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. The primary outcome was the difference in wound drainage over 24 hours. .arrowPurpleSmall, a:hover.arrowPurpleSmall { Reduction mammoplasty has been performed to relieve back and shoulder pain on the theory that reducing breast weight will relieve this pain. } 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. 2021 Aug 11 [Online ahead of print]. Breast J. skin should not be excised horizontally below the inframammary fold. 2 . padding: 10px; Behmand et al (2000) reported on the results of a questionnaire pre- and post-surgery in 69 subjects from a single practice who underwent reduction mammoplasty. 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. J Plast Surg Hand Surg. This Clinical Policy Bulletin contains only a partial, general description of plan or program benefits and does not constitute a contract. This may lead to additional scarring and additional operating time. Leclere FM, Spies M, Gohritz A, Vogt PM. Breast reduction for symptomatic macromastia. Furthermore, no serious complications were observed in vacuum-assisted breast biopsy group. Brown DM, Young VL. border-radius: 4px; 2000;44(2):125-134. 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. Subjects responses were compared to an age-matched comparison group of women, although no further details about how this comparison group were provided. In contrast, tobacco use and BMI were associated with worse breast reduction outcomes. A total of 3 RCTs were identified and included in the review out of 190 studies that were initially screened; all evaluated wound drainage after breast reduction surgery. Reduction mammoplasty also known as breast reduction surgery, is a surgical procedure in women to reduce the weight, mass, and size of the breast. Burns JL, Blackwell SJ. --> 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. The average age was 24.7 years (range of 18 to 47 years). You may be able to buy a breast pump and supplies from one of our medical equipment suppliers at no charge or at a discounted rate. Managed care's methods for determining coverage of plastic surgery procedures: The example of reduction mammaplasty. Cochrane Database Syst Rev. Complications following reduction mammaplasty: A review of 3538 cases from the 2005-2010 NSQIP data sets. Surgical treatment of gynecomastia by vacuum-assisted biopsy device. In these cases, breast reduction for men may take 2 to 3 hours. Surg Laparosc Endosc Percutan Tech. Aetna is the brand name used for products and services provided by one or more of the Aetna group of subsidiary companies, including Aetna . In a review on Surgical treatment of primary gynecomastia in children and adolescents, Fischer et al (2014b) concluded that surgical correction of gynecomastia remains a purely elective intervention. J Plast Reconstr Aesthet Surg. This investigators stated that these studies should include data from older individuals affected by gynecomastia and utilize valid tools of psychological measurement in order to better quantify the effect; elderly patients affected by the disease have been over-looked in the current research; more data on this subject could improve the pre-operative evaluation of these patients and help identify the patients who will benefit from treatment. Treating providers are solely responsible for medical advice and treatment of members. Gynecomastia resection plus high-definition liposculpture was successfully performed in 436 consecutive men (open inverted-omega incision resection, n = 132; liposuction, n = 304). Plast Reconstr Surg. Plastic surgery for teenagers briefing paper. Devalia HL, Layer GT. The requirement for coverage is that the amount of breast tissue to be removed has to be enough to improve your symptoms or function. Until now, most published research on the subject has focused on how effective surgical treatment is on correcting the cosmetic appearance of the breast. 2015;(10):CD007258. This population-wide analysis - the largest and most heterogeneous study to date - has demonstrated that increasing obesity class is associated with increased early postoperative complications. The surgeon removes excess tissue, fat and skin before adjusting the placement of the nipple and areola appropriately. Here's what Aetna said in the denial: "We used the Clinical Policy Bulletin (CPB): Breast Reduction Surgery. Exposure to partners using estrogen containing vaginal creams; Cancer chemotherapy (alkylating agents, methotrexate, vinca alkaloids, imatinib, combination chemotherapy), Androgen receptor blockers - bicalutamide, 5 reductase inhibitors - finasteride, dutasteride, Angiotensin converting enzyme inhibitors (captopril, enalapril), Calcium channelblockers(diltiazem, nifedipine, verapamil), Anabolic steroids(e.g., in body builders). In a Cochrane review, Khan and colleagues (2015) stated that wound drains are often used after plastic and reconstructive surgery of the breast in order to reduce potential complications. Impact of surgical treatment for gynecomastia appeared to be beneficial for several psychological domains. Reduction mammaplasty: A review of managed care medical policy coverage criteria. bottom: 20px; Horm Res Paediatr. Health insurance companies frequently have different criteria for whether breast reduction surgery is medically necessary. Breast asymmetries: A brief review and our experience. Gynecomastia, its etiologies and its surgical management: A difference between the bilateral and unilateral cases? 