2005;58(3):286-289. Plastic Reconstr Surg. Howrigan P. Reduction and augmentation mammoplasty. Wound drainage after plastic and reconstructive surgery of the breast. 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). Gynecomastia Treatment through Open Resection and Pectoral High-Definition Liposculpture. Open surgery was performed in 56 patients, and vacuum-assisted breast biopsy was performed in 27 patients. The study subjects were stratified into groups based on ages of <60 years and 60 years. Plast Reconstr Surg. Macromastia: all . Of these, 28.4 % were bilateral gynecomastia and 71.6 % were unilateral. 2017;139(6):1313-1322. 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. 1998;26(1):61-65. Arlington Heights, IL: ASPS; March 9, 2002. text-decoration: line-through; Health insurance companies frequently have different criteria for whether breast reduction surgery is medically necessary. Answer: Aetna Insurance Breast reduction may or may not be covered depending on your insurance carrier and your breast size. Am J Infect Control. Analysis was on an intention-to-treat basis. 2015;10(8):e0136094. American Society of Plastic Surgeons (ASPS). Collins ED, Kerrigan CL, Kim M, et al. 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. list-style-type : square !important; Clinical Policy: Reduction Mammoplasty and Gynecomastia Surgery - WellCare 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. Surgical implications of obesity. Fagerlund A, Cormio L, Palangi L, et al. #backTop { Anzarut A, Guenther CR, Edwards DC, Tsuyuki RT. Liposuction facilitated the easy handling to remove the breast tissue via small incisional design; showed consistent improved QOL in terms of satisfaction after surgery. 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). Prepubertal gynecomastia linked to lavender and tea tree oils. The Breast: Comprehensive Management of Benign and Malignant Diseases. World J Surg. Third, reliable evidence is especially important for pain interventions, because of the waxing and waning nature of pain and the susceptibility of this symptom to placebo effects and other biases that may confound interpretation of study results. In a systematic review, Prasetyono and colleagues (2021) examined the quality of studies and re-visited liposuction-assisted gynecomastia surgery performed via minimal incision. 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. font-size: 18px; 2006;9(2):109-114. 40 . Often times, insurance company will dictate how much breast tissue to be removed. 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. skin should not be excised horizontally below the inframammary fold. Subjects responses were compared to an age-matched comparison group of women, although no further details about how this comparison group were provided. Statistical analysis was performed with student t-test and chi-square test. Reduction mammoplasty for asymptomatic members is considered cosmetic. In addition, reduction mammoplasty needs to be compared with other established methods of relieving back, neck and shoulder pain. Imahiyerobo TA, Pharmer LA, Swistel AJ, Talmor M. A comparative retrospective analysis of complications after oncoplastic breast reduction and breast reduction for benign macromastia: Are these procedures equally safe? Fan L, Yang X, Zhang Y, Jiang J. Endoscopic subcutaneous mastectomy for the treatment of gynecomastia: A report of 65 cases. 2006;30(3):309-319. Reduction mammaplasty: Defining medical necessity. Plastic Reconstruct Surg. 2003;111(2):688-694. Marshall WA, Tanner JM. Burdette TE, Kerrigan CL, Homa KA. Kalliainen LK; ASPS Health Policy Committee. Plastic surgery for teenagers briefing paper. J Laparoendosc Adv Surg Tech A. All patients underwent routine investigations to exclude secondary causes of gynecomastia. Reduction mammaplasty: An outcome study. Klinefelters syndrome, testicular, adrenal, or pituitary tumors, and thyroid or hepatic dysfunction are also associated with gynecomastia. Am Surg. 2015;49(6):363-366. and areola. In the case of breast reduction, however, for insurance purposes, it . Ann Plast Surg. A population-level analysis of bilateral breast reduction: does age affect early complications? However, it is unclear if there is any evidence to support this practice. } 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). 2000;106(5):991-997. 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). 2012;69(5):510-515. Of the responding surgeons, 71.6 % (151/211) routinely inserted post-operative drains, for a mean of 1.32 days. 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). 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. 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. 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. } Mannu GS, Sudul M, Bettencourt-Silva JH, et al. Patient demographics, surgical technique, and outcomes were analyzed. .strikeThrough { } 2015;75(4):383-387. Special Clinical Concerns. Management of gestational gigantomastia. Blomqvist L, Eriksson A, Brandberg Y. The traditional method of breast reduction requires an open incision around the areola extending downward to the crease beneath the breast. 