What are the guidelines for medically necessary breast augmentation plastic surgery?

Guidelines for Medically Necessary Breast Augmentation Plastic Surgery

Breast augmentation is considered medically necessary only in specific clinical scenarios related to breast cancer treatment, risk reduction in high-risk individuals, or reconstruction following mastectomy, rather than for cosmetic purposes. 1

Indications for Medically Necessary Breast Surgery

Post-Mastectomy Reconstruction

• Breast reconstruction should be available and proposed to all women requiring mastectomy 1
• Immediate breast reconstruction should be offered to the vast majority of patients, except those with inflammatory breast cancer 1
• The optimal reconstruction technique should be discussed individually, considering anatomic factors, treatment-related factors, and patient preferences 1

Risk-Reducing Surgery

• Risk-reducing surgery with prophylactic bilateral mastectomy and reconstruction may be offered to women at very high risk, such as:
  • BRCA1 or BRCA2 gene mutation carriers
  • Those with previous chest irradiation for lymphoma 1
• Careful genetic assessment and psychological counseling are mandatory before undertaking such surgery 1
• With bilateral mastectomy, the risk for both subsequent breast cancer incidence and mortality is reduced by 90-95% 1

Oncoplastic Procedures

• Oncoplastic procedures can achieve better cosmetic outcomes, especially in patients with:
  • Large breasts
  • Less favorable tumor/breast size ratio
  • Cosmetically difficult tumor location 1
• BCS (breast-conserving surgery) is the preferred local treatment option for most early breast cancer patients, with oncoplastic techniques used to maintain good cosmetic outcomes in technically challenging cases 1

Decision-Making Process

Patient Involvement

• The choice of treatment strategy must be extensively discussed with the patient and take into account patient preferences 1
• Patients should be provided with the opportunity to be actively involved in all management decisions 1
• Information on diagnosis and treatment choice should be given repeatedly (both verbally and in writing) in a comprehensive and easily understandable form 1

Multidisciplinary Approach

• Treatment should be carried out in specialized breast units/centers by a multidisciplinary team consisting of:
  • Medical oncologists
  • Breast surgeons
  • Radiation oncologists
  • Breast radiologists
  • Breast pathologists
  • Breast nurses 1
• The breast unit/center should have or be able to refer patients to plastic/reconstructive surgeons, psychologists, physiotherapists, and geneticists when appropriate 1

Reconstruction Options

Implant-Based Reconstruction

• Silicone gel implants are safe and acceptable components of the reconstructive armamentarium 1
• Should be considered when appropriate based on patient anatomy and preferences 1

Autologous Tissue Reconstruction

• May be preferred in certain cases, especially for patients who have had or will have radiation therapy
• Options include TRAM flaps, DIEP flaps, latissimus dorsi flaps, and other techniques 1

Common Pitfalls and Caveats

• Immediate reconstruction should not be offered to patients with inflammatory breast cancer 1
• Reconstruction should not jeopardize the administration of locoregional and/or systemic treatment 1
• When re-excision is needed for positive margins, the aesthetic result should remain satisfactory 1
• For purely cosmetic breast augmentation (not related to cancer treatment or risk reduction), medical necessity criteria are not met according to current guidelines
• Patients should be informed about potential complications of breast reconstruction, including implant-related issues, donor site morbidity for autologous reconstruction, and the potential need for revision surgeries

By following these guidelines, healthcare providers can ensure that breast augmentation procedures are performed when medically necessary, with appropriate consideration of patient factors, surgical options, and expected outcomes.