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]. Pain/discomfort/ulceration from bra straps cutting into shoulders; Skin breakdown (severe soft tissue infection, tissue necrosis, ulceration hemorrhage) from overlying breast tissue; There is a reasonable likelihood that the member's symptoms are primarily due to macromastia; Reduction mammoplasty (also spelled as 'mammaplasty') is likely to result in improvement of the chronic pain; Pain symptoms persist as documented by the physician despite at least a 3-month trial of therapeutic measures such as: Analgesic/non-steroidal anti-inflammatory drugs (NSAIDs) interventions and/or muscle relaxants, Dermatologic therapy of ulcers, necrosis and refractory infection, Physical therapy/exercises/posturing maneuvers, Supportive devices (e.g., proper bra support, wide bra straps), Chiropractic care or osteopathic manipulative treatment. 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). These investigators stated that in an era of evidence-based medicine, surgeons performing breast reductions must adopt the results from scientific research into their clinical practice. Reduction mammoplasty has also been used for relief of pain in the back, neck and shoulders. Radiotherapy for prevention or management of gynecomastia recurrence: Future role for general gynecomastia patients in plastic surgery given current role in management of high-risk prostate cancer patients on anti-androgenic therapy. The investigators found that comorbid conditions increased across obesity classifications (p < 0.001), with significant differences noted in all cohort comparisons except when comparing class I to class II (p = 0.12). Level of Evidence = III. A physician-supervised diet and exercise plan may be indicated in obese patients. 2008;32(1):38-44. padding-right: 18px; Sood R, Mount DL, Coleman JJ 3rd, et al. A total of 15 articles met the inclusion criteria for review. Mistry and associates (2017) examined outcomes following breast re-reduction surgery using a random pattern blood supply to the nipple and vertical scar reduction. For example, if the body surface area is 1.40 m2 , the estimated breast tissue to be removed should at least be 324 grams. Lonie S, Sachs R, Shen A, et al. Prepubertal gynecomastia linked to lavender and tea tree oils. Medical reduction has been achieved with agents such as dihydrotestosterone, danazol, and clomiphene. Clinical Policy Bulletins are developed by Aetna to assist in administering plan benefits and constitute neither offers of coverage nor medical advice. Grade II: Moderate breast enlargement exceeding areola boundaries with edges that are indistinct from the chest. 2006;118(4):840-848. Plast Reconstr Surg. Patients undergoing surgery for gynecomastia should know that their scars may be visible when they are shirtless. Gonzalez FG, Walton RL, Shafer B, et al. 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. Brown MH, Weinberg M, Chong N, et al. 2nd ed. Note: Chronic intertrigo, eczema, dermatitis, and/or ulceration in the infra-mammary fold in and of themselves are not considered medically necessary indications for reduction mammoplasty. ASPS clinical practice guideline summary on reduction mammaplasty. Gynecomastia Treatment through Open Resection and Pectoral High-Definition Liposculpture. Ages ranged from 18 to 66 years. Socioeconomic Committee Position Paper. Links to various non-Aetna sites are provided for your convenience only. A systematic search of the published literature was performed. Nelson et al (2014a) analyzed population data from the 2005-2010 American College of Surgeons National Surgical Quality Improvement Program (NSQIP) database. Reduction mammaplasty in patients with history of breast cancer: The incidence of occult cancer and high-risk lesions. Philadelphia, PA: W.B. } Obstet Gynecol Clin North Am. The risks included infection, wound breakdown, scarring, and the need for re-operating. } An 18-question survey was created evaluating various aspects of BBR practice; UK and Irish plastic and reconstructive and breast surgeons were invited to participate by an e-mail containing a link to a web-based survey. 2001;108(1):62-67. Plast Reconstr Surg. Am Surg. Studies have suggested that 2.4% to 14% of breast reduction cases resulted in major complications and 2.4% . Thus, more than 1/3of operative subjects selected for inclusion in the study did not complete it; most of the operative subjects who did not complete the study were lost to follow-up. I have recently met with my primary doctor after speaking to my insurance company (aetna) for months about getting a breast reduction. 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). 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). OL OL OL OL OL LI { Medical therapy should be aimed at correcting any reversible causes (e.g., drug discontinuance). The investigators found little difference between obese and non-obese women concerning patient's reports of resolution of symptoms and improvement in body image. Kinell I, Baeusang-Linder M, Ohlsen L. The effect on the preoperative symptoms and the late results of Skoog's reduction mammoplasty: A follow-up study on 149 patients. Ann Plast Surg. Breast. Med Decis Making. The nipple-areola complex was re-positioned in 60 % of patients (n = 54). Plast Reconstr Surg. 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., breastsize stable over one year) when any of the following criteria (A, B, or C) is met: Member has persistent symptoms in at leasttwoof the anatomical body areas below, directly attributed to macromastia and affecting daily activities for at least1 year: Member has severe breast hypertrophy, documented by high-quality color frontal-view and side-view photographs;and, Women50 years of age or older are required to have a mammogram that was negative for cancer performed within the twoyears prior to the date of the planned reduction mammoplasty;and. Krieger LM, Lesavoy MA. and areola. Glatt BS, Sarwer DB, O'Hara DE, et al. Causes may include testosterone-estrogen imbalance, increased prolactin levels, or abnormal serum binding protein levels. Analysis was on an intention-to-treat basis. 