A retrospective review was conducted of patients who underwent bilateral breast re-reduction surgery performed by a single surgeon over a 12-year period. 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. 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. Miller AP, Zacher JB, Berggren RB, et al. #closethis { Collins ED, Kerrigan CL, Kim M, et al. color:#eee; Flancbaum L, Choban PS. Seitchik MW. The majority (87.7 %) of cases presented with accompanying mastalgia. 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]. Two review authors undertook independent data extraction of study characteristics, methodological quality and outcomes (e.g., infection, other wound complications, pain, and length of hospital stay [LOS]). Reduction mammoplasty for macromastia. .strikeThrough { Level of Evidence = IV. 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. } Management of gynecomastia should include evaluation, including laboratory testing, to identify underlying etiologies. Li CC, Fu JP, Chang SC, et al. background-position: right 65%; Plast Reconstr Surg. 2015;49(6):363-366. Gynecomastia in patients with prostate cancer: A systematic review. A population-level analysis of bilateral breast reduction: does age affect early complications? Kasielska-Trojan A, Danilewicz M, Antoszewski B. A retrospective study of changes in physical symptoms and body image after reduction mammaplasty. Beer GM, Kompatscher P, Hergan K. Diagnosis of breast tumors after breast reduction. Grooving where the bra straps sit on the shoulder. 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.. /*margin-bottom: 43px;*/ 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 author listed. 1999;103(1):76-82; discussion 83-85. Long-term functional results after reduction mammoplasty. 1999;103(6):1687-1690. Complications following reduction mammaplasty: A review of 3538 cases from the 2005-2010 NSQIP data sets. Krieger LM, Lesavoy MA. } Studies have suggested that 2.4% to 14% of breast reduction cases resulted in major complications and 2.4% . This study included 35 patients who underwent breast reduction due to the idiopathic form of gynecomastia. Nelson et al (2014a) analyzed population data from the 2005-2010 American College of Surgeons National Surgical Quality Improvement Program (NSQIP) database. 40 . Level of Evidence = IV. For example, if the body surface area is 1.40 m2 , the estimated breast tissue to be removed should at least be 324 grams. Seitchik (1995) reviewed the amount of breast tissue removed from a series of 100 patients that underwent breast reduction surgery. Obesity and complications in breast reduction surgery: Are restrictions justified? Plast Reconstr Surg. The authors concluded that even with the high level of evidence demonstrating the safety of BBR without drains, they are still routinely utilized. Risk factors for complications following breast reduction: Results from a randomized control trial. A total of 90 patients underwent breast re-reduction surgery. 2009;62(2):195-199. Liposuction was also used adjunctively in all cases (average of 455 cc; range, 50 to 1,750 cc). 1969;44(235):291-303. 2007;119(4):1159-1166. 2011;21(5):431-434. Henley DV, Lipson N, Korach KS, Bloch CA. All studies on the subject were evaluated for inclusion and 6 studies were included in the review. 2010;45(3):650-654. Computed tomography scan of adrenal glands to identify adrenal lesions. Bruhlmann Y, Tschopp H. Breast reduction improves symptoms of macromastia and has a long-lasting effect. Plast Reconstr Surg. Safran T, Abi-Rafeh J, Alabdulkarim A, et al. Three review authors undertook independent screening of the search results. 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. 1999;103(6):1674-1681. Nguyen JT, Wheatley MJ, Schnur PL, et al. 2018;89(6):408-412. A non-standardized survey showed a very high satisfaction index. 1995;95(1):77-83. Safran and colleagues (2021) noted that several technologies and innovative approaches continue to emerge for the optimal management of gynecomastia by plastic surgeons. Of 291 subjects who were selected for inclusion in the study, only 179 completed follow-up. In addition, reduction mammoplasty needs to be compared with other established methods of relieving back, neck and shoulder pain. Reduction mammoplasty is among the most commonly performed cosmetic procedures in the United States. 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. 2001;108(6):1591-1599. 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. 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. This may lead to additional scarring and additional operating time. Recommended criteria for insurance coverage of reduction mammoplasty. 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. He and associates (2011) examined the safety and feasibility of vacuum-assisted biopsy device in the treatment of gynecomastia. 