2021 Aug 11 [Online ahead of print]. Schnur PL, Hoehn JG, Ilstrup DM, et al. OL OL OL OL LI { 2014a;34(3):409-416. Study appraisal was carried out using MINORS to evaluate the methodological quality of the paper. Until now, most published research on the subject has focused on how effective surgical treatment is on correcting the cosmetic appearance of the breast. In: Townsend CM, Beuchamp RD, Evers BM, eds. Aetna plans exclude coverage of cosmetic surgery that is not medically necessary, . Please check your insurance policy to see whether breast reduction is a covered procedure. Post-operative complications included 1 case of hematoma, but no nipple necrosis, local skin necrosis, or skin buttonhole occurred. J Plast Surg Hand Surg. 2002;33:208-217. Breast reduction surgery is considered reconstructive and medically necessary in certain circumstances . Liposuction was also used adjunctively in all cases (average of 455 cc; range, 50 to 1,750 cc). 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. American Society of Plastic Surgeons (ASPS). Reduction mammoplasty specimens revealed abnormal findings in 68 (21.5 %) patients. Kerrigan CL, Collins ED, Kim HM, et al. Kasielska A, Antoszewski B. Surgical management of gynecomastia: An outcome analysis. Hermans, BJ, Boeckx, WD, De Lorenzi, F, Vand der Hulst, RR. These investigators support its use for idiopathic gynecomastia in eligible men following the careful discussion of its risks and benefits. 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. Chemical peels (chemical exfoliation): Considered medically necessary when criteria in CPB 0251 - Dermabrasion, Chemical Peels, and Acne No necrosis, systemic infection, or muscle paralysis was reported. Philadelphia, PA: W.B. }. Med Decis Making. Hello! Aetna Inc. and its subsidiary companies are not responsible or liable for the content, accuracy, or privacy practices of linked sites, or for products or services described on these sites. 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. 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. For those with large breasts, breast reduction surgery can ease discomfort and improve appearance. Role of tamoxifen in idiopathic gynecomastia: A 10-year prospective cohort study. Vacuum-assisted minimally invasive mastectomy was performed successfully in all cases, with no residual glands or adipose tissue observed on US. Autorino R, Perdona S, D'Armiento M, et al. list-style-image: url('https://www.aetna.com/cpb/medical/data/assets/images/purplearrow.jpg') !important; Patients in vacuum-assisted breast biopsy group had a better cosmetic outcome than those in open surgery group. The safety, efficacy, complications, and patient satisfactions were recorded during post-operative follow-up periods. --> However, the BRAVO study is not of sufficient quality to reach reliable conclusions about the effectiveness of breast reduction surgery as a pain intervention. The surgeon removes excess tissue, fat and skin before adjusting the placement of the nipple and areola appropriately. A detailed drug history, including list of medications, an assessment of indirect or environmental exposure to estrogenic compounds, and recreational drug use. Karamanos et al (2015) identified their study as the largest sample on breast reduction in the literature, in which age and surgeon specialty did not correlate with negative results. 2008;61(5):493-502. display: block; American Society of Plastic and Reconstructive Surgery (ASPRS). The majority (87.7 %) of cases presented with accompanying mastalgia. Plast Reconstr Surg. These investigators concluded that their findings do not support the use of completely autologous platelet gel to improve outcomes after reduction mammoplasty. 2011;21(5):431-434. Henley DV, Lipson N, Korach KS, Bloch CA. 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. Treatment of adolescent gynecomastia. Mistry and associates (2017) examined outcomes following breast re-reduction surgery using a random pattern blood supply to the nipple and vertical scar reduction. No other operation-related complications were observed. Breast reduction for symptomatic macromastia. The only criterion that the authors found supportable wasa requirementfor a pre-operative mammogram for women aged 40 years and older. color: red!important; After these researchers 1st report of pectoral etching in 2012, patients and surgeons became more aware regarding gynecomastia resection when performing pectoral enhancement. The author identified the psychological domains affected by the disease and the effect of surgical treatment on these. 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. 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. 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. 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. 