Ann Plast Surg. 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.. Vacuum-assisted minimally invasive surgery was carried out under general anesthesia; subjects were followed-up with physical examination and ultrasonography (US). 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. The Breast: Comprehensive Management of Benign and Malignant Diseases. Reduction mammaplasty in patients with history of breast cancer: The incidence of occult cancer and high-risk lesions. Gynecomastia in patients with prostate cancer: A systematic review. After these researchers 1st report of pectoral etching in 2012, patients and surgeons became more aware regarding gynecomastia resection when performing pectoral enhancement. Abnormalities in Adolescent Breast Development. 1998;49:215-234. Nguyen JT, Wheatley MJ, Schnur PL, et al. Plast Reconstr Surg. Philadelphia, PA: W.B. Ann Plast Surg. In contrast, tobacco use and BMI were associated with worse breast reduction outcomes. The author identified the psychological domains affected by the disease and the effect of surgical treatment on these. Marshall WA, Tanner JM. In these cases, breast reduction for men may take 2 to 3 hours. } 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. Reduction mammoplasty: Cosmetic or reconstructive procedure? font-size: 18px; There were 18 out of 415 studies eligible to review. All patients underwent routine investigations to exclude secondary causes of gynecomastia. The Mammotome procedure represented another novel therapeutic option for gynecomastia. ASPS Recommended Coverage Criteria for Third Party Payors. 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. Level of Evidence = IV. Doses examined ranged from 8 to 16 Gy, delivered between 1 and 11 fractions. Breast cancer found at the time of breast reduction. Computed tomography scan of adrenal glands to identify adrenal lesions. text-decoration: underline; 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. height:2px; Breast reduction surgery is considered cosmetic for all indications not listed in section I, A. Mental health care professionals may be consulted to address psychological distress from gynecomastia. Kasielska-Trojan and associates (2018) analyzed digit ratio in relation to estrogen receptor (ER) and progesterone receptor (PR) expression and verified digit ratio (2D: 4D) as a marker of ER and PR over-expression in the male breast. Sixty to 70% of males develop a transient subareolar breast tissue during their adolescence (Tanner Stages II and III). 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. } Estrogens and estrogen like drugs,including: Drugsthat enhance estrogen formation, including: Drugs which inhibit testosterone synthesis, including, Drugs that inhibit testosterone action, including. Anzarut A, Guenther CR, Edwards DC, Tsuyuki RT. Am Surg. There were only 2 studies of a total 25 patients that were considered as good in quality. The article by Blomqvist et al (2000) is to another questionnaire study about health status and quality of life before and after surgery. Surgical treatment of gynecomastia: Complications and outcomes. However, it is unclear if there is any evidence to support this practice. The median complication rate was 12.4 % with no major complications, such as neoplastic, pulmonary, or adverse cardiac outcomes. 2011;21(5):431-434. Henley DV, Lipson N, Korach KS, Bloch CA. 2009;62(2):195-199. color: white; The safety, efficacy, complications, and patient satisfactions were recorded during post-operative follow-up periods. In a systematic review, these investigators examined the role of radiotherapy in this context. Fagerlund A, Lewin R, Rufolo G, et al. Ann Plast Surg. Mistry and associates (2017) examined outcomes following breast re-reduction surgery using a random pattern blood supply to the nipple and vertical scar reduction. 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. This Clinical Policy Bulletin addresses breast reduction surgery and gynecomastia surgery. 2017;139(6):1313-1322. Mannu and colleagues (2018) stated that idiopathic gynecomastia is a benign breast disorder characterized by over-development of male breast tissue. In: Townsend CM, Beuchamp RD, Evers BM, eds. Raispis T, Zehring RD, Downey DL. Variations in pattern of pubertal changes in girls. All studies on the subject were evaluated for inclusion and 6 studies were included in the review. Fat grafting volume ranged from 50 to 300 cc in each pectoral muscle. 1994;21(3):539-543. While 1 study showed high patient's satisfaction rate; both studies indicated high surgeon's satisfaction rate. Drains were used significantly less by surgeons performing greater than or equal to 20 BBRs (p = 0.02). The majority of patients had previously undergone primary breast reduction using an inferior pedicle [n = 37 (41 %)]. @media print { CPT Codes 19316 & 19318 - Mastopexy & Reduction No significant changes have been made to the Srinivasaiah N, Iwuchukwu OC, Stanley PR, et al. 