Reduction mammaplasty: The need for prospective randomized studies. In other patients, excess skin and nipple and areola relocation are necessary. The operation was successfully performed in all 20 patients with a mean operating time of 51 mins and a hospital stay of 4 days. 1995;34(2):113-116. A detailed physical examination, including testicular examination. } } Chadbourne EB, Zhang S, Gordon MJ, et al. Ann Plast Surg. text-decoration: line-through; Sugrue CM, McInerney N, Joyce CW, et al. The study subjects were stratified into groups based on ages of <60 years and 60 years. 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. World J Surg. The surgeon estimates that at least the following amounts (in grams) of breast tissue, not fatty tissue, will be removed from each breast, based on the member's body surface area (BSA) calculated using theMosteller formula. Also, there was no correlation between PR expression and 2D: 4D. margin-bottom: 38px; 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. 1993;91(7):1270-1276. The end-point was the complete resolution of gynecomastia. 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). Setala L, Papp A, Joukainen S, et al. The majority of patients had previously undergone primary breast reduction using an inferior pedicle [n = 37 (41 %)]. The operation had a mean duration of 73.5 mins per side, ranging from 40 to 102 mins. Safran T, Abi-Rafeh J, Alabdulkarim A, et al. Completely autologous platelet gel in breast reduction surgery: A blinded, randomized, controlled trial. 1. 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. Although the BRAVO study is described as a controlled study, the "control" group is obtained, not from the same cohort, but from a separate cohort of individuals recruited from newspaper advertisements and solicitations at meetings for inclusion in a study of the population burden of breast hypertrophy; 75 % of this control group were obtained from2 centers, but the characteristics of those2 centers were not described. From January 2006 to January 2010, a total of 20 men with gynecomastia were treated by an 8-G vacuum-assisted biopsy device. Breast hypertrophy. However, the measuring method of satisfaction rate varied, resulting in difficulties to interpret the results. Plast Reconstr Surg. Cambridge, UK: Oxbridge Solutions, Ltd.; 2003. Managed care's methods for determining coverage of plastic surgery procedures: The example of reduction mammaplasty. Brown DM, Young VL. border-radius: 4px; While 1 study showed high patient's satisfaction rate; both studies indicated high surgeon's satisfaction rate. Med Decis Making. Morbidly obese patients are at the highest risk, with complications occurring in nearly 12% of this cohort. Breast reduction surgery is considered reconstructive and medically necessary in certain circumstances . Sollie M. Management of gynecomastia-changes in psychological aspects after surgery-a systematic review. and areola. 2021 Aug 11 [Online ahead of print]. Cochrane Database Syst Rev. PDF Breast Reduction Surgery - Commercial Medical Policy - UHCprovider.com Bruhlmann Y, Tschopp H. Breast reduction improves symptoms of macromastia and has a long-lasting effect. Marshall WA, Tanner JM. In a prospective, cohort study, these investigators evaluated the efficacy of tamoxifen therapy in resolving this condition. text-decoration: underline; 2019;166(5):934-939. } Pediatr Surg Int. A total of 211 responding surgeons were analyzed, including 80.1 % (171/211) plastic surgeons and 18.9 % (40/211) breast surgeons. 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. 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). N Engl J Med. Variations in pattern of pubertal changes in girls. 2008;121(4):1092-1100. 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. Asian J Surg. The authors concluded that this study was the largest to-date examining the role of tamoxifen in idiopathic gynecomastia, and these findings showed approximately 9 in every 10 men treated with tamoxifen therapy had successful resolution of their symptoms. 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. All subjects were satisfied with their cosmetic outcome, graded as excellent by 22 patients (100 %). Tang CL, Brown MH, Levine R, et al. He Q, Zheng L, Zhuang D, et al. Of the responding surgeons, 71.6 % (151/211) routinely inserted post-operative drains, for a mean of 1.32 days. Flancbaum L, Choban PS. Liposuction was also used adjunctively in all cases (average of 455 cc; range, 50 to 1,750 cc). Kerrigan CL, Collins ED, Kim HM, et al. Gynecomastia may be drug-induced. Wound drainage after plastic and reconstructive surgery of the breast. Does Aetna Cover Breast Reduction? | HelpAdvisor.com Ann Plast Surg. of . Breast Reduction Surgery | Johns Hopkins Medicine 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. Other just require 500 grams no matter what your height and weight. For many patients the psychological impact of the disease is substantial. 2001;76(5):503-510. Because of their inherently subjective nature, pain symptoms are especially prone to placebo effects. The authors concluded that treatment of gynecomastia by the Mammotome device was distinctive, practicable in manipulation, safe, and could achieve excellent cosmetic results. } 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. display: block; 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. Gynecomastia has been classified into2 types. 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). 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. This trial included all male patients who presented to the authors breast clinic who were diagnosed with primary gynecomastia, and were treated with a trial of tamoxifen 10 mg daily therapy, over a 10-year period from October 2004 to October 2015. 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. Patients in vacuum-assisted breast biopsy group had a better cosmetic outcome than those in open surgery group. Breast Reduction | American Society of Plastic Surgeons ol.numberedList LI { 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. Clinical Policy Bulletins are developed by Aetna to assist in administering plan benefits and constitute neither offers of coverage nor medical advice. Work-up of gynecomastia may include the following (GP Notebook, 2003): Treatment should be directed at correcting any underlying reversible causes. Two patients experienced unilateral minor partial necrosis of the areolar edge but not of the nipple itself (2 %). And if you are in Canada the surgeon decides. OL OL OL OL LI { The requirement for coverage is that the amount of breast tissue to be removed has to be enough to improve your symptoms or function. For individuals who received radiation treatment to the chest . Harmonic scalpel versus electrocautery in breast reduction surgery: A randomized controlled trial. Clinical outcomes in reduction mammaplasty: A systemic review and meta-analysis of published studies. The NSQIP recorded two complication types: major complications (deep infection and return to operating room) and any complication (all surgical complications). Aesthetic Plast Surg. 40 . 