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									                                                                        AGENDA ITEM 11
                                                                          ENCLOSURE 7




                     COMMISSIONING POLICY



      AESTHETIC SURGERY GUIDELINES



                          SPECIALTY : PLASTIC SURGERY




Distribution list:

Standard:                                             Date of issue (revised) : November 2004
All GP practices                                               Date of review: November 2005
PCT chairs
PCT Chief Executives
Executive Directors of Redditch and Bromsgrove PCT
Chief Executive of West Midlands South Strategic Health Authority
University Hospital Birmingham Trust
Birmingham City and Sandwell Hospital Trust



Commissioning Policy – Aesthetic Surgery Guidelines                              Page 1 of 17
PCT Board Meeting 26 April 2005
                                                                                              AGENDA ITEM 11
                                                                                                ENCLOSURE 7

CONTENTS                                                                                                   PAGE
Introduction ........................................................................................................... 3
Specific Guidelines ............................................................................................... 4
     1. Benign skin lesions .................................................................................... 5
     2. Congenital skin lesions .............................................................................. 6
     3. Breast augmentation .................................................................................. 6
     4. Breast Mastopexy ...................................................................................... 7
     5. Female Breast Reduction .......................................................................... 7
     7. Eyelid surgery Belpharoplasty ................................................................... 8
     8. Tattoos ....................................................................................................... 8
     9. Correction of Prominent Ears..................................................................... 8
     10. Rhinoplasty .............................................................................................. 9
     11. Face Lifts ................................................................................................. 9
     12. Abdominoplasty ....................................................................................... 9
     13. Liposuction............................................................................................... 9
     14. Buttock, thigh and arm surgery ................................................................ 9
     15. Congenital vascular abnormalities ........................................................... 9
     16. Thread veins Telangectasias ................................................................. 10
     17. Abnormally placed hair .......................................................................... 10
     18. Acne scarring ......................................................................................... 10
     19. Refashioning of scars ............................................................................ 11
     20. Split earlobes ......................................................................................... 11
References ......................................................................................................... 12
Appendix 1 .......................................................................................................... 13
Appendix 2 .......................................................................................................... 14
Appendix 3 .......................................................................................................... 15
Appendix 4 .......................................................................................................... 16




Commissioning Policy – Aesthetic Surgery Guidelines                                                       Page 2 of 17
PCT Board Meeting 26 April 2005
                                                                AGENDA ITEM 11
                                                                  ENCLOSURE 7

Introduction
Redditch and Bromsgrove PCT have recently seen an increase in the number of
referrals for aesthetic surgery procedures on the NHS. There is not only a need
for equity and fairness across the PCT in respect of access for NHS funding, but
also a need to ensure provision of aesthetic surgery procedures in the context of
the needs of the overall population and evidence of clinical and cost-
effectiveness.

Referral guidelines have been developed for a number of aesthetic procedures.
In addition, 3 appendices around breast reduction, breast augmentation and
breast mastopexy have been included which provide further detail around referral
information required in order for a robust decision to be made regarding referral
on the NHS. It is intended that the guidelines provide the referring individual with
sufficient guidance when collecting information to support a patient’s case, for
NHS funding.

Given the emphasis on BMI for some procedures, GPs are encouraged to
consider NICE guidelines around obesity management.

These guidelines are based upon the West Midlands Regional Guidelines for the
Commissioning and Provision of Aesthetic Surgery for NHS patients and have
been updated by taking into consideration Cheshire West PCT, Countess of
Chester Hospital NHS Trust, Ellesmore Port and Neston PCT, Flintshire LHB
Aesthetic Surgery Referral Guidelines, Thames Valley Priorities Committees
(Berkshire PCTs) Cosmetic Procedures, Cambridgeshire and Peterborough
Public Health Network Cosmetic Surgery Policy and Northumberland Care Trust
Approval process to access non-routine or restricted services .

These guidelines are not designed to advise on access to aesthetic surgery per
se; rather they are designed to assist GPs in making appropriate referrals on the
NHS. A patient not eligible for NHS funding under these guidelines may access
and fund their treatment privately.

As with all commissioning policies, exceptional cases will be considered by the
Redditch and Bromsgrove Complex Case Panel. Straight forward cases, which
clearly meet the new guidelines, will be authorised by the PCT’s commissioning
team.

Patients should be made aware of the process to be undertaken, and should also
be made aware that, in order to reach a fully informed and fair decision,
supporting information (as detailed within the guidelines) will need to be made
available.

Note: Further information about the Complex Case process is available from the
commissioning department at the PCT or via the website.

