} Quality of life after breast reduction. All RCTs that compared the use of a wound drain with no wound drain following plastic and reconstructive surgery of the breast (breast augmentation, breast reduction and breast reconstruction) in women were eligible. Miller AP, Zacher JB, Berggren RB, et al. However, it is unclear if there is any evidence to support this practice. 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 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 Other just require 500 grams no matter what your height and weight. Treatment of adolescent gynecomastia. Surgical management of gynecomastia--a 10-year analysis. 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. 2021;74(11):3128-3140. skin should not be excised horizontally below the inframammary fold. Of these 33 operative sides, 2 complications occurred, but satisfactory chest contour was attained in all subjects. } 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). The majority (87.7 %) of cases presented with accompanying mastalgia. 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. 2015;10(8):e0136094. Patients undergoing surgery for gynecomastia should know that their scars may be visible when they are shirtless. The authors also noted that patients with BMI greater than 40 kg/m were significantly more likely to develop postoperative wound complications (p = 0.02). Laituri CA, Garey CL, Ostlie DJ, et al. Current practice patterns of drain usage amongst UK and Irish surgeons performing bilateral breast reductions: Evidence down the drain. Thus, this study would not be considered of sufficient quality to provide reliable evidence of the effectiveness of a pain intervention. 2017;139(6):1313-1322. 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. Data was then analyzed for surgical complications, wound complications, and medical complications within 30 days of surgery on 4545 patients. 1. A study by Bruhlmann and Tschopp (1998) was a retrospective study of 246 patients from a surgical practice, approximately 50 % (132) of whom returned a questionnaire about their symptoms and satisfaction with aesthetic results, and their recollection of symptoms prior to surgery. Plast Reconstr Surg. 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. 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. 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. First, the opinions and guidelines of medical professional organizations and consensus groups are considered according to the quality of the scientific evidence and supporting rationale. In addition, reduction mammoplasty needs to be compared with other established methods of relieving back, neck and shoulder pain. It should be noted that this study reported a strong correlation between the amount of tissue removed and pain amelioration. No data were provided on loss to follow-up. Note: For breast surgeries pertaining to gender affirmation, refer to CP.MP.95 Gender Affirming Procedures. .newText { 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). Li CC, Fu JP, Chang SC, et al. Burns JL, Blackwell SJ. Surg Laparosc Endosc Percutan Tech. For individuals who received radiation treatment to the chest . Medical reduction has been achieved with agents such as dihydrotestosterone, danazol, and clomiphene. 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. Jansen DA, Murphy M, Kind GM, Sands K. Breast cancer in reduction mammoplasty: Case reports and a survey of plastic surgeons. Reduction mammoplasty specimens revealed abnormal findings in 68 (21.5 %) patients. Arlington Heights, IL: ASPS; 2011. 2013;71(5):471-475. 1991;27(3):232-237. 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). 2018;7(Suppl 1):S70-S76. Effects of reduction mammaplasty on pulmonary function and symptoms of macromastia. 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. All patients underwent routine investigations to exclude secondary causes of gynecomastia. Little is known about the effect of surgical treatment on the psychological aspects of the disease. American Society of Plastic Surgeons (ASPS). 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. Sugrue and associates (2015) evaluated the current practice patterns of drains usage by plastic and reconstructive and breast surgeons in United kingdom (UK) and Ireland performing bilateral breast reduction (BBR). Recommended criteria for insurance coverage of reduction mammoplasty. Aesthetic Plast Surg. The 2 vacuum-assisted breast biopsy systems (Mammotome and Encor) were used for the patients with gynecomastia. text-decoration: underline; Merkkola-von Schantz and colleagues (2017) stated that contralateral reduction mammoplasty is regularly included in the treatment of breast cancer patients. Reduction mammaplasty: The need for prospective randomized studies. When seeking preauthorization for a breast reduction, your goal is generally twofold. @media print { J Pediatr Surg. Qu S, Zhang W, Li S, et al. Lonie S, Sachs R, Shen A, et al. Fischer et al (2014a) evaluated predictors of postoperative complications following reduction mammoplasty using the NSQIP) data sets. OL OL OL OL OL LI { Bertin ML, Crowe J, Gordon SM. 2020 Sep 4 [Online ahead of print]. 