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. Conversely, many patients believe if a procedure is considered cosmetic, it is not a medically indicated and covered procedure. 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. 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. Kerrigan CL, Collins ED, Kim HM, et al. Nelson JA, Fischer JP, Wink JD, Kovach SJ 3rd. Early complications were rare (6.1%), with superficial skin and soft tissue infections accounting for 45.8% of complications. Grade III: Moderate breast enlargement exceeding areola boundaries with edges that are indistinct from the chest with skin redundancy present. Reduction mammoplasty also known as breast reduction surgery, is a surgical procedure in women to reduce the weight, mass, and size of the breast. From January 2006 to January 2010, a total of 20 men with gynecomastia were treated by an 8-G vacuum-assisted biopsy device. bottom: 20px; Here's what Aetna said in the denial: "We used the Clinical Policy Bulletin (CPB): Breast Reduction Surgery. Clinical outcomes in reduction mammaplasty: A systemic review and meta-analysis of published studies. OL LI { Brown MH, Weinberg M, Chong N, et al. 1999;103(6):1682-1686. Work-up of gynecomastia may include the following (GP Notebook, 2003): Treatment should be directed at correcting any underlying reversible causes. Obstet Gynecol Clin North Am. It is universally believed by patients that if a surgery is considered reconstructive, it is medically indicated and covered by health insurance. The member has gigantomastia of pregnancy accompanied byany of the following complications, and delivery is not imminent: For medical necessity criteria for surgery to correct breast asymmetry, seeCPB 0185 - Breast Reconstructive Surgery. He Q, Zheng L, Zhuang D, et al. outline: none; Surgeon. Preoperative patient factors and comorbidities, as well as intraoperative variables, were assessed. 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. list-style-type: upper-roman; Choban PS, Heckler R, Burge JC, Flancbaum L. Increased incidence of nosocomial infections in obese surgical patients. Grade IV: Marked breast enlargement with skin redundancy and feminization of the breast. (This refers to actual breast tissue only; any fatty tissue removed doesn't count.) Measuring health state preferences in women with breast hypertrophy. I have recently met with my primary doctor after speaking to my insurance company (aetna) for months about getting a breast reduction. Beer GM, Kompatscher P, Hergan K. Diagnosis of breast tumors after breast reduction. 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. Analysis was on an intention-to-treat basis. Breast reduction surgery (also called reduction mammaplasty) is a type of invasive procedure that involves incisions (cuts) in your skin to decrease the size and weight of your breasts . A retrospective review was conducted of patients who underwent bilateral breast re-reduction surgery performed by a single surgeon over a 12-year period. Vacuum-assisted minimally invasive mastectomy was performed successfully in all cases, with no residual glands or adipose tissue observed on US. 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. 40 . 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. 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. When seeking preauthorization for a breast reduction, your goal is generally twofold. Sollie (2018) noted that gynecomastia affects up to 2/3 of the male population. Surgical management of gynecomastia--a 10-year analysis. 2018;89(6):408-412. 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]. 2014b;48(5):334-339. display: none; The American Society for Plastic Surgery (2011) advises to delay surgery until breast growth ceases: Although waiting may prolong the psychological awkwardness, it is advisable to delay surgery until breast growth ceases in order to achieve the best result. This is similar tothe American College of Obstetricians and Gynaecologists'2011 Guidelines forAdolescent Health Care chapter on breast concerns in adolescents, which states regarding breast hypertrophy: Preferably, treatment should be deferred until breast growth has been completed. Of these, 28.4 % were bilateral gynecomastia and 71.6 % were unilateral. background-position: right 65%; These investigators support its use for idiopathic gynecomastia in eligible men following the careful discussion of its risks and benefits. The NSQIP recorded two complication types: major complications (deep infection and return to operating room) and any complication (all surgical complications). Reduction mammoplasty is among the most commonly performed cosmetic procedures in the United States. } Prasetyono TOH, Budhipramono AG, Andromeda I, et al. Reduction mammoplasty has also been used for relief of pain in the back, neck and shoulders. Dancey A, Khan M, Dawson J, Peart F. Gigantomastia--a classification and review of the literature. Often times, insurance company will dictate how much breast tissue to be removed. The data were retrospectively analyzed for demographics, operative and histopathology reports, oncological treatment, and post-operative follow-up. 