Sood R, Mount DL, Coleman JJ 3rd, et al. 2017;35:157-161. Beer GM, Kompatscher P, Hergan K. Diagnosis of breast tumors after breast reduction. The authors concluded that breast re-reduction can be performed safely and predictably, even when the previous technique is not known; and 4 key principles were developed: Language services can be provided by calling the number on your member ID card. Breast reduction surgery is considered reconstructive and medically necessary in certain circumstances . Kerrigan CL, Collins ED, Kim HM, et al. Plast Reconstr Surg. Qu S, Zhang W, Li S, et al. Results illustrated that 3050 patients were <60 years of age (39.7 11.8 years) and 487 were 60 years of age (65.1 4.7 years). Marshall WA, Tanner JM. Chadbourne EB, Zhang S, Gordon MJ, et al. 2019;8(4):431-440. color:#eee; Burdette TE, Kerrigan CL, Homa KA. You first need to demonstrate that the procedure is "medically necessary and therefore reconstructive rather than cosmetic," says board-certified New York City plastic surgeon Dr. Umbareen Mahmood. World J Surg. Third, reliable evidence is especially important for pain interventions, because of the waxing and waning nature of pain and the susceptibility of this symptom to placebo effects and other biases that may confound interpretation of study results. Reduction mammoplasty performed solely for cosmetic indications is considered by insurers to be not medically necessary treatment of disease and subject to the standard cosmetic surgery plan exclusion. In contrast, tobacco use and BMI were associated with worse breast reduction outcomes. 2003;111(2):688-694. 1997;100(4):875-883. Aetna considers breast reduction surgery medically necessary for non-cosmetic indications for women aged 18 or older or for whom growth is complete (i.e., breast size stable over one year) when any of the following criteria (A, B, or C) is met: Macromastia: all of the following criteria must be met: 2021;74(11):3128-3140. ASPS Recommended Coverage Criteria for Third Party Payors. z-index: 99; 2006;118(4):840-848. 2015;49(6):363-366. 2008;32(1):38-44. American Society of Plastic Surgeons (ASPS). hr.separator { } The member has gigantomastia of pregnancy accompanied byany of the following complications, and delivery is not imminent: For medical necessity criteria for surgery to correct breast asymmetry, seeCPB 0185 - Breast Reconstructive Surgery. The operative group in the BRAVO study was drawn from a number of surgical practices that volunteered to participate in the study; no details are provided about how each center selected candidates for reduction mammoplasty, or how they chose patients who underwent mammoplasty for inclusion in the study. Evidence-based clinical practice guideline: Reduction mammaplasty. list-style-type: decimal; High-risk lesions (atypical ductal hyperplasia [ADH], atypical lobular hyperplasia [ALH], and lobular carcinoma in situ [LCIS]) were revealed in 37 (11.7 %), and cancer in 6 (1.9 %) patients. Please check your insurance policy to see whether breast reduction is a covered procedure. Grade III: Moderate breast enlargement exceeding areola boundaries with edges that are indistinct from the chest with skin redundancy present. The health burden of breast hypertrophy. 2005;58(3):286-289. Krieger LM, Lesavoy MA. Abnormalities in Adolescent Breast Development. Often times, insurance company will dictate how much breast tissue to be removed. The traditional method of breast reduction requires an open incision around the areola extending downward to the crease beneath the breast. 2018;24(6):1043-1045. Kasielska-Trojan and associates (2018) analyzed digit ratio in relation to estrogen receptor (ER) and progesterone receptor (PR) expression and verified digit ratio (2D: 4D) as a marker of ER and PR over-expression in the male breast. 