Tang CL, Brown MH, Levine R, et al. Brown DM, Young VL. /*margin-bottom: 43px;*/ 2016;20(3):256-260. 2021;147(5):1072-1083. Drainage in breast reduction surgery: A prospective randomised intra-patient trail. 2007;36(2):497-519. Nguyen JT, Wheatley MJ, Schnur PL, et al. 40 . 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. Clinical Policy Bulletins are developed by Aetna to assist in administering plan benefits and constitute neither offers of coverage nor medical advice. In the case of breast reduction, however, for insurance purposes, it . 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. list-style-type: decimal; Oxford, UK: National Health Service (NHS); October 2008. Araco A, Gravante G, Araco F, et al. The author average amount of breast tissue removed for women in 5 kg weight bands, ranging from 45-49 kg to 90+ kg. Ann Plast Surg. Yao Y, Yang Y, Liu J, et al. 2017;35:157-161. From January 2006 to January 2010, a total of 20 men with gynecomastia were treated by an 8-G vacuum-assisted biopsy device. Of these, 28.4 % were bilateral gynecomastia and 71.6 % were unilateral. ul.ur li{ Aesthet Surg J. Vacuum-assisted minimally invasive surgery-An innovative method for the operative treatment of gynecomastia. Gynecomastia in patients with prostate cancer: Update on treatment options. 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. Ann Plast Surg. However, the BRAVO study is not of sufficient quality to reach reliable conclusions about the effectiveness of breast reduction surgery as a pain intervention. --> Gynecomastia: Evolving paradigm of management and comparison of techniques. Fat grafting to the breast can now be reported with CPT codes 15771 and 15772. Iwuagwu OC, Stanley PW, Platt AJ, Drew PJ. Early complications were rare (6.1%), with superficial skin and soft tissue infections accounting for 45.8% of complications. Causes may include testosterone-estrogen imbalance, increased prolactin levels, or abnormal serum binding protein levels. Petty PM, Solomon M, Buchel EW, Tran NV. Study subjects included 3538 patients with an average age of 43 years and body mass index of 31.6 kg/m(2) and most patients underwent outpatient surgery (80.5%) with an average operative time of 180 minutes.The incidence of overall surgical complications was 5.1% and the incidence of major surgical complications was 2.1%. J Laparoendosc Adv Surg Tech A. The traditional method of breast reduction requires an open incision around the areola extending downward to the crease beneath the breast. Aetna is the brand name used for products and services provided by one or more of the Aetna group of subsidiary companies, including Aetna . 1998;101(2):361-364. 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. Breast Concerns of Adolescents. 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. #closethis { Breast reduction for symptomatic macromastia. A detailed drug history, including list of medications, an assessment of indirect or environmental exposure to estrogenic compounds, and recreational drug use. Miller AP, Zacher JB, Berggren RB, et al. 2017;139(6):1313-1322. 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. Determinants of surgical site infection after breast surgery. Mistry RM, MacLennan SE, Hall-Findlay EJ. The authors concluded that vacuum-assisted, minimally invasive mastectomy was a feasible approach for the treatment of gynecomastia with acceptable complications. Breast pumps. Based on CPB criteria and the information we have, we're denying coverage for breast reduction surgery. } Clinical outcomes were measured by operative subjects' responses to a questionnaire about symptoms and quality of life. Abnormalities in Adolescent Breast Development. Cochrane Database Syst Rev. These investigators analyzed the incidence of occult breast cancer and high-risk lesions in reduction mammoplasty specimens of women with previous breast cancer. They evaluated the use of radiotherapy for the prevention and treatment of gynecomastia incidence or recurrence by plastic surgeons. Macromastia: all . 1995;34(2):113-116. Arlington Heights, IL: ASPS; 2011. font-size: 18px; Merkkola-von Schantz and colleagues (2017) stated that contralateral reduction mammoplasty is regularly included in the treatment of breast cancer patients. Risk factors for complications following breast reduction: Results from a randomized control trial. 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. .strikeThrough { Qu and colleagues (2020) examined the effectiveness of vacuum-assisted breast biopsy systems for the treatment of gynecomastia. He and associates (2011) examined the safety and feasibility of vacuum-assisted biopsy device in the treatment of gynecomastia. color: blue Role of tamoxifen in idiopathic gynecomastia: A 10-year prospective cohort study. Reduction mammaplasty. Of these 33 operative sides, 2 complications occurred, but satisfactory chest contour was attained in all subjects. 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. 1995;61(11):1001-1005. height:2px; 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. The majority (87.7 %) of cases presented with accompanying mastalgia. 1995;95(1):77-83. 