Breast reduction is one of many operations the NHS is beginning to refuse to do on the basis that it is “of low clinical worth“. We challenge this. We believe this refusal is part of rationing of treatments, especially treatments for conditions where private health sector has been established. Moreover the My Choices scandal saw attempts to charge for these operations within the NHS itself. It is rationing care, funding the private sector and depriving those without funds of treatment that can stop pain and be life changing.

Sheila Altes reviews the evidence

Response to the 2017/2018 Revised Policy Position A14 Plastic Surgery

A14.1 Reduction Mammoplasty- Female Breast Reduction

The British Association of Plastic Reconstructive and Aesthetic Surgeons (BAPRAS) published a commissioning guide for breast reduction surgery(2014).

The guidance relates to patients that present with breast hyperplasia where breasts are large enough to cause symptom, infection, pain and effects quality of life. It goes on to say that the quality of life of patients undergoing breast reduction surgery will improve by amelioration of associated physical symptoms and they will be unlikely to present with further symptoms. There will also be an improvement in the patient’s psychological well being, self-esteem, willingness to engage in social activities and employment potential. They conclude that this is a low cost procedure which will gain patient improvement and reduce the need for primary care physical treatment.

They state that breast reduction surgery should be considered for patients who meet the following criteria:

* Are physically fit

* Have a body mass index (BMI) less than 27.5

* Excised breast weight of 500grams and upwards

* Are non-smokers

*If the patient is taking medication for other long term conditions eg. Diabetes

Have some OR all of the following signs and symptoms:

* Emotionally and socially bothered by having large breasts

* Low self-esteem

* Breast size limits physical activity

* Back, neck and shoulder pain caused by heavy breasts

* Has regular indentations from bra straps that support heavy breasts

* Has skin irritation, intertrigo beneath the breast crease

* Breasts hang low and has stretched skin

* Nipples rest below the breast crease when breasts are unsupported

* Enlarged areoles caused by stretched skin.

The 2017/2018 Revised Policy on breast reduction surgery, list eligibility criteria to meet before funding reduction mammoplasty that is similar to the guidance. However they stipulate that ALL of the criteria must be met.

BMI as a criteria for allowing the operation Particularly contentious are those relating to BMI, which they state should be less than 25 and cup size which must be size H or over.

To deny access to breast reduction surgery based on a patient having an ideal BMI and maintaining that  measurement for 12 months is not realistic in a country where 64% of adults are classed as overweight or obese (Health Survey 2017). There have been several studies on the incidence of complications in overweight or obese patients following breast reduction surgery.

In a study of 273 women in Finland (Setala 2009) the impact of body weight on post operative complications was recorded. Post operative complications were frequent but overall complication rate did not correlate with body weight, BMI, age, surgical technique or surgical experience. Results indicated that obesity did not increase the complication risk in breast surgery reduction to the extent  that access to reduction mammoplasty should be restricted based solely on body mass index.

The implications of obesity in the context of breast reduction surgery remain unclear. Several studies have demonstrated an increased risk of surgical site complications including delayed healing, infections and haematoma. However a large prospective multicentre trial demonstrated no association between obesity and complications (Simpson et al 2018). The study demonstrated that an increased BMI is independently associated with total complications, thus indicating that obesity affects local wound complications. However it is impossible to say whether increased local complications were due to impairment of wound healing resulting from obesity or from the surgical  management differences. Such differences could include differing operative techniques in obese individuals.

Complications following breast reduction surgery are uncommon and generally mild. It is important to weigh the potential risk against benefits when operating on patients with an elevated BMI. Coincident medical conditions may preclude surgery, but isolated obesity may represent an acceptable risk to both patient and practitioner.

A prospective evaluation on health after breast reduction concluded that breast reduction surgery reduced or removed disease associated pain (Lewin et al 2019). It improved or normalized perceived health and psychosocial self esteem in obese women and women of normal weight.

Although many studies have shown that breast reduction surgery is effective in reducing neck, back and lumbar pain, most of these studies are subjective evaluations that usually provide data through pain scales. A study was undertaken to objectively evaluate the radiologic effects of breast reduction surgery on the vertebral column (Findikcioglu et al 2013). The symptomatic relief of breast reduction surgery on the musculoskeletal system is widely accepted, the objective assessment of this relief will be beneficial in persuading those who think of this surgery as a purely aesthetic procedure.

Patients had lateral thoracolumbar radiographs taken before and three months after surgery. The impact of breast reduction surgery on posture was elevated according to the comparison of radiographs before and after surgery.