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:. With approval from the authors institutional ethics committee and written informed consent, a total of 22 patients with 33 abnormally hyperplastic breasts were enrolled at the First Affiliated Hospital with Nanjing Medical University between June 2016 and September 2018. The study by Schnur et al was based on a survey of 92 plastic surgeons who reported on their care for 591 patients. While 1 study showed high patient's satisfaction rate; both studies indicated high surgeon's satisfaction rate. Preoperative patient factors and comorbidities, as well as intraoperative variables, were assessed. 2015;75(4):370-375. Open surgery was performed in 56 patients, and vacuum-assisted breast biopsy was performed in 27 patients. Grade II: Moderate breast enlargement exceeding areola boundaries with edges that are indistinct from the chest. A follow-up study of 105 women with breast cancer following reduction mammaplasty. background: url('https://www.aetna.com/cpb/medical/data/assets/images/purplearrow.jpg') no-repeat; J Plast Surg Hand Surg. Obstet Gynecol Clin North Am. The author identified the psychological domains affected by the disease and the effect of surgical treatment on these. Of these, 28.4 % were bilateral gynecomastia and 71.6 % were unilateral. Of the responding surgeons, 71.6 % (151/211) routinely inserted post-operative drains, for a mean of 1.32 days. color: red!important; All the patients recovered well and were satisfied with the cosmetic outcomes. 2003;111(2):688-694. Plastic Reconstruct Surg. Yao and co-workers (2019) described an innovative method for the operative treatment of gynecomastia -- vacuum-assisted minimally invasive mastectomy. The study subjects were stratified into groups based on ages of <60 years and 60 years. Examining any complication, a significant increase was noted with increasing obesity class (p < 0.001). Sollie M. Management of gynecomastia-changes in psychological aspects after surgery-a systematic review. (This refers to actual breast tissue only; any fatty tissue removed doesn't count.) 18th ed. Approximately 25 % of the 49 subjects included in this study did not return the post-operative questionnaire. Asian J Surg. Ann Plast Surg. 2015;49(6):363-366. Measurement of plasma gonadotrophins, human chorionic gonadotropin (hCG), testosterone, estradiol, and dehydroepiandosterone sulphate (DHEAS). display: block; 2015;75(4):383-387. Study appraisal was carried out using MINORS to evaluate the methodological quality of the paper. This will be computed based on your body area. Morbidly obese patients are at the highest risk, with complications occurring in nearly 12% of this cohort. 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. Fat grafting volume ranged from 50 to 300 cc in each pectoral muscle. 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. Analysis was on an intention-to-treat basis. The author average amount of breast tissue removed for women in 5 kg weight bands, ranging from 45-49 kg to 90+ kg. For example, if the body surface area is 1.40 m2 , the estimated breast tissue to be removed should at least be 324 grams. 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. Cochrane Database Syst Rev. Hermans, BJ, Boeckx, WD, De Lorenzi, F, Vand der Hulst, RR. Breast hypertrophy. right: 30px; 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. Plast Reconstr Surg. Arch Dis Child. } Because reduction mammoplasty may be used for both medically necessary and cosmetic indications, Aetna has set forth above objective criteria to distinguish medically necessary reduction mammoplasty from cosmetic reduction mammoplasty. Burdette TE, Kerrigan CL, Homa KA. Klinefelters syndrome, testicular, adrenal, or pituitary tumors, and thyroid or hepatic dysfunction are also associated with gynecomastia. Marshall WA, Tanner JM. Is there a rationale behind pharmacotherapy in idiopathic gynecomastia? There were no restrictions on the basis of date or language of publication. 