2002;109(5):1556-1566. If gynecomastia is idiopathic, reassurance of the common, transient and benign nature of the condition should be given. Gynecomastia is a very common concern of male adolescence. Type II gynecomastia is more generalized breast enlargement. Following treatment, 90.1 % (n = 73) had a complete response of their gynecomastia with tamoxifen therapy. Surgical management of gynecomastia--a 10-year analysis. list-style-type: decimal; Thus, this study would not be considered of sufficient quality to provide reliable evidence of the effectiveness of a pain intervention. border-radius: 4px; Reduction mammoplasty: Criteria for insurance coverage. Vacuum-assisted minimally invasive surgery was carried out under general anesthesia; subjects were followed-up with physical examination and ultrasonography (US). 2019;8(4):431-440. outline: none; Leclere FM, Spies M, Gohritz A, Vogt PM. Work-up of gynecomastia may include the following (GP Notebook, 2003): Treatment should be directed at correcting any underlying reversible causes. If an insufficient amount of breast tissue is removed, the surgery is less likely to be successful in relieving pain and any related symptoms from excessive breast weight (e.g., excoriations, rash). Nelson JA, Fischer JP, Chung CU, et al Obesity and early complications following reduction mammaplasty: An analysis of 4545 patients from the 2005-2011 NSQIP datasets. 2017;35:157-161. } Breast pumps. bottom: 20px; Ann Plastic Surg. The characteristics of patients as well as the curative effects between the 2 groups were analyzed. Sixty to 70% of males develop a transient subareolar breast tissue during their adolescence (Tanner Stages II and III). Subgroup analysis further stratified the younger cohort into those <50 years and 50-60 years of age. 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. Three review authors undertook independent screening of the search results. A retrospective review was conducted of patients who underwent bilateral breast re-reduction surgery performed by a single surgeon over a 12-year period. Miller AP, Zacher JB, Berggren RB, et al. Srinivasaiah N, Iwuchukwu OC, Stanley PR, et al. 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. Jansen DA, Murphy M, Kind GM, Sands K. Breast cancer in reduction mammoplasty: Case reports and a survey of plastic surgeons. GP Notebook. Although operative subjects were examined before and after surgery, there was no attempt to employ any blinded or objective measures of disability and function to verify these self-reports. Aesthetic Plast Surg. /* aetna.com standards styles for templates */ Reduction mammoplasty also known as breast reduction surgery, is a surgical procedure in women to reduce the weight, mass, and size of the breast. Handschin AE, Bietry D, Hsler R, et al. 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. Copyright Aetna Inc. All rights reserved. Harmonic scalpel versus electrocautery in breast reduction surgery: A randomized controlled trial. Insurers have commonly used the amount of breast tissue to be removed as a criterion for evaluating the medical necessity of breast reduction surgery. 1969;44(235):291-303. The authors concluded that small incisional design for breast parenchymal removal in gynecomastia assisted by liposuction showed a good technical approach for consistent improvement in QOL; however, only 2 studies reported good quality methods of non-randomized case-series urging for a better quality of studies in the future. 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. Mistry RM, MacLennan SE, Hall-Findlay EJ. Aesthetic 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. Drainage in breast reduction surgery: A prospective randomised intra-patient trail. Surgical treatment is indicated when medical treatments fail. See Appendix for Table 1. The authors concluded that treatment of gynecomastia by the Mammotome device was distinctive, practicable in manipulation, safe, and could achieve excellent cosmetic results. 2015;(10):CD007258. These investigators presented their experience with pectoral high-definition liposculpture combined with inverted-omega incision resection for gynecomastia. cursor: pointer; This Clinical Policy Bulletin contains only a partial, general description of plan or program benefits and does not constitute a contract. Tobacco use and body mass index as predictors of outcomes in patients undergoing breast reduction mammoplasty. 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). It should be noted that this study reported a strong correlation between the amount of tissue removed and pain amelioration. 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. Determinants of surgical site infection after breast surgery. Plast Reconstr Surg. 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. Secondary outcomes included subjective as well as objective assessments of pain and wound healing. However, the measuring method of satisfaction rate varied, resulting in difficulties to interpret the results. Hoyos and colleagues (2021) stated that male chest definition surgery and patients complaining of breast tissue over-growth have been increasing in recent decades. PDF Gender Dysphoria Treatment - Cigna Surg Laparosc Endosc Percutan Tech. Surgery. 