Breast Reduction Surgery

This is a national Evidence Based Intervention policy formally adopted by Hertfordshire and West Essex Integrated Care Board. Please see https://ebi.aomrc.org.uk/

Breast reduction surgery is a procedure used to treat women with breast hyperplasia (enlargement), where breasts are large enough to cause problems like shoulder girdle dysfunction, intertrigo and adverse effects to quality of life, therefore, the patient must be aged over 18 years.

Recommendation:

The NHS will only provide breast reduction for women if all the following criteria are met: 

• The woman has received a full package of supportive care from their GP such as advice on weight loss and managing pain
  
  
• In cases of thoracic/ shoulder girdle discomfort, a physiotherapy assessment has been provided
  
  
• Breast size results in functional symptoms that require other treatments/interventions (e.g. intractable candidal intertrigo; thoracic backache/kyphosis where a professionally fitted bra has not helped with backache, soft tissue indentations at site of bra straps).  

• Breast reduction planned to be 500gms or more per breast or at least 4 cup sizes
  
  
• Body mass index (BMI) is <27 and stable for at least twelve months
  
  
• The woman must be provided with written information to allow her to balance the risks and benefits of breast surgery  

• Women should be informed that smoking increases complications following breast reduction surgery and should be advised to stop smoking
  
  
• Women should be informed that breast surgery for hypermastia can cause permanent loss of lactation
   

Unilateral breast reduction is considered for asymmetric breasts as opposed to breast augmentation if there is an impact on health as per the criteria above.

Surgery will not be funded for cosmetic reasons. Surgery can be approved for a difference of 150 – 200gms size as measured by a specialist. The BMI needs to be <27 and stable for at least twelve months. 

Resection weights, for bilateral or unilateral (both breasts or one breast) breast reduction should be recorded for audit purposes.

This recommendation does not apply to therapeutic mammoplasty for breast cancer treatment or contralateral (other side) surgery following breast cancer surgery, and local policies should be adhered to. The Association of Breast Surgery support contralateral surgery to improve cosmesis as part of the reconstruction process following breast cancer treatment.

Gynaecomastia: Surgery for gynaecomastia is not routinely funded by the NHS. This recommendation does not cover surgery for gynaecomastia caused by medical treatments such as treatment for prostate cancer.

Patients who are not eligible for treatment under this policy may be considered on an individual basis where their GP or consultant believes exceptional circumstances exist that warrant deviation from the rule of this policy. Individual cases will be reviewed as per the ICB policy.
 

Rationale for Recommendation

One systematic review and three non-randomized studies regarding breast reduction surgery for hypermastia were identified and showed that surgery is beneficial in patients with specific symptoms. Physical and psychological improvements, such as reduced pain, increased quality of life and less anxiety and depression were found for women with hypermastia following breast reduction surgery.

Breast reduction surgery for hypermastia can cause permanent loss of lactation function of breasts, as well as decreased areolar sensation, bleeding, bruising, and scarring and often alternative approaches (e.g. weight loss or a professionally fitted bra) work just as well as surgery to reduce symptoms. For women who are severely affected by complications of hypermastia and for whom alternative approaches have not helped, surgery can be offered. The aim of surgery is not cosmetic, it is to reduce symptoms (e.g. back ache).

Patient Information

Information for Patients
Surgery to reduce the size of your breasts is a procedure which should only be carried out when specific criteria are met. This is because the medical evidence tells us that the operation can sometimes do more harm than good, especially if you are overweight or if you smoke and there are other treatments which can be more effective.

About the condition
Large breasts can cause several problems for women. They can affect daily living and prevent an active lifestyle. Many patients report pain in their back, neck and shoulders. Some patients may get a rash or infection under their breast tissue. Having large breasts may mean it’s difficult to find clothes that fit and are comfortable.

It’s important you and your doctor make a shared decision about what’s best for you if your breasts are so large they are causing you problems. When making that decision you should both consider the benefits, the risks, the alternatives and what will happen if you do nothing.

What are the BENEFITS of the intervention?
Breast reduction surgery may improve your mobility and make everyday activities easier, but it can only be carried out in specific circumstances and when other options have been tried and shown not to work. 

