aG9yPjxZZWFyPjIwMTQ8L1ll
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ADDIN EN.CITE.DATA [26]Randomised control trial of 57 patients with an IRD > 3 cm and had related clinical symptoms were included in a prospective randomised study (Mesh vs Quil)?1All patients completed a validated questionnaire for pain assessment (VHPQ); muscle strength (VAS) and for quality of life (SF36) at baseline and 3 M post-surgery. IRD was assessed using ultrasound AE: 25% wound infection; seroma (16%); recurrent RD (2%)Patients reported statically significant improvements in measures: VPHQ, SF36 and VAS for muscle strength.Patients’ SF36 scores were significantly below Swedish norms prior to surgery but reached Swedish post-surgery Emanuelsson, Gunnarsson et al. (2016) PEVuZE5vdGU+PENpdGU+PEF1dGhvcj5FbWFudWVsc3NvbjwvQXV0aG9yPjxZZWFyPjIwMTY8L1ll
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ADDIN EN.CITE.DATA [25]Randomised three-arm trial that compared two surgical techniques used in abdominoplasty1 to 3 M of physiotherapy.97 patients with an IRD > 3 cm; ≥12 month PP and experienced abdominal wall discomfort or tendernessAll patients completed a validated questionnaire for pain assessment (VHPQ); muscle strength (VAS) and for quality of life (SF36) at baseline and 3 M post-surgery or exercise. Muscle strength was also objectively assessed using Biodex System-4.All patients experienced improvements in VPHQ; VAS and SF-36. However, improvements were much greater in patients undergoing surgery. Surgical patients’ SF36 scores reached Swedish population norms at follow up; whilst physio patient’s SF-36 score were below population norms. The authors concluded exercise objectively improves muscle strength but does not reduce pain or discomfort and does not result in the same improvements in quality of lifeAE = adverse events; IRD = inter rectus distance; LA = linea alba; M = months; post-op = post-operation; PP = post-partum; SF-36 = 36-item Short Form Survey; RD = rectus diastasis; UI = urinary incontinence, VAS = visual analogue scale; VHPQ = Ventral Hernia Pain Questionnaire1 Abdominoplasty using retromuscular polypropylene mesh to repair the diastasis compared to double-row plication with Quill technologyTable SEQ Table \* ARABIC 11: Review of the literature for abdominoplasty’s impact on chronic lower back pain and/or lumbopelvic painStudyStudy type /Measurements Improvements in key outcomes (pain, reoccurrence, and AE following lipectomy Oneal, Mulka et al. (2011) PEVuZE5vdGU+PENpdGU+PEF1dGhvcj5PbmVhbDwvQXV0aG9yPjxZZWFyPjIwMTE8L1llYXI+PFJl
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ADDIN EN.CITE.DATA [17]*Case-study of 8 patients (follow-up 2-11 years). All patients had chronic low back pain that was unresponsive to conservative treatment and marked lower abdominal wall muscular laxity. 7 (88%) were parous women Abdominal wall contour and lower abdominal muscle tone was evaluated. Patients reported reduced back pain as measured and improved muscle tone at follow-upToranto (1990) ADDIN EN.CITE <EndNote><Cite><Author>Toranto</Author><Year>1990</Year><RecNum>12</RecNum><DisplayText>[16]</DisplayText><record><rec-number>12</rec-number><foreign-keys><key app="EN" db-id="dzdeaarzbt5r08ew2sbxav03ffxesxv25spp" timestamp="1535518374">12</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Toranto, I. R.