2000;44(2):125-134. Other referencesto smaller studies published prior to the BRAVO study have been cited,examining symptoms before and after reduction mammoplasty; each of these studies suffer from limitations similar to those identified with the BRAVO study. Surg Laparosc Endosc Percutan Tech. 2000;106(2):280-288. } For additional language assistance: Chemical exfoliation for acne (eg, acne paste, acid), Mastectomy, partial (e.g., lumpectomy, tylectomy, quadrantectomy, segmentectomy), Diagnostic mammography, including computer-aided detection (CAD) when performed, Photodynamic therapy by external application of light to destroy premalignant and/or malignant lesions of the skin and adjacent mucosa (eg, lip) by activation of photosensitive drug(s), each phototherapy exposure session, Photodynamic therapy by external application of light to destroy premalignant lesions of the skin and adjacent mucosa with application and illumination/activation of photosensitizing drug(s) provided by a physician or other qualified health care professional, per day, Basic life and/or disability examination that includes: Measurement of height, weight, and blood pressure; Completion of a medical history following a life insurance pro forma; Collection of blood sample and/or urinalysis complying with "chain of custody" protocols; and Completion of necessary documentation/certificates, Weight management classes, non-physician provider, per session, Mononeuropathies of upper limb [upper extremity paresthesia], Gangrene, not elsewhere classified [tissue necrosis], Non-pressure chronic ulcer of skin of other sites, Hypertrophy of breast [symptomatic-causing significant pain, paresthesias, or ulceration], Other specified disorders of breast [soft tissue infection]. J Plast Reconstr Aesthet Surg. /* aetna.com standards styles for templates */ The 2 vacuum-assisted breast biopsy systems (Mammotome and Encor) were used for the patients with gynecomastia. Plast Reconstr Surg. # font-weight: bold; Mistry and associates (2017) examined outcomes following breast re-reduction surgery using a random pattern blood supply to the nipple and vertical scar reduction. In this study the National Surgical Quality Improvement Program data set was queried for the Current Procedural Terminology code 19318 from the years 2005 to 2010, with principal outcome measurements of wound complications, surgical site infections, and reoperations. Gynecomastia. Study subjects included 3538 patients with an average age of 43 years and body mass index of 31.6 kg/m(2) and most patients underwent outpatient surgery (80.5%) with an average operative time of 180 minutes.The incidence of overall surgical complications was 5.1% and the incidence of major surgical complications was 2.1%. Furthermore, the lack of an expected "dose-response" relationship between the amount of breast tissue removed and the magnitude of symptomatic relief in these studies raises questions about the validity of these studies and the effectiveness of breast reduction as a method of relieving shoulder and back pain. Iwuagwu OC, Stanley PW, Platt AJ, Drew PJ. Completely autologous platelet gel in breast reduction surgery: A blinded, randomized, controlled trial. Causes may include testosterone-estrogen imbalance, increased prolactin levels, or abnormal serum binding protein levels. While the efficacy of radiotherapy as a therapeutic modality for gynecomastia was also established, it was shown to be less effective than other available options. 2001;108(1):62-67. Principles of breast re-reduction: A reappraisal. Klinefelters syndrome, testicular, adrenal, or pituitary tumors, and thyroid or hepatic dysfunction are also associated with gynecomastia. of the following criteria must be met: In: Townsend CM, Beuchamp RD, Evers BM, eds. Work-up of gynecomastia may include the following (GP Notebook, 2003): Treatment should be directed at correcting any underlying reversible causes. (This refers to actual breast tissue only; any fatty tissue removed doesn't count.) Cochrane Database Syst Rev. It can cause discomfort and concern, resulting in patients seeking diagnosis and treatment. Nelson JA, Fischer JP, Wink JD, Kovach SJ 3rd. Aetna Inc. and its subsidiary companies are not responsible or liable for the content, accuracy, or privacy practices of linked sites, or for products or services described on these sites. margin-top: 38px; Also, there was no correlation between PR expression and 2D: 4D. 2014b;30(6):641-647. Li CC, Fu JP, Chang SC, et al. Reduction mammoplasty has been performed to relieve back and shoulder pain on the theory that reducing breast weight will relieve this pain. Choban PS, Flancbaum L. The impact of obesity on surgical outcomes: A review. Reduction mammaplasty. Complications following radiotherapy were minor and self-limiting in all cases, restricted to minor skin reactions, and associated with larger radiotherapy doses delivered in fewer fractions. These investigators support its use for idiopathic gynecomastia in eligible men following the careful discussion of its risks and benefits. Level of Evidence = III. American Society of Plastic Surgeons (ASPS). Sollie