Many women with breast hypertrophy suffer back and neck pain because of the weight of  their breast tissue. Some women also find painful indentations and even scarring along their shoulders where bra straps dig into the skin. Compression of nerves along the shoulders can cause numbness and tingling in the fingers. Dr. Deborah Venesy, a medical spine specialist at Cleveland Clinic, USA- a non profit academic medical centre- does not believe that bras in themselves, even badly fitted ones, can cause pain anymore than they can prevent it. Research by the American Society of Plastic Surgeons (Parry 2011) found that half of women with breast sizes larger than DD had almost constant pain. Painkillers for back pain should not be intended as a long term solution. The revised policy for breast reduction surgery would have women attending their GP. Surgery for two years with history of musculo skeletal symptoms before considering breast reduction surgery and exclude women with a cup size of less than H.

According to the American Society of Aesthetic Plastic Surgery (Collins et al 2002), breast reduction was the eighth most common plastic surgery procedure in the US when compared with aesthetic procedures only. This underscores the fact that non-surgical interventions have not been shown to provide lasting relief of symptomatic breast hypertrophy. In addition numerous studies have demonstrated increased satisfaction and better quality of life following breast reduction surgery. Such studies demonstrate the importance of breast reduction surgery as a therapeutic option and not a cosmetic one (Miller et al 2005).

The criteria outlined by the Revised Policy Position on female breast reduction surgery are substantial. The stipulation that women should be at their ideal BMI and have participated in a trial period of exercise and physiotherapy is problematic for overweight or obese women. Pain and discomfort can be exacerbated for obese women, whereas some studies have shown that obese women have a greater ability to exercise and lose weight following breast reduction surgery ( Shah et al 2006).

In the largest study to date ( Singh et al 2011) comparing breast reduction complication rates and BMI, they found that surgical breast reduction is a safe procedure with a low risk of complications – even with patients with a high BMI. This supports the practice of performing reduction mammoplasty on patients who are overweight.

The eligibility criteria stated in the Revised Policy Position on female breast reduction surgery will exclude the majority of women with breast hypertrophy from receiving this procedure. NICE guidelines in their consultation document (2018) state that women should have had a full package of supportive care including physiotherapy assessment and not have to endure a two year history of musculoskeletal symptoms.

Breast size should be disproportionate to chest wall circumference and not dependent on a cup size H.

BMI of less than 27 and stable for 12 months and not less than 25 as stated in the Revised Policy, Although numerous studies state the importance of weight reduction before surgery they do not demonstrate that an isolated obesity is a reason to deny breast reduction surgery.

The Hierarchy of Goals, produced in the consultation document concerning evidence based interventions (2018), are to:

* Reduce avoidable harm to patients. With surgical intervention there is always a risk of complications and adverse effects which could be avoided.

* Save precious professional time, when the NHS is severely short of staff.

* Help clinicians maintain their professional practice in line with the changing evidence base.

* Create headroom for innovation. If we want to accelerate the adaption of new proven innovations, we need to reduce the number of least effective interventions performed.

* Maximise value and avoid waste. Ineffective care is poor value for money for the taxpayer and the NHS.

However research has shown that:

* Breast reduction surgery is a low risk cost effective procedure.

* The principles of commissioning referral decisions requires GPs and consultants to go through a time consuming referral process. If the referral is not routinely funded then the referring clinician has to go through another application for individual funding, hardly saving precious professional time. Further time is wasted on GP appointments as patients denied breast reduction surgery return time and again for symptom control related to breast hyperplasia.

* Subjecting experienced consultants, experts in their field, to bow to the decisions of a funding panel is hardly conducive to maintaining professional practice.

* Breast reduction surgery is proven to be effective in eliminating physical symptoms associated with breast hypertrophy and cannot be described as clinically ineffective.

* Breast reduction surgery is not of low clinical value nor a waste of taxpayers money as demonstrated by research.

The criteria stipulated in the revised policy for breast reduction surgery is too restrictive and does not meet national guidelines. It prevents women from having surgery which has been proven to limit pain and improve quality of life.

The revised policy also puts GPs under pressure as the very harsh criteria are almost impossible to be met. They then have to go through the lengthy process of applying for exceptional funding which will almost certainly be rejected. (Bristol Cable 2018), as well as dealing with the frustration of patients who are being denied treatment.

It is not acceptable to describe this policy as best practice as it denies access to a treatment which will limit pain and improve the quality of life to so many women.