1997;185(6):593-603. Aetna plans exclude coverage of cosmetic surgery that is not medically necessary, . 2015;75(4):383-387. Aesthet Surg J. Breast reduction surgery might also help improve self-image and the ability to take part in physical activities. Breast reduction surgery, also known as reduction mammaplasty, removes fat, breast tissue and skin from the breasts. 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.. position: fixed; These individuals cite evidence from observational studies to support this position (e.g., Chadbourne et al, 2001; Kerrigan et al, 2001). Principles of breast re-reduction: A reappraisal. Miller AP, Zacher JB, Berggren RB, et al. 2018;89(6):408-412. 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. Schnur PL, Schnur DP, Petty PM, et al. Breast Reduction Surgery and Gynecomastia Surgery - Medical Clinical Policy Bulletins | Aetna Page . 1999;103(1):76-82; discussion 83-85. No new trials were identified for this first update. The effectiveness of surgical and nonsurgical interventions in relieving the symptoms of macromastia. } The NSQIP recorded two complication types: major complications (deep infection and return to operating room) and any complication (all surgical complications). .strikeThrough { Surgeon. 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 Henley et al (2007) reported that repeated topical exposure to lavender and tea tree oils may be linked to prepubertal gynecomastia (idiopathic gynecomastia). Swelstad MR, Swelstad BB, Rao VK, Gutowski KA. Patients were randomized to receive the gel applied to the left or right breast after hemostasis was achieved; the other breast received no treatment. Pediatr Surg Int. 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. padding: 10px; 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. Type II gynecomastia is more generalized breast enlargement. Reduction mammoplasty has also been used for relief of pain in the back, neck and shoulders. list-style-type : square !important; Seitchik MW. 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. Patients in vacuum-assisted breast biopsy group had a better cosmetic outcome than those in open surgery group. A total of 90 patients underwent breast re-reduction surgery. See Appendix for Table 1. Reduction mammoplasty: Cosmetic or reconstructive procedure? } Minor complications (3.2 %) included prolonged swelling, bruising, asymmetries, and residual gynecomastia. Liposuction facilitated the easy handling to remove the breast tissue via small incisional design; showed consistent improved QOL in terms of satisfaction after surgery. Ann Plast Surg. Behmand et al (2000) reported on the results of a questionnaire pre- and post-surgery in 69 subjects from a single practice who underwent reduction mammoplasty. Prepubertal gynecomastia linked to lavender and tea tree oils. 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. These investigators retrospectively examined 83 patients with gynecomastia between January 2015 and December 2019. text-decoration: line-through; } Reduction mammoplasty specimens revealed abnormal findings in 68 (21.5 %) patients. 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. Kasielska A, Antoszewski B. Surgical management of gynecomastia: An outcome analysis. Fourth, insurers have provided coverage for reduction mammoplasty in women with excessively large breasts; thus, the debate is about the effectiveness of removal of smaller amounts of breast tissue from women whose breast size most persons would consider within the normal range. They reviewed their records on pectoral high-definition liposculpture between January of 2005 and October of 2019 in 4 surgical centers in Colombia. 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). 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). 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. Most cases of type I gynecomastia are unilateral, and 20% of cases are bilateral. In the case of breast reduction, however, for insurance purposes, it . Gynecomastia. 2012;130(4):785-789. width: 100%; 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. Gynecomastia may be drug-induced. Measuring health state preferences in women with breast hypertrophy. 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. An 18-question survey was created evaluating various aspects of BBR practice; UK and Irish plastic and reconstructive and breast surgeons were invited to participate by an e-mail containing a link to a web-based survey. CPT Codes 19316 & 19318 - Mastopexy & Reduction No significant changes have been made to the #closethis { 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. 2015;(10):CD007258. color: #FFF; The authors concluded that the incidences of malignant and high-risk lesions were doubled compared to patients without prior breast cancer. There were no restrictions on the basis of date or language of publication. Among these domains were: vitality, emotional discomfort, limitations due to physical aspects and limitations due to pain. Tobacco use and body mass index as predictors of outcomes in patients undergoing breast reduction mammoplasty. This may justify an early use of tamoxifen in men with gynecomastia and a high digit ratio. Schnur PL, Hoehn JG, Ilstrup DM, et al. Breast. Reduction mammoplasty: Criteria for insurance coverage. Patients with abnormal histopathology could not be pre-operatively identified based on demographics. 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. 