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2009;19(3):e85-e90. Dancey A, Khan M, Dawson J, Peart F. Gigantomastia--a classification and review of the literature. Swelstad MR, Swelstad BB, Rao VK, Gutowski KA. Abnormal histopathology correlated with higher age (p = 0.0053), heavier specimen (p = 0.0491), and with no previous breast surgery (p < 0.001). Many men with breast enlargement are found to have pseudo-gynecomastia. However, if liposuction is used as an adjunctive technique, the decision to use drains should be left to the surgeon's discretion. 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. position: fixed; 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. J Plast Surg Hand Surg. Srinivasaiah N, Iwuchukwu OC, Stanley PR, et al. Oxfordshire NHS Trust. 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. and areola. .fixedHeaderWrap { padding-right: 18px; 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. Here's what Aetna said in the denial: "We used the Clinical Policy Bulletin (CPB): Breast Reduction Surgery. Patients with abnormal histopathology could not be pre-operatively identified based on demographics. Townsend: Sabiston Textbook of Surgery. Alternatively, you may qualify if your breast size causes significant symptoms, such as: Long-term neck, shoulder or neck pain. Refer to the member's specific plan document for applicable coverage. They stated that no data are available for breast augmentation or breast reconstruction, and this requires investigation. Preoperative patient factors and comorbidities, as well as intraoperative variables, were assessed. Open surgery was performed in 56 patients, and vacuum-assisted breast biopsy was performed in 27 patients. 18th ed. Criteria for reduction mammoplasty surgery from the American Society of Plastic Surgeons (ASPS, 2002; ASPS, 2011) states, among other things, that breast weight or breast volume is not a legitimate criterion upon which to distinguish cosmetic from functional indications. Note: For breast surgeries pertaining to gender affirmation, refer to CP.MP.95 Gender Affirming Procedures. 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. The condition not only must be unresponsive to dermatological treatments (e.g., antibiotics or antifungal therapy) and conservative measures (e.g., good skin hygiene, adequate nutrition) for a period of 6 months or longer, but also must satisfy criteria stated insection I above. Plast Reconstr Surg. Often, you'll be eligible for Blue Cross Blue Shield breast reduction coverage if your surgeon plans to remove at least 500 grams of breast tissue per breast. Aetna does not provide health care services and, therefore, cannot guarantee any results or outcomes. Med Decis Making. Gynecomastia, its etiologies and its surgical management: A difference between the bilateral and unilateral cases? The author average amount of breast tissue removed for women in 5 kg weight bands, ranging from 45-49 kg to 90+ kg. background-color: #cc0066; Burdette TE, Kerrigan CL, Homa KA. #backTop { Nguyen JT, Wheatley MJ, Schnur PL, et al. Conversely, many patients believe if a procedure is considered cosmetic, it is not a medically indicated and covered procedure. Reduction mammoplasty: Cosmetic or reconstructive procedure? Oxford, UK: National Health Service (NHS); October 2008. color: blue 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. 2014a;34(1):66-73. Principles of breast re-reduction: A reappraisal. Managed care's methods for determining coverage of plastic surgery procedures: The example of reduction mammaplasty. Cochrane Database Syst Rev. I have recently met with my primary doctor after speaking to my insurance company (aetna) for months about getting a breast reduction. Although the BRAVO study nominally included a "control group", there was no comparison group of subjects selected from the same cohort, who were randomized or otherwise appropriately assigned to reduce bias, and treated with conservative management according to a protocol to ensure optimal conservative care. 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. 2015;10(8):e0136094. In: Townsend CM, Beuchamp RD, Evers BM, eds. 2009;7(2):114-119. 2016;20(3):256-260. For example, at a body surface area of 1.5m, Aetna requires a minimum weight of 385 grams removed from each breast, whereas the Schnur scale would only require 260g. Am J Infect Control. Ann Chir Plast Esthet. However, these medications should be reserved for those with no decrease in breast size after 2 years. 2000;45(6):575-580. Breast reduction surgery, also known as reduction mammaplasty, removes fat, breast tissue and skin from the breasts. Gynecomastia in patients with prostate cancer: A systematic review. Philadelphia, PA: WB Saunders Company; 2008; Ch 73. 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. Women's Health and Cancer Rights Act of 1998. The surgeon must also certify that a certain weight of breast tissue (based on Aetna's table) will be removed in every breast, and not entirely fatty tissue. Washington, DC: ACOG; 2011:121-122. After these researchers 1st report of pectoral etching in 2012, patients and surgeons became more aware regarding gynecomastia resection when performing pectoral enhancement. Safran T, Abi-Rafeh J, Alabdulkarim A, et al. 2005;55(3):227-231. Of the responding surgeons, 71.6 % (151/211) routinely inserted post-operative drains, for a mean of 1.32 days. Reduction mammoplasty specimens revealed abnormal findings in 68 (21.5 %) patients. Leclere FM, Spies M, Gohritz A, Vogt PM. The authors concluded that high digit ratio in men with gynecomastia may tend to be a marker of over-expression of ER and PR. Fan L, Yang X, Zhang Y, Jiang J. Endoscopic subcutaneous mastectomy for the treatment of gynecomastia: A report of 65 cases. Plastic Reconstruct Surg. list-style-type: lower-alpha; Anesthesia may be injected along with saline solution until the tissue is firm, and a suction cannula is used to extract fat from the breast. Vacuum-assisted minimally invasive surgery was carried out under general anesthesia; subjects were followed-up with physical examination and ultrasonography (US). The nipple-areola complex was re-positioned in 60 % of patients (n = 54). Reduction mammaplasty: Defining medical necessity. Studies have suggested that 2.4% to 14% of breast reduction cases resulted in major complications and 2.4% . 