Criteria for referral to public hospital service

• Patients with body mass index (BMI) < 30, not a current smoker and HbA1c < 8mmol/mol (if diabetic) with:
  • significant clinical symptoms present (e.g. intractable intertigo, correction of asymmetry following previous breast conserving surgery for breast cancer, severe gynaecomastia)
  • macromastia with pain in the neck or shoulder region with functional or psychological impact or both.

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
• How symptoms are impacting on activities of daily living including impact on work, study, exercise or carer role
• Details of previous medical or non-medical management of symptoms including conservative management such as professionally fitted supportive garments, counselling and weight loss
• Relevant medical history and comorbidities
• Current and complete medication history (including hormonal treatments, non-prescription medicines, herbs and supplements and recreational or injectable drugs)
• Body Mass Index (BMI)
• History of smoking
• Patient’s age
• Recent HbA1c (if applicable)
• If > 50 years, most recent mammography results including when and where imaging was performed.

Provide if available

• If < 50 years, most recent mammography results including when and where imaging was performed
• 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.

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

Note the indications for breast reduction surgery in the Aesthetic procedures and indications for surgery in Victorian public health services: breast reduction (bilateral/unilateral) where significant clinical symptoms are present (for example intractable intertigo and severe gynaecomastia) and BMI < 30.

Some health services may accept referrals in limited circumstances for patients with a BMI < 35 provided they are non-smokers and have a HbA1c < 8mmol/mol with severe symptoms impacting on activities of daily living.

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.

Referral to a public hospital is not appropriate for

Referrals that do not meet the criteria.