RAG rating
Document type
Clinical policy
Hertfordshire and West Essex ICB
Output type
Clinical Policies & Evidence-based Interventions

Breast Surgery

August 2023 v1.1

The guidance covers breast augmentation (excluding replacement of implants), mastopexy, removal of accessory (supernumerary) nipple or breast tissue, surgery for benign nipple inversion and breast reconstruction. 

The following are outside of the scope of this policy as they are included in alternative policies.
  • Breast prosthesis removal and replacement – See https://ebi.aomrc.org.uk/
  • Breast reduction - See https://ebi.aomrc.org.uk/ 
  • Gynaecomastia – See local HWE ICB policy.
  • Breast asymmetry – See Local HWE ICB policy.
This guidance applies to those over 18 years. Cosmetic breast surgery will not normally be considered for those under 18. 
Photographic evidence may be requested to demonstrate the case that the patient meets criteria or to demonstrate exceptionality.

Breast augmentation

Insertion of breast implants for cosmetic reasons is considered low priority and therefore not commissioned.
Breast implants may be funded to correct congenital or acquired chest cavity wall deformity if breast augmentation is part of the chest reconstruction.

Mastopexy (breast lift)
Mastopexy is not routinely funded. 

Removal of accessory (supernumerary) nipple or breast tissue

Supernumerary nipples or breast tissue are a minor congenital malformation of mammary tissue resulting in extra nipple(s) and/or associated breast tissue. They are common and are found in up to 6% of the population. Depending on what type of breast tissue is present and the site, they may also be known as accessory breast tissue, axillary breast tissue, polymastia, polythelia, accessory nipple, third nipple, ectopic nipple, or extra nipple. They may be solitary or multiple, and whilst most develop along the two lines from the axilla (armpit) to groin, they may occur at other sites such as the skin of the neck, back, vulva or thigh. They can occur in males and females.

Supernumerary nipples and breast tissue can be affected by hormonal changes, in particular if there is glandular tissue. There may be tenderness and swelling during adolescence or associated with the menstrual cycle. During pregnancy, swelling and lactation may occur. Some clothing can rub against axillary breast tissue causing discomfort. 
However, supernumerary nipples and breast tissue are generally not considered to be a health issue. Removal of supernumerary nipples or breast tissue is not routinely funded. 

Benign nipple inversion

Surgical correction of nipple inversion for cosmetic purposes is not funded.
Funding may be considered on an individual basis for functional reasons where the inversion cannot be corrected by correct use of a non-invasive suction device.

Breast reconstruction

Reconstructive breast surgery will be commissioned:
  • As part of reconstruction surgery after physical trauma
  • After mastectomy or wide local excision (lumpectomy) undertaken as part of treatment or prophylaxis of cancer.
Wide local excisions are unlikely to require extensive reconstruction. All intended procedures should be agreed upon during the treatment MDT. One reconstructive procedure will be routinely funded.
Please note, that due to extensive swelling following radiotherapy treatment any reconstructive processes may begin up to 4 years following the excision surgery which is acceptable within this policy.

Following initial cancer surgery, reconstructive surgery will be funded if it involves: 

  • a maximum of three procedures within three years of initial reconstructive surgery in order to adequately complete reconstruction. 
  • a maximum of four procedures in the case of delayed-immediate reconstruction
For the purpose of this guidance, initial mastectomy procedures do not constitute as the beginning of reconstruction and patients reserve the right to delay the beginning of their reconstruction process. Reconstructive procedures may involve but are not limited to surgery to the contralateral side, course of lipofilling and nipple reconstruction surgeries (excluding nipple tattooing)
The treatment plan should be documented at the start of treatment and should not exceed a total of three operations or four in a delayed-immediate procedure. Patients should be advised, and it should be documented that if they chose not to have surgery on their contralateral breast at the time of reconstruction that this may cause asymmetry later in life due to natural ageing and at that point they are unlikely to qualify for further reconstructive surgery.

Any further surgery required beyond the original documented treatment plan for primary reconstruction; in excess of three initial procedures or four in the case of delayed-immediate reconstruction; or beyond three years after the first procedure will require approval from the ICBs EBI and IFR team. 
Exceptions to this requirement are if the patient suffers from:
  • Complications (such as severe infection)
  • If there is a recurrence of disease or nodules discovered
In this instance where patients may require further surgery, the reconstructive process (time limits and number of procedures) will recommence at the start again at the commencement at the beginning of the first reconstructive procedure following surgery to correct complications.
All patients must be advised that further requests for surgery to address concerns about appearance, size, position, angle, or balance will be considered to be cosmetic and as such will not be routinely funded, however exceptional cases will be considered by the Individual Funding Requests department.

With regards to implant-based reconstructions, patients must be made aware of all known complications, including rippling and capsular contracture. Implant replacements will only be considered in line with the national EBI programme (list 3) guidance on breast prosthesis removal and replacement.
Funding will not be routinely approved for procedures to correct any naturally occurring change in the breast shape and symmetry following the completion of the reconstruction process. This includes but is not limited to as a consequence of aging.
Biological mesh will only be considered for funding on a case-by-case basis.


Breast reconstruction after treatment for breast cancer, in particular mastectomy, is a routinely funded procedure. Women currently are given the choice for immediate reconstruction – i.e., at the same time of the original surgery to remove the cancer, or to delay it until cancer treatment has been completed. Usually this can be completed in between one and three operations depending on the surgery required. There are a variety of different operations available for breast reconstruction.
This guidance recognises that women who have had surgery for breast cancer should be entitled to reconstructive surgery with the aim of replicating the appearance of the original breast as far as possible, rather than create the perfect replacement of the breast.