Note: For breast surgeries pertaining to gender affirmation, refer to CP.MP.95 Gender Affirming Procedures. Ann Plast Surg. Medical reduction has been achieved with agents such as dihydrotestosterone, danazol, and clomiphene. 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: The surgeon must also certify that a certain weight of breast tissue (based on Aetna's table) will be removed in every breast, and not entirely fatty tissue. Sollie (2018) noted that gynecomastia affects up to 2/3 of the male population. In a within-patient, randomized, patient- and assessor-blinded, controlled study, Anzarut et al (2007) evaluated the use of completely autologous platelet gel in 111 patients undergoing bilateral reduction mammoplasty to reduce post-operative wound drainage. Liposuction assisted gynecomastia surgery with minimal periareolar incision: A systematic review. 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. 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. American Society of Plastic Surgeons (ASPS). 2006;9(2):109-114. The 2 studies, which discussed laser-assisted liposuction technique, showed minor complication of seroma in 2 patients. list-style-type: decimal; The health burden of breast hypertrophy. They also analyzed if timing of reduction mammoplasty in relation to oncological treatment influenced the incidence of abnormal findings, and compared if patients with abnormal contralateral histopathology differed from the study population in terms of demographics. Little is known about the effect of surgical treatment on the psychological aspects of the disease. Arlington Heights, IL: ASPS; 2011. A follow-up study of 105 women with breast cancer following reduction mammaplasty. 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. 2014a;34(1):66-73. color: blue!important; Level of Evidence = IV. 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. Aetna considers associated nipple and areolar reconstruction and tattooing of the nipple area medically necessary. 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). Plast Reconstr Surg. Guidelines for Adolescent Health Care. 1969;44(235):291-303. text-decoration: underline; The average amount of breast tissue removed ranged from 430 g per breast to 1.6 kg per breast, with increased body weight associated with an increased amount of breast tissue to be removed. } The 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. If gynecomastia is idiopathic, reassurance of the common, transient and benign nature of the condition should be given. In Type I (idiopathic) gynecomastia, the adolescent presents with a tender, firm mass beneath the areola. He Q, Zheng L, Zhuang D, et al. Treatment of adolescent gynecomastia. There were no statistically significant differences between the 2 vacuum-assisted breast biopsy systems according to the mean age, the mean operation time, sites, or grade. The article by Blomqvist et al (2000) is to another questionnaire study about health status and quality of life before and after surgery. Setala L, Papp A, Joukainen S, et al. Khan SM, Smeulders MJ, Van der Horst CM. color: #FFF; The majority (87.7 %) of cases presented with accompanying mastalgia. The data were retrospectively analyzed for demographics, operative and histopathology reports, oncological treatment, and post-operative follow-up. li.bullet { 2 . 2010;45(3):650-654. Wound drainage after plastic and reconstructive surgery of the breast. All subjects were satisfied with their cosmetic outcome, graded as excellent by 22 patients (100 %). 2001;108(1):62-67. 2006;30(3):309-319. 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. Photographs were taken pre-operatively and 1, 3, 6, and 12 months post-operatively. Current concepts in gynaecomastia. Araco A, Gravante G, Araco F, et al. Conversely, many patients believe if a procedure is considered cosmetic, it is not a medically indicated and covered procedure. Surgical treatment of primary gynecomastia in children and adolescents. Aesthetic Plast Surg. 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. cursor: pointer; 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. Surg Laparosc Endosc Percutan Tech. 2018;24(6):1043-1045. Breast and aesthetic surgery. skin should not be excised horizontally below the inframammary fold. Karamanos et al (2015) noted that although breast reduction mammoplasty accounts for more than 60,000 procedures annually, the literature remains sparse on outcomes. Furthermore, no serious complications were observed in vacuum-assisted breast biopsy group. 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. } Am J Infect Control. All the patients recovered well and were satisfied with the cosmetic outcomes. A study by Bruhlmann and Tschopp (1998) was a retrospective study of 246 patients from a surgical practice, approximately 50 % (132) of whom returned a questionnaire about their symptoms and satisfaction with aesthetic results, and their recollection of symptoms prior to surgery. Aesthetic Plast Surg. 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. Several of the included studies reported improvement in QOL and several psychological domains after surgical treatment for gynecomastia. Sugrue CM, McInerney N, Joyce CW, et al. Choban PS, Flancbaum L. The impact of obesity on surgical outcomes: A review. 1995;34(2):113-116. 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. 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). Impact of surgical treatment for gynecomastia appeared to be beneficial for several psychological domains. 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). The authors concluded that high digit ratio in men with gynecomastia may tend to be a marker of over-expression of ER and PR. 2014b;48(5):334-339. 2018;7(Suppl 1):S70-S76. 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. 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. display: block; Alternatively, you may qualify if your breast size causes significant symptoms, such as: Long-term neck, shoulder or neck pain. Brown DM, Young VL. However, the BRAVO study is not of sufficient quality to reach reliable conclusions about the effectiveness of breast reduction surgery as a pain intervention. 