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. In addition, Nguyen et al (2004) ignored a wealth of published evidence of the effectiveness of physical therapy, analgesics and other conservative measures on back and neck pain generally. # color: white; Mistry and associates (2017) examined outcomes following breast re-reduction surgery using a random pattern blood supply to the nipple and vertical scar reduction. 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. They stated that no data are available for breast augmentation or breast reconstruction, and this requires investigation. 2018;24(6):1043-1045. 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. Fat grafting volume ranged from 50 to 300 cc in each pectoral muscle. The study by Schnur et al was based on a survey of 92 plastic surgeons who reported on their care for 591 patients. Tang CL, Brown MH, Levine R, et al. Schnur PL, Hoehn JG, Ilstrup DM, et al. Plast Reconstr Surg. Doses examined ranged from 8 to 16 Gy, delivered between 1 and 11 fractions. There were only 2 studies of a total 25 patients that were considered as good in quality. Breast reconstruction/breast enlargement Breast reduction/mammoplasty Excision of excessive skin due to weight loss Gastroplasty/gastric bypass Emiroglu M, Salimoglu S, Karaali C, et al. 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. } Gynecomastia: Evolving paradigm of management and comparison of techniques. Transient pain that may occur as the breast enlarges and the capsule is stretched; these symptoms may be managed with analgesics. 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. Aetna's Itty Bitty Titty Committee - by Libby Watson - Sick Note You must be at least 18 years old or show completed breast growth (no change in breast size over at least a year) to qualify for Aetna breast reduction coverage. 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). Burdette TE, Kerrigan CL, Homa KA. American Society of Plastic Surgeons (ASPS). 1998;101(2):361-364. 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. 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. Removing the adipose tissue in pseudogynecomastia usually has no long term effect as adipose tissue reaccumulates unless the individual loses weight. There were 18 out of 415 studies eligible to review. 2 . Burns JL, Blackwell SJ. Hello! 2018;89(6):408-412. Links to various non-Aetna sites are provided for your convenience only. list-style-type : square !important; This study included 35 patients who underwent breast reduction due to the idiopathic form of gynecomastia. The authors concluded that high digit ratio in men with gynecomastia may tend to be a marker of over-expression of ER and PR. Karamanos E, Wei B, Siddiqui A, Rubinfeld I. Sabistons Textbook of Surgery (Burns & Blackwell, 2008)states that breast size should be stable for one year: There is no set lower age limit but, for the adolescent with breast hypertrophy, reduction is deferred until the breasts have stopped growing and are stable in size for at least 12 months before surgery.. Khan SM, Smeulders MJ, Van der Horst CM. The risks included infection, wound breakdown, scarring, and the need for re-operating. Of these 33 operative sides, 2 complications occurred, but satisfactory chest contour was attained in all subjects. Vacuum-assisted minimally invasive surgery was carried out under general anesthesia; subjects were followed-up with physical examination and ultrasonography (US). This may justify an early use of tamoxifen in men with gynecomastia and a high digit ratio. Policy Statement 6d: Aesthetic surgery procedures. Yao Y, Yang Y, Liu J, et al. Reduction mammaplasty: An outcome study. 1995;95(1):77-83. Surgeon. 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 . 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). The health burden of breast hypertrophy. 1996;20(5):391-397. 2005;55(3):227-231. Does Blue Cross Blue Shield Cover Breast Reduction Surgery? - HelpAdvisor These investigators searched the literature on the treatment of Simon's grade I and II gynecomastia in PubMed, Scopus, Science Direct, and Cochrane using keywords "gynecomastia" and "liposuction". Determinants of surgical site infection after breast surgery. A cohort study of breast cancer risk in breast reduction patients. 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. Inclusion criteria were as follows: men diagnosed with gynecomastia and BMI of less than or equal to 32 kg/m2, adequate skin elasticity, and general good health. They have argued that removal of even a few hundred grams of breast tissue can result in substantial pain relief. The study consisted of 329 breast cancer patients, who underwent symmetrizing reduction mammoplasty between 1/2007 and 12/2011. In the case of breast reduction, however, for insurance purposes, it . Open surgery was performed in 56 patients, and vacuum-assisted breast biopsy was performed in 27 patients. This Clinical Policy Bulletin addresses breast reduction surgery and gynecomastia surgery. Lonie S, Sachs R, Shen A, et al. American College of Obstetricians and Gynecologists (ACOG), Committee on Adolescent Health Care. 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). } 2008;61(5):493-502. 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. Reduction mammoplasty has also been used for relief of pain in the back, neck and shoulders. Plastic Reconstr Surg. Current practice patterns of drain usage amongst UK and Irish surgeons performing bilateral breast reductions: Evidence down the drain. border: none; 1997;185(6):593-603. 2001;108(1):62-67. J Plast Surg Hand Surg. 2021;74(11):3128-3140. Mistry RM, MacLennan SE, Hall-Findlay EJ. 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. Narula HS, Carlson HE. Of 110 subjects who were mailed questionnaires, approximately50 %(61 subjects) provided responses. No data were provided on loss to follow-up. 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. A follow-up study of 105 women with breast cancer following reduction mammaplasty. 2014b;30(6):641-647. Choban PS, Heckler R, Burge JC, Flancbaum L. Increased incidence of nosocomial infections in obese surgical patients. A total of 81 patients were included in this study.
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