2000;45(6):575-580. Li CC, Fu JP, Chang SC, et al. Yao Y, Yang Y, Liu J, et al. list-style-type: lower-alpha; 01/04/2023 Plast Reconstr Surg. Ann Plast Surg. Schnur subsequently refuted the validity of the Schnursliding scaleand stated that thescale should no longer be used as a criterion for the determination of insurance coverage for breast reduction surgery (Nguyen et al, 1999). Does Health Insurance Cover Breast Reduction Surgery? - GoodRx Mental health care professionals may be consulted to address psychological distress from gynecomastia. The authors concluded that even with the high level of evidence demonstrating the safety of BBR without drains, they are still routinely utilized. OL OL LI { Washington, DC: ACOG; 2011:121-122. Breast J. 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". Patients were randomized to receive the gel applied to the left or right breast after hemostasis was achieved; the other breast received no treatment. Aetna and the City shall each abide by all applicable laws, regulations and government requirements regarding the confidentiality and the safeguarding of individually identifiable health and other personal information, including the privacy and security requirements of HIPAA. Reduction mammaplasty: The need for prospective randomized studies. Level of Evidence = IV. Ann Plast Surg. Plastic Reconstruct Surg. top: 0px; They investigated effects of age on 30-day surgical outcomes for reduction mammoplasty with a goal of improving patient care, counseling, and risk stratification on 3537 patients. 1997;185(6):593-603. Drugs commonly associated with the development of gynecomastia include amphetamines, marijuana, mebrobamate, opiates, amitriptyline, chlordiazepoxide, chlorpromazine, cimetidine, diazepam, digoxin, fluphenazine, haloperidol, imipramine, isoniazid, mesoridazine, methyldopa, perphenazine, phenothiazines, reserpine, spironolactone, thiethylperazine, tricyclic antidepressants, tirfluoperazine, trimeparazine, busulfan, vincristine, tamoxifen, , methyltestosterone, human chorionic gonadotropins, and estrogens. Breast Reduction Surgery | Johns Hopkins Medicine The Mammotome procedure represented another novel therapeutic option for gynecomastia. Kerrigan CL, Collins ED, Striplin D, et al. 1999;103(6):1687-1690. 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 2000;44(2):125-134. 2010;125(5):1301-1308. .newText { Conversely, many patients believe if a procedure is considered cosmetic, it is not a medically indicated and covered procedure. Karamanos E, Wei B, Siddiqui A, Rubinfeld I. These preliminary findings need to be validated by well-designed studies. Exposure to partners using estrogen containing vaginal creams; Cancer chemotherapy (alkylating agents, methotrexate, vinca alkaloids, imatinib, combination chemotherapy), Androgen receptor blockers - bicalutamide, 5 reductase inhibitors - finasteride, dutasteride, Angiotensin converting enzyme inhibitors (captopril, enalapril), Calcium channelblockers(diltiazem, nifedipine, verapamil), Anabolic steroids(e.g., in body builders). The article by Blomqvist et al (2000) is to another questionnaire study about health status and quality of life before and after surgery. Alternatively, you may qualify if your breast size causes significant symptoms, such as: Long-term neck, shoulder or neck pain. Level of Evidence = III. The operation had a mean duration of 73.5 mins per side, ranging from 40 to 102 mins. Breast hypertrophy. Gland Surg. Gynecomastia may be drug-induced. Pediatr Surg Int. 2006;118(4):840-848. Laituri CA, Garey CL, Ostlie DJ, et al. CPT Codes 19316 & 19318 - Mastopexy & Reduction No significant changes have been made to the However, if liposuction is used as an adjunctive technique, the decision to use drains should be left to the surgeon's discretion. li.bullet { Reduction (or some cases augmentation) mammoplasty and related reconstructive procedures on the unaffected side for symmetry are also considered medically necessary. They evaluated the use of radiotherapy for the prevention and treatment of gynecomastia incidence or recurrence by plastic surgeons. A total of 211 responding surgeons were analyzed, including 80.1 % (171/211) plastic surgeons and 18.9 % (40/211) breast surgeons. Gynecomastia in patients with prostate cancer: A systematic review. Surgeon. Several important points should be considered in evaluating these challenges to insurers' criteria for breast reduction surgery. color: red 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. It is not intuitively obvious, however, that breast weight would substantially contribute to back, neck and shoulder pain in women with normal or small breasts. Aetna does not provide health care services and, therefore, cannot guarantee any results or outcomes.