2014b;30(6):641-647. Fischer et al (2014a) evaluated predictors of postoperative complications following reduction mammoplasty using the NSQIP) data sets. Conversely, many patients believe if a procedure is considered cosmetic, it is not a medically indicated and covered procedure. Reduction mammaplasty: A review of managed care medical policy coverage criteria. 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. Follow-up ranged from 2 months to 3 years. 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). } Level of Evidence = IV. These investigators concluded that their findings do not support the use of completely autologous platelet gel to improve outcomes after reduction mammoplasty. Plastic Reconstr Surg. Cochrane Database Syst Rev. 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). In addition, reduction mammoplasty needs to be compared with other established methods of relieving back, neck and shoulder pain. American Society of Plastic Surgeons (ASPS). 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). The author average amount of breast tissue removed for women in 5 kg weight bands, ranging from 45-49 kg to 90+ kg. Plast Reconstr Surg. .strikeThrough { 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. Is there a rationale behind pharmacotherapy in idiopathic gynecomastia? ol.numberedList LI { } 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. It should be noted that this study reported a strong correlation between the amount of tissue removed and pain amelioration. 1998;41(3):240-245. Blomqvist L, Eriksson A, Brandberg Y. Managed care's methods for determining coverage of plastic surgery procedures: The example of reduction mammaplasty. } 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., breast size stable over one year) when any of the following criteria (A, B, or C) is met: Macromastia: all of the following criteria must be met: Breast asymmetries: A brief review and our experience. Of the responding surgeons, 71.6 % (151/211) routinely inserted post-operative drains, for a mean of 1.32 days. Oxford, UK: National Health Service (NHS); October 2008. It was also found that only 3 % of subjects reported that they had no aesthetic motivation for surgery. Three review authors undertook independent screening of the search results. A total of 244 out of 1,628 patients with the average age of 23.13 years. World J Surg. right: 30px; Open surgery was performed in 56 patients, and vacuum-assisted breast biopsy was performed in 27 patients. Plast Reconstr Surg. of the following criteria must be met: 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. A population-level analysis of bilateral breast reduction: does age affect early complications? Breast cancer found at the time of breast reduction. Obstet Gynecol Clin North Am. Gynecomastia surgery is the surgical correction of over-developed or enlarged breasts in men. 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. 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. Analysis was on an intention-to-treat basis. No other operation-related complications were observed. When seeking preauthorization for a breast reduction, your goal is generally twofold. 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. OL OL OL OL LI { Nelson et al (2014a) analyzed population data from the 2005-2010 American College of Surgeons National Surgical Quality Improvement Program (NSQIP) database. Obesity and complications in breast reduction surgery: Are restrictions justified? breast augmentation with implant. Surgical treatment is indicated when medical treatments fail. Cambridge, UK: Oxbridge Solutions, Ltd.; 2003. text-decoration: underline; There were 18 out of 415 studies eligible to review. OL OL OL OL OL LI { Lonie S, Sachs R, Shen A, et al. li.bullet { Fagerlund A, Lewin R, Rufolo G, et al. Drainage in breast reduction surgery: A prospective randomised intra-patient trail. 1991;27(3):232-237. 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. Glatt BS, Sarwer DB, O'Hara DE, et al. Howrigan P. Reduction and augmentation mammoplasty. Iwuagwu OC, Stanley PW, Platt AJ, Drew PJ. Compared with the open surgery group, the vacuum-assisted breast biopsy group had significantly smaller scar sizes left after the operation (5.5 1.3 cm versus 0.8 0.2 cm, p < 0.001), and shorter hospital stay time (5.5 2.4 days versus 3.1 1.6 days, p < 0.001). OL LI { 2021 Aug 11 [Online ahead of print]. Women's Health and Cancer Rights Act of 1998. However, the measuring method of satisfaction rate varied, resulting in difficulties to interpret the results. 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. 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 . @media print { display: block; 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 average age was 24.7 years (range of 18 to 47 years). Reduction mammoplasty is among the most commonly performed cosmetic procedures in the United States. Breast reduction for symptomatic macromastia. Reduction mammaplasty: The need for prospective randomized studies. Thus, this study would not be considered of sufficient quality to provide reliable evidence of the effectiveness of a pain intervention. Jones SA, Bain JR. Review of data describing outcomes that are used to assess changes in quality of life after reduction mammaplasty. PLoS One. However, these medications should be reserved for those with no decrease in breast size after 2 years. Covered items may include: A manual or standard electric pump (non-hospital grade) while you are pregnant or for the duration of breastfeeding. ASPS clinical practice guideline summary on reduction mammaplasty. Approximately 25 % of the 49 subjects included in this study did not return the post-operative questionnaire. Gynaecomastia. cursor: pointer; A non-standardized survey showed a very high satisfaction index. 