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Tuesday 28 January 2014

NHS Funding for Breast Asymmetry

So... I've recently been in 'discussions' with our local CCG (the panel responsible for determining who gets treatment funded on the NHS) about why they have made certain decisions declining surgery to patients of mine that, in my view, are clearly deserving. I also read with interest a follow-up interview with Miles Berry in PMFA News (a new information journal for Plastic, Maxillary-Facial and Aesthetic Surgery) where he was asked to define the difference between 'cosmetic', 'aesthetic', and 'reconstructive' surgery. Personally, I think that 'aesthetic' and 'cosmetic' are interchangeable terms although I tend to agree with Miles that 'cosmetic' does invoke undertones of vanity whereas 'aesthetic' tends to imply an attempt to marry form with function.

It seems to me that pretty much all reconstructive cases are aesthetic or, at least, have a considerable aesthetic component. After all, breast reconstruction after mastectomy aims to provide a breast that looks like a breast. The functional aspects of breast reconstruction are often overlooked but involve complex psychosocial factors as well as the simpler issues such as the basic ability to buy and wear clothes that fit. More obviously functional reconstructions might include transfer of a toe to a thumb in order to improve hand function. However, every effort is made to provide a reconstruction that is as aesthetically pleasing as possible.

I have recently had patients turned down for funding who have breast asymmetry. Now, EVERY woman has breast asymmetry. It's normal. Some women, however, have a degree of asymmetry that could never be classified as 'normal' by anyone with binocular vision. Yet they are still being turned down. Why? According to the CCG, they will not fund an implant into the smaller side. They don't come right out and say it, but it's clear to me that they do not want to burden the NHS with the duty of care of replacing those implants every 10 years (or so) in a young patient. Their suggestion? To reduce the larger side to match. Actually not a bad idea... were it not for the fact that in my letter requesting funding I wrote something along the lines of 'breast reduction to the larger side would not be remotely in the patient's best interests as the smaller side is so hypoplastic (small) that to match it would mean giving her a mastectomy'. Don't get me wrong, I don't like using implants for breast asymmetry; I much prefer to use fat grafting techniques to the smaller side and I've had some staggeringly good results from that. However, the CCG don't like the idea of multiple attempts at fat grafting (in fact, they rather nonsensically deem this to be 'cosmetic', arguing that the NHS would not fund fat grafting to enlarge hypoplastic breasts - something I also believe that it should do). So after several backwards and forwards emails, I have finally found a solution: a small reduction to the larger side and a single attempt at fat grafting to the smaller side. One operation. By no means a perfect solution but one that will almost certainly leave the patient better off aesthetically. This is now my standard practice for breast asymmetry on the NHS for those patients who cannot afford to go down the private practice route and it works well. Try it out for yourself the next time you have a breast asymmetry go unfunded...

The moral of the story is this: Don't give up. Look for workable solutions - the NHS is not a bottomless pit, but while funding is still being provided for less worthy causes, I'm going to continue the good fight for my patients.

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