Isle of Man Clinical Recommendation CommitteeAESTHETIC (COSMETIC) SURGERY POLICY                                 TABLE OF ...
BACKGROUND & INTRODUCTIONAesthetic (Cosmetic) surgery is commonly considered to be surgery which aimsto change appearance ...
GUIDELINESThese guidelines cover a group of procedures or surgery for cosmetic purposes.It is important to note that a sub...
1.   Skin Lesions     1.1.      Benign Skin Lesions     •     Interventions will normally only be funded for visible lesio...
Routine replacements of implants and revision following private operationswill not usually be supported. However, surgery ...
The referral letter should always include the BMI measurement.     2.6      Breast reduction for male gynaecomastia     Br...
5.    Rhinoplasty      Rhinoplasty is not normally commissioned unless there are significant      functional problems. Ref...
11.    Tattoos       Tattoo removal is not available under the NHS. If a GP feels there is a       case for such a procedu...
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AESTHETIC (COSMETIC) SURGERY POLICY

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AESTHETIC (COSMETIC) SURGERY POLICY

  1. 1. Isle of Man Clinical Recommendation CommitteeAESTHETIC (COSMETIC) SURGERY POLICY TABLE OF CONTENTSContents Page numberBackground & Introduction 2Guidelines 31. Skin Lesions 4 1.1 Benign Skin lesions 1.2 Congenital Skin Lesions2. Breast Surgery 4 2.1 Breast augmentation (enlargement, mammoplasty) 5 2.2 Breast asymmetry 5 2.3 Breast Lift (Mastopexy) 5 2.4 Inverted nipples 5 2.5 Breast reduction 5 2.6 Breast reduction for male gynaecomastia 63. Abdominoplasty 64. Buttock, Thigh and Arm Lift Surgery 65. Rhinoplasty 66. Rhinophyma 77. Face lifts and brow lift (Rhytidectomy) 7 7.1 Botulinum Toxin 78. Blepharoplasty 79. Liposuction 710. Prominent Ears 711. Tattoos 712. Refashioning of scar 813. Hair depilation (hair removal) 814. Split earlobes 815. Thread veins/Telangectasias 816. Alopecia 8 Page 1 of 8
  2. 2. BACKGROUND & INTRODUCTIONAesthetic (Cosmetic) surgery is commonly considered to be surgery which aimsto 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 otherreason than that of improving appearance. Many individual procedures whichare commonly labelled as ‘aesthetic’ also have functional indications and allexternal surgery has an aesthetic element to it given that the best visual result isbeing sought. Finally while ‘pure aesthetic surgery’ aims to change appearancealone – this in itself may not always be the main objective but rather to treatsome underlying psychological and social dysfunction some of which can beconsidered as being legitimately ‘clinical’ due to the severity.The procedures covered in this policy (excluding varicose veins surgery) areestimated to comprise less than 10% of a plastic surgeon’s activity in the NHS inthe UK. Of the non-aesthetic element about 30% concerns the primary andsecondary treatment of trauma, usually hand, lower limb, facial and burn trauma.The other major aspects of plastic surgery are the treatment of head and neckand skin cancer, the treatment of congenital abnormalities, especially those ofthe 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 notcovered by this CRC policy on aesthetic or cosmetic surgery. If in doubt theproblem should be discussed with the GP or Consultant surgeon.In any health care system there are limits set on what is available and on whatpeople can expect. The DHSS is required to achieve financial balance; there is acomplex task in balancing this with individuals’ rights to health care. It is thepurpose of the criteria set out here to make the limits on cosmetic specialistplastic surgery procedures fair, clear and explicit.The DHSS has its own mechanism for approving specialist plastic surgery caseson 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 criteriafor approval. Page 2 of 8
  3. 3. GUIDELINESThese guidelines cover a group of procedures or surgery for cosmetic purposes.It is important to note that a substantial proportion of aesthetic surgery is carriedout by a number of specialties other than Plastic Surgery, the main ones beingEar, Nose and Throat Surgery, Ophthalmology, Maxillofacial Surgery, GeneralSurgery and Dermatology. This policy only concerns procedures carried out inhospitals.Elements to be taken into consideration during the decision making process areseverity, effectiveness of the interventions requested, cost and cost effectiveness. GENERAL GUIDELINES1. 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.8. Plastic surgery procedures will only normally be considered in patients with a BMI in the range of 18.5 to 29.9 unless weight is not relevant to the proposed surgery.*SIGN (1996) Integrated Prevention and Management of Overweight and Obesity,Edinburgh Page 3 of 8
  4. 4. 1. Skin Lesions 1.1. Benign Skin Lesions • Interventions will normally only be funded for visible lesions of 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 seborrhoeic keratoses (warts). • 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 port wine stains requiring NHS treatment should be referred to a laser centre once approval has been obtained from the CRC.2. Breast Surgery 2.1. Breast augmentation (enlargement mammoplasty) Breast augmentation will not be routinely funded by the NHS for cosmetic reasons. Referrals should only be made for women with a complete 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. 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. Page 4 of 8
  5. 5. Routine replacements of implants and revision following private operationswill not usually be supported. However, surgery may be supported whenthere is a pathological condition relating directly to the implant.Revision of breast augmentation will be funded only where the originalsurgery was NHS procedure.Breast augmentation will not usually be funded to alleviate psychologicaldistress.2.2 Breast asymmetryRefer only if there is a marked asymmetry and if there is need toremove/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 notbe available for purely cosmetic reasons, for example post lactation or agerelated breast ptosis (drooping).Where there is significant breast asymmetry of shape and/or volumeapproval will normally be given for reduction of the larger breast ratherthan augmentation of the smaller. The smaller breast should fulfil thecriteria for breast augmentation for this to be considered.2.4 Inverted nipplesNipple inversion may occur as a result of malignancy and this must beexcluded.Surgical correction of nipple inversion should only be available forfunctional reasons in post pubertal women and if the inversion has notbeen corrected by correct use of a non-invasive suction device.2.5 Breast reductionRefer only for hyperplasia where there is a proposed volume reduction ofgreater than 550g per side (American Medical Association criteria) i.e.referral is indicated if there is more than the equivalent of half a bag ofsugar to remove per side, and where the breast size is the cause ofgravitational pain such as shoulder girdle dysfunction or significant backpain, and where BMI is <30. The operation will not usually be offered tothose patients who have a BMI >30. Page 5 of 8
  6. 6. The referral letter should always include the BMI measurement. 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.3. Abdominoplasty Refer only if accompanied by significant divarication of the recti and the abdominal apron is profound and accompanied by functional problems. BMI must be <26. (The referral letter must always include the patients BMI). Functional problems include: • Recurrent severe infection or ulceration beneath the skin fold. • Experiencing severe difficulties with daily living i.e. ambulatory / urological. • Where post trauma or surgical scarring (usually midline vertical or multiple) leads to very poor appearance and results in disabling psychological distress or risk of infection. • Problems associated with poorly fitting stoma bags.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.(Contd…) Page 6 of 8
  7. 7. 5. Rhinoplasty Rhinoplasty is not normally commissioned 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.7. Face Lifts and brow lifts (Rhytidectomy) These procedures will 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. These procedures are not available to treat the natural processes of ageing. 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 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 The patient must be 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 commissioned where there are significant deformities or ear asymmetry. Page 7 of 8
  8. 8. 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.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 NHS15. Thread veins/Telangectasias Treatment for thread veins and telangectasias will not 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 Committee2009 Page 8 of 8

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