Women in South Africa recently came together in support of a weighty issue concerning breast reduction surgery not being covered by medical aid schemes. The gauntlet was thrown down to the larger health care conglomerates by Goodluck singer, Juliet Harding, when she shared her story on social media. According to doctors from APRASSA, (Association of Plastic, Reconstructive and Aesthetic Surgeons of Southern Africa) her courage and conviction achieved more awareness in minutes compared to their years of constant petitioning around these interests.

Juliet’s Journey

After battling for years with unbearable back pain, Juliet made a momentous decision to undergo breast reduction surgery. She sent motivational letters to her medical aid, Momentum, in order to show that it was a clinical necessity for her to have the operation. She was declined, but she went ahead, as she had saved up for the surgery.

However, this got her thinking about other women who perhaps could not afford the operation. Surely, if the situation was motivated by doctors, it would merit consideration? She wrote: “Ok, CLEARLY these rules have been written by men, because if they had half an idea of what it’s like, and how debilitating the pain can be- then I don’t think this would be the case… I would like to challenge both Momentum (my current Medical Aid) and Discovery South Africa to both relook at this policy exclusion. Besides, don’t you think back surgery will be more expensive”?

Juliet is now recovering well from her surgery, and kindly answered some questions we had about her experience:

When did you first start experiencing back pain?

“I noticed my symptoms about four years ago. In the beginning, I assumed I had put my back out and started visiting a chiropractor regularly. Although temporary relief was often achieved for a few days, the pain would creep back in at some point. It became more frequent, and eventually, I was suffering – ending every day flat on my back with a hot water bottle to ease the pain”.

Did your doctor suggest that having breast reduction surgery might alleviate the pain, and further avoid back surgeries in the future?

“I went to a couple of different specialists to see if there was a way I could use regular exercise to strengthen my muscles around my spine, but nothing was working. My chiropractor suggested that my back pain was more than likely being caused by my disproportionately large size E breasts, and that I should consider a reduction to help alleviate the symptoms I was experiencing daily. I knew that even though it was not an easy decision, it would benefit my general health and well-being in the long run”. 

Dr Do Vale elaborates on this point: “Women who request breast reduction usually have excessively large breasts that are out of proportion with the rest of their body. This puts additional strain on the neck and upper back, causing unbearable physical symptoms including neck, back, shoulder pain, and headaches. They often experience deep shoulder grooving where bra straps cut into the shoulders under the strain of supporting heavy breasts, and rashes in the fold under the breasts. Their disproportionate breasts mean that they usually struggle to find bras that fit properly or give them adequate support, and they also battle to find clothes that fit them appropriately. It is difficult, if not impossible, to exercise or play sports. Teenage girls with macromastia often avoid participating in school sports or are reluctant to change in front of their peers”.

And yet, according to spokesperson for Fedhealth, Hans Rheeders, it is often very difficult to draw a conclusive link between the size of breasts and musco-skeletal pain. He says: “The scheme cannot simply accept and fund breast reduction surgery – which is very invasive and has a high risk of complications – because there is a view that it causes pain. That large breasts can be uncomfortable and even cause embarrassment is understood; it does not follow that schemes should be compelled to fund the procedure”.

Did your doctor help you with motivational letters (in order to push the medical necessity)?

“Yes, I received a full break down and motivation from the specialists I had been to see, the chiropractor and my surgeon, Dr Shane Barker, who not only sent drawings but also photographs through to the medical aid for approvals. I felt that this was quite an invasion of privacy- but I guess they have their reasons for needing to see those”.

Dr do Vale clarifies this: “Some medical aids may consider authorising breast reduction surgery following a motivation by your surgeon (this includes photographs, body weight, BMI and an estimate of the amount of tissue to be removed).  Only if the patient fits the medical aid’s stringent criteria, will they be granted the authorisation”.

Damian McHugh, Executive Head, Growth and Marketing at Momentum Health Solutions elaborates further: “In cases relating to breast reductions to alleviate back pain, proving a substantive link between breast size, back pain and ultimately spinal surgery is more difficult than in most other procedures we cover. This is where the Scheme Rules and clinical policies have a very important role to play in protecting the collective members of a medical scheme, and have been established to protect the funds of all members”.

Now, surely this begs the question of whether women are part of this membership base or not?

McHugh says, “It is important to note that Momentum Medical Scheme does consider and provides benefits for various breast surgeries related to illness and congenital abnormality, where clinical efficacy and cost effectiveness has been confirmed”.