What are the RISKS?
Breast reduction surgery is a major operation. There is a risk of complications which can include, bleeding, infection, significant scarring, loss of the nipple, alteration to nipple sensation and problems with breast feeding. A cup size cannot be guaranteed. These risks are greater in smokers and patients who are overweight. 

What are the ALTERNATIVES?
There are lots of alternatives you should try first. These include losing weight, having a professionally fitted bra, pain relief, physiotherapy or seeking psychological support.

What if you do NOTHING?
Doing nothing is not likely to be harmful and you should try the alternatives to surgery first.

Further information can be found at https://ebi.aomrc.org.uk/interventions/breast-reduction/ This weblink was correct as of 06/01/2025.

Coding

WHEN Primary_Spell_Procedure IN ('B311')
AND (Primary_Spell_Diagnosis like '%N62%'
OR (Any_Spell_Diagnosis like '%Z411%' AND not Any_Spell_Diagnosis like '%Z853%') )
AND not (Any_Spell_Diagnosis like '%C50[0-9]%')
-- Only Elective Activity
AND APCS.Admission_Method not like ('2%')
THEN 'E_breast_red'

Exclusions

 WHERE 1=1
-- Cancer Diagnosis Exclusion
AND (Any_Spell_Diagnosis not like '%C[0-9][0-9]%'
AND Any_Spell_Diagnosis not like '%D0%'
AND Any_Spell_Diagnosis not like '%D3[789]%'
AND Any_Spell_Diagnosis not like '%D4[012345678]%'
OR Any_Spell_Diagnosis IS NULL)

-- Private Appointment Exclusion
AND apcs.Administrative_Category<>'02'

References

1.   An investigation into the relationship between breast size, bra size and mechanical back British School of Osteopathy (2010). Pages 13 & 14

2.   Royal College of Surgeons of England (2014) Commissioning Guide: Breast Reduction

3.   Greenbaum, a. R., Heslop, T., Morris, J., & Dunn, K. W. (2003). An investigation of the suitability of bra fit in women referred for reduction British Journal of Plastic Surgery, 56(3), 230–236.

4.   Wood, K., Cameron, M., & Fitzgerald, K. (2008). Breast size, bra fit and thoracic pain in young women: a correlational study. Chiropractic & Osteopathy, 16(1), 1-7.

5.   Singh KA, Losken A. Additional benefits of reduction mammaplasty: a systematic review of the literature. Plast Reconstr Surg. 2012 Mar;129(3):562-70. PubMed: PM22090252

6.   Strong B, Hall-Findlay EJ. How Does Volume of Resection Relate to Symptom Relief for Reduction Mammaplasty Patients? Ann Plast Surg. 2014 Apr 10. PubMed: PM24727444

7.   Valtonen JP, Setala LP, Mustonen PK, Blom M. Can the efficacy of reduction mammoplasty be predicted? The applicability and predictive value of breast-related symptoms questionnaire in measuring breast-related symptoms pre- and postoperatively. J Plast Reconstr Aesthet Surg. 2014 May;67(5):676-81. PubMed: PM24508223

8.   Foreman KB, Dibble LE, Droge J, Carson R, Rockwell WB. The impact of breast reduction surgery on low-back compressive forces and function in individuals with macromastia. Plast Reconstr Surg. 2009 Nov;124(5):1393-9. PubMed: PM20009823

9.   Shah R, Al-Ajam Y, Stott D, Kang N. Obesity in mammaplasty: a study of complications following breast reduction. J Plast Reconstr Aesthet Surg. 2011 Apr;64(4):508-14. doi: 10.1016/j.bjps.2010.07.001. Epub 2010 Aug 3. PubMed PMID: 20682461.

10.  Oo M, Wang Z, Sakakibara T, Kasai Y. Relationship Between Brassiere Cup Size and Shoulder-Neck Pain in Women. The Open Orthopaedics Journal. 2012;6:140-142. doi:10.2174/1874325001206010140.

11.  NHS information. Brest reduction on the NHS

12.  Chen CL(1), Shore AD, Johns R, Clark JM, Manahan M, Makary MA The impact of obesity on breast surgery complications. Plast Reconstr Surg. 2011 Nov;128(5):395e-402e DOI:10.1097/PRS.0b013e3182284c05