2021 Aug 11 [Online ahead of print]. Well-designed clinical trials provide reliable information about the effectiveness of an intervention, and provide valid information about the characteristics of patients who would benefit from that intervention. Thus, more than 1/3of operative subjects selected for inclusion in the study did not complete it; most of the operative subjects who did not complete the study were lost to follow-up. Plast Reconstr Surg. cursor: pointer; These investigators presented their experience with pectoral high-definition liposculpture combined with inverted-omega incision resection for gynecomastia. Li CC, Fu JP, Chang SC, et al. Patients in vacuum-assisted breast biopsy group had a better cosmetic outcome than those in open surgery group. Women's Health and Cancer Rights Act of 1998. Of the responding surgeons, 71.6 % (151/211) routinely inserted post-operative drains, for a mean of 1.32 days. There were no restrictions on the basis of date or language of publication. 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). Breast Reduction Surgery and Gynecomastia Surgery - Medical Clinical Policy Bulletins | Aetna Page . 2015;10(8):e0136094. Level of Evidence = IV. Copyright Aetna Inc. All rights reserved. Surgery. In a liposuction-only reduction mammoplasty, a small access incision is made in one of the following locations: axillary (under the arm), periareolar (around the nipple) or in the inframammary fold (under the breast). Another set of breast pump supplies if you get pregnant . 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). Administration of Benefits and Transition Responsibilities Ann Plast Surg. Reduction mammaplasty in patients with history of breast cancer: The incidence of occult cancer and high-risk lesions. Also, there was no correlation between PR expression and 2D: 4D. Level of Evidence = III. Annu Rev Med. 1997;185(6):593-603. width: 100%; Aesthet Plastic Surg. Lonie S, Sachs R, Shen A, et al. Grade III: Moderate breast enlargement exceeding areola boundaries with edges that are indistinct from the chest with skin redundancy present. Reduction mammoplasty is among the most commonly performed cosmetic procedures in the United States. Mistry and associates (2017) examined outcomes following breast re-reduction surgery using a random pattern blood supply to the nipple and vertical scar reduction. 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. 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. I have recently met with my primary doctor after speaking to my insurance company (aetna) for months about getting a breast reduction. It was also found that only 3 % of subjects reported that they had no aesthetic motivation for surgery. For pain interventions, evidence of effectiveness is necessary from well controlled, randomized prospective clinical trials assessing effects on pain, disability, and function. Aetna considers associated nipple and areolar reconstruction and tattooing of the nipple area medically necessary. Patient demographics, surgical technique, and outcomes were analyzed. 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. 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. 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. .headerBar { The NSQIP recorded two complication types: major complications (deep infection and return to operating room) and any complication (all surgical complications). The data were retrospectively analyzed for demographics, operative and histopathology reports, oncological treatment, and post-operative follow-up. The article by Blomqvist et al (2000) is to another questionnaire study about health status and quality of life before and after surgery. 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). Analysis was on an intention-to-treat basis. Handschin AE, Bietry D, Hsler R, et al. Plast Reconstr Surg. In a prospective, cohort study, these investigators evaluated the efficacy of tamoxifen therapy in resolving this condition. 2014;20(3):274-278. This may justify an early use of tamoxifen in men with gynecomastia and a high digit ratio. Plastic Reconstr Surg. text-decoration: line-through; Breast reduction surgery is considered reconstructive and medically necessary in certain circumstances . There were only 2 studies of a total 25 patients that were considered as good in quality. Little is known about the effect of surgical treatment on the psychological aspects of the disease. ol.numberedList LI { 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. 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). 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. A retrospective study of changes in physical symptoms and body image after reduction mammaplasty. Fan L, Yang X, Zhang Y, Jiang J. Endoscopic subcutaneous mastectomy for the treatment of gynecomastia: A report of 65 cases. Reduction mammaplasty: An outcome study. Liposuction was also used adjunctively in all cases (average of 455 cc; range, 50 to 1,750 cc). 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. list-style-image: url('https://www.aetna.com/cpb/medical/data/assets/images/purplearrow.jpg') !important; 2002;33:208-217. Gynecomastia: A systematic review. The authors concluded that the incidences of malignant and high-risk lesions were doubled compared to patients without prior breast cancer. 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. 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. These investigators support its use for idiopathic gynecomastia in eligible men following the careful discussion of its risks and benefits. Several important points should be considered in evaluating these challenges to insurers' criteria for breast reduction surgery. Furthermore, no serious complications were observed in vacuum-assisted breast biopsy group. Type II gynecomastia is more generalized breast enlargement. These individuals cite evidence from observational studies to support this position (e.g., Chadbourne et al, 2001; Kerrigan et al, 2001). Arlington Heights, IL: ASPS; May 2011. Special Clinical Concerns. 