M. Management of gynecomastia-changes in psychological aspects after surgery-a systematic review. They stated that in the light of these findings, contralateral reduction mammoplasty with histopathological evaluation in breast cancer patients offered a sophisticated tool to catch those patients whose contralateral breast needs increased attention. All subjects were satisfied with their cosmetic outcome, graded as excellent by 22 patients (100 %). From January 2006 to January 2010, a total of 20 men with gynecomastia were treated by an 8-G vacuum-assisted biopsy device. They also analyzed if timing of reduction mammoplasty in relation to oncological treatment influenced the incidence of abnormal findings, and compared if patients with abnormal contralateral histopathology differed from the study population in terms of demographics. list-style-type : square !important; Compared with the open surgery group, the vacuum-assisted breast biopsy group had significantly smaller scar sizes left after the operation (5.5 1.3 cm versus 0.8 0.2 cm, p < 0.001), and shorter hospital stay time (5.5 2.4 days versus 3.1 1.6 days, p < 0.001). A total of 182 thirty-day postoperative surgical complications were documented, but stratifying patients into 2 age groups did not reveal an association between age and any surgical complication (P = .26). } The mean volume of tissue resected was 250 g (range of 22 to 758 g) from the right breast and 244 g (range of 15 to 705 g) from the left breast. Measurement of plasma gonadotrophins, human chorionic gonadotropin (hCG), testosterone, estradiol, and dehydroepiandosterone sulphate (DHEAS). Plast Reconstr Surg. Drainage in breast reduction surgery: A prospective randomised intra-patient trail. Breast reduction for symptomatic macromastia. Each surgeon who participated in the study reported on the height, weight, and volume of reduction of their last 15 to 20 patients, and each surgeon provided their intuitive sense regarding the motivation of each patient for breast reduction surgery. The authors concluded that high digit ratio in men with gynecomastia may tend to be a marker of over-expression of ER and PR. Tobacco use was shown to have a higher rate of reoperation (p= 0.02) and BMI was identified as an independent risk factor for wound complications (odds ratio, 1.85, P = 0.005). 2001;108(6):1591-1599. A study by Glatt et al (1999) was a retrospective analysis of responses to questionnaires sent to patients who underwent reduction mammoplasty regarding physical symptoms and body image. A physician-supervised diet and exercise plan may be indicated in obese patients. Plast Reconstr Surg. Redundant skin was observed in 1 patient at 1 month post-operatively, whose breast, defined as grade-III, was the largest before operation. If an insufficient amount of breast tissue is removed, the surgery is less likely to be successful in relieving pain and any related symptoms from excessive breast weight (e.g., excoriations, rash). Tobacco use and body mass index as predictors of outcomes in patients undergoing breast reduction mammoplasty. 2014b;48(5):334-339. Three review authors undertook independent screening of the search results. Bruhlmann Y, Tschopp H. Breast reduction improves symptoms of macromastia and has a long-lasting effect. ol.numberedList LI { Wound drainage after plastic and reconstructive surgery of the breast. In fact, according to the American Society of Plastic Surgeons, more than 46,000 breast reduction procedures were performed in 2019, a six percent increase compared to 2018; but in recent years, insurance companies have become more likely to deny coverage for this medically recommended procedure. background-color: #cc0066; The authors concluded that the limited evidence available showed no significant benefit of using post-operative wound drains in reduction mammoplasty, although LOS may be shorter when drains are not used. Breast Reduction Surgery and Gynecomastia Surgery - Medical Clinical Policy Bulletins | Aetna Page . Reduction mammoplasty improves symptoms of macromastia. Women's Health and Cancer Rights Act of 1998. Endocrinol Metab Clin North Am. Ann Plast Surg. A follow-up study of 105 women with breast cancer following reduction mammaplasty. The authors concluded that gynecomastia treatment combining high-definition liposculpture to male breast tissue resection via a new, almost invisible incision allowed these researchers to achieve an athletic and natural appearance