Criteria for referral to public hospital service

• Post mastectomy (immediate or delayed)
• Significant deformity and surgery is indicated due to disease, trauma or congenital conditions (e.g. extensive burns, chemotherapy, radiotherapy, large cell lymphoma, contralateral breast Poland syndrome).

Information to be included in the referral

Information that must be provided

• Expectation, or outcome, anticipated by the patient, and the referring clinician from the referral to the health service
• Reconstruction detail: side, timing (immediate or delayed)
• Details of previous medical management such as chemotherapy, radiotherapy or plans for treatment in breast cancer patients
• Current and complete medication history (including hormonal treatments, non-prescription medicines, herbs and supplements and recreational or injectable drugs)
• Details of any previous breast surgery including when and where procedures were performed
• Relevant medical history and comorbidities
• Body Mass Index (BMI)
• Smoking status
• Recent HbA1c results (if applicable)
• If > 40 years mammography results including when and where imaging was performed (unless contraindicated)
• Patient’s age.

Provide if available

• Statement that the patient has indicated interest in having surgical treatment
• If the person identifies as an Aboriginal and Torres Strait Islander.

Additional comments

The Summary and referral information lists the information that should be included in a referral request.

Note patients can only be referred for elective surgery at a public hospital if they meet the clinical threshold for that surgery at the time of referral for surgery. Health services can accept referrals to specialist clinics for patients who do not meet the clinical threshold for reconstructive surgery. These patients may require another referral when they do meet the clinical threshold for surgery (e.g. different BMI, smoking status or HbA1C (if diabetic)).

Some health services may accept referrals in limited circumstances for patients who are unable to return to the surgeon, practice or health service where the surgery was performed.

Note the indications for breast reconstruction surgery in the Aesthetic procedures and indications for surgery in Victorian public health services: breast augmentation (bilateral/unilateral):

• post mastectomy reconstruction
• with or without augmentation for contra lateral breast Poland syndrome
• patient had significant deformity and surgery is indicated due to disease, trauma or congenital conditions.

Where appropriate and available the referral may be directed to an alternative specialist clinic or service.

Referral to a public hospital is not appropriate for

Referrals that do not meet the criteria without specific medical indication and that would be considered a cosmetic procedure would not be accepted.

Patients who develop complications of cosmetic breast augmentation should be directed to return to the surgeon, practice or health service where the surgery was performed.