2009;7(2):114-119. From January 2006 to January 2010, a total of 20 men with gynecomastia were treated by an 8-G vacuum-assisted biopsy device. An average of 320 specimens were excised from each side with mean blood loss of 34 ml. Please check your insurance policy to see whether breast reduction is a covered procedure. Estrogens and estrogen like drugs,including: Drugsthat enhance estrogen formation, including: Drugs which inhibit testosterone synthesis, including, Drugs that inhibit testosterone action, including. 2019;8(4):431-440. 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. Re-operation rate of liposuction-assisted surgery was between 0.6 % and 25 %. 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. J Plast Reconstr Aesthet Surg. A total of 90 patients underwent breast re-reduction surgery. Gynecomastia resection plus high-definition liposculpture was successfully performed in 436 consecutive men (open inverted-omega incision resection, n = 132; liposuction, n = 304). A physician-supervised diet and exercise plan may be indicated in obese patients. Plast Reconstr Surg. padding-bottom: 4px; OL LI { 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. The health burden of breast hypertrophy. The vacuum-assisted breast biopsy system is an effective strategy for the treatment of gynecomastia. Wound drainage after plastic and reconstructive surgery of the breast. 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. Krieger LM, Lesavoy MA. No author listed. Nor is it intuitively obvious that removal of smaller amounts of breast tissue would offer significant relief of back, shoulder or neck pain. border: none; Conversely, many patients believe if a procedure is considered cosmetic, it is not a medically indicated and covered procedure. Breast reduction surgery might also help improve self-image and the ability to take part in physical activities. 2010;45(3):650-654. He and associates (2011) examined the safety and feasibility of vacuum-assisted biopsy device in the treatment of gynecomastia. No other operation-related complications were observed. 2009;62(2):195-199. Blomqvist L, Eriksson A, Brandberg Y. Schnur PL, Schnur DP, Petty PM, et al. border-radius: 4px; 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. 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. See Appendix for Table 1. 2002;33:208-217. 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. In a survey of managed care policies regarding breast reduction surgery, Krieger and colleagues reported (2001)found that mostof the respondentsstated that they use weight of excised tissue as the main criterion for allowing the procedure, with anaverage cut-off value of 472 grams for a typicalwoman. } Gynecomastia is a very common concern of male adolescence. They stated that no data are available for breast augmentation or breast reconstruction, and this requires investigation. Horm Res Paediatr. They also analyzed if timing of reduction mammoplasty in relation to oncological treatment influenced the incidence of abnormal findings, and compared if patients with abnormal contralateral histopathology differed from the study population in terms of demographics. 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). These preliminary findings need to be validated by well-designed studies. Aesthetic Plast Surg. 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. Completely autologous platelet gel in breast reduction surgery: A blinded, randomized, controlled trial. Narula HS, Carlson HE. .strikeThrough { Breast pumps. 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. Reduction mammoplasty: Criteria for insurance coverage. The NSQIP recorded two complication types: major complications (deep infection and return to operating room) and any complication (all surgical complications). 2015;49(6):311-318. Secondary outcomes included subjective as well as objective assessments of pain and wound healing. Policy Statement 6d: Aesthetic surgery procedures. Two patients experienced unilateral minor partial necrosis of the areolar edge but not of the nipple itself (2 %). 1995;95(6):1029-1032. Health insurance companies frequently have different criteria for whether breast reduction surgery is medically necessary. If gynecomastia is idiopathic, reassurance of the common, transient and benign nature of the condition should be given. 2021 Aug 11 [Online ahead of print]. list-style-type: upper-roman; bottom: 20px; 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. hr.separator { For medical 1996;20(5):391-397. 2nd ed. Aesthetic Plast Surg. Ann Plast Surg. 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 median complication rate was 12.4 % with no major complications, such as neoplastic, pulmonary, or adverse cardiac outcomes. Nguyen JT, Wheatley MJ, Schnur PL, et al. Tang CL, Brown MH, Levine R, et al. 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.
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