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. 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. /*margin-bottom: 43px;*/ The data were retrospectively analyzed for demographics, operative and histopathology reports, oncological treatment, and post-operative follow-up. Reduction mammoplasty improves symptoms of macromastia. 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. Abnormalities in Adolescent Breast Development. Drains were used significantly less by surgeons performing greater than or equal to 20 BBRs (p = 0.02). 1995;34(2):113-116. 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). Fat grafting to the breast can now be reported with CPT codes 15771 and 15772. Management of gestational gigantomastia. Complication rates were inconsistent throughout the studies, ranging from 0.06 % to 26.67 %. 2005;55(3):227-231. 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. Many men with breast enlargement are found to have pseudo-gynecomastia. Arlington Heights, IL: ASPS; May 2011. Surgical treatment of gynecomastia by vacuum-assisted biopsy device. 1998;101(2):361-364. In a majority of boys with pubertal gynecomastia, the condition resolves within 18 months. 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. Behmand RA, Tang DH, Smith DJ Jr. Outcomes in breast reduction surgery. Satisfactory chest contour was gained in all cases without any abnormality, skin redundancy, or recurrence during the follow-up of 6 to 48 months. Reduction mammoplasty has been performed to relieve back and shoulder pain on the theory that reducing breast weight will relieve this pain. } J Am Coll Surg. Emiroglu M, Salimoglu S, Karaali C, et al. Collins ED, Kerrigan CL, Kim M, et al. The 2 studies, which discussed laser-assisted liposuction technique, showed minor complication of seroma in 2 patients. Complications following reduction mammaplasty: A review of 3538 cases from the 2005-2010 NSQIP data sets. An average of 320 specimens were excised from each side with mean blood loss of 34 ml. In contrast, tobacco use and BMI were associated with worse breast reduction outcomes. 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. 2014a;34(1):66-73. In a prospective, cohort study, these investigators evaluated the efficacy of tamoxifen therapy in resolving this condition. margin-top: 38px; Gynecomastia in patients with prostate cancer: Update on treatment options. 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. 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. 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. 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). 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. Management of gynecomastia should include evaluation, including laboratory testing, to identify underlying etiologies. 2014b;48(5):334-339. 2008;61(5):493-502. The study consisted of 329 breast cancer patients, who underwent symmetrizing reduction mammoplasty between 1/2007 and 12/2011. J Plast Reconstr Aesthet Surg. 1999;103(6):1687-1690. 2007;119(4):1159-1166. Plastic surgery for teenagers briefing paper. They have argued that removal of even a few hundred grams of breast tissue can result in substantial pain relief. Vacuum-assisted minimally invasive surgery was carried out under general anesthesia; subjects were followed-up with physical examination and ultrasonography (US). Quality of life after breast reduction. Vacuum-assisted minimally invasive surgery-An innovative method for the operative treatment of gynecomastia. Plastic Reconstr Surg. Disproportionately large breasts can cause both physical and emotional . For pain interventions, evidence of effectiveness is necessary from well controlled, randomized prospective clinical trials assessing effects on pain, disability, and function. 2012;69(5):510-515. 1993;17(3):211-223. Burns JL, Blackwell SJ. Nelson JA, Fischer JP, Wink JD, Kovach SJ 3rd. 2000;106(2):280-288. 2021;147(5):1072-1083. The characteristics of patients as well as the curative effects between the 2 groups were analyzed. Can objective predictors for operative success be identified? Completely autologous platelet gel in breast reduction surgery: A blinded, randomized, controlled trial. 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. Wound drainage after plastic and reconstructive surgery of the breast. # color: white; 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. The study subjects were stratified into groups based on ages of <60 years and 60 years. Subgroup analysis further stratified the younger cohort into those <50 years and 50-60 years of age. All subjects were satisfied with their cosmetic outcome, graded as excellent by 22 patients (100 %). ul.ur li{ Prostate Cancer Prostatic Dis. Furthermore, there is insufficient evidence that surgical removal is more effective than conservative management for pain due to gynecomastia. 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. 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. Plast Reconstr Surg. 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. .newText { 2nd ed. Arch Dis Child. Mizgala CL, MacKenzie KM. 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. Plast Reconstr Surg. Answer: Aetna Insurance Breast reduction may or may not be covered depending on your insurance carrier and your breast size. 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. 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). 2011;128(4):243e-249e. The risks included infection, wound breakdown, scarring, and the need for re-operating.
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