The American Society of Plastic Surgeons' evidence-based clinical practice guideline on reduction mammoplasty (ASPS, 2011) states thatin standard reduction mammoplasty procedures, evidence indicates that the use of drains is not beneficial. Analysis was on an intention-to-treat basis. Reduction mammaplasty provides long-term improvement in health status and quality of life. The following procedures are considered experimental and investigational because there is insufficient evidence of itseffectiveness or itseffectiveness has not been established: Aetna considers breast reduction, surgical mastectomy or liposuction for gynecomastia, either unilateral or bilateral, a cosmetic surgical procedure. list-style-image: url('https://www.aetna.com/cpb/medical/data/assets/images/purplearrow.jpg') !important; The safety, efficacy, complications, and patient satisfactions were recorded during post-operative follow-up periods. Gynecomastia, its etiologies and its surgical management: A difference between the bilateral and unilateral cases? Seitchik (1995) reviewed the amount of breast tissue removed from a series of 100 patients that underwent breast reduction surgery. Data was then analyzed for surgical complications, wound complications, and medical complications within 30 days of surgery on 4545 patients. The goal of medically necessary breast reduction surgery is to relieve symptoms of pain and disability. 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). 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). Open surgery was performed in 56 patients, and vacuum-assisted breast biopsy was performed in 27 patients. 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). } Ann Plast Surg. Of 291 subjects who were selected for inclusion in the study, only 179 completed follow-up. } Ann Plast Surg. 2 . J Plast Reconstr Aesthet Surg. Medical reduction has been achieved with agents such as dihydrotestosterone, danazol, and clomiphene. list-style-type: upper-roman; Philadelphia, PA: WB Saunders Company; 2008; Ch 73. Sollie (2018) noted that gynecomastia affects up to 2/3 of the male population. These investigators support its use for idiopathic gynecomastia in eligible men following the careful discussion of its risks and benefits. GP Notebook. Nguyen JT, Wheatley MJ, Schnur PL, et al. Reduction (or some cases augmentation) mammoplasty and related reconstructive procedures on the unaffected side for symmetry are also considered medically necessary. American College of Obstetricians and Gynecologists (ACOG), Committee on Adolescent Health Care. Breast reduction surgery, also known as reduction mammaplasty, removes fat, breast tissue and skin from the breasts. 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. Setala L, Papp A, Joukainen S, et al. 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. Tobacco use and body mass index as predictors of outcomes in patients undergoing breast reduction mammoplasty. These investigators analyzed the incidence of occult breast cancer and high-risk lesions in reduction mammoplasty specimens of women with previous breast cancer. Plast Reconstr Surg. border-width:0; Breast re-reduction surgery was most commonly performed using a random pattern blood supply, rather than recreating the primary pedicle [n = 77 (86 %)]. 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). There were 18 out of 415 studies eligible to review. 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. Gland Surg. For many patients the psychological impact of the disease is substantial. Chemical peels (chemical exfoliation): Considered medically necessary when criteria in CPB 0251 - Dermabrasion, Chemical Peels, and Acne 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). Furthermore, you must test negative for breast cancer on a mammogram a maximum of two years before your surgery if you are 50 or older. Sood R, Mount DL, Coleman JJ 3rd, et al. Kalliainen LK; ASPS Health Policy Committee. 2011;128(4):243e-249e. Level of Evidence = III. Glatt BS, Sarwer DB, O'Hara DE, et al. Reduction mammoplasty has also been used for relief of pain in the back, neck and shoulders. Gynecomastia may be drug-induced. Am J Infect Control. color: white; } Answer: Aetna Insurance Breast reduction may or may not be covered depending on your insurance carrier and your breast size. They have argued that removal of even a few hundred grams of breast tissue can result in substantial pain relief. Liposuction facilitated the easy handling to remove the breast tissue via small incisional design; showed consistent improved QOL in terms of satisfaction after surgery. 2014a;34(1):66-73. The NSQIP recorded two complication types: major complications (deep infection and return to operating room) and any complication (all surgical complications). 