Reduction mammaplasty in patients with history of breast cancer: The incidence of occult cancer and high-risk lesions. Determinants of surgical site infection after breast surgery. The investigators reported that subjects who were of normal weight were as likely to report benefit from reduction mammoplasty as subjects who were over-weight. Srinivasaiahet al (2014) stated that although reduction mammoplasty has been shown to benefit physical, physiological, and psycho-social health there are recognized complications. li.bullet { Nelson et al (2014a) analyzed population data from the 2005-2010 American College of Surgeons National Surgical Quality Improvement Program (NSQIP) database. These investigators presented their experience with pectoral high-definition liposculpture combined with inverted-omega incision resection for gynecomastia. ul.ur li{ 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. Women's Health and Cancer Rights Act of 1998. 2007;36(2):497-519. The 2 studies, which discussed laser-assisted liposuction technique, showed minor complication of seroma in 2 patients. #backTop { Data was then analyzed for surgical complications, wound complications, and medical complications within 30 days of surgery on 4545 patients. 2004;113(1):436-437. These studies did not find a relationship between breast weight or amount of breast tissue removed and the likelihood of response or magnitude of relief of pain after reduction mammoplasty. 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. Seitchik MW. Here's what Aetna said in the denial: "We used the Clinical Policy Bulletin (CPB): Breast Reduction Surgery. 2017;35:157-161. @media print { Insurers have commonly used the amount of breast tissue to be removed as a criterion for evaluating the medical necessity of breast reduction surgery. Drugs whose mechanism of action is unknown: Others situations which can cause or lead to gynecomastia: The above policy is based on the following references: Last Review The authors concluded that treatment of gynecomastia by the Mammotome device was distinctive, practicable in manipulation, safe, and could achieve excellent cosmetic results. Raispis T, Zehring RD, Downey DL. 1997;100(4):875-883. 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. Fischer S, Hirsch T, Hirche C, et al. A total of 81 patients were included in this study. Surgical implications of obesity. Hoyos AE, Perez ME, Dominguez-Millan R, et al. This study included 35 patients who underwent breast reduction due to the idiopathic form of gynecomastia. Araco A, Gravante G, Araco F, et al. Yao and co-workers (2019) described an innovative method for the operative treatment of gynecomastia -- vacuum-assisted minimally invasive mastectomy. Sugrue CM, McInerney N, Joyce CW, et al. 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. Risk of bias was assessed independently by 2review authors. A study reporting on a survey of health insurer policies on breast reduction surgery (Nguyen et al, 2004) found that no insurer medical policies could be supported by the medical literature. Statistical analysis was performed with student t-test and chi-square test. .strikeThrough { 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). Vacuum-assisted minimally invasive surgery-An innovative method for the operative treatment of gynecomastia. 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. 1990;24(1):61-67. PLoS One. 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. 1998;49:215-234. Breast Reduction Surgery and Gynecomastia Surgery - Medical Clinical Policy Bulletins | Aetna Page . hr.separator { Kerrigan CL, Collins ED, Kim HM, et al. 2009;19(3):e85-e90. Endocrinol Metab Clin North Am. Aetna considers associated nipple and areolar reconstruction and tattooing of the nipple area medically necessary. 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. Kerrigan CL, Collins ED, Kneeland TS, et al. Br J Plast Surg. border-width:0; .strikeThrough { Last Review01/04/2023. Plastic Reconstr Surg. 2001;108(1):62-67. Choban PS, Heckler R, Burge JC, Flancbaum L. Increased incidence of nosocomial infections in obese surgical patients. Medical reduction has been achieved with agents such as dihydrotestosterone, danazol, and clomiphene. Reduction mammoplasty specimens revealed abnormal findings in 68 (21.5 %) patients. Patients with abnormal histopathology could not be pre-operatively identified based on demographics. The authorsleave the reader with the conclusionthat decisions about the medical necessity of breast reduction surgery in symptomatic women should be left entirely to the surgeon's discretion. A retrospective study of changes in physical symptoms and body image after reduction mammaplasty. Level of Evidence = IV. Gonzalez FG, Walton RL, Shafer B, et al. N Engl J Med. 2006;9(2):109-114. 2006;30(3):309-319. A lack of correlation between these variables may result from the fact that the analyzed group of men with idiopathic gynecomastia was small in number, but at the same time, it appeared to be homogenous in these aspects (positive ER and/or PR expression and high digit ratio). display: none; Early complications were rare (6.1%), with superficial skin and soft tissue infections accounting for 45.8% of complications. #closethis { J Am Coll Surg. top: 0px; OL LI { Reduction mammoplasty has been performed to relieve back and shoulder pain on the theory that reducing breast weight will relieve this pain. In these cases, breast reduction for men may take 2 to 3 hours. 