You found out that you need to have a medically necessary procedure. You and your provider have submitted all of your necessary documentation and insurance has approved your case. While you’re not necessarily thrilled about going under the knife, there just so happen to be a few cosmetic tweaks that you’re interested in making to that same part of the body you already scheduled to have surgery on. So, can you blend functional and aesthetic surgeries? We asked the experts.
Functional vs. Aesthetic Procedures
First things first, you may be wondering what the difference is between functional and aesthetic procedures? The best way to understand it is to look at these two definitions from the American Medical Association (AMA):
- Cosmetic Surgery: Performed to reshape normal structures of the body in order to improve the patient’s appearance and self-esteem.
- Reconstructive Surgery: Performed on abnormal structures of the body, caused by congenital defects, developmental abnormalities, trauma, infection, tumors, or disease.
Another way to put it? A functional procedure is one that you probably need to have, whereas an aesthetic procedure is one that you want to have. As you may have guessed, functional procedures are more likely to be covered by insurance than cosmetic ones.
While it may sound straightforward enough, there is actually quite a bit of gray area. Many procedures have dual purposes and can treat both functional and aesthetic concerns. For example, patients who have trouble breathing due to a deviated septum (medically necessary) and are also unhappy with the appearance (aesthetic) of their asymmetrical or crooked nose could address both concerns with the same rhinoplasty surgery.
Blending Functional & Aesthetic Procedures
Rhinoplasty isn’t the only procedure that has functional and aesthetic benefits though. And, if you are curious as to what other plastic surgery fits the bill, we’re breaking down six of the most common:
1. Rhinoplasty (a.k.a. nose job)
While we often think of rhinoplasty as a way to improve the appearance and shape of the nose, it also can help with breathing problems. “It is a very well understood scientific fact that the nose is the primary organ for delivery of oxygen to the body,” explains Oren Friedman, MD, a double board certified facial plastic and reconstructive surgeon and director of facial plastic surgery at the University of Pennsylvania. “The nose humidifies, filters, and warms the air we breathe, so that, when the air reaches the lungs, it is primed for gas exchange, allowing for oxygen to reach important functional regions of our bodies and brains.” Needless to say, the proper function of the nose is medically necessary. “It is essential that people be able to breathe through their noses, and, as such, insurance companies should cover surgery to correct a patient's nasal breathing surgery,” he adds.
How does this relate to aesthetic concerns a patient may have? If a patient has a major nasal shape deformity that is directly contributing to their inability to breathe through the nose, the surgeon will correct it as part of the functional rhinoplasty procedure. According to Dr. Friedman, nasal deformities that need to be corrected in order to improve the breathing function include cleft lip nasal deformities, nasal defects following cancer removal, and traumatic defects as with a dog bite.
2. Abdominoplasty (a.k.a. tummy tuck)
For patients with a body mass index (BMI) of 35 or higher, weight loss procedures (e.g. gastric sleeves, lap gastric bands, gastric bypass, etc.) are often covered by insurance. This is especially true if it is coupled with medical complications, like diabetes, heart disease, or pulmonary hypertension. Procedures like an abdominoplasty (to remove excess fat and skin) and panniculectomy (to address extra skin) may also qualify as medically necessary in certain patients, though it is not as common as the weight loss treatments.
But complementing a significant weight loss isn’t the only functional benefit of abdominal surgery. “Body contouring procedures such as a tummy tuck often provide much more than aesthetic outcomes and may actually improve function,” explains Gregory Buford, MD, a board certified plastic and reconstructive surgeon in Englewood, CO. “When we tighten the abdominal muscles, the overall core is made more functionally competent.”
As a result, he says patients “will often report improvement in chronic back pain” and has also seen patients comment that “bladder function has improved.” While these benefits will probably not qualify the procedure for insurance coverage, Dr. Buford notes that a good number of his tummy tuck patients experience health improvements in addition to the cosmetic benefits.
3. Blepharoplasty (a.k.a. eyelid surgery)
Eyelid surgery is another procedure that can be performed for cosmetic or functional reasons — and, in some cases, both. Lower and upper eyelid blepharoplasty surgeries can treat loose or sagging skin, under eye bags or puffiness, and eyelid droopiness.
Functionally, a blepharoplasty may be medically necessary when excess skin impedes vision. Dr. Friedman says that when the degree of eyelid droop is so extensive that it obstructs a patient's ability to see, insurance usually covers the eyelid surgery. “Failure to see well is a hazard to the patient and to those around the patient, and, as a result, functional surgery should be performed for health reasons,” he explains.