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). Prepubertal gynecomastia linked to lavender and tea tree oils. 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. Karamanos et al (2015) noted that although breast reduction mammoplasty accounts for more than 60,000 procedures annually, the literature remains sparse on outcomes. Re-operation rate of liposuction-assisted surgery was between 0.6 % and 25 %. In Type I (idiopathic) gynecomastia, the adolescent presents with a tender, firm mass beneath the areola. A retrospective review was conducted of patients who underwent bilateral breast re-reduction surgery performed by a single surgeon over a 12-year period. 2004;113(1):436-437. PLoS One. N Engl J Med. They reviewed their records on pectoral high-definition liposculpture between January of 2005 and October of 2019 in 4 surgical centers in Colombia. Plast Reconstr Surg. The investigators found little difference between obese and non-obese women concerning patient's reports of resolution of symptoms and improvement in body image. 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. Drains were used significantly less by surgeons performing greater than or equal to 20 BBRs (p = 0.02). 2009;7(2):114-119. Breast reduction surgery is considered cosmetic for all indications not listed in section I, A. It should be noted that this study reported a strong correlation between the amount of tissue removed and pain amelioration. Impact of surgical treatment for gynecomastia appeared to be beneficial for several psychological domains. 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.. color: blue!important; 2007;356(5):479-485. 2015;49(6):363-366. A non-standardized survey showed a very high satisfaction index. 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. 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. margin-bottom: 38px; 1993;91(7):1270-1276. The nipple-areola complex was re-positioned in 60 % of patients (n = 54). Priorities Forum Policy Statement. Jones SA, Bain JR. Review of data describing outcomes that are used to assess changes in quality of life after reduction mammaplasty. #backTop:hover { Kasielska-Trojan A, Danilewicz M, Antoszewski B. Medical reduction has been achieved with agents such as dihydrotestosterone, danazol, and clomiphene. Oxfordshire NHS Trust. J Plast Surg Hand Surg. 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). Kasielska A, Antoszewski B. Surgical management of gynecomastia: An outcome analysis. 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. These studies did not find a relationship between breast weight or amount of breast tissue removed and the likelihood of response or magnitude of relief of pain after reduction mammoplasty. While the efficacy of radiotherapy as a therapeutic modality for gynecomastia was also established, it was shown to be less effective than other available options. No other operation-related complications were observed. Satisfactory chest contour was gained in all cases without any abnormality, skin redundancy, or recurrence during the follow-up of 6 to 48 months. 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. Autorino R, Perdona S, D'Armiento M, et al. and areola. Bland KI, Copeland EM, eds. 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. Studies have suggested that 2.4% to 14% of breast reduction cases resulted in major complications and 2.4% . 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. Grade IV: Marked breast enlargement with skin redundancy and feminization of the breast. J Plast Reconstr Aesthet Surg. Management of gynecomastia should include evaluation, including laboratory testing, to identify underlying etiologies. Measuring health state preferences in women with breast hypertrophy. Scand J Plast Reconstr Hand Surg. Work-up of gynecomastia may include the following (GP Notebook, 2003): Treatment should be directed at correcting any underlying reversible causes. Surg Laparosc Endosc Percutan Tech. No data were provided on loss to follow-up. The author identified the psychological domains affected by the disease and the effect of surgical treatment on these. 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. Gynaecomastia. Health insurance companies frequently have different criteria for whether breast reduction surgery is medically necessary. Burns JL, Blackwell SJ. Plast Reconstr Surg. 2019;8(4):431-440. A population-level analysis of bilateral breast reduction: does age affect early complications? Reduction mammoplasty also known as breast reduction surgery, is a surgical procedure in women to reduce the weight, mass, and size of the breast. 2000;106(2):280-288. Tang CL, Brown MH, Levine R, et al. 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. display: block; J Plast Surg Hand Surg. ASPS Recommended Coverage Criteria for Third Party Payors. The primary outcome was the difference in wound drainage over 24 hours. 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. Vacuum-assisted minimally invasive surgery was carried out under general anesthesia; subjects were followed-up with physical examination and ultrasonography (US). Gynecomastia has been classified into2 types. Flancbaum L, Choban PS.