1. East Midlands Cosmetic Procedures Policy Review March-April 2014 1

2. Public perceptions of cosmetic surgery have mainly been shaped by images of celebrities and media coverage of private ‘plastic surgery’ to enhance body image. Less information is in circulation about the cosmetic surgery available to NHS patients. The public image 2

3. What the policy is for The East Midland Cosmetic Procedures Policy sets out the region’s approach to the treatments which are only made available when specific criteria are met based on medical need and effectiveness. The criteria have been drawn up based on clinical evidence and expert opinion. The policy also details the cosmetic procedures that are not normally provided. All NHS Clinical Commissioning Groups in the East Midlands are now working together to review the 2011 East Midlands Cosmetic Procedures Policy. 3

4. The need for review In general, cosmetic procedures have relatively small health benefits compared to many other forms of healthcare There must be compelling clinical evidence before such procedures can compete for limited NHS funds. 4

5. Our approach The review of the current cosmetic policy has been led by colleagues in public health across the region. The commissioning criteria set in the revised policy have been decided on evidence of clinical and cost effectiveness, local and national guidelines, and clinical expert opinion from local GPs and hospital doctors. The starting point of the review was ‘no change unless compelling evidence of clinical effectiveness was available’. The policy retains a single policy for adults and children with age limits only being applied when clinically appropriate. 5

6. The proposed changes The changes are not extensive and mainly affect the eligibility criteria for treatment associated with: the nose earlobes both male and female genitals male and female breasts hair transplant to correct baldness will not be routinely available on the NHS. 6

7. Earlobes The proposed policy says that a patient will only be allowed to have an earlobe repaired if it was completely torn. This may be due to injury, for instance. This procedure will not be funded if there is only a partial split or tear of the lobe or if the lobe has elongated holes due to deliberate piecing. The key change to policy is that this procedure is only available if it was completely torn. 7

8. Genitals Women: Guidance from the Royal College of Gynaecology concluded there was little physical and psychological benefit to the patient in vaginal labia repair. Therefore we will continue to not routinely commission this procedure. The policy rewording clarifies that this includes hymen ‘repair’. Men: Surgery may be performed to correct congenital defects with male genitals. The key change to the policy is that the surgery will only be routinely funded following cancer, injury, and small number of specified conditions. 8

9. Removal of breast implants Breast implants may need to be removed if they rupture or cause breast disease, repeated infections, severe pain or they interfere with breast x-rays. The proposed policy says breast implants will only be removed from patients who have undergone cosmetic surgery, either on the NHS or privately, if they have any of the following: breast disease implants causing repeated infections implants associated with severe pain implants that interferes with breast x-rays rupture of silicon gel-filled implants. 9

10. Removal of breast implants The key change is that for women who comply with the criteria, and whose original surgery was funded by the NHS, we will also fund the insertion of replacement implants. Re- insertion was not previously commissioned. This is in line with Department of Health guidance following issues with Poly Implant Prothèse (PIP) implants in 2011/12. 10

11. Removal of breast implants We will not fund the insertion of replacement implants where the original surgery was funded privately We will also not fund or part-fund corrective treatment in the private sector, irrespective of whether part of that procedure involves removal of a breast implant. Co-funding to have the breast implants replaced is not permitted in the NHS. The East Midlands Cosmetic Procedures Policy does not cover the surgery available to cancer patients, whose treatment is based on other clinical considerations. 11

12. Enlarged male breasts the patient must have reached sexual maturity in men under 25 a period of at least two years has been allowed for natural recovery screening done for glandular and drug related causes non-surgical treatments have been tried but failed BMI is 18 to 25 and has been for a year the patient is a confirmed non-smoker no history of steroid use for body enhancement photographic evidence of the condition is available. The key change is that men with a history of use of steroids for body building will not be eligible for surgery. 12

13. Structure of the nose Correct airway obstruction causing serious breathing problems, due to injury or an inherited condition, such as cleft palate, or prevents access to perform other surgery, if: symptoms remain despite treatment for 3 months or more photographs show the deformity form all sides history of accidental, surgical, or congenital defect documentation about duration and degree of symptoms the recorded results of the basic treatment of symptoms. The key difference in new policy is that doctors are asked for more to detail on patients, in order to show the valid need for treatment and to clarify what is required. 13

14. How to have your say You may complete the questionnaire on our website, https://www.surveymonkey.com/s/emidscosm2014 Please submit a paper based survey form to: Vivienne Parish Public Health Specialty Registrar Room G58, County Hall, Glenfield Leicestershire LE3 8TB The survey lasts until until 9am on Thursday 17 April 2014. Decisions will be taken during the summer of 2014, when the latest version of the policy will be published. 14

15. Any questions? 15