2008;53(3):255-261. All patients underwent routine investigations to exclude secondary causes of gynecomastia. Note: Breast reduction surgery will be considered medically necessary for women meeting the symptomatic criteria specified above, regardless of BSA, with more than 1 kg of breast tissue to be removed per breast. 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. Insurers have commonly used the amount of breast tissue to be removed as a criterion for evaluating the medical necessity of breast reduction surgery. Reduction mammoplasty for asymptomatic members is considered cosmetic. Br J Plast Surg. @media print { Until now, most published research on the subject has focused on how effective surgical treatment is on correcting the cosmetic appearance of the breast. A cohort study of breast cancer risk in breast reduction patients. Copyright Aetna Inc. All rights reserved. Aetna considers breast reconstructive surgery to correct 2011;21(5):431-434. Henley DV, Lipson N, Korach KS, Bloch CA. Plast Reconstr Surg. (This refers to actual breast tissue only; any fatty tissue removed doesn't count.) Redundant skin was observed in 1 patient at 1 month post-operatively, whose breast, defined as grade-III, was the largest before operation. Nor is it intuitively obvious that removal of smaller amounts of breast tissue would offer significant relief of back, shoulder or neck pain. 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:. Is there a rationale behind pharmacotherapy in idiopathic gynecomastia? Aetna considers molecular susceptibility testing for breast and/or epithelial ovarian cancer ("BRCA testing") medically necessary once per lifetime in any of the following categories of high-risk adults with breast or epithelial ovarian cancer (adapted from guidelines from the U.S. Preventive Services Task Force (for 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). right: 30px; They reviewed their records on pectoral high-definition liposculpture between January of 2005 and October of 2019 in 4 surgical centers in Colombia. These individuals cite evidence from observational studies to support this position (e.g., Chadbourne et al, 2001; Kerrigan et al, 2001). Of these 33 operative sides, 2 complications occurred, but satisfactory chest contour was attained in all subjects. 2008;121(4):1092-1100. Subjects responses were compared to an age-matched comparison group of women, although no further details about how this comparison group were provided. background: #5e9732; Special Clinical Concerns. Surg Laparosc Endosc Percutan Tech. Breast reduction surgery is considered cosmetic for all indications not listed in section I, A. color: blue!important; If breast growth has been completed, breast reduction surgery is an option. Marshall and Tanner (1969)shows that the final stage of breast maturityoccurs about age 15 on average, but there is wide variation. 1999;103(6):1674-1681. 2007;356(5):479-485. Plast Reconstr Surg. Moreover, these researchers stated that further studies are needed within the common gynecomastia population managed by plastic surgeons to examine the clinical and economical utility of this intervention before a recommendation for its ubiquitous adoption in plastic surgery can be made to continue improving outcomes for high-risk gynecomastia patients. With the majority of BBRs performed as an inpatient procedure, there was a trend towards less drain usage in surgeons performing this procedure as an out-patient; however, this was not statistically significant (p = 0.07). margin-bottom: 38px; background-color: #663399; Ann Plast Surg. Gynecomastia in patients with prostate cancer: Update on treatment options. 2006;118(4):840-848. The 2 studies, which discussed laser-assisted liposuction technique, showed minor complication of seroma in 2 patients. There are alsoseveral earlier, smaller studies that found reductions in symptoms and improvements in quality of life after reduction mammoplasty (Glatt et al, 1999; Bruhlmannand Tschopp, 1998; Blomqvist et al, 2000; and Behmand et al, 2000). Patients in vacuum-assisted breast biopsy group had a better cosmetic outcome than those in open surgery group. Surgical treatment is indicated when medical treatments fail. # color: white; list-style-type : square !important; The following factors were independently associated with any surgical complications: morbid obesity (odds ratio [OR], 2.1; P < .001), active smoking (OR, 1.7; P < .001), history of dyspnea (OR, 2.0; P < .001), and resident participation (OR, 1.8; P = .01) while factors associated with major complications included active smoking (OR, 2.7; P < .001), dyspnea (OR, 2.6; P < .001), resident participation (OR, 2.1; P < .001), and inpatient surgery (OR, 1.8; P = .01). Because of their inherently subjective nature, pain symptoms are especially prone to placebo effects. 