Commissioning Policy – Aesthetic Surgery Guidelines                      Page 3 of 17
PCT Board Meeting 26 April 2005
                                                                  AGENDA ITEM 11
                                                                    ENCLOSURE 7

Specific Guidelines
Aesthetic surgery may be funded on the NHS under the following
circumstances:

Anatomical indications: Physical deformities which most people would
recognise as abnormal.

Functional indications: In the following sections the functional indications for
some procedures have been outlined.

Psychosocial indications: A review of the evidence of the benefit of ‘pure’
aesthetic surgery was undertaken by ARIF at the University of Birmingham. The
review found that there was significant health gain associated with surgery in
terms of psychological and social well being. This was regardless of the type of
surgery being undertaken. In addition size of benefit was not related to degree of
the aesthetic problem but to the severity of psychosocial dysfunction.

Where psychological or physical difficulties are cited as the justification for the
proposed intervention, all efforts should have been made already to manage
these problems. Using a psychological assessment as a hurdle is inappropriate
and a waste of resources. Where physical characteristics fall within the range
considered normal in the population, an assessment that indicates someone
might be happier if their request for cosmetic surgery were approved, would not
in itself justify consideration as exceptional circumstances. It is expected that
appropriate interventions to improve psychological well-being would have been
used over a period of time before surgery would ever be considered as an option.
Similarly, where physical symptoms such as neck or back pain are the reasons
for considering surgery (such as breast reduction), all other appropriate
interventions should have been tried and failed. Documentation of such efforts
will be expected for any potential referrals.

Who Pays? As clearly stated within the Complex Case Policy, the statutory duty
of PCTs is ‘to provide comprehensive healthcare within the resources available’.
The inference of this statement is that it is both reasonable and legitimate, under
certain circumstances, for a PCT not to fund a treatment.

Redditch and Bromsgrove PCT has a duty to ensure equality of access and
fairness to health services for the people in the local area, within the budget it
has been allocated. In order effectively and fairly ration the NHS resources
available, methods of prioritisation need to be adhered to, including the Aesthetic
Guidelines to follow.

It is anticipated that the Aesthetic Guidelines will provide individual GPs with a
clearer understanding of the patient groups who are likely to be successful in
their bid for treatment.

Commissioning Policy – Aesthetic Surgery Guidelines                       Page 4 of 17
PCT Board Meeting 26 April 2005
                                                                     AGENDA ITEM 11
                                                                       ENCLOSURE 7




           AESTHETIC SURGERY REFERRAL GUIDELINES

      Patients with the following problems/conditions should only be referred
       after a clinical assessment when there is a symptomatic or functional
       requirement for surgery.

      All cases where referral on the NHS is being requested should be sent to
       the Redditch and Bromsgrove Commissioning Team in the first
       instance. A decision will be based upon the revised Aesthetic Surgery
       Guidelines for the more straight forward referrals. Any complex referrals
       will be presented to the Redditch and Bromsgrove Complex Case
       Panel.

      Note to service providers: If treatment is authorised, the relevant
       receiving Acute Trust will be formally notified, in writing, of PCT approval.
       No treatment should be commenced prior to PCT authorisation. Failure to
       adhere to this guidance will result in a refusal to pay for treatment.


PROCEDURE                       CRITERIA

1. Benign skin lesions          Refer only if there is suspicion of malignancy or
                                where the lesion is subjected to repeated trauma or
                                where the lesion is causing a functional problem.

                                Funding for Benign naevi removal will not be
                                authorised purely for cosmetic reasons.

                                Funding for treatment for viral warts will not be
                                routinely authorised (other than for genital warts).
                                Referral will be considered only if there is a doubt
                                about diagnosis, for patients who are immuno-
                                suppressed and those patients who present with
                                significant symptoms and failed on at least a 6-
                                month trial of topical salicylic acid, correctly applied.

                                If the patient meets the above criteria, please
                                view appendix 1 before referring to Redditch and
                                Bromsgrove Commissioning Team.



Commissioning Policy – Aesthetic Surgery Guidelines                           Page 5 of 17
PCT Board Meeting 26 April 2005
                                                                      AGENDA ITEM 11
                                                                        ENCLOSURE 7


PROCEDURE                       CRITERIA

2. Congenital skin              Refer only if there is long-term risk of malignancy or
lesions                         disfigurement.

                                Criteria includes:

                                Children with facial and neck port wine stains.

                                Children with strawberry haemangioma which
                                interferes with function.

                                Adolescents and adults with facial and neck port
                                wine stains.

                                If the patient meets the above criteria, please
                                view appendix 1 before referring to Redditch and
                                Bromsgrove Commissioning Team.