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. In a prospective, cohort study, these investigators evaluated the efficacy of tamoxifen therapy in resolving this condition. Tang CL, Brown MH, Levine R, et al. 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. Gynecomastia in patients with prostate cancer: Update on treatment options. 1998;101(2):361-364. 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. 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. 1999;103(1):76-82; discussion 83-85. Little is known about the effect of surgical treatment on the psychological aspects of the disease. Work-up of gynecomastia may include the following (GP Notebook, 2003): Treatment should be directed at correcting any underlying reversible causes. Plastic surgery for teenagers briefing paper. Ages ranged from 18 to 66 years. Plast Reconstr Surg. It's important to note that CPT 19324 - mammaplasty, augmentation without pros-thetic implant - has been deleted. They evaluated the use of radiotherapy for the prevention and treatment of gynecomastia incidence or recurrence by plastic surgeons. Khan SM, Smeulders MJ, Van der Horst CM. The traditional method of breast reduction requires an open incision around the areola extending downward to the crease beneath the breast. In other patients, excess skin and nipple and areola relocation are necessary. 2011;128(4):243e-249e. This Clinical Policy Bulletin contains only a partial, general description of plan or program benefits and does not constitute a contract. Surgical treatment is indicated when medical treatments fail. 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. Second, it is the burden of the proponent of an intervention to provide reliable evidence of its effectiveness, not the burden of ones whoquestion the effectivenessan intervention to provide definitive proof of ineffectiveness. 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 . Arlington Heights, IL: ASPS; May 2011. 2014b;48(5):334-339. Glatt BS, Sarwer DB, O'Hara DE, et al. Philadelphia, PA: W.B. Gynecomastia: Evolving paradigm of management and comparison of techniques. Breast reduction outcome study. Plast Reconstr Surg. 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. Reduction mammaplasty: A review of managed care medical policy coverage criteria. Grade III: Moderate breast enlargement exceeding areola boundaries with edges that are indistinct from the chest with skin redundancy present. J Pediatr Surg. Wound drainage after plastic and reconstructive surgery of the breast. Following treatment, 90.1 % (n = 73) had a complete response of their gynecomastia with tamoxifen therapy. Reduction mammoplasty improves symptoms of macromastia. 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. 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. A systematic review of patient reported outcome measures for women with macromastia who have undergone breast reduction surgery. Computed tomography scan of adrenal glands to identify adrenal lesions. Quality of life after breast reduction. Breast cancer found at the time of breast reduction. The study consisted of 329 breast cancer patients, who underwent symmetrizing reduction mammoplasty between 1/2007 and 12/2011. Drains were used significantly less by surgeons performing greater than or equal to 20 BBRs (p = 0.02). Covered items may include: A manual or standard electric pump (non-hospital grade) while you are pregnant or for the duration of breastfeeding. They reviewed their records on pectoral high-definition liposculpture between January of 2005 and October of 2019 in 4 surgical centers in Colombia. 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. # font-weight: bold; In a systematic review, these investigators examined the role of radiotherapy in this context. Aesthetic Plast Surg. Collis N, McGuiness CM, Batchelor AG. Transient pain that may occur as the breast enlarges and the capsule is stretched; these symptoms may be managed with analgesics. Aesthetic Plast Surg. Merkkola-von Schantz PA, Jahkola TA, Krogerus LA, Kauhanen SMC. 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. Only 8 (9.9 %) patients did not have a complete resolution following tamoxifen therapy, of which 2 underwent subsequent surgical resection of their symptomatic gynecomastia. From January 2006 to January 2010, a total of 20 men with gynecomastia were treated by an 8-G vacuum-assisted biopsy device. Gynecomastia has been classified into2 types. border: none; 2008;61(5):493-502. Effects of reduction mammaplasty on pulmonary function and symptoms of macromastia. 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. For example, if the body surface area is 1.40 m2 , the estimated breast tissue to be removed should at least be 324 grams. 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. } Administration of Benefits and Transition Responsibilities It is universally believed by patients that if a surgery is considered reconstructive, it is medically indicated and covered by health insurance. Obstet Gynecol Clin North Am. 