0017 - Breast Reduction Surgery and Gynecomastia Surgery, are met. PLoS One. Grade III: Moderate breast enlargement exceeding areola boundaries with edges that are indistinct from the chest with skin redundancy present. Beer GM, Kompatscher P, Hergan K. Diagnosis of breast tumors after breast reduction. Kasielska-Trojan A, Danilewicz M, Antoszewski B. A total of 90 patients underwent breast re-reduction surgery. 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). Most UnitedHealthcare plans have a specific exclusion for breast reduction surgery except as required by the . These preliminary findings need to be validated by well-designed studies. 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. Klinefelters syndrome, testicular, adrenal, or pituitary tumors, and thyroid or hepatic dysfunction are also associated with gynecomastia. Aetna has their own sliding scale which requires more from smaller patients relative to the Schnur scale, but maxes out at 1000 gms per breast. 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: Plastic Reconstruct Surg. Tang CL, Brown MH, Levine R, et al. 2016;20(3):256-260. The health burden of breast hypertrophy. Of these, 28.4 % were bilateral gynecomastia and 71.6 % were unilateral. Clinical outcomes were measured by operative subjects' responses to a questionnaire about symptoms and quality of life. display: block; Reduction mammoplasty specimens revealed abnormal findings in 68 (21.5 %) patients. 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. 2018;24(6):1043-1045. The author identified the psychological domains affected by the disease and the effect of surgical treatment on these. American Society of Plastic Surgeons (ASPS). 1993;91(7):1270-1276. This will be computed based on your body area. Plast Reconstr Surg. 2014;20(3):274-278. No new trials were identified for this first update. Often times, insurance company will dictate how much breast tissue to be removed. Breast hypertrophy. Jones SA, Bain JR. Review of data describing outcomes that are used to assess changes in quality of life after reduction mammaplasty. Copyright Aetna Inc. All rights reserved. Well-designed, prospective, controlled clinical studies have not been performed to assess the effectiveness of surgical removal of modest amounts of breast tissue in reducing neck, shoulder, and back pain and related disability in women. 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. These investigators support its use for idiopathic gynecomastia in eligible men following the careful discussion of its risks and benefits. 1996;20(5):391-397. 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 . Gynecomastia may be drug-induced. 2012;130(4):785-789. Patients with abnormal histopathology could not be pre-operatively identified based on demographics. 2006;30(3):309-319. /* aetna.com standards styles for templates */ 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). 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. Mistry RM, MacLennan SE, Hall-Findlay EJ. 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. 2001;76(5):503-510. 2015;49(6):311-318. 2014b;48(5):334-339. Of the responding surgeons, 71.6 % (151/211) routinely inserted post-operative drains, for a mean of 1.32 days. Gynaecomastia. Kerrigan CL, Collins ED, Striplin D, et al. The author average amount of breast tissue removed for women in 5 kg weight bands, ranging from 45-49 kg to 90+ kg. Kerrigan CL, Collins ED, Kim HM, et al. Breast re-reduction surgery was most commonly performed using a random pattern blood supply, rather than recreating the primary pedicle [n = 77 (86 %)]. } The average amount of tissue removed from an average weight woman (within the 70 to 74.9 kg weight band) in this study was 600 g per breast, with a range of 502 g to 700 g of tissue removed per breast. The median complication rate was 12.4 % with no major complications, such as neoplastic, pulmonary, or adverse cardiac outcomes. } Subgroup analysis further stratified the younger cohort into those <50 years and 50-60 years of age. Most cases of type I gynecomastia are unilateral, and 20% of cases are bilateral. Several of the included studies reported improvement in QOL and several psychological domains after surgical treatment for gynecomastia. Reduction mammaplasty: The need for prospective randomized studies. Aesthet Plastic Surg. 1997;100(4):875-883. Measuring health state preferences in women with breast hypertrophy. 2007;36(2):497-519. 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. .strikeThrough { Surgical implications of obesity. Karamanos et al (2015) identified their study as the largest sample on breast reduction in the literature, in which age and surgeon specialty did not correlate with negative results. Photographs were taken pre-operatively and 1, 3, 6, and 12 months post-operatively. Li CC, Fu JP, Chang SC, et al. Karamanos E, Wei B, Siddiqui A, Rubinfeld I. A retrospective review was conducted of patients who underwent bilateral breast re-reduction surgery performed by a single surgeon over a 12-year period. Resolution of idiopathic gynecomastia may take several months to years. Abnormalities in Adolescent Breast Development. Dancey A, Khan M, Dawson J, Peart F. Gigantomastia--a classification and review of the literature. As explained below, 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. Ann Plastic Surg. margin-top: 38px; The following procedures are considered experimental and investigational because there is insufficient evidence of itseffectiveness or itseffectiveness has not been established: Aetna considers breast reduction, surgical mastectomy or liposuction for gynecomastia, either unilateral or bilateral, a cosmetic surgical procedure. Grooving where the bra straps sit on the shoulder.
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