3. Breast augmentation          Refer only for congenital absence or significant
                                chest wall deformity or significant asymmetry,
                                resulting in obvious body disproportion.

                                Revision is permissible where clinically indicated and
                                where the original operation was carried out under
                                the NHS.

                                Routine implant replacement and revision will not be
                                supported if originally a private operation. However,
                                surgery may be supported when there is a
                                pathological condition relating directly to the implant.

                                Generally it is difficult to justify surgery for simple
                                post involutional breast changes for surgery.

                                Note: Breast reconstruction is always supported
                                following mastectomy, reconstruction recommended
                                by a plastic surgeon at the time of mastectomy,
                                wherever possible.

                                If the patient meets with the above criteria,
                                please view appendix 2 before referring to the
                                Redditch and Bromsgrove Commissioning Team.


Commissioning Policy – Aesthetic Surgery Guidelines                            Page 6 of 17
PCT Board Meeting 26 April 2005
                                                                    AGENDA ITEM 11
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PROCEDURE                       CRITERIA

4. Breast Mastopexy             Referral is only for severe breast ptosis with
                                significant functional problems, in particular hygiene
                                or skin problems.

                                Refer only if there is marked asymmetry and if there
                                is no reduction in volume desired >500g (American
                                Medical Association criteria) i.e. referral is indicated
                                if there is less than the equivalent of half a bag of
                                sugar one or both sides, otherwise, consider breast
                                reduction.


                                If the patient meets with the above criteria please
                                view appendix 3 before referring to the Redditch
                                and Bromsgrove Commissioning Team.


5. Female Breast                Refer only for hyperplasia where there is a proposed
Reduction                       reduction of greater than 500g 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.

                                Refer only when breast size is causing functional
                                symptoms such as gravitational pain, intertrigo, high
                                back and neck pain and shoulder girdle dysfunction,
                                where conservative measures have failed to alleviate
                                symptoms (see appendix 4 for full details).

                                Referral only for patients whose BMI<26, unless in
                                very exceptional circumstances where a proven
                                weight loss program continues to result in obvious
                                body disproportion.

                                If the patient meets with the above criteria please
                                view appendix 4 before referring to the Redditch
                                and Bromsgrove Commissioning Team.




Commissioning Policy – Aesthetic Surgery Guidelines                          Page 7 of 17
PCT Board Meeting 26 April 2005
                                                                   AGENDA ITEM 11
                                                                     ENCLOSURE 7


PROCEDURE                       CRITERIA

6. Corrective Surgery of        Corrective surgery for inverted nipples is not
   the Nipple                   available.

                                GPs should be aware that there are now well proven
                                non-operative ways of correcting inverted nipples by
                                devices which can be obtained relatively cheaply
                                commercially and are suitable for simple lack of
                                nipple protrusion.

                                Note: any acquired nipple inversion should be
                                assessed to rule out carcinoma of the breast.


7. Eyelid surgery               Refer only if visual field impairment is experienced.
   Belpharoplasty
                                Note: Refer to ophthalmology for correction of
                                ectropion.


8. Tattoos                      Tattoo removal is not generally available.

                                Referral is only indicated when a tattoo has been
                                applied under duress, particularly in the under 16
                                age group or where the tattoo is the source of an
                                allergic phenomenon.

                                If the patient meets the above criteria, please
                                view appendix 1 before referring to Redditch and
                                Bromsgrove Commissioning Team.


9. Correction of                Referral only in children under the age of 18 years
   Prominent Ears               where the child, rather than the parent alone,
                                expresses concern.

                                Referral is only indicated when there is obvious
                                deformity or ear asymmetry.




Commissioning Policy – Aesthetic Surgery Guidelines                          Page 8 of 17
PCT Board Meeting 26 April 2005
                                                                    AGENDA ITEM 11
                                                                      ENCLOSURE 7


PROCEDURE                       CRITERIA

10. Rhinoplasty                 Refer only for post traumatic rhinoplasty, complex
                                congenital conditions e.g. cleft lip and or airway
                                problems.

                                Note: Straight forward cosmetic rhinoplasty not
                                available.



11. Face Lifts                  Referral only for patients with facial paralysis or a
                                congenital abnormality.


12. Abdominoplasty              Refer only if the abdominal apron is profound
                                resulting in adverse physical health effects e.g.
                                infection. It will be considered in patients who have
                                lost at least 10 points on BMI and whose current
                                BMI is less than 27. The patient should have
                                retained this weight loss for at least 6 months.


13. Liposuction                 Cosmetic liposuction is not available but may be
                                used as a technique in the management of true
                                lipodystrophies, lymphoedema or lipomas, or as part
                                of other surgery, e.g. thinning of transplanted flap.