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. Behmand RA, Tang DH, Smith DJ Jr. Outcomes in breast reduction surgery. All studies on the subject were evaluated for inclusion and 6 studies were included in the review. The authors concluded that vacuum-assisted, minimally invasive mastectomy was a feasible approach for the treatment of gynecomastia with acceptable complications. Flancbaum L, Choban PS. In addition, reduction mammoplasty needs to be compared with other established methods of relieving back, neck and shoulder pain. It's important to note that CPT 19324 - mammaplasty, augmentation without pros-thetic implant - has been deleted. The traditional method of breast reduction requires an open incision around the areola extending downward to the crease beneath the breast. Plast Reconstr Surg. The author identified the psychological domains affected by the disease and the effect of surgical treatment on these. These investigators support its use for idiopathic gynecomastia in eligible men following the careful discussion of its risks and benefits. For example, if the body surface area is 1.40 m2 , the estimated breast tissue to be removed should at least be 324 grams. From January 2006 to January 2010, a total of 20 men with gynecomastia were treated by an 8-G vacuum-assisted biopsy device. .arrowPurpleSmall, a:hover.arrowPurpleSmall { Disproportionately large breasts can cause both physical and emotional . Seitchik MW. 2019;166(5):934-939. American Society of Plastic and Reconstructive Surgery (ASPRS). of the following criteria must be met: 2003;111(2):688-694. The authors concluded that breast re-reduction can be performed safely and predictably, even when the previous technique is not known; and 4 key principles were developed: Language services can be provided by calling the number on your member ID card. Can objective predictors for operative success be identified? To get insurance coverage, you'll probably need . 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. The author concluded that the current level of evidence on this subject was very low and future studies, examining the impact of the surgical intervention for gynecomastia on psychological domains, are greatly needed. Hoyos AE, Perez ME, Dominguez-Millan R, et al. Policy. width: 100%; 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 physician-supervised diet and exercise plan may be indicated in obese patients. Kerrigan CL, Collins ED, Kim HM, et al. Obstet Gynecol Clin North Am. 2019;8(4):431-440. Plastic Reconstr Surg. 2012;69(5):510-515. Based on CPB criteria and the information we have, we're denying coverage for breast reduction surgery. 2009;62(2):195-199. American Society of Plastic Surgeons (ASPS). This may lead to additional scarring and additional operating time. Aesthet Surg J. 2008;32(1):38-44. 2002;109(5):1556-1566. } Surgical treatment of gynecomastia by vacuum-assisted biopsy device. 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). Collis N, McGuiness CM, Batchelor AG. Safran and colleagues (2021) noted that several technologies and innovative approaches continue to emerge for the optimal management of gynecomastia by plastic surgeons. Hermans, BJ, Boeckx, WD, De Lorenzi, F, Vand der Hulst, RR. 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. Long-term functional results after reduction mammoplasty. margin-top: 38px; Management of gynecomastia should include evaluation, including laboratory testing, to identify underlying etiologies. Open surgery was performed in 56 patients, and vacuum-assisted breast biopsy was performed in 27 patients. Reduction mammaplasty: An outcome study. 40 . Analysis was on an intention-to-treat basis. Devalia HL, Layer GT. Aetna considers magnetic resonance imaging (MRI), with or without contrast materials, of the breast medically necessary for members who have had a recent (within the past year) conventional mammogram and/or breast sonogram, in any of the following circumstances where MRI of the breast may affect their clinical management:. 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). Mizgala CL, MacKenzie KM. Karamanos E, Wei B, Siddiqui A, Rubinfeld I. 2014;20(3):274-278. He and associates (2011) examined the safety and feasibility of vacuum-assisted biopsy device in the treatment of gynecomastia. In a majority of boys with pubertal gynecomastia, the condition resolves within 18 months. When seeking preauthorization for a breast reduction, your goal is generally twofold. Plast Reconstr Surg. Marshall WA, Tanner JM. 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. Fischer S, Hirsch T, Hirche C, et al. Anzarut A, Guenther CR, Edwards DC, Tsuyuki RT. 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. Ann Chir Plast Esthet. 1993;17(3):211-223. 1995;61(11):1001-1005. 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. 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. .strikeThrough { list-style-type: lower-alpha; Henley et al (2007) reported that repeated topical exposure to lavender and tea tree oils may be linked to prepubertal gynecomastia (idiopathic gynecomastia). Plast Reconstr Surg. Evidence-based clinical practice guideline: Reduction mammaplasty. Removing the adipose tissue in pseudogynecomastia usually has no long term effect as adipose tissue reaccumulates unless the individual loses weight. 2021;74(11):3128-3140. Pseudo-gynecomastia refers to excessive fat tissue or prominent pectoralis muscles. Liposuction was also used adjunctively in all cases (average of 455 cc; range, 50 to 1,750 cc). All patients underwent routine investigations to exclude secondary causes of gynecomastia. Of the responding surgeons, 71.6 % (151/211) routinely inserted post-operative drains, for a mean of 1.32 days. ul.ur li{ 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. Treating providers are solely responsible for medical advice and treatment of members. 