If vision is not impaired, don’t expect the procedure to be classified as functional. “At times, patients do not like the heavy appearance of their eyelids and may want to have skin removed from the upper eyelids,” Dr. Friedman notes. “In such cases of cosmetic dissatisfaction, insurance should not cover the procedure.” Depending on the patient’s goals, a blepharoplasty can help with rejuvenation or reshaping the eyes.
4. Breast Surgery
No, your standard breast augmentation — be it with implants, fat transfer, or some hybrid of the two — is not functional. But breast surgery encompasses a wide range of procedures, some of which are considered medically necessary. Mastectomy, breast reconstruction, and breast reduction are three such treatments.
As per the 1998 Women’s Health and Cancer Rights Act (WHCRA), health insurance plans that cover mastectomy (whether it’s for breast cancer prevention or treatment) must also cover breast reconstruction — in the form of prostheses (like breast implants) — for both breasts. In these cases, providers do not need to document health problems or trials of alternative treatment as is usually custom in insurance cases.
In the case of breast reduction, addressing the size of the breasts can have a true impact on the patient’s quality of life. “When we reduce a woman's breasts, our goal is not only to achieve functional improvement (e.g. less weight and, so, less pressure on the lower back and neck) but to also create an aesthetic outcome that is attractive,” Dr. Buford says. “In this sense, breast reduction is likely one of the best examples in plastic surgery where form meets function to achieve an endpoint that creates benefit for our patients on multiple levels.”
5. Otoplasty (a.k.a. ear surgery)
In order to understand the functional benefits of otoplasty, it’s important to understand the functional benefits of the outer ear. “The external ear serves the primary function of funneling sound to the middle and inner ear in order to aid in hearing,” Dr. Friedman explains. “Repair of deformities that cause poor hearing should generally be covered by insurance.”
Cosmetic ear surgeries, as you may have guessed, are usually paid for out of pocket. “Aesthetic ear deformities often present as children and adults expressing that their ears protrude from their heads too far, making their ears stand out,” he says. “Patients sometimes come in stating ‘I get bullied for my funny looking ears’ or ‘my ears look like dumbo ears.’” Despite the mental health component to such concerns, Dr. Friedman shares that “otoplasty to correct these types of cosmetic deformities are generally not covered by insurance.”
There are, however, certain exceptions. “At times, children are born with excessively small ears [or] with no identifiable ears at all,” he notes. “These ear deformities require reconstruction of the missing ear and should be covered by insurance.”
While it’s not a surgery, we’d be remiss not to mention the therapeutic benefits of a certain cosmetic injectable. As you likely know, Botox® is a form of botulinum toxin type A (BoNT-A) that is used in aesthetic medicine to reduce the appearance of fine lines and wrinkles caused by facial expressions (think: forehead lines and crow’s feet). But the neurotoxin is approved by the United States Food and Drug Administration (FDA) to treat medical conditions as well.
Therapeutic uses for Botox® include the treatment of migraines, hyperhidrosis (read: excessive sweating), and eye spasms (to name a few). “I treat a good number of patients with Botox® who report additional benefits such as reduced local sweating and an overall reduction in migraines,” Dr. Buford shares. “For these patients, the additional benefits often vastly outweigh the cosmetic improvements and are literally life changing.” In such cases, insurance may cover the cost of routine Botox® treatments.
How to Find the Right Provider
The most important part of any procedure — functional or aesthetic? Finding the right provider to ensure you receive the best and safest treatment for your needs. “Choosing the right surgeon is always the most important predictor of success for a surgical procedure,” Dr. Friedman says. During the research and consultation process, be sure to inquire about how often they perform the procedure(s) you are interested in and ask to see before and after photos.
No matter what area you are looking to treat, it is important that the surgeon has extensive knowledge of anatomy and how the body works. “A surgeon who understands the functions of the facial sense organs — the nose, the eyes, the ears — is well suited to safely and comprehensively achieve the best possible surgical outcomes,” Dr. Friedman says. “Knowing the nose, eyes, and ears inside and out allows us to insure success in both form and function.”
In choosing a board certified plastic surgeon, you are often, well, blending the best of both worlds. “The beauty of plastic surgery is that it is essentially an art,” Dr. Buford concludes. “And, when form meets function, art is ultimately achieved.”
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