14. Buttock, thigh and          Referral only when cutis laxa or severe weight loss
   arm surgery                  results in functional problems.


15. Congenital vascular         Referral only when congenital vascular
   abnormalities                abnormalities are in an obviously exposed area,
                                causing psychosocial distress or a functional
                                problem.




Commissioning Policy – Aesthetic Surgery Guidelines                          Page 9 of 17
PCT Board Meeting 26 April 2005
                                                                     AGENDA ITEM 11
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PROCEDURE                       CRITERIA


16. Thread veins                Referrals generally not considered.
   Telangectasias
                                Indications for treatment include severe facial
                                telangectasias which is treatment induced (e.g.
                                topical steroids) or as a result of a skin disorder (e.g.
                                Rosacea)

                                If the patient meets the above criteria, please
                                view appendix 1 before referring to Redditch and
                                Bromsgrove Commissioning Team.


17. Abnormally placed           Referrals for treatment from patients who have an
   hair                         underlying congenital or endocrine abnormality
                                resulting in abnormally placed or excessive hair (e.g.
                                patients with Spina Bifida Occulta, Stein Leventhal
                                Syndrome or Giant Hairy Naevi)

                                Other patients not generally considered.

                                If the patient meets the above criteria, please
                                view appendix 1 before referring to Redditch and
                                Bromsgrove Commissioning Team.


18. Acne scarring               Referrals will only be considered for those patients
                                with facial acne scarring who demonstrate severe
                                psychological problems.

                                If the patient meets the above criteria, please
                                view appendix 1 before referring to Redditch and
                                Bromsgrove Commissioning Team.




Commissioning Policy – Aesthetic Surgery Guidelines                          Page 10 of 17
PCT Board Meeting 26 April 2005
                                                                   AGENDA ITEM 11
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PROCEDURE                       CRITERIA

19. Refashioning of             Refer only for post burn cases or severe traumatic
   scars                        or surgical scarring.

                                Revision surgery on scars is indicated only if there is
                                any functional problem caused by the scar or when it
                                can be demonstrated that facial scarring is causing
                                significant psycho-social problems.

                                If the patient meets the above criteria, please
                                view appendix 1 before referring to Redditch and
                                Bromsgrove Commissioning Team.


20. Split earlobes              Referrals for incomplete tears will not be considered.

                                Referrals for complete tears may be considered.




Commissioning Policy – Aesthetic Surgery Guidelines                        Page 11 of 17
PCT Board Meeting 26 April 2005
                                                              AGENDA ITEM 11
                                                                ENCLOSURE 7

 References
      BlueCross BlueShield of North Carolina – Corporate Medical Policy,
       September 2002.

      Cambridgeshire and Peterborough Public Health Network – Cosmetic
       Surgery Policy, November 2002.

      Cheshire West PCT, Countess of Chester Hospital NHS Trust, Ellesmere
       Port and Neston PCT and Flintshire LHB - Aesthetic Surgery Guidelines –
       May 2002.

      Northumberland NHS Care Trust – Approval process to access non-
       routine or restricted services – current arrangements, March 2004.

      South Worcestershire PCT - Commissioning Policy for Breast
       Augmentation and Breast Reduction – Revised version, March 2004.

      Thames Valley Priorities Committees (Berkshire PCTs) Cosmetic
       Procedures Policy – December 2003.

      The Birmingham Skin Services Group (BSSG) Lasercare referral
       guidelines.

      The West Midlands regional guidelines for the commissioning and
       provision of aesthetic surgery for NHS patients – Revised version, October
       2003.




Commissioning Policy – Aesthetic Surgery Guidelines                  Page 12 of 17
PCT Board Meeting 26 April 2005
                                                                AGENDA ITEM 11
                                                                  ENCLOSURE 7

Appendix 1
Referral to Lasercare

The referral process for all categories mentioned will need to include a detailed
account of the patient specific case.

Information required at time of referral:

      Relevant previous medical history.

      Clear rationale for referral, including hopes and expectations should the
       treatment be authorised.

      Detail of any previous therapy or treatment and outcomes.

      With patient consent, photographic evidence in support of the individual
       case.

      Where the condition is affecting psychological and social well being, a
       detailed account of specific problems encountered, along with any
       previous referrals, treatment and outcomes.

Note: An absence of requested supporting information will result in a delay in
patient referral and subsequent treatment, if authorised.