</author></authors></contributors><titles><title>The relief of low back pain with the WARP abdominoplasty: a preliminary report</title><secondary-title>Plast Reconstr Surg</secondary-title><alt-title>Plastic and reconstructive surgery</alt-title></titles><periodical><full-title>Plast Reconstr Surg</full-title><abbr-1>Plastic and reconstructive surgery</abbr-1></periodical><alt-periodical><full-title>Plast Reconstr Surg</full-title><abbr-1>Plastic and reconstructive surgery</abbr-1></alt-periodical><pages>545-55</pages><volume>85</volume><number>4</number><edition>1990/04/01</edition><keywords><keyword>Abdominal Muscles/*surgery</keyword><keyword>Adult</keyword><keyword>Aged</keyword><keyword>Back Pain/etiology/pathology/*surgery</keyword><keyword>Female</keyword><keyword>Follow-Up Studies</keyword><keyword>Humans</keyword><keyword>Intervertebral Disc/pathology</keyword><keyword>Lumbar Vertebrae/pathology</keyword><keyword>Magnetic Resonance Imaging</keyword><keyword>Male</keyword><keyword>Methods</keyword><keyword>Middle Aged</keyword><keyword>Sacrum/pathology</keyword></keywords><dates><year>1990</year><pub-dates><date>Apr</date></pub-dates></dates><isbn>0032-1052 (Print)
0032-1052 (Linking)</isbn><accession-num>2138335</accession-num><urls><related-urls><url>;[16]Retrospective case series of 24 patients who reported had severe chronic low back pain (LBP) preoperatively and RD with bulging. All patients reported that it was disruptive to their normal life and had failed conservative treatment. 11 (44%) had undergone previous spinal surgery. All patients stated symptoms improved with a brace or corset. 24 (96%) had pain when pressure was applied to the abdomen during physical examination. Following abdominoplasty, 21/25 subjects (84%) reported complete resolution of lower back pain without recurrence at long-term follow-up. 3 (12%) reported significant decreases in back pain and 1 (4%) reported no change. 23 (92%) reported their level of activity to be unrestricted.RD = rectus diastasis* Presented previously to the Department of Health by the Lipectomy Review References ADDIN EN.REFLIST 1.Department of Health, MBS Reviews: Lipectomy Report. 2013, Department of Health and Ageing Canberra 2.Liaw, L.J., et al., The relationships between inter-recti distance measured by ultrasound imaging and abdominal muscle function in postpartum women: a 6-month follow-up study. J Orthop Sports Phys Ther, 2011. 41(6): p. 435-43.3.Spitznagle, T.M., F.C. Leong, and L.R. Van Dillen, Prevalence of diastasis recti abdominis in a urogynecological patient population. Int Urogynecol J Pelvic Floor Dysfunct, 2007. 18(3): p. 321-8.4.Akram, J. and S.H. Matzen, Rectus abdominis diastasis. J Plast Surg Hand Surg, 2014. 48(3): p. 163-9.5.Benjamin, D.R., A.T. van de Water, and C.L. Peiris, Effects of exercise on diastasis of the rectus abdominis muscle in the antenatal and postnatal periods: a systematic review. Physiotherapy, 2014. 100(1): p. 1-8.6.Hickey, F., J.G. Finch, and A. Khanna, A systematic review on the outcomes of correction of diastasis of the recti. Hernia, 2011. 15(6): p. 607-14.7.Carruthers, K.H., et al., Improvement in stress urinary incontinence after abdominoplasty. Aesthet Surg J, 2014. 34(7): p. 1091-8.8.Lazar, C.C., et al., Abdominoplasty after major weight loss: improvement of quality of life and psychological status. Obes Surg, 2009. 19(8): p. 1170-5.9.Matarasso, A., Traditional abdominoplasty. Clin Plast Surg, 2010. 37(3): p. 415-37.10.Papadopulos, N.A., et al., Does abdominoplasty have a positive influence on quality of life, self-esteem, and emotional stability? Plastic and reconstructive surgery, 2012. 129(6): p. 957e-962e.11.Staalesen, T., et al., A systematic review of outcomes of abdominoplasty. Journal of plastic surgery and hand surgery, 2012. 46(3-4): p. 139-144.12.Department of Health, Attatchment B: Repair of diastasis recti and MBS-funded abdominoplasty (RWG Response). 