Isle of Man Clinical Recommendation Committee AESTHETIC (COSMETIC) SURGERY POLICY TABLE OF CONTENTS Contents Page number Background & Introduction 2 Guidelines 3 1. Skin Lesions 4 1.1 Benign Skin lesions 1.2 Congenital Skin Lesions 2. Breast Surgery 4 2.1 Breast augmentation (enlargement, mammoplasty) 4 2.2 Breast asymmetry 5 2.3 Breast Lift (Mastopexy) 5 2.4 Inverted nipples 6 2.5 Breast reduction 6 2.6 Breast reduction for male gynaecomastia 6 3. Abdominoplasty 7 4. Buttock, Thigh and Arm Lift Surgery 7 5. Rhinoplasty 7 6. Rhinophyma 7 7. Face lifts and brow lift (Rhytidectomy) 8 7.1 Botulinum Toxin 8 8. Blepharoplasty 8 9. Liposuction 8 10. Prominent Ears 8 11. Tattoos 8 12. Refashioning of scar 9 13. Hair depilation (hair removal) 9 14. Split earlobes 9 15. Thread veins/telangectasias 9 16. Alopecia 9 Page 1 of 8
BACKGROUND & INTRODUCTION Aesthetic (Cosmetic) surgery is commonly considered to be surgery which aims to change appearance in the absence of deformities caused by disease, accidents and congenital malformations. However there are instances when a pathological lesion such as a congenital abnormality is removed for no other reason than that of improving appearance. Many individual procedures which are commonly labelled as aesthetic also have functional indications and all external surgery has an aesthetic element to it given that the best visual result is being sought. Finally while pure aesthetic surgery aims to change appearance alone this in itself may not always be the main objective but rather to treat some underlying psychological and social dysfunction some of which can be considered as being legitimately clinical due to the severity. The procedures covered in this policy (excluding varicose veins surgery) are estimated to comprise less than 10% of a plastic surgeon s activity in the NHS in the UK. Of the non-aesthetic element about 30% concerns the primary and secondary treatment of trauma, usually hand, lower limb, facial and burn trauma. The other major aspects of plastic surgery are the treatment of head and neck and skin cancer, the treatment of congenital abnormalities, especially those of the cranio-facial region, the genitalia and the skin, re-constructive breast surgery, and finally all aspects of hand surgery; trauma, degenerative and congenital. This policy is not exhaustive but covers the major aesthetic procedures. Exclusion of a procedure from this list does not imply that the procedure is not covered by this CRC policy on aesthetic or cosmetic surgery. If in doubt the problem should be discussed with the GP or Consultant surgeon. In any health care system there are limits set on what is available and on what people can expect. The DHSS is required to achieve financial balance; there is a complex task in balancing this with individuals rights to health care. It is the purpose of the criteria set out here to make the limits on cosmetic specialist plastic surgery procedures fair, clear and explicit. The DHSS has its own mechanism for approving specialist plastic surgery cases on an individual case-by-case basis through the Exceptions group of the CRC. The purpose of this document is to ensure that the group uses the same criteria for approval. Patients under the age of 21 are not generally considered for cosmetic surgery but individual cases can be considered by the Exceptions committee of the CRC. Referrals within the NHS for the revision of treatments originally performed outside the NHS will not usually be funded by the DHSS. Referrers will be encouraged to re-refer to the practitioner who carried out the original treatment. Page 2 of 8
GUIDELINES These guidelines cover a group of procedures or surgery for cosmetic purposes. It is important to note that a substantial proportion of aesthetic surgery is carried out by a number of specialties other than Plastic Surgery, the main ones being Ear, Nose and Throat Surgery, Ophthalmology, Maxillofacial Surgery, General Surgery and Dermatology. This policy only concerns procedures carried out in hospitals. Elements to be taken into consideration during the decision making process are severity, effectiveness of the interventions requested, cost and cost effectiveness. GENERAL GUIDELINES 1. Patients can always be considered for reconstructive surgery. 2. If there is concern that a patient presenting with an apparently simple aesthetic problem may have an underlying medical or severe psychiatric problem the GP should consider referring the patient for an appropriate opinion relating to that problem. 3. It is accepted that there will be individual patients who do not fit the guidelines but who the GP nonetheless feels would benefit from an opinion. This opinion on the Isle of Man can be obtained through the Exceptions sub group of the Clinical Recommendations Committee (CRC) (see www.gov.im/crc). 4. Patients who have been previously operated on in an NHS hospital, as an NHS patient for an aesthetic problem can, in principle, expect treatment for complications and revisions related to that procedure based on clinical need and priority. 5. Patients who have been operated on privately will not usually be accepted for NHS treatment for complications or secondary procedures. However we do accept that there may be unusual or severe complications or circumstances that require transfer of a patient to the NHS for appropriate management. 6. Plastic surgery procedures will not normally be funded to alleviate psychological problems alone. 7. Body Mass Index referred to as per SIGN* guidance where: Less than 18.5 underweight 18.5 24.9 Normal BMI 25.0 29.9 Overweight 30.0 39.9 Obese 40 or above extremely obese. *SIGN (1996) Integrated Prevention and Management of Overweight and Obesity, Edinburgh Page 3 of 8
