Health: Storm in an A-cup

Last week, a 12-year-old had a breast implant on the NHS. So what's the big deal?

Say you had a young child, maybe 12 years old, and that child had a congenital abnormality, so severe that he had to wear a prosthesis under his clothes and was afraid to undress in front of other children. No one would question the wisdom of operating, if possible, to correct the abnormality. If the operation was not available on the NHS, it's the sort of thing people would fund-raise for; not a life-saving operation maybe, but a worthy cause.

But make that child a girl with Poland's syndrome (the same condition Jeremy Beadle has - which, along with an underdeveloped upper limb, can mean absence of chest wall structures including the breast), or perhaps mammary aplasia (complete lack of one breast) and suddenly a whole new twist is put on the story.

So instead of "Surgeons battle to give little girl a normal life", last week we got "Twelve-year-old girl has boob job on NHS". Technically speaking, the headline was correct. The age was right, and she was having a breast augmentation using NHS time and facilities. It was seemingly going to cost the taxpayer pounds 1,000, and even the "quality" press were calling it a "breast enhancement operation". Nor was the surgery life-saving - it was purely cosmetic, in the way that much plastic surgery aims to improve appearance more than function. But does that justify the sort of coverage afforded this little girl and her surgeon last week? The consultant, Douglas McGeorge, who practises in Chester, was forced onto the defensive in the media, when most other paediatric operations which do not include the word "breast" in the title, result in nothing but automatic praise for all those involved.

The story comes at a time when rationing in the NHS is more of an issue than ever. As usual, it's the unglamorous or the supposedly non-essential procedures that bear the brunt of criticism and cutbacks. Plastic surgery techniques can usually be found in the non-essential group, being associated in most people's minds with vanity. And if you really want to stir things up, just mention the words "tattoo removal": this is guaranteed to make medical managers squirm, especially when there are so many little old ladies waiting to have their hips done. (Thanks to this attitude, one patient who had himself tattooed with a full-facial spider's web while suffering from acute schizophrenia found it impossible to get it removed on the NHS once he had recovered and started to look for work.) While cosmesis, or a nice result, is the aim of all operations carried out by cosmetic surgeons, the benefits that can flow from a good outcome are far more than simply a pretty patient.

Take these sensitive political considerations, add the fact that the operation was on an "immature" girl, and it's easy to see why the story was pounced upon. Then there's our complete inability in this country, thanks to the influence of Sid James, Barbara Windsor and the rest, to discuss anything about breast sizes (too big, too small, or one of each) without a degree of giggling prurience.

Mr Chris Khoo, a consultant plastic surgeon in Berkshire with a special interest in breast reconstruction, takes a different view. While he has not personally performed surgery of this type on a girl of this age, he can see how it is completely justified, and necessary. He sometimes carries out breast reductions on girls younger than 16, with a condition bearing the self-descriptive name of gigantomastia. It can blight a girl's life completely, making it impossible to run, lie on her front, or even stand up straight. Breast reduction in these circumstances is far more than merely "cosmetic". He is impressed that the health authorities in Chester chose to pay for the procedure on the 12-year-old, indicating that they, if no one else, recognised its merits.

It seems as though the girl probably had two distinct problems - one breast was pathologically large for her age, and the other was pathologically small. Similar breast asymmetry occurs in up to a third of the female population, to differing extents. There is a little more involved than simply taking tissue out of one side and transferring it to the other, although along with increasing the size of the underdeveloped breast with an implant, an adult with this condition may have the larger side simultaneously reduced to balance things up.

A special type of "tissue expander" is used to augment the abnormally small or non-existent breast. These devices are also used by plastic surgeons to slowly stretch areas of flesh later employed in a separate operation to cover defects left by the removal of a tumour, or by a severe burn. Rather than an implant that is already of the desired size (which would be too big to insert straight away), an empty sac is placed in the breast attached to an injection pod just beneath the skin. Over time, saline is injected at intervals to increase the size of the sac, and when breast development is finished, the injection port can be removed, leaving the saline-filled sac as a permanent implant. As Mr Khoo points out, puberty is starting in girls at younger ages than ever before, and at 12 it is by no means unusual for breasts to be quite well advanced in their development. So in someone with a discrepancy this marked, the chances of her simply "growing out of it" are nil.

Of course, less contentious cosmetic operations are carried out on children every day, such as correction of "hare- lips" and prominent ears, or removal of conspicuous birthmarks. All are provided by the NHS even though, as in this ease, they are hardly life-threatening or even detrimental to health. But nobody would consider forbidding these operations simply to save money.

The other worry expressed was that this may represent the thin end of the wedge, and before you know where you are, kids will be getting tummy tucks, and tots having liposuction. Chris Khoo and his colleagues working within the NHS have very firm views on this. He regards the thought of even so much as a breast augmentation on a girl under 16 with small but equal-sized breasts as "completely irresponsible". Nor would any of them consider doing it in their private practice. Which is not to say that it is impossible for such surgery to be carried out in this country; some less scrupulous people will do anything if you pay them enough, and it would not be illegal for them to do it if they had the correct certificate on the wall.

But this is all far removed from what happened last week, when a brave little girl had a clever operation to correct a physical deformity. The details of the decision are something between the girl, her family and her doctors. Maybe the fact that it was performed on the NHS is of legitimate concern for some - hopefully many others would also be able to see it as money well spent.