Breast Surgery – Plastic & Reconstructive (Patients 18yrs and Above)

Threshold

Norfolk and Waveney ICB will not routinely fund Aesthetic / Cosmetic Breast Surgery for the conditions or procedures listed below:

Surgical treatment of Inverted Nipples
Hypoplasia or Aplasia of Breast(s)
Other Breast Asymmetry
Gynaecomastia
Ptosis/ Mastopexy
Breast Augmentation

Congenital Breast Deformity/Absence of Breast

Exception may be made for absence of clinically palpable breast tissue and breast deformities as a result of a congenital condition*, where the following criteria are met:

The patient should be assessed by specialist oncoplastic MDT and deemed that exceptional circumstances exist that warrant deviation from the rule of this policy.

And

Exceptionality must be clearly documented and agreed by at least 2 surgeons.

*Congenital conditions may include (but are not limited to): macromastia, Poland Syndrome, tuberous breast, unilateral or asymmetric hypoplasia, amazia (unilateral/bilateral), congenital symmastia. Congenital symmastia is very rare and should be considered for treatment on that basis.

Patients may be considered for treatment by submission of an individual funding request which should be submitted by the specialist clinician responsible for the patients care.

Link to IFR:

Individual Funding Requests – Non-Drugs – Knowledge NoW (nwknowledgenow.nhs.uk)

Removal and/or Replacement of Breast Implants

Norfolk and Waveney ICB will fund removal and replacement of breast implants on a restricted basis and where there is documented evidence of ANY of the below criteria:

Breast disease (current or prior to previous mammoplasty)
Implant complicated by recurrent infection OR seroma.
Implant with severe capsular contracture between III/IV Baker classification score.
Implant is ruptured.
Implant leakage
The patient develops breast implant associated anaplastic large cell lymphoma (BIA – ALCL)

Removal and replacement of implant(s) will be carried out as part of the same surgical procedure, however for implants complicated by recurrent infection, it may not be possible to remove and replace the implant at the same time, and decisions should be based on clear clinical need.

Breast implants can be removed and replaced if implanted under NHS care where there is clear clinical need. If the patient has received breast implants in the private sector as part of a treatment that is also offered in the NHS e.g. as part of a cancer treatment pathway, and the implants become faulty, these implants can be removed and replaced funded by the NHS.

Patients whose initial procedure was privately funded should seek assurance from their private provider in the first instance.

If the patient had breast implants in the private sector for cosmetic/aesthetic reasons, implants can be removed, if clinically indicated, under the NHS, but not replaced.

The removal of breast implants due to symptoms termed as breast implant illness (BII) or autoimmune syndrome induced by adjuvants (ASIA) on social media, or due to the risk of developing breast implant associated anaplastic large cell lymphoma (BIA) – (ALCL) is not currently recommended.

Where a patient is eligible for implant removal due to a problem associated with a single implant, bilateral implant removal should be offered.

Patients should be advised that removing/replacing the faulty breast implant may cause asymmetry and offered the choice that both breast implants could be removed in order to achieve symmetry. Patients should also be advised that breast implants will not be replaced just to achieve symmetry in the contralateral breast. Contralateral insertion of a breast implant to restore symmetry following a replacement implant in the other breast is not routinely funded.

NICE guidelines – discuss lifestyle modifications with patients having surgery e.g. stop smoking, reduce alcohol etc to reduce the risk of post-op complications (NG180)

All applications for replacement will be considered via the IFR process.

Breast Reduction

Norfolk and Waveney ICB will fund breast reduction for women if all the following criteria are met:

The woman has received a full package of supportive care from their GP such as advice on weight loss and managing pain.
In cases of thoracic/ shoulder girdle discomfort, a physiotherapy assessment has been provided and supports the patient application.
Breast size results in functional symptoms that require other treatments/interventions (e.g. intractable candidal intertrigo; thoracic backache/kyphosis where a professionally fitted bra has not helped with backache, soft tissue indentations at site of bra straps).
Breast reduction planned to be 500gms or more per breast or at least 4 cup sizes.
Body mass index (BMI) is <27 and stable for at least twelve months.
Woman must be provided with written information to allow her to balance the risks and benefits of breast surgery.

Women should be informed that smoking increases complications following breast reduction surgery and should be advised to stop smoking.

Note: Please note that in cases of unilateral breast reduction, the above criteria will apply plus the difference in the current size of both breasts must be a minimum of 200g as measured by a specialist.

Transgender Patients

Breast surgery for Transgender Patients is undertaken as part of their package of care and is not covered in this policy.

NHS commissioning » Gender Services Clinical Programme (england.nhs.uk)

Policy exclusions:

Reconstructive surgery following malignancy, trauma or other disease is routinely commissioned across Norfolk and Waveney on a separate care pathway.

Cases for Individual Funding Consideration (Patients who do not meet the policy criteria)

On a case-to-case basis, patients might be eligible for surgical intervention, in consideration of their exceptionality. The requesting clinician must provide information to support the case for being considered an exception, by submitting an individual funding request.