Juliet, can you explain what happened with your medical aid, Momentum:

“We engaged in a very open and honest discussion. They explained the challenges that they face as medical aid provider, as well as their understanding on the fact that these policies have got to be updated. The Council of Medical Schemes is a body that determines many of the rules and the minimum benefits which all medical aids have to cover. At this point in time, the Council does not even allow for those benefits to be gender specific, so some of the health concerns that pertain to women are not even considered. The great thing that came out of the meeting is a willingness to engage. I really hope that they follow through with their promise to update their policy benefits and make them more inclusive”.

Damian McHugh concludes: “Our clinical policies are reviewed on an ongoing basis, and we will continue to investigate and engage with experts in their fields to make sure our clinical policies support cost effective evidence based treatment, in the best interest of the entire membership base, and in a way that does not create an imbalance, or make medical scheme cover unaffordable”.

You probably didn’t think that your statement on social media would have such far reaching repercussions – only the future will tell whether the medical aid schemes are serious about looking at their exclusionary policies, particularly with issues regarding women. Your thoughts?

“I honestly had no idea I was opening a can of worms when I wrote the post. I was just being honest and feeling vulnerable. It resulted in a tidal wave of women speaking out about their similar stories. It’s up to the medical aids to make a change, or potentially lose support from their female clients. I have shone a spotlight on this issue and I am proud of how it has created a wave of pressure to make a definitive change”.

Dr Do Vale agrees, The Association of Plastic Reconstructive and Aesthetic Surgeon of South Africa (APRASSA) has over the years unsuccessfully lobbied the medical aids to make their criteria a bit more reasonable and inclusive of a wider patient profile – especially because this particular surgery offers such immense physical and psychological benefits. These benefits would ultimately allow patients to live healthier, more active lifestyles, thereby reducing their healthcare requirements. A perfect example is tennis Star Simona Halep, who underwent a breast reduction in 2009, as the weight of her breasts affected her ability to react quickly. Her large breasts also made her uncomfortable when she played. Following her surgery, she climbed to No.2 in the world rankings and went on to win the 2018 French Open, as well as the 2019 Wimbledon Grand Slams”.

Breast Reduction Procedures Explained…

What a Breast Reduction Involves

Breast reduction (or reduction mammaplasty), is a surgical procedure that aims to decrease the size of the breasts and position them higher on the chest wall – all the while maintaining symmetry and enhancing the breast shape to better suit the proportions of the body. Disproportionately large breasts also tend to cause ptosis (sagging) of the breasts, which is also corrected as part of the surgery. The procedure is usually done under general anaesthesia and typically takes around two to three hours.

Breast reduction techniques differ by their incision pattern, amount of tissue removed and subsequent results.

Surgical markings are measured and made by your plastic surgeon before going into theatre. During surgery, incisions are made around the areolae in a key-hole pattern, with the excess breast tissue, fat and skin being removed to achieve the patient’s desired breast size. The nipples and areolae are repositioned higher up on the breast, and the breast is reshaped prior to being sutured closed.

Post-operatively it may be a struggle to lift arms above shoulders in the first few days. It is necessary to wear a supportive sports bra, free of underwire, for 6 weeks after surgery. Most patients will take about one to two weeks to recover before returning to work. It may take a few weeks for the incisions to fully heal, so strenuous activity or exercise should be avoided for about six weeks after the surgery.

The Pros & Cons of A Breast Reduction

The pros are obvious: smaller, lighter, lifted breasts that are more ergonomically positioned on the chest wall. No more neck, shoulder or back pain caused by the weight of heavy breasts. A huge boost in self-esteem and confidence. The ability to exercise and find clothing that fits properly.

The downside is the recovery time and the scars (these run around the pigmented areola, vertically down the lower part of the breast and horizontally in the breast fold, making an anchor shaped scar). However, most women say that the benefits far outweigh the scars, which for the most part heal well and are easily forgiven. Breast reduction patients are almost always ecstatic with their results, with some being the most satisfied patients we operate on. This is largely due to the immediate relief they get from their pre-operative symptoms.