1. Skin Lesions 1.1. Benign Skin Lesions Interventions will normally only be funded for visible lesions on the face and hands. Clinically benign skin lesions should not be removed on purely cosmetic grounds. This should include, amongst other conditions, skin tags and viral (not genital) warts. Painful persistent or extensive viral warts (particularly in the immunosuppressed patient) may need specialist assessment usually by a Dermatologist and for some of these cases surgical removal may be appropriate. Treatment under the NHS should be only if there is suspicion of malignancy or where the lesion is subjected to repeated trauma. 1.2 Congenital skin lesions Refer only if there is long term risk of malignancy or disfigurement. Facial and neck port wine stains requiring NHS treatment should be referred to a local laser centre once approval has been obtained from the CRC. 1.3 Skin resurfacing techniques These may include laser, Dermabrasion and chemical peels but should only be considered for traumatic scarring or severe acne scarring once the active disease is controlled. 1.4 Refashioning of a scar This will be funded only for post burns cases or severe traumatic or surgical scarring 1.5 Thread veins Referrals generally not considered unless severe facial telangectasias which is treatment induced or as a result of a skin disorder 2. Breast Surgery 2.1. Breast augmentation (enlargement mammoplasty) Breast augmentation will not be routinely funded by the NHS for cosmetic reasons. Page 4 of 8
Referrals should only be made for women with a congenital absence of breast tissue (amastia) or absence of breast tissue unilaterally, or in women with a significant degree of asymmetry of breast shape and or volume or significant chest wall deformity. Such situations may arise as a result of-: Previous mastectomy or other excisional breast surgery Trauma to the breast during or after development Congenital amastia (total failure of breast development) Endocrine abnormalities Development disorder Transsexual patients will be considered under the gender dysphoria policy. Revision surgery is permissible where clinically indicated and where the original surgery was carried out under the NHS. Routine replacements of implants and revision following private operations will not usually be supported. However, surgery will be supported when there is a pathological condition relating directly to an implant. Revision of breast augmentation will be funded only where the original surgery was NHS procedure. Breast augmentation will not usually be funded to alleviate psychological distress. 2.2 Breast asymmetry Refer only if there is a marked asymmetry and if there is need to remove/or add at least 500g of breast weight. 2.3 Breast Lift (Mastopexy) This is included as part of the treatment of breast asymmetry but will not be available for purely cosmetic reasons, for example post lactation or age related breast ptosis (drooping). Where there is significant breast asymmetry of shape and/or volume approval will normally be given for reduction of the larger breast rather than augmentation of the smaller. The smaller breast should fulfil the criteria for breast augmentation for this to be considered. Page 5 of 8
2.4 Inverted nipples Nipple inversion may occur as a result of malignancy and this must be excluded. Surgical correction of nipple inversion should only be available for functional reasons in post pubertal women and if the inversion has not been corrected by correct use of a non-invasive suction device. 2.5 Breast reduction Breast reduction surgery is regarded as a procedure of low priority and will not normally be funded by the DHSS. It should not be offered for cosmetic reasons. Exceptions to this are when: There are significant musculo-skeletal pain or functional problems that are impacting significantly upon individual s quality of life All other advice and support has failed including a professional bra fitting service The person must have a BMI of 28 or less and be 18 years of age or over Refer only for hyperplasia where there is a proposed volume reduction of greater than 550g per side (American Medical Association criteria) i.e. referral is indicated if there is more than the equivalent of half a bag of sugar to remove per side. The referral letter should always include the BMI measurement and evidence relating to the above listed points for consideration by the Exceptions committee of the CRC. 2.6 Breast reduction for male gynaecomastia Breast surgery in males will not normally be funded. Surgery to correct gynaecomastia maybe considered if the BMI is in the normal range (18.5 24.9) and when the reduction to be obtained will be significant i.e. greater than 100g per side (estimated), or where there is gross asymmetry. Individuals who are taking sport performance-enhancing drugs, in whom the gynaecomastia is potentially drug induced, should be refused surgery unless such drugs have not been taken for more than 12 months and they meet the criteria above. Page 6 of 8