2014, Department of Health and Ageing: Canberra.13.McGinness, J., Attachment C - Review of abdominoplasty in management of urinary incontinence. 2014, Department of Health Canberra 14.Solanki, N.S., et al., The effect of abdominoplasty on urinary incontinence in women. Plast Reconstr Surg, 2010. 126(4): p. 206e-209e.15.Braga, A., et al. Diastasis recti abdominis: correlation with parity and stress urinary incontinence. in Neurourology and Urodynamics. 2014. Wiley-Blackwell 111 River St, Hoboken 07030-5774, NJ USA.16.Toranto, I.R., The relief of low back pain with the WARP abdominoplasty: a preliminary report. Plast Reconstr Surg, 1990. 85(4): p. 545-55.17.Oneal, R.M., et al., Wide abdominal rectus plication abdominoplasty for the treatment of chronic intractable low back pain. Plast Reconstr Surg, 2011. 127(1): p. 225-31.18.Hsia, M. and S. Jones, Natural resolution of rectus abdominis diastasis. Two single case studies. Aust J Physiother, 2000. 46(4): p. 301-307.19.Chiarello, C.M. and J.A. McAuley, Concurrent validity of calipers and ultrasound imaging to measure interrecti distance. J Orthop Sports Phys Ther, 2013. 43(7): p. 495-503.20.Beer, G.M., et al., The normal width of the linea alba in nulliparous women. Clin Anat, 2009. 22(6): p. 706-11.21.Nahabedian, M.Y., Management Strategies for Diastasis Recti. Semin Plast Surg, 2018. 32(3): p. 147-154.22.Gluppe, S.L., et al., Effect of a Postpartum Training Program on the Prevalence of Diastasis Recti Abdominis in Postpartum Primiparous Women: A Randomized Controlled Trial. Phys Ther, 2018. 98(4): p. 260-268.23.Sperstad, J.B., et al., Diastasis recti abdominis during pregnancy and 12 months after childbirth: prevalence, risk factors and report of lumbopelvic pain. Br J Sports Med, 2016. 50(17): p. 1092-6.24.Cholewicki, J., K. Juluru, and S.M. McGill, Intra-abdominal pressure mechanism for stabilizing the lumbar spine. J Biomech, 1999. 32(1): p. 13-7.25.Emanuelsson, P., et al., Operative correction of abdominal rectus diastasis (ARD) reduces pain and improves abdominal wall muscle strength: A randomized, prospective trial comparing retromuscular mesh repair to double-row, self-retaining sutures. Surgery, 2016. 160(5): p. 1367-1375.26.Emanuelsson, P., et al., Early complications, pain, and quality of life after reconstructive surgery for abdominal rectus muscle diastasis: a 3-month follow-up. J Plast Reconstr Aesthet Surg, 2014. 67(8): p. 1082-8.27.Stark, B., et al., Validation of Biodex system 4 for measuring the strength of muscles in patients with rectus diastasis. J Plast Surg Hand Surg, 2012. 46(2): p. 102-5.28.Taylor, D.A., et al., Abdominoplasty Improves Low Back Pain and Urinary Incontinence. Plast Reconstr Surg, 2018. 141(3): p. 637-645.29.Gallus, K.M., K.F. Golberg, and R. Field, Functional Improvement Following Diastasis Rectus Abdominus Repair in an Active Duty Navy Female. Mil Med, 2016. 181(8): p. e952-4.30.Mommers, E.H.H., et al., The general surgeon's perspective of rectus diastasis. A systematic review of treatment options. Surg Endosc, 2017. 31(12): p. 4934-4949.31.Keshwani, N. and L. McLean, Ultrasound Imaging in Postpartum Women With Diastasis Recti: Intrarater Between-Session Reliability. J Orthop Sports Phys Ther, 2015. 45(9): p. 713-8.32.Nahas, F.X., An aesthetic classification of the abdomen based on the myoaponeurotic layer. Plast Reconstr Surg, 2001. 108(6): p. 1787-95; discussion 1796-7.33.Rath, A.M., et al., The abdominal linea alba: an anatomo-radiologic and biomechanical study. Surg Radiol Anat, 1996. 18(4): p. 281-8. ................
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