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. 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. Reduction mammaplasty: The need for prospective randomized studies. Many men with breast enlargement are found to have pseudo-gynecomastia. Gynecomastia Treatment through Open Resection and Pectoral High-Definition Liposculpture. 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. 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). Follow-up ranged from 2 months to 3 years. 1998;49:215-234. Post-operative complications included 1 case of hematoma, but no nipple necrosis, local skin necrosis, or skin buttonhole occurred. 1996;20(5):391-397. Health insurance companies frequently have different criteria for whether breast reduction surgery is medically necessary. In other patients, excess skin and nipple and areola relocation are necessary. 2008;53(3):255-261. Breast re-reduction surgery was most commonly performed using a random pattern blood supply, rather than recreating the primary pedicle [n = 77 (86 %)]. Of 110 subjects who were mailed questionnaires, approximately50 %(61 subjects) provided responses. These individuals cite evidence from observational studies to support this position (e.g., Chadbourne et al, 2001; Kerrigan et al, 2001). 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. These researchers compared the safety and effectiveness of the use of wound drains following elective plastic and reconstructive surgery procedures of the breast. Grade II: Moderate breast enlargement exceeding areola boundaries with edges that are indistinct from the chest. Study appraisal was carried out using MINORS to evaluate the methodological quality of the paper. Patients undergoing surgery for gynecomastia should know that their scars may be visible when they are shirtless. #backTop:hover { A retrospective study of changes in physical symptoms and body image after reduction mammaplasty. For pain interventions, evidence of effectiveness is necessary from well controlled, randomized prospective clinical trials assessing effects on pain, disability, and function. font-size: 18px; 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. However, if liposuction is used as an adjunctive technique, the decision to use drains should be left to the surgeon's discretion. ASPS clinical practice guideline summary on reduction mammaplasty. Risk of bias was assessed independently by 2review authors. 2010;125(5):1301-1308. Breast Concerns of Adolescents. This Clinical Policy Bulletin addresses breast reduction surgery and gynecomastia surgery. Plast Reconstr Surg. 2004;113(1):436-437. Of these 33 operative sides, 2 complications occurred, but satisfactory chest contour was attained in all subjects. 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. Bruhlmann Y, Tschopp H. Breast reduction improves symptoms of macromastia and has a long-lasting effect. J Plast Reconstr Aesthet Surg. 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. 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. Gynecomastia, its etiologies and its surgical management: A difference between the bilateral and unilateral cases? Sood R, Mount DL, Coleman JJ 3rd, et al. Nguyen JT, Wheatley MJ, Schnur PL, et al. N Engl J Med. 2014a;34(3):409-416. For medical Effects of reduction mammaplasty on pulmonary function and symptoms of macromastia. Subjects responses were compared to an age-matched comparison group of women, although no further details about how this comparison group were provided. # color: white; If reduction mammoplasty was performed before oncological treatment, the incidence of abnormal findings was higher. They reviewed their records on pectoral high-definition liposculpture between January of 2005 and October of 2019 in 4 surgical centers in Colombia. position: fixed; Several important points should be considered in evaluating these challenges to insurers' criteria for breast reduction surgery. 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). background-position: right 65%; Am Surg. This Clinical Policy Bulletin contains only a partial, general description of plan or program benefits and does not constitute a contract. For those with large breasts, breast reduction surgery can ease discomfort and improve appearance. 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. #backTop { 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). 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. Fischer et al (2014a) evaluated predictors of postoperative complications following reduction mammoplasty using the NSQIP) data sets. Ann Plast Surg. 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. J Plast Surg Hand Surg. Breast pumps. There were 18 out of 415 studies eligible to review. Beer GM, Kompatscher P, Hergan K. Diagnosis of breast tumors after breast reduction. Oxford, UK: National Health Service (NHS); October 2008. Also, there was no correlation between PR expression and 2D: 4D. height:2px; Abnormal histopathology correlated with higher age (p = 0.0053), heavier specimen (p = 0.0491), and with no previous breast surgery (p < 0.001). Plastic Reconstr Surg. Measurement of plasma gonadotrophins, human chorionic gonadotropin (hCG), testosterone, estradiol, and dehydroepiandosterone sulphate (DHEAS). 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. Ann Plast Surg. 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. 1990;24(1):61-67. Complications following reduction mammaplasty: A review of 3538 cases from the 2005-2010 NSQIP data sets. Yao Y, Yang Y, Liu J, et al. Schnur PL, Hoehn JG, Ilstrup DM, et al. Prepubertal gynecomastia linked to lavender and tea tree oils. Morbidly obese patients are at the highest risk, with complications occurring in nearly 12% of this cohort. Aesthetic Plast Surg. Special Clinical Concerns. Plast Reconstr Surg. Often times, insurance company will dictate how much breast tissue to be removed. Surgical implications of obesity. 2006;118(4):840-848.
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