Commissioning Policy – Aesthetic Surgery Guidelines                    Page 13 of 17
PCT Board Meeting 26 April 2005
                                                                 AGENDA ITEM 11
                                                                   ENCLOSURE 7

 Appendix 2
Breast Augmentation Guidelines

If the patient meets with the breast augmentation criteria, the following
information will be required by the Redditch and Bromsgrove Complex Case
Panel in order to reach a fully informed and fair decision about the individual
patient request.

Please ensure the following information is submitted to the Panel:

      Actual breast size, assurance that the patient’s breasts have been
       professionally measured by a reputable underwear fitter.

      Detail of body disproportion including photographic supporting evidence, if
       the patient wishes to provide it.

      Detail of height, weight and BMI.

      Where the condition is affecting psychological and social well being, a
       detailed account of specific problems encountered, along with any
       previous referrals treatment and outcomes..


Note: An absence of requested supporting information will result in a delay in
patient referral and subsequent treatment, if authorised.




Commissioning Policy – Aesthetic Surgery Guidelines                     Page 14 of 17
PCT Board Meeting 26 April 2005
                                                                    AGENDA ITEM 11
                                                                      ENCLOSURE 7

Appendix 3
Breast Mastopexy Guidelines

If the patient meets with the breast mastopexy criteria, the following information
will be required by the Redditch and Bromsgrove Complex Case Panel in order
to reach a fully informed and fair decision about the individual patient request.

Please ensure the following information is submitted to the Panel:

      Actual breast size, assurance that the patient’s breasts have been
       professionally measured by a reputable underwear fitter and that the
       patient is wearing appropriate support underwear

      Full detail of how breast ptosis (if present) is causing difficulties, including
       hygiene or skin problems

      Detail of any breast volume reduction required (if any)

      Detail of body disproportion (including asymmetry detail) including
       photographic supporting evidence, if the patient wishes to provide it

      Detail of height, weight and BMI

      Where the condition is affecting psychological and social well being, a
       detailed account of specific problems encountered, along with any
       previous referrals treatment and outcomes


Note: An absence of requested supporting information will result in a delay in
patient referral and subsequent treatment, if authorised.




Commissioning Policy – Aesthetic Surgery Guidelines                        Page 15 of 17
PCT Board Meeting 26 April 2005
                                                                   AGENDA ITEM 11
                                                                     ENCLOSURE 7

Appendix 4
Breast Reduction Guidelines

If the patient meets with the breast reduction criteria, the following information will
be required by the Redditch and Bromsgrove Complex Case Panel in order to
reach a fully informed and fair decision about the individual patient request.

Please ensure the following information is submitted to the Panel:

      Actual breast size, assurance that the patient’s breasts have been
       professionally measured by a reputable underwear fitter and that the
       patient is wearing appropriate support underwear

      A detailed account of functional problems as a result of breast size
       including detail of any pain experienced, interigo etc

Note: conservative treatments for neck and shoulder pain should be trialled for a
minimum of 6 weeks and should include: wearing appropriate support, NSAIDS
(if not contraindicated) and exercises (as directed via physiotherapy assessment)

Note: conservative treatment for submammary interigo should be trialled for a
minimum of 6 weeks and should include: appropriate hygiene, appropriate
pharmacological treatment and utilisation of an appropriate support bra.

      Detail of height, weight and BMI

      Basic detail of breast volume reduction required i.e. ensuring volume for
       reduction is at least 500g each side, as equivalent to half a bag of sugar
       each side

      Detail of any body disproportion (including asymmetry detail)

      Where the condition is affecting psychological and social well being, a
       detailed account of specific problems encountered, along with any
       previous referrals treatment and outcomes

      If BMI>26, detail is required around exceptional circumstances for the
       referral. There should be evidence of a legitimate attempt to lose weight.

Note: clear evidence of regular visits to a recognised weight loss programme
over a minimum of 3 months is required. The weight loss programme should
include reasonable dietary modifications and appropriate aerobic exercise. The
evidence needs to demonstrate patient compliance. The patient weight loss
programme should be monitored by a member of the Primary Healthcare Team


Commissioning Policy – Aesthetic Surgery Guidelines                       Page 16 of 17
PCT Board Meeting 26 April 2005
                                                               AGENDA ITEM 11
                                                                 ENCLOSURE 7
e.g. G.P. or practice nurse. The patient needs to demonstrate a plateau in weight
loss and an inability to lose any more weight, together with a maintenance of
breast size before consideration for funding for breast reduction on the NHS.

Note: An absence of requested supporting information will result in a delay in
patient referral and subsequent treatment, if authorised.




Commissioning Policy – Aesthetic Surgery Guidelines                   Page 17 of 17
PCT Board Meeting 26 April 2005

								
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