of the male pectoral area with a very low rate of complications. Safran and colleagues (2021) noted that several technologies and innovative approaches continue to emerge for the optimal management of gynecomastia by plastic surgeons. The authors (Nguyen et al, 2004) argue, based primarily on the results of the ASPS-funded BRAVO study (described below), that (with a single exception) no objective criteria for breast reduction surgery are supportable, including criteria based upon the presence of particular signs or symptoms, requirements based upon breast size or the amount of breast tissue removed, any minimum age limitations, any limitation based upon maximum body weight, requirements for a trial of conservative therapy, or the exclusion of certain procedures (liposuction). Apart from a significantly shorter LOS for those participants who did not have drains (MD 0.77; 95 % CI: 0.40 to 1.14), there was no statistically significant impact of the use of drains on outcomes. Aesthetic Plast Surg. Determinants of surgical site infection after breast surgery. The authors reach the remarkable conclusion that a woman with normal sized breasts who has only a few ounces of breast tissue removed is as likely to receive as much benefit from breast reduction surgery as a women with large breasts who has substantially more breast tissue removed. The average amount of breast tissue removed ranged from 430 g per breast to 1.6 kg per breast, with increased body weight associated with an increased amount of breast tissue to be removed. Re-operation rate of liposuction-assisted surgery was between 0.6 % and 25 %. Yao Y, Yang Y, Liu J, et al. Horm Res Paediatr. Ann Plast Surg. 18th ed. 1999;103(6):1687-1690. Reduction mammoplasty has also been used for relief of pain in the back, neck and shoulders. Karamanos et al (2015) noted that although breast reduction mammoplasty accounts for more than 60,000 procedures annually, the literature remains sparse on outcomes. .newText { Breast reduction surgery (also called reduction mammaplasty) is a type of invasive procedure that involves incisions (cuts) in your skin to decrease the size and weight of your breasts . text-decoration: line-through; J Plast Reconstr Aesthet Surg. To calculate body surface area (BSA) see:BMI and BSA (Mosteller) Calculator;orBSA (m2) = ([height (in) x weight (lb)]/3131)(denotes square root), BSA (m2) = ([height (cm) x weight (kg)]/3600)(denotes square root). Morbidly obese patients are at the highest risk, with complications occurring in nearly 12% of this cohort. Fan L, Yang X, Zhang Y, Jiang J. Endoscopic subcutaneous mastectomy for the treatment of gynecomastia: A report of 65 cases. Studies have suggested that 2.4% to 14% of breast reduction cases resulted in major complications and 2.4% . Plastic Reconstruct Surg. Thus, this study would not be considered of sufficient quality to provide reliable evidence of the effectiveness of a pain intervention. } Health insurance companies frequently have different criteria for whether breast reduction surgery is medically necessary. Plastic Reconstr Surg. the nipple-areola complex can be elevated by de-epithelialization rather than recreating or developing a new pedicle; breast tissue is removed where it is in excess, usually inferiorly and laterally; the resection is complemented with liposuction to elevate the bottomed-out inframammary fold; and. These investigators concluded that their findings do not support the use of completely autologous platelet gel to improve outcomes after reduction mammoplasty. Reduction mammaplasty: Defining medical necessity. 2001;107(5):1234-1240. The goal of medically necessary breast reduction surgery is to relieve symptoms of pain and disability. Abnormal histopathological findings were more frequent in patients with reduction mammoplasty performed prior to oncological treatment (p < 0.001), and in patients with immediate reconstruction (p = 0.0064). } Mayo Clin Proc. The vacuum-assisted breast biopsy system is an effective strategy for the treatment of gynecomastia. list-style-type: decimal; Of these 33 operative sides, 2 complications occurred, but satisfactory chest contour was attained in all subjects. The goals of the surgery are to relieve symptoms caused by heavy breasts, to create a natural, balanced appearance with normal location of the nipple and areola, to maintain the capacity for lactation and allow for future breast exams/mammograms with minimal scarring or decreased sensation. Plast Reconstr Surg. Last Review01/04/2023. Gland Surg. And if you are in Canada the surgeon decides. 