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. PLoS One. For many patients the psychological impact of the disease is substantial. Surgical removal is rarely indicated and the vast majority of the time is for cosmetic reasons, as there is no functional impairment associated with this disorder. Aesthet Surg J. The 2 vacuum-assisted breast biopsy systems (Mammotome and Encor) were used for the patients with gynecomastia. Treatment of adolescent gynecomastia. Refer to the member's specific plan document for applicable coverage. } Schnur et al (1991) reported on a sliding scale assigns a weight of breast tissue to be removed based on body weight and surface area. Quality of life after breast reduction. A total of 15 articles met the inclusion criteria for review. J Plast Reconstr Aesthet Surg. Grade IV: Marked breast enlargement with skin redundancy and feminization of the 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. The goal of medically necessary breast reduction surgery is to relieve symptoms of pain and disability. The authors of the BRAVO study reached several conclusions about reduction mammoplasty, most notably that breast size or the amount of breast tissue removed does not have any relationship to the outcome of breast reduction surgery (Kerrigan et al, 2002; Collins et al, 2002). Drains were used significantly less by surgeons performing greater than or equal to 20 BBRs (p = 0.02). 2014b;30(6):641-647. 2015;49(6):311-318. Some individuals, however, have argued that reduction mammoplasty may be indicated in any woman who suffers from back and shoulder pain, regardless of how small her breasts are or how little tissue is to be removed (ASPS, 2002). Little is known about the effect of surgical treatment on the psychological aspects of the disease. Early complications were rare (6.1%), with superficial skin and soft tissue infections accounting for 45.8% of complications. These investigators analyzed the incidence of occult breast cancer and high-risk lesions in reduction mammoplasty specimens of women with previous breast cancer. Following treatment, 90.1 % (n = 73) had a complete response of their gynecomastia with tamoxifen therapy. This Clinical Policy Bulletin addresses breast reduction surgery and gynecomastia surgery. 1998;41(3):240-245. Arch Dis Child. Reduction (or some cases augmentation) mammoplasty and related reconstructive procedures on the unaffected side for symmetry are also considered medically necessary. The authors concluded that vacuum-assisted, minimally invasive mastectomy was a feasible approach for the treatment of gynecomastia with acceptable complications. 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%. list-style-type: lower-alpha; It is universally believed by patients that if a surgery is considered reconstructive, it is medically indicated and covered by health insurance. Most UnitedHealthcare plans have a specific exclusion for breast reduction surgery except as required by the . Plastic Reconstr Surg. Ann Plast Surg. It can cause discomfort and concern, resulting in patients seeking diagnosis and treatment. Ann Plastic Surg. Aetna considers breast reconstructive surgery to correct breast asymmetry cosmetic except for the following conditions: Surgical correction of chest wall deformity causing functional deficit in Poland syndrome when criteria are met in CPB 0272 - Pectus Excavatum and Poland's Syndrome: Surgical Correction; or 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). Coding Plast Reconstr Surg. Impact of surgical treatment for gynecomastia appeared to be beneficial for several psychological domains. list-style-type: decimal; } Management of gestational gigantomastia. 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. 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. Based largely upon these results, Nguyen et al (2004) reached the conclusion that a trial of conservative management is not an appropriate criterion for insurance coverage, even though responses to the BRAVO questionnaire indicated that operative candidates and hypertrophy controls received at least some pain relief from all of the conservative interventions, and for some conservative interventions, virtually all subjects reported at least some pain relief. The operation had a mean duration of 73.5 mins per side, ranging from 40 to 102 mins. 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). Bertin ML, Crowe J, Gordon SM. Ann Plast Surg. Plast Reconstr Surg. color: blue!important; These preliminary findings need to be validated by well-designed studies. Mental health care professionals may be consulted to address psychological distress from gynecomastia. The requirement for coverage is that the amount of breast tissue to be removed has to be enough to improve your symptoms or function. 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:. Aesthetic Plast Surg. Breast J. This may justify an early use of tamoxifen in men with gynecomastia and a high digit ratio. Abnormal histopathology correlated with higher age (p = 0.0053), heavier specimen (p = 0.0491), and with no previous breast surgery (p < 0.001). 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. Most cases of type I gynecomastia are unilateral, and 20% of cases are bilateral. Arlington Heights, IL: ASPS; March 9, 2002. 