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. There were no restrictions on the basis of date or language of publication. 2012;130(4):785-789. Anesthesia may be injected along with saline solution until the tissue is firm, and a suction cannula is used to extract fat from the breast. 2021;147(5):1072-1083. Mistry and associates (2017) examined outcomes following breast re-reduction surgery using a random pattern blood supply to the nipple and vertical scar reduction. Grade III: Moderate breast enlargement exceeding areola boundaries with edges that are indistinct from the chest with skin redundancy present. Vacuum-assisted minimally invasive mastectomy was performed successfully in all cases, with no residual glands or adipose tissue observed on US. @media print { 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. margin-top: 38px; 2018;7(Suppl 1):S70-S76. These investigators presented their experience with pectoral high-definition liposculpture combined with inverted-omega incision resection for gynecomastia. 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. In this study the National Surgical Quality Improvement Program data set was queried for the Current Procedural Terminology code 19318 from the years 2005 to 2010, with principal outcome measurements of wound complications, surgical site infections, and reoperations. Iwuagwu OC, Stanley PW, Platt AJ, Drew PJ. Oncoplastic reduction mammoplasty for breast cancer in women with macromastia: Oncological long-term outcomes. 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). Health insurance companies frequently have different criteria for whether breast reduction surgery is medically necessary. A total of 211 responding surgeons were analyzed, including 80.1 % (171/211) plastic surgeons and 18.9 % (40/211) breast surgeons. Hermans, BJ, Boeckx, WD, De Lorenzi, F, Vand der Hulst, RR. 2007;356(5):479-485. padding: 10px; color: red 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. } Wound drainage after plastic and reconstructive surgery of the breast. Plast Reconstr Surg. 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. Merkkola-von Schantz PA, Jahkola TA, Krogerus LA, Kauhanen SMC. For example, if the body surface area is 1.40 m2 , the estimated breast tissue to be removed should at least be 324 grams. 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). The requirement for coverage is that the amount of breast tissue to be removed has to be enough to improve your symptoms or function. ASPS clinical practice guideline summary on reduction mammaplasty. 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. 2015;(10):CD007258. Tobacco use was shown to have a higher rate of reoperation (p= 0.02) and BMI was identified as an independent risk factor for wound complications (odds ratio, 1.85, P = 0.005). A cohort study of breast cancer risk in breast reduction patients. Dancey A, Khan M, Dawson J, Peart F. Gigantomastia--a classification and review of the literature. In a systematic review, these investigators examined the role of radiotherapy in this context. Drains were used significantly less by surgeons performing greater than or equal to 20 BBRs (p = 0.02). Reduction mammaplasty: The need for prospective randomized studies. In fact, according to the American Society of Plastic Surgeons, more than 46,000 breast reduction procedures were performed in 2019, a six percent increase compared to 2018; but in recent years, insurance companies have become more likely to deny coverage for this medically recommended procedure. PLoS One. 1. No new trials were identified for this first update. No other operation-related complications were observed. All patients underwent routine investigations to exclude secondary causes of gynecomastia. Pseudo-gynecomastia refers to excessive fat tissue or prominent pectoralis muscles. Aesthet Surg J. 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. For the first update of this review, these investigators searched the Cochrane Wounds Group Specialised Register (searched March 4, 2015); the Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library 2015, Issue 2); Ovid Medline (2012 to March 3, 2015); Ovid Medline (In-Process & Other Non-Indexed Citations March 3, 2015); Ovid Embase(2012 to March 3, 2015); and EBSCO CINAHL (2012 to March 4, 2015). 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 You must be at least 18 years old or show completed breast growth (no change in breast size over at least a year) to qualify for Aetna breast reduction coverage. Subgroup analysis further stratified the younger cohort into those <50 years and 50-60 years of age. Examining any complication, a significant increase was noted with increasing obesity class (p < 0.001). 