1. The authors specified the value of these study results was in the identification of morbid obesity as a significant predictor of overall morbidity and active smoking as a strong predictor of major surgical morbidity. Reduction (or some cases augmentation) mammoplasty and related reconstructive procedures on the unaffected side for symmetry are also considered medically necessary. OL LI { Br J Plast Surg. 2015;75(4):370-375. Hoyos AE, Perez ME, Dominguez-Millan R, et al. J Plast Surg Hand Surg. Aetna does not provide health care services and, therefore, cannot guarantee any results or outcomes. Other just require 500 grams no matter what your height and weight. Several important points should be considered in evaluating these challenges to insurers' criteria for breast reduction surgery. color: blue 2014a;34(3):409-416. Karamanos E, Wei B, Siddiqui A, Rubinfeld I. The author concluded that the current level of evidence on this subject was very low and future studies, examining the impact of the surgical intervention for gynecomastia on psychological domains, are greatly needed. These researchers calculated the risk ratio (RR) for dichotomous outcomes and mean differences (MD) for continuous outcomes, with 95 % confidence intervals (CI). Complication rates were inconsistent throughout the studies, ranging from 0.06 % to 26.67 %. An average of 320 specimens were excised from each side with mean blood loss of 34 ml. The American Society of Plastic Surgeons' evidence-based clinical practice guideline on reduction mammoplasty (ASPS, 2011) states thatin standard reduction mammoplasty procedures, evidence indicates that the use of drains is not beneficial. background-position: right 65%; They stated that no data are available for breast augmentation or breast reconstruction, and this requires investigation. Vacuum-assisted minimally invasive mastectomy was performed successfully in all cases, with no residual glands or adipose tissue observed on US. Breast asymmetries: A brief review and our experience. Photographs were taken pre-operatively and 1, 3, 6, and 12 months post-operatively. Can objective predictors for operative success be identified? ASPS clinical practice guideline summary on reduction mammaplasty. Follow-up ranged from 2 months to 3 years. American College of Obstetricians and Gynecologists (ACOG), Committee on Adolescent Health Care. Reduction mammaplasty: A review of managed care medical policy coverage criteria. Saunders Co.; 1991. A systematic search of the published literature was performed. The authors concluded that the incidences of malignant and high-risk lesions were doubled compared to patients without prior breast cancer. Breast J. Copyright Aetna Inc. All rights reserved. Plastic Reconstruct Surg. Of the responding surgeons, 71.6 % (151/211) routinely inserted post-operative drains, for a mean of 1.32 days. Fourth, insurers have provided coverage for reduction mammoplasty in women with excessively large breasts; thus, the debate is about the effectiveness of removal of smaller amounts of breast tissue from women whose breast size most persons would consider within the normal range. A total of 2779 patients were identified with a mean age of 42.7 (14.1) years and BMI of 31.6 (7.0) kg/m. Transient pain that may occur as the breast enlarges and the capsule is stretched; these symptoms may be managed with analgesics. Mizgala CL, MacKenzie KM. Gynecomastia in patients with prostate cancer: Update on treatment options. 2010;45(3):650-654. outline: none; Disproportionately large breasts can cause both physical and emotional . The data were retrospectively analyzed for demographics, operative and histopathology reports, oncological treatment, and post-operative follow-up. These investigators presented their experience with pectoral high-definition liposculpture combined with inverted-omega incision resection for gynecomastia. This may justify an early use of tamoxifen in men with gynecomastia and a high digit ratio. A study by Bruhlmann and Tschopp (1998) was a retrospective study of 246 patients from a surgical practice, approximately 50 % (132) of whom returned a questionnaire about their symptoms and satisfaction with aesthetic results, and their recollection of symptoms prior to surgery. Arch Dis Child. Abnormal histopathology correlated with higher age (p = 0.0053), heavier specimen (p = 0.0491), and