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). No author listed. The end-point was the complete resolution of gynecomastia. 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). Open surgery was performed in 56 patients, and vacuum-assisted breast biopsy was performed in 27 patients. The vacuum-assisted breast biopsy system is an effective strategy for the treatment of gynecomastia. Well-designed trials are especially important in assessing pain management interventions to isolate the contribution of the intervention from placebo effects, the effects of other concurrently administered pain management interventions, and the natural history of the medical condition. 1998;41(3):240-245. Breast re-reduction surgery was most commonly performed using a random pattern blood supply, rather than recreating the primary pedicle [n = 77 (86 %)]. In the case of reduction mammoplasty for relief of back, neck and shoulder pain, Aetna has considered this procedure medically necessary in women with excessively large breasts because it seems logical, even in the absence of firm clinical trial evidence, that this excessive weight would contribute to back and shoulder pain, and that removal of this excessive breast tissue would provide substantial pain relief, reductions in disability, and improvements in function. Fat grafting volume ranged from 50 to 300 cc in each pectoral muscle. Abnormal histopathology correlated with higher age (p = 0.0053), heavier specimen (p = 0.0491), and with no previous breast surgery (p < 0.001). 2016;20(3):256-260. These preliminary findings need to be validated by well-designed studies. 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. Furthermore, you must test negative for breast cancer on a mammogram a maximum of two years before your surgery if you are 50 or older. Of these 33 operative sides, 2 complications occurred, but satisfactory chest contour was attained in all subjects. Qu and colleagues (2020) examined the effectiveness of vacuum-assisted breast biopsy systems for the treatment of gynecomastia. Townsend: Sabiston Textbook of Surgery. text-decoration: line-through; } 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%. Breast asymmetries: A brief review and our experience. Risk factors for complications following breast reduction: Results from a randomized control trial. 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. Schnur PL, Schnur DP, Petty PM, et al. position: fixed; 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. Aesthet Surg J. Blomqvist L, Eriksson A, Brandberg Y. The effectiveness of surgical and nonsurgical interventions in relieving the symptoms of macromastia. 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. Most cases of type I gynecomastia are unilateral, and 20% of cases are bilateral. Plast Reconstr Surg. OL OL OL OL LI { Health insurance companies frequently have different criteria for whether breast reduction surgery is medically necessary. The authors concluded that the incidences of malignant and high-risk lesions were doubled compared to patients without prior breast cancer. In addition, reduction mammoplasty needs to be compared with other established methods of relieving back, neck and shoulder pain. 2010;125(5):1301-1308. 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. Morbidly obese patients are at the highest risk, with complications occurring in nearly 12% of this cohort. 2010;45(3):650-654. Obesity and complications in breast reduction surgery: Are restrictions justified? } 2018;24(6):1043-1045. Subjects were compared to age-matched norms from another study cohort. Gynecomastia surgery is the surgical correction of over-developed or enlarged breasts in men. J Plast Reconstr Aesthet Surg. 2007;119(4):1159-1166. However, if liposuction is used as an adjunctive technique, the decision to use drains should be left to the surgeon's discretion. Management of gynecomastia should include evaluation, including laboratory testing, to identify underlying etiologies. The authors concluded that high digit ratio in men with gynecomastia may tend to be a marker of over-expression of ER and PR. Safran T, Abi-Rafeh J, Alabdulkarim A, et al. A retrospective review was conducted of patients who underwent bilateral breast re-reduction surgery performed by a single surgeon over a 12-year period. Plastic Reconstruct Surg. Plast Reconstr Surg. The nipple-areola complex was re-positioned in 60 % of patients (n = 54). (25 y/o female with a 38J bra size) according to aetna, I should more than qualify for a reduction as I have back, neck, shoulder pain, chest pain and pressure, arm numbness while laying on sides, etc. ER expression did not correlate with the right (p = 0.51) and left 2D: 4D (p = 0.97). Conversely, many patients believe if a procedure is considered cosmetic, it is not a medically indicated and covered procedure. Abnormalities in Adolescent Breast Development. Aetna considers breast reconstructive surgery to correct The study by Schnur et al was based on a survey of 92 plastic surgeons who reported on their care for 591 patients. Kalliainen LK; ASPS Health Policy Committee. margin-top: 38px; Ann Plast Surg. 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.
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