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. The authors concluded that the vacuum-assisted breast biopsy system could be used as a feasible and minimally invasive approach for the treatment of gynecomastia. 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. 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. Abnormal histopathology correlated with higher age (p = 0.0053), heavier specimen (p = 0.0491), and with no previous breast surgery (p < 0.001). Causes may include testosterone-estrogen imbalance, increased prolactin levels, or abnormal serum binding protein levels. Re-operation rate of liposuction-assisted surgery was between 0.6 % and 25 %. 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. Breast reduction outcome study. Transient pain that may occur as the breast enlarges and the capsule is stretched; these symptoms may be managed with analgesics. 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. Ann Plast Surg. Links to various non-Aetna sites are provided for your convenience only. Gynecomastia is a very common concern of male adolescence. This Clinical Policy Bulletin contains only a partial, general description of plan or program benefits and does not constitute a contract. --> } The 2 vacuum-assisted breast biopsy systems (Mammotome and Encor) were used for the patients with gynecomastia. Management of gynecomastia should include evaluation, including laboratory testing, to identify underlying etiologies. Plast Reconstr Surg. Of 291 subjects who were selected for inclusion in the study, only 179 completed follow-up. 2021 Aug 11 [Online ahead of print]. 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. Also, there was no correlation between PR expression and 2D: 4D. Mannu GS, Sudul M, Bettencourt-Silva JH, et al. 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. These researchers compared the safety and effectiveness of the use of wound drains following elective plastic and reconstructive surgery procedures of the breast. Complications following reduction mammaplasty: A review of 3538 cases from the 2005-2010 NSQIP data sets. Subjects were compared to age-matched norms from another study cohort. These investigators presented their experience with pectoral high-definition liposculpture combined with inverted-omega incision resection for gynecomastia. Liposuction was also used adjunctively in all cases (average of 455 cc; range, 50 to 1,750 cc). list-style-type : square !important; Collis N, McGuiness CM, Batchelor AG. } Medical reduction has been achieved with agents such as dihydrotestosterone, danazol, and clomiphene. The average amount of tissue removed from an average weight woman (within the 70 to 74.9 kg weight band) in this study was 600 g per breast, with a range of 502 g to 700 g of tissue removed per breast. The only criterion that the authors found supportable wasa requirementfor a pre-operative mammogram for women aged 40 years and older. 2019;8(4):431-440. Aesthet Surg J. It can cause discomfort and concern, resulting in patients seeking diagnosis and treatment. margin-bottom: 38px; Level of Evidence = III. Open surgery was performed in 56 patients, and vacuum-assisted breast biopsy was performed in 27 patients. Liposuction facilitated the easy handling to remove the breast tissue via small incisional design; showed consistent improved QOL in terms of satisfaction after surgery. Secondary outcomes included subjective as well as objective assessments of pain and wound healing. Surgical treatment of gynecomastia by vacuum-assisted biopsy device. Surgical treatment of primary gynecomastia in children and adolescents. top: 0px; 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). Hoyos and colleagues (2021) stated that male chest definition surgery and patients complaining of breast tissue over-growth have been increasing in recent decades. 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 Gynecomastia, its etiologies and its surgical management: A difference between the bilateral and unilateral cases? 2015;75(4):370-375. 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. 2004;113(1):436-437. Burdette TE, Kerrigan CL, Homa KA. } A total of 81 patients were included in this study. breast augmentation with implant. 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). Plast Reconstr Surg. Plast Reconstr Surg. Grade II: Moderate breast enlargement exceeding areola boundaries with edges that are indistinct from the chest. The traditional method of breast reduction requires an open incision around the areola extending downward to the crease beneath the breast. Redundant skin was observed in 1 patient at 1 month post-operatively, whose breast, defined as grade-III, was the largest before operation. The authors stated that operative subjects were told that their responses to the questionnaire were not to be used for insurance and thus the subjects had no motivation to exaggerate symptoms prior to surgery in questionnaire responses; however, it is not clear whether operative subjects would be willing to submit responses to a questionnaire from the doctor that differed substantially from the history that they provided to the doctor during their preoperative evaluation. 