3. Abdominoplasty Requests to fund Abdominoplasty and the removal of loose skin can be considered by the Exceptions Committee for: Patients who received morbid obesity (Bariatric) surgery and other previously obese patients who have achieved significant weight loss of the order of 20 BMI points and Have maintained their weight loss for at least 2 years and The patient is experiencing severe difficulties with daily living i.e. ambulatory restrictions or The patient suffers from severe intertrigo beneath the skin fold not responding to other measures or Where previous post trauma or surgical scarring leads to a very poor appearance which has been assessed by a psychiatrist or psychologist as both the primary cause of disabling psychological distress and likely to be resolved by corrective surgery or Problems with poorly fitting stoma bags. The scale of the weight loss and the period for which it has been sustained must be verified in the patient s clinical records. 4. Buttock, Thigh and Arm Lift Surgery Buttock, thigh and arm surgery will only be commissioned in exceptional circumstances, for example cutis laxa (rare inherited or acquired connective tissue disorder in which the skin becomes inelastic and hangs loosely in folds) or severe weight loss with resulting mechanical problems. Patients must have attained a stable BMI (below 30) for a minimum of 2 years. 5. Rhinoplasty Rhinoplasty is not normally funded unless there are significant functional problems. Refer only for post traumatic rhinoplasty, complete congenital conditions e.g. cleft lip and palate or airway problems. 6. Rhinophyma Refer to Dermatology Consultant. Page 7 of 8
7. Face Lifts and brow lifts (Rhytidectomy) These procedures are not funded for cosmetic reasons. They should be considered for the treatment of-: Congenital facial abnormalities Facial palsy (congenital or acquired paralysis) To correct the consequences of trauma To correct deformity following surgery Treatment of specific conditions affecting the skin e.g. cutis laxa and neurofibromatosis These procedures are not funded to treat the natural ageing processes. 7.1. Botulinum Toxin Botulinum toxin will NOT be funded for the treatment of facial ageing or excessive wrinkles. Botulinum toxin can be funded for the treatment of pathological conditions such as Frey s syndrome, belpharospasm, cerebral palsy and severe axillary hyperhidrosis (sweating). 8. Blepharoplasty (eyelid reduction) Not normally funded. Refer only if visual field impairment is experienced. Refer to Ophthalmology for correction of ectropion and entropion. 9. Liposuction Cosmetic liposuction is not available on the NHS but may be used as a technique in the management of true lipodystrophies, lumphoedoema or lipomas, or as part of other surgery e.g. thinning of transplanted flap. 10. Prominent Ears ( bat ears ) The patient must be over the age of 6 years and under the age of 18 at the time of referral and should express a concern independently to the parent regarding desire to have surgery. Correction of prominent ears will be funded where there are significant deformities or ear asymmetry that is causing significant psychological distress. Isle of Man will follow the agreed (in 2010) Liverpool NHS pathway for this condition. 11. Tattoos Tattoo removal is not available under the NHS. If a GP feels there is a case for such a procedure it should be referred to the CRC Exceptions Committee. If a tattoo has been applied under duress against the patient s Page 8 of 8
will a request for removal of such should be made to the Exceptions Committee of the CRC. Tattoo removal may be considered where the tattoo is a source of an allergic phenomenon. 12. Refashioning of scar Refer only for post burn cases or severe traumatic or surgical scarring. 13. Hair depilation (hair removal) Hair depilation will not normally be funded. Exceptions may include those who have undergone reconstructive surgery leading to abnormally located hair bearing skin, or those with a proven underlying endocrine disturbance resulting in Hirsutism (e.g. polycystic ovary syndrome). Such cases should be referred to the local Consultant Endocrinologist. 14. Split earlobes Not funded for the NHS 15. Thread veins/telangectasias Treatment for thread veins and telangectasias will not normally be funded. 16. Alopecia Correction of hair loss (alopecia) is only available under the NHS when it is a result of previous surgery or trauma including burns. Clinical Recommendations Committee 2008 Page 9 of 8