2015;(10):CD007258. Annu Rev Med. 2002;109(5):1556-1566. Several of the included studies reported improvement in QOL and several psychological domains after surgical treatment for gynecomastia. 2001;108(1):62-67. Aetna does not provide health care services and, therefore, cannot guarantee any results or outcomes. Plast Reconstr Surg. Cambridge, UK: Oxbridge Solutions, Ltd.; 2003. Approximately 25 % of the 49 subjects included in this study did not return the post-operative questionnaire. They have argued that removal of even a few hundred grams of breast tissue can result in substantial pain relief. No data were provided on loss to follow-up. Mistry RM, MacLennan SE, Hall-Findlay EJ. padding: 10px; 1993;91(7):1270-1276. 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. text-decoration: line-through; Reduction mammaplasty: A review of managed care medical policy coverage criteria. 2019;8(4):431-440. Major complications (1.6 %) included unilateral hematoma and localized infection. 1997;100(4):875-883. Thus, this study would not be considered of sufficient quality to provide reliable evidence of the effectiveness of a pain intervention. Grade III: Moderate breast enlargement exceeding areola boundaries with edges that are indistinct from the chest with skin redundancy present. Howrigan P. Reduction and augmentation mammoplasty. } 2001;107(5):1234-1240. background-color: #663399; 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. Breast cancer found at the time of breast reduction. 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). Srinivasaiahet al (2014) stated that although reduction mammoplasty has been shown to benefit physical, physiological, and psycho-social health there are recognized complications. Breast pumps. 1995;95(6):1029-1032. These researchers compared the safety and effectiveness of the use of wound drains following elective plastic and reconstructive surgery procedures of the breast. The investigators found little difference between obese and non-obese women concerning patient's reports of resolution of symptoms and improvement in body image. However, if liposuction is used as an adjunctive technique, the decision to use drains should be left to the surgeon's discretion. Medical reduction has been achieved with agents such as dihydrotestosterone, danazol, and clomiphene. This Clinical Policy Bulletin contains only a partial, general description of plan or program benefits and does not constitute a contract. 2013;71(5):471-475. Aesthet Plastic Surg. Oxfordshire NHS Trust. Statistical analysis was performed with student t-test and chi-square test. The Breast: Comprehensive Management of Benign and Malignant Diseases. They evaluated the use of radiotherapy for the prevention and treatment of gynecomastia incidence or recurrence by plastic surgeons. In: Townsend CM, Beuchamp RD, Evers BM, eds. J Plast Surg Hand Surg. The NSQIP recorded two complication types: major complications (deep infection and return to operating room) and any complication (all surgical complications). Satisfactory chest contour was gained in all cases without any abnormality, skin redundancy, or recurrence during the follow-up of 6 to 48 months. 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). 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. 2012;69(5):510-515. World J Surg. Medical therapy should be aimed at correcting any reversible causes (e.g., drug discontinuance). @media print { 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. Special Clinical Concerns. 1994;21(3):539-543. 2017;35:157-161. Two patients experienced unilateral minor partial necrosis of the areolar edge but not of the nipple itself (2 %). The author identified the psychological domains affected by the disease and the effect of surgical treatment on these. Reduction mammaplasty: The need for prospective randomized studies. Swelstad MR, Swelstad BB, Rao VK, Gutowski KA. Breast asymmetries: A brief review and our experience. hr.separator { Gynecomastia: A systematic review. 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. Level of Evidence = IV. Study appraisal was carried out using MINORS to evaluate the methodological quality of the paper. Surgical management of gynecomastia--a 10-year analysis. 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. Aetna considers associated nipple and areolar reconstruction and tattooing of the nipple area medically necessary. ul.ur li{ They reviewed their records on pectoral high-definition liposculpture between January of 2005 and October of 2019 in 4 surgical centers in Colombia. } Fat grafting to the breast can now be reported with CPT codes 15771 and 15772. Determinants of surgical site infection after breast surgery. A systematic search of the published literature was performed. Measurement of plasma gonadotrophins, human chorionic gonadotropin (hCG), testosterone, estradiol, and dehydroepiandosterone sulphate (DHEAS). 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.

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