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. 1998;26(1):61-65. right: 30px; Surgical implications of obesity. border-radius: 4px; Reduction mammoplasty for macromastia. Collins ED, Kerrigan CL, Kim M, et al. 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). 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. Surgical treatment is indicated when medical treatments fail. } 2014;20(3):274-278. The end-point was the complete resolution of gynecomastia. 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. 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. Managed care's methods for determining coverage of plastic surgery procedures: The example of reduction mammaplasty. 2001;108(6):1591-1599. Furthermore, the lack of an expected "dose-response" relationship between the amount of breast tissue removed and the magnitude of symptomatic relief in these studies raises questions about the validity of these studies and the effectiveness of breast reduction as a method of relieving shoulder and back pain. Evidence-based clinical practice guideline: Reduction mammaplasty. The authors concluded that the incidences of malignant and high-risk lesions were doubled compared to patients without prior breast cancer. Schnur subsequently refuted the validity of the Schnursliding scaleand stated that thescale should no longer be used as a criterion for the determination of insurance coverage for breast reduction surgery (Nguyen et al, 1999). Type II gynecomastia is more generalized breast enlargement. The operation was successfully performed in all 20 patients with a mean operating time of 51 mins and a hospital stay of 4 days. Coding .headerBar { Breast Concerns of Adolescents. 2014a;34(3):409-416. However, the measuring method of satisfaction rate varied, resulting in difficulties to interpret the results. Qu S, Zhang W, Li S, et al. 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: 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. Surg Laparosc Endosc Percutan Tech. Clinical Policy Bulletins are developed by Aetna to assist in administering plan benefits and constitute neither offers of coverage nor medical advice. Gonzalez FG, Walton RL, Shafer B, et al. Drugs whose mechanism of action is unknown: Others situations which can cause or lead to gynecomastia: The above policy is based on the following references: Last Review } Plast Reconstr Surg. Insurers have commonly used the amount of breast tissue to be removed as a criterion for evaluating the medical necessity of breast reduction surgery. Morbidly obese patients are at the highest risk, with complications occurring in nearly 12% of this cohort. J Plast Surg Hand Surg. The condition not only must be unresponsive to dermatological treatments (e.g., antibiotics or antifungal therapy) and conservative measures (e.g., good skin hygiene, adequate nutrition) for a period of 6 months or longer, but also must satisfy criteria stated insection I above. Plastic Reconstr Surg. These investigators analyzed the incidence of occult breast cancer and high-risk lesions in reduction mammoplasty specimens of women with previous breast cancer. 2007;356(5):479-485. Completely autologous platelet gel in breast reduction surgery: A blinded, randomized, controlled trial. Br J Plast Surg. Policy. 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 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). Karamanos et al (2015) noted that although breast reduction mammoplasty accounts for more than 60,000 procedures annually, the literature remains sparse on outcomes. 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. Many men with breast enlargement are found to have pseudo-gynecomastia. Burns JL, Blackwell SJ. 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. All the patients recovered well and were satisfied with the cosmetic outcomes. # font-weight: bold; Wound drainage after plastic and reconstructive surgery of the breast. 2nd ed. Bruhlmann Y, Tschopp H. Breast reduction improves symptoms of macromastia and has a long-lasting effect. Safran T, Abi-Rafeh J, Alabdulkarim A, et al. Vacuum-assisted minimally invasive surgery-An innovative method for the operative treatment of gynecomastia. Note: For breast surgeries pertaining to gender affirmation, refer to CP.MP.95 Gender Affirming Procedures. Role of tamoxifen in idiopathic gynecomastia: A 10-year prospective cohort study. 2 . American Society of Plastic Surgeons (ASPS). Often, you'll be eligible for Blue Cross Blue Shield breast reduction coverage if your surgeon plans to remove at least 500 grams of breast tissue per breast.
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