2015;75(4):370-375. In contrast, tobacco use and BMI were associated with worse breast reduction outcomes. In total there were 306 women in the 3 trials, and 505 breasts were studied (254 drained, and 251 who were not drained). Merkkola-von Schantz and colleagues (2017) stated that contralateral reduction mammoplasty is regularly included in the treatment of breast cancer patients. The investigators found little difference between obese and non-obese women concerning patient's reports of resolution of symptoms and improvement in body image. Breast reduction, also known as reduction mammaplasty, is a procedure to remove excess breast fat, glandular tissue and skin to achieve a breast size more in proportion with your body and to alleviate the discomfort associated with excessively large breasts (macromastia). 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. Reduction mammaplasty. The effectiveness of surgical and nonsurgical interventions in relieving the symptoms of macromastia. 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. 2007;119(4):1159-1166. Bertin ML, Crowe J, Gordon SM. Patients were randomized to receive the gel applied to the left or right breast after hemostasis was achieved; the other breast received no treatment. Surgeon. 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. Reduction mammoplasty for asymptomatic members is considered cosmetic. Aetna considers breast reconstructive surgery to correct Fagerlund A, Lewin R, Rufolo G, et al. 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. You first need to demonstrate that the procedure is "medically necessary and therefore reconstructive rather than cosmetic," says board-certified New York City plastic surgeon Dr. Umbareen Mahmood. All the patients recovered well and were satisfied with the cosmetic outcomes. Measuring health state preferences in women with breast hypertrophy. Bruhlmann Y, Tschopp H. Breast reduction improves symptoms of macromastia and has a long-lasting effect. If gynecomastia is idiopathic, reassurance of the common, transient and benign nature of the condition should be given. 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. 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. 1994;21(3):539-543. Plastic Reconstr Surg. Plast Reconstr Surg. Fat grafting to the breast can now be reported with CPT codes 15771 and 15772. Jones SA, Bain JR. Review of data describing outcomes that are used to assess changes in quality of life after reduction mammaplasty. 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. J Plast Surg Hand Surg. 2015;49(6):363-366. Principles of breast re-reduction: A reappraisal. Breast reduction surgery is considered reconstructive and medically necessary in certain circumstances . Li CC, Fu JP, Chang SC, et al. Plast Reconstr Surg. skin should not be excised horizontally below the inframammary fold. Surgery. You may be able to buy a breast pump and supplies from one of our medical equipment suppliers at no charge or at a discounted rate. Leclere FM, Spies M, Gohritz A, Vogt PM. 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". Burdette TE, Kerrigan CL, Homa KA. Oxfordshire NHS Trust. J Am Coll Surg. 2006;30(3):309-319. The authors concluded that with proper patient selection, reduction mammoplasty can be performed safely on older patients. However, the BRAVO study is not of sufficient quality to reach reliable conclusions about the effectiveness of breast reduction surgery as a pain intervention. .arrowPurpleSmall, a:hover.arrowPurpleSmall { 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. 2011;21(5):431-434. Henley DV, Lipson N, Korach KS, Bloch CA. Breast Reduction Surgery and Gynecomastia Surgery - Medical Clinical Policy Bulletins | Aetna Page . 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. Arlington Heights, IL: ASPS; March 9, 2002. Criteria for reduction mammoplasty surgery from the American Society of Plastic Surgeons (ASPS, 2002; ASPS, 2011) states, among other things, that breast weight or breast volume is not a legitimate criterion upon which to distinguish cosmetic from functional indications. Petty PM, Solomon M, Buchel EW, Tran NV. These preliminary findings need to be validated by well-designed studies. Gynecomastia has been classified into2 types. Operative subjects who completed the study reported reductions in pain and improvements in quality of life; however, these improvements may be attributable to placebo effects, the natural history of back pain, other concurrent interventions, regression to the mean, improvements in cosmesis (for quality of life measures), or other confounding variables that may bias in interpretation of results. 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]. For those with large breasts, breast reduction surgery can ease discomfort and improve appearance. 1995;61(11):1001-1005.

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