1998;41(3):240-245. The 2 vacuum-assisted breast biopsy systems (Mammotome and Encor) were used for the patients with gynecomastia. breast augmentation with implant. The mean incidence of gynecomastia was 70 % in the high-risk population examined representing prostate cancer patients on estrogen or anti-androgen therapy. Evidence-based clinical practice guideline: Reduction mammaplasty. This conclusion is based primarily upon the Breast Reduction Assessment of Value and Outcomes (BRAVO) study, which is described in several articles (Kerrigan et al, 2001; Kerrigan et al, 2002; Collins et al, 2002). /*margin-bottom: 43px;*/ Bland KI, Copeland EM, eds. 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. Plastic Reconstruct Surg. Radiotherapy was shown to significantly reduce the incidence to a median of 23 %, with all 6 RCTs assessed demonstrating a statistically significant decrease in incidence following radiotherapy prophylaxis. of . 2005;58(3):286-289. Post-operative complications included 1 case of hematoma, but no nipple necrosis, local skin necrosis, or skin buttonhole occurred. This was further isolated when comparing morbidly obese patients to non-obese (p < 0.001), class I (p < 0.001), and class II (p = 0.01) patients. Ann Plastic Surg. Aesthet Surg J. J Am Coll Surg. These investigators analyzed the incidence of occult breast cancer and high-risk lesions in reduction mammoplasty specimens of women with previous breast cancer. Ann Plast Surg. Please check your insurance policy to see whether breast reduction is a covered procedure. Removing the adipose tissue in pseudogynecomastia usually has no long term effect as adipose tissue reaccumulates unless the individual loses weight. The authors concluded that low-dose radiotherapy to the male breast might be a safe and effective strategy to prevent gynecomastia incidence or recurrence in high-risk patients. Plast Reconstr Surg. } Measuring health state preferences in women with breast hypertrophy. .arrowPurpleSmall, a:hover.arrowPurpleSmall { Treating providers are solely responsible for medical advice and treatment of members. The characteristics of patients as well as the curative effects between the 2 groups were analyzed. Breast cancer found at the time of breast reduction. Patients undergoing surgery for gynecomastia should know that their scars may be visible when they are shirtless. In a liposuction-only reduction mammoplasty, a small access incision is made in one of the following locations: axillary (under the arm), periareolar (around the nipple) or in the inframammary fold (under the breast). American College of Obstetricians and Gynecologists (ACOG), Committee on Adolescent Health Care. 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. Breast reduction surgery is considered cosmetic and not medically necessary for the following conditions: poor posture, breast asymmetry, pendulousness, problems with clothes fitting properly and nipple-areola distortion. Tang CL, Brown MH, Levine R, et al. Endocrinol Metab Clin North Am. 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 . In a systematic review, Prasetyono and colleagues (2021) examined the quality of studies and re-visited liposuction-assisted gynecomastia surgery performed via minimal incision. In other patients, excess skin and nipple and areola relocation are necessary. Clinical outcomes in reduction mammaplasty: A systemic review and meta-analysis of published studies. border: none; They concluded that higher resection weight, increased BMI, older age, and smoking are risk factors for complication and that patients should therefore be adequately counseled about losing weight and stopping smoking. 2019;8(4):431-440. The average interval between primary and secondary surgery was 14 years (range of 0 to 42 years). Plast Reconstr Surg. border-radius: 4px; Fagerlund A, Cormio L, Palangi L, et al. li.bullet { Burns JL, Blackwell SJ. Recommended criteria for insurance coverage of reduction mammoplasty. Clinical outcomes were measured by operative subjects' responses to a questionnaire about symptoms and quality of life. Aesthetic Plast Surg. J Plast Surg Hand Surg. 2014b;30(6):641-647. Major complications (1.6 %) included unilateral hematoma and localized infection. } } 2015;75(4):370-375. Key takeaways: Health insurance does not cover cosmetic breast reduction, but it usually does cover breast reduction surgery that is considered medically necessary. The American Society for Plastic Surgery (2011) advises to delay surgery until breast growth ceases: Although waiting may prolong the psychological awkwardness, it is advisable to delay surgery until breast growth ceases in order to achieve the best result. This is similar tothe American College of Obstetricians and Gynaecologists'2011 Guidelines forAdolescent Health Care chapter on breast concerns in adolescents, which states regarding breast hypertrophy: Preferably, treatment should be deferred until breast growth has been completed. This Clinical Policy Bulletin addresses breast reduction surgery and gynecomastia surgery. 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. Prepubertal gynecomastia linked to lavender and tea tree oils. The authors stated that operative subjects were told that their responses to the questionnaire were not to be used for insurance and thus the subjects had no motivation to exaggerate symptoms prior to surgery in questionnaire responses; however, it is not clear whether operative subjects would be willing to submit responses to a questionnaire from the doctor that differed substantially from the history that they provided to the doctor during their preoperative evaluation.