The new cosmetic surgery regulations: 'cosmetic' vs. 'medically necessary/reconstructive' surgery?
June 15, 2023
December 7, 2021
By Dr. Andrew Campbell-Lloyd

The new cosmetic surgery regulations: 'cosmetic' vs. 'medically necessary/reconstructive' surgery?

With the new cosmetic surgery regulations being introduced in July, we have noticed that there is a lot of confusion about what this will mean for the patients we see. This confusion seems to stem from the fact that a lot of surgeons are posting stuff on Instagram (and elsewhere) which is basically saying that ALL patients will be subjected to new rules and requirements, when in fact it will only apply to those patients who are considering "purely cosmetic" procedures.

Patients having medically necessary/reconstructive procedures will NOT be subjected to the new "cosmetic surgery regulations" that are being introduced.

I am sure there are surgeons who will subject all of their patients to the new rules for referrals, psychological screening etc. That is not the purpose of these regulatory changes. Make of it what you will.

So, what do we mean by "purely cosmetic" and how does that differ from other operations which may be considered to have an aesthetic/cosmetic focus, but which are deemed "reconstructive" or "medically necessary"?

This is actually much simpler than you think.

The easiest way to consider the difference between cosmetic and reconstructive/medical procedures relates to whether a procedure has an item number. If a procedure is covered by an item number (which allows a Medicare rebate, and private insurance coverage) then by definition, it is reconstructive.

So, here is a list of procedures to consider.

Breast reduction

Purpose: to reduce discomfort associated with heavy breasts. Whilst the aesthetic improvements associated with a more proportionate bust are undeniable, breast reduction is NOT cosmetic surgery. If however a surgeon removes a small amount of tissue to facilitate what is otherwise intended to just be a cosmetic breast lift, then this would not meet criteria to be medically necessary.

Item number: Yes - 45523

Category: medically necessary/reconstructive

Breast implant removal

Purpose: to manage complications associated with previous cosmetic breast implants by removing the implants with a capsulectomy (and whatever else we need to do). The main point here is that for this procedure to be considered medically necessary, the implants cannot be replaced. If an implant is replaced to manage complications from an original cosmetic breast augmentation, then the replacement procedure is considered purely cosmetic (see below).

Item number: Yes - 45551

Category: medically necessary/reconstructive

Correction of asymmetry/tuberous breasts

Purpose: to manage congenital breast differences (which are developmental conditions) and substantial breast asymmetry.

Item number: Yes - 45060 and others

Category: medically necessary/reconstructive

Breast reconstruction

Purpose: to rebuild a breast (either with implants or a patient's own tissue) after treatment for breast cancer.

Item number: Yes - there are quite a few, but the main numbers that you would want to check with your health fund are for DIEP flaps (46080, 46082, 45538), implant-based reconstruction (45527, 45529 46094) and fat transfer (45534, 45535)

Category: medically necessary/reconstructive

Fat transfer to the breast

Purpose: this one depends on the purpose of the fat transfer. Fat transfer can only ever be considered medically necessary when performed for ladies who have either had treatment for breast cancer, or ladies who are being treated for a congenital difference.

Fat transfer just to make the breast bigger is, obviously, purely cosmetic. Fat transfer done at the time of a cosmetic breast implant, or to manage the complications of a cosmetic breast implant, is purely cosmetic. If you got implants and they weren't done to manage a tuberous breast deformity, and then your surgeon tells you that your "double bubble" can be managed with fat graft, well, that is cosmetic too.

Item number: 45534, 45535

Category: medically necessary/reconstructive

Breast augmentation (regardless of whether done with fat transfer or implants)

Purpose: making a breast bigger, just becuase you want your breasts to be bigger, is quite obviously the main focus of all the cosmetic surgery reforms. This applies to you regardless of how you choose to make your breast bigger. So for anyone consider breast augmentation by fat transfer (becuase I don't do implants), you will be affected by these new rules.

Item number: No.

Category: Purely cosmetic

Correction or revision of cosmetic breast implants

Purpose: I have written a bit about this before. I am all too aware that there are surgeons who will tell patients that they can have their breast implants revised and partly covered by their insurance, but I am here to tell you that you can't. Period.

If you have cosmetic breast implants, and you choose to have them replaced (it doesn't matter whether they are ruptured, or contracted) then that is a purely cosmetic operation. If your surgeon has told you that item number 45554 would apply, then I hate to tell you but that is Medicare fraud and whilst you may get away with it initially, eventually your surgeon will be audited and you (and the surgeon) are going to face a big bill.

The only way manging a ruptured or contracted breast implant will receive a Medicare or health insurance rebate is if the implants are removed and NOT replaced. Which is an explant procedure.

Item number: No.

Category: Purely cosmetic


Purpose: if the goal of surgery is to maintain as much natural volume as possible, and to simply lift/reshape the breast, then that is a cosmetic procedure. Even if a small amount of tissue is removed to facilitate this surgery, a breast lift can NEVER be called a breast reduction.

The problem here is that the item number for a breast reduction doesn't actually stipulate how much tissue must be removed for the operation to classify as medically necessary. So some surgeons will remove maybe 20-40g of tissue in a breast lift and then try to call that a breast reduction. It isn't. If the surgeon is removing anything less than about 150g, then let's be honest, the purpose of the surgery is a breast lift and by definition it is cosmetic.

There is however an exception to this rule: If a woman has severe breast drooping and "at least two‑thirds of the breast tissue, including the nipple, lies inferior to the inframammary fold where the nipple is located at the most dependent, inferior part of the breast contour" (ie. there is no part of the breast sitting below the nipple - which means your nipples are quite literally point at the floor), then once in a patient's lifetime, they may qualify for an item number. The use of this item number is under strict review, and your surgeon may be asked to demonstrate applicability with photographic evidence.

Item number: No (unless the above criteria is met, in which case item number 45558 may apply).

Category: nearly always purely cosmetic

In the regulator's own words "Reconstructive surgery differs from cosmetic surgery as, while it incorporates aesthetic techniques, it restores form and function as well as normality of appearance. These guidelines (regarding the new regulations from July 1) apply to plastic surgery when it is performed only for cosmetic or aesthetic reasons. They (the guidelines) do not apply to reconstructive surgery."

We have updated our appointment request forms to reflect the new changes that are coming. For patients who select a procedure that is considered to be cosmetic, you will be asked to complete a screening assessment for body dysmorphia, as well as a separate consent form for the use of clinical photography. We realise that this is a bit of a pain, but honestly, we have made it as easy as we can and it will only take a few extra minutes.

If you have any questions, as always, please send us an email or get in touch via our socials.

Have a great day.