Potential Complications of Breast Reduction Surgery

As with all surgery there exists the possibility of complications, and breast reduction is no exception. The most likely complications would include:

• Bleeding within the breast tissue (hematoma) may occur, as a result of elevated blood pressure after the surgery, over-exertion or trauma to the area.
• Infection is always a risk with any surgery and effort should be made to keep the wounds clean and dry.
• Wound breakdown may occur due to the tension on the suture lines that are holding the breast in its new shape and position. Wearing a supportive post-surgical bra helps support the breasts and takes some tension off the wounds.
• Loss of sensation to the nipple can occur in some patients but it is usually only temporary, however it can be permanent in a small group of patients.
• Breast feeding – while it is normally still possible for a woman to breast feed an infant after breast reduction, it is advisable to supplement with formula feeds. This is because some of the breast ducts have been cut and rearranged, so it may not be able to produce enough breast milk to fully sustain an infant, requiring some supplementation with formula.
• Asymmetry can occur after a reduction. Most women have subtle asymmetries of the breasts and these are often more pronounced with macromastia. One of the goals of breast reduction surgery is to achieve better symmetry of the breasts, however, perfect symmetry may not be possible. Your breast are siblings, not twins- they look similar but may not look perfectly identical.
• Scarring is the natural consequence of any surgery. Your plastic surgeon will make every effort to ensure the most inconspicuous scars possible, but in some instances, due to your genetics and other factors beyond their control, scars may tend to widen or become hypertrophic. You will be given a scar management protocol which may include silicone sheets or gels.

How Do I Get the Best Results from My Breast Reduction?

If you are considering breast reduction surgery, start by looking for an APRASSA member plastic surgeon in your area. Discuss your symptoms and your goals of surgery, and let them advise you on the safest way to achieve the results you want.

If your BMI is greater than 35, your surgeon may advise you to lose some weight before the surgery, as this might reduce the risk of complications. Plan to have the surgery when you are able to take the necessary time out to recover.

Follow your surgeons instructions with regards to wearing a supportive post-operative bra, and avoid strenuous activity or exercise immediately after the surgery. Your surgeon will also give you a scar therapy regimen to follow.

The results of the surgery will be permanent and long-lasting, providing your weight remains stable and does not fluctuate significantly.

Will My Medical Aid Cover the Costs of Breast Reduction Surgery?

The short answer – probably not. Most medical aids view breast reduction as a cosmetic procedure, despite the fact that there are clear physical benefits. Unfortunately, most patients seeking breast reduction do not fit these extremely prohibitive criteria, despite being very deserving candidates. Hopefully in time they will reconsider these measures – but as it stands now, most patients will not qualify and will have to fully fund the surgery themselves.

What The Medical Aids Have To Say

Momentum:

“We ensure healthcare cover for our members when they need it, but in certain cases, the industry finds it challenging to assess whether there is a real evidence based medical need for surgical intervention – or whether members and/or providers may have used certain medical codes to obtain authorisation for surgery where there is limited evidence to support its clinical efficacy.

Discovery Health:

“CEO Dr Ryan Noach says: “DHMS funds breast reduction surgery for DHMS members on higher plans who have specific clinical need for these procedures. This funding has been in place for many years. DHMS does not pay for this surgery where it is solely for aesthetic purposes, as all cosmetic surgery is considered a General Scheme Exclusion for open schemes in South Africa”.

However, while the above sounds all very well and good, it must noted that plastic surgeons will tell you that in the majority of cases, breast reduction is NOT considered cosmetic – despite what the scheme may say.

Now, on the other hand, if you have the money, most medical aids have a solution:

Fedhealth:
They offer a MediVault and Wallet system which allows members the option to use allocated funds for day-to-day expenditure for this specific procedure. This is, in effect, an interest free loan that the member pays off over a maximum period of 12 months.

Discovery Health:
Breast reduction surgery can be funded on the Executive and Comprehensive plans (except Classic Smart Comprehensive plan), BUT again, ONLY if the patient falls within their selection criteria.

Yet one has to wonder:  In terms of our demographics in South Africa, where women find themselves in a position of inequality in terms of the gender-based pay gap-amongst other issues – surely this leaves the majority with a lot to be desired?

Final Thought

As medical aid schemes in SA all have a similar stance in terms of breast reduction surgery, it seems to be a moot point at this stage. If you are a woman that is considering breast reduction surgery that is clinically indicated, take heart from the fact that doctors from APRASSA, (Association of Plastic, Reconstructive and Aesthetic Surgeons of Southern Africa) are campaigning for you. Perhaps if more women add their voice to Juliet Harding’s petition for change, it could bring about a revolutionary and significant transformation in the way medical cover policies are written. Only time will tell.

This article was written by Paola Chellew and Dr Isabel do Vale. Edited by the A2 team EXCLUSIVELY for the A2 Aesthetic & Anti-Ageing Magazine March/Autumn 2020 Edition (Issue 33).