with no previous breast surgery (p < 0.001). The 2 studies, which discussed laser-assisted liposuction technique, showed minor complication of seroma in 2 patients. The control group was not followed longitudinally or treated according to any protocol to ensure that they received optimal conservative management; conclusions about the lack of effectiveness of conservative management were based on their responses to a questionnaire about whether subjects tried any of 15 conservative interventions, and whether or not they thought these interventions provided relief of symptoms. No statistically significant differences in the drainage, level of pain, size of open areas, clinical appearance, degree of scar pliability, or scar erythema were noted. Alternatively, you may qualify if your breast size causes significant symptoms, such as: Long-term neck, shoulder or neck pain. Sixty to 70% of males develop a transient subareolar breast tissue during their adolescence (Tanner Stages II and III). Within this study population, 54.4% of patients were obese (BMI > 30 kg/m2), of which 1308 (28.8%) were Class I (BMI = 30-34.9 kg/m2), 686 (15.1%) were Class II (BMI = 35-39.9 kg/m2), and 439 (9.7%) were Class III (BMI > 40 kg/m2). Behmand RA, Tang DH, Smith DJ Jr. Outcomes in breast reduction surgery. A detailed drug history, including list of medications, an assessment of indirect or environmental exposure to estrogenic compounds, and recreational drug use. Aetna considers magnetic resonance imaging (MRI), with or without contrast materials, of the breast medically necessary for members who have had a recent (within the past year) conventional mammogram and/or breast sonogram, in any of the following circumstances where MRI of the breast may affect their clinical management:. Doses examined ranged from 8 to 16 Gy, delivered between 1 and 11 fractions. 1998;26(1):61-65. 1995;95(1):77-83. Key takeaways: Health insurance does not cover cosmetic breast reduction, but it usually does cover breast reduction surgery that is considered medically necessary. For these reasons, there is insufficient evidence to support the use of reduction mammoplasty, without regard to the size of the breasts or amount of breast tissue to be removed, as a method of relieving chronic back, neck, or shoulder pain. The studies used to support the arguments for the medical necessity of breast reduction surgery are poorly controlled and therefore subject to a substantial risk of bias in the interpretation of results. Howrigan P. Reduction and augmentation mammoplasty. For those with large breasts, breast reduction surgery can ease discomfort and improve appearance. Initial breast reconstruction including augmentation with implants 15771-15772 (when specific to breast), 19325, 19340, 19342, C1789 Fat grafting (alone, or with implant based feminization) 15771, 15772 *Note: CPT 19318 (breast reduction) includes the work necessary to reposition and reshape the nipple . 1997;185(6):593-603. Nelson et al (2014b) separately conducted a population level analysis of the 2005-2011 NSQIP datasets, identifying patient who underwent reduction mammoplasty, to determine the impact of obesity on early complications after reduction mammoplasty. GP Notebook. Aesthetic Plast Surg. No author listed. 2007;36(2):497-519. Handschin AE, Bietry D, Hsler R, et al. Vacuum-assisted minimally invasive surgery-An innovative method for the operative treatment of gynecomastia. This study included 35 patients who underwent breast reduction due to the idiopathic form of gynecomastia. Oxford, UK: National Health Service (NHS); October 2008. Breast. Tang CL, Brown MH, Levine R, et al. Coding Imahiyerobo TA, Pharmer LA, Swistel AJ, Talmor M. A comparative retrospective analysis of complications after oncoplastic breast reduction and breast reduction for benign macromastia: Are these procedures equally safe? list-style-type: upper-alpha; 1995;95(6):1029-1032. The mean age was 42.8 years (SD 19.5 years). Subjects responses were compared to an age-matched comparison group of women, although no further details about how this comparison group were provided. Swelstad MR, Swelstad BB, Rao VK, Gutowski KA. 2005;55(3):227-231. The authors recruited 67 consecutive female patients who underwent inferior pedicle reduction mammoplasty in order to determine the effects of resection weight, BMI, age, and smoking on complication rates following reduction mammoplasty.
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