The authors concluded that gynecomastia treatment combining high-definition liposculpture to male breast tissue resection via a new, almost invisible incision allowed these researchers to achieve an athletic and natural appearance of the male pectoral area with a very low rate of complications. Reduction (or some cases augmentation) mammoplasty and related reconstructive procedures on the unaffected side for symmetry are also considered medically necessary. Breast reduction surgery, also known as reduction mammaplasty, removes fat, breast tissue and skin from the breasts. GP Notebook. Arlington Heights, IL: ASPRS; 1987. Aetna considers associated nipple and areolar reconstruction and tattooing of the nipple area medically necessary. The operation was successfully performed in all 20 patients with a mean operating time of 51 mins and a hospital stay of 4 days. .strikeThrough { Mistry and associates (2017) examined outcomes following breast re-reduction surgery using a random pattern blood supply to the nipple and vertical scar reduction. Patients were randomized to receive the gel applied to the left or right breast after hemostasis was achieved; the other breast received no treatment. Clinical Policy Bulletins are developed by Aetna to assist in administering plan benefits and constitute neither offers of coverage nor medical advice. Safran T, Abi-Rafeh J, Alabdulkarim A, et al. For individuals who received radiation treatment to the chest . The authors concluded that treatment of gynecomastia by the Mammotome device was distinctive, practicable in manipulation, safe, and could achieve excellent cosmetic results. Bland KI, Copeland EM, eds. Patient demographics, surgical technique, and outcomes were analyzed. OL OL OL OL OL LI { Recommended criteria for insurance coverage of reduction mammoplasty. 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. Of 110 subjects who were mailed questionnaires, approximately50 %(61 subjects) provided responses. Satisfactory chest contour was gained in all cases without any abnormality, skin redundancy, or recurrence during the follow-up of 6 to 48 months. Aesthetic 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. Prasetyono TOH, Budhipramono AG, Andromeda I, et al. Other just require 500 grams no matter what your height and weight. border-width:0; Plastic Reconstruct Surg. A non-standardized survey showed a very high satisfaction index. Reduction mammoplasty specimens revealed abnormal findings in 68 (21.5 %) patients. 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. Early complications were rare (6.1%), with superficial skin and soft tissue infections accounting for 45.8% of complications. Merkkola-von Schantz PA, Jahkola TA, Krogerus LA, Kauhanen SMC. 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). Computed tomography scan of adrenal glands to identify adrenal lesions. 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. In a majority of boys with pubertal gynecomastia, the condition resolves within 18 months. Devalia HL, Layer GT. Seitchik (1995) reviewed the amount of breast tissue removed from a series of 100 patients that underwent breast reduction surgery. Swelstad MR, Swelstad BB, Rao VK, Gutowski KA. Note: For breast surgeries pertaining to gender affirmation, refer to CP.MP.95 Gender Affirming Procedures. Covered items may include: A manual or standard electric pump (non-hospital grade) while you are pregnant or for the duration of breastfeeding. 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). Clinical outcomes in reduction mammaplasty: A systemic review and meta-analysis of published studies. Guidelines for Adolescent Health Care. } Aesthetic Plast Surg. border: none; World J Surg. When seeking preauthorization for a breast reduction, your goal is generally twofold. Post-operative complications included 1 case of hematoma, but no nipple necrosis, local skin necrosis, or skin buttonhole occurred. They stated that no data are available for breast augmentation or breast reconstruction, and this requires investigation. Sood R, Mount DL, Coleman JJ 3rd, et al. Endocrinol Metab Clin North Am. 2001;108(1):62-67. 2006;9(2):109-114. For example, if the body surface area is 1.40 m2 , the estimated breast tissue to be removed should at least be 324 grams. Mizgala CL, MacKenzie KM. The operative group in the BRAVO study was drawn from a number of surgical practices that volunteered to participate in the study; no details are provided about how each center selected candidates for reduction mammoplasty, or how they chose patients who underwent mammoplasty for inclusion in the study. Several of the included studies reported improvement in QOL and several psychological domains after surgical treatment for gynecomastia. list-style-image: url('https://www.aetna.com/cpb/medical/data/assets/images/purplearrow.jpg') !important; Tobacco use and body mass index as predictors of outcomes in patients undergoing breast reduction mammoplasty. } Reduction mammoplasty improves symptoms of macromastia. Studies have suggested that 2.4% to 14% of breast reduction cases resulted in major complications and 2.4% . Breast Concerns of Adolescents. } 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. An average of 320 specimens were excised from each side with mean blood loss of 34 ml. Philadelphia, PA: W.B. 2018;89(6):408-412. Collins ED, Kerrigan CL, Kim M, et al. However, these medications should be reserved for those with no decrease in breast size after 2 years. } 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. Healing balms, scented soaps, skin lotions, shampoos and styling gels containing lavender oilor tea tree oil. Current practice patterns of drain usage amongst UK and Irish surgeons performing bilateral breast reductions: Evidence down the drain. Grade IV: Marked breast enlargement with skin redundancy and feminization of the breast. Reduction mammaplasty in patients with history of breast cancer: The incidence of occult cancer and high-risk lesions. However, the measuring method of satisfaction rate varied, resulting in difficulties to interpret the results. Priorities Forum Policy Statement. Coding In contrast, tobacco use and BMI were associated with worse breast reduction outcomes. And if you are in Canada the surgeon decides. Plast Reconstr Surg. N Engl J Med. 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. Sixty to 70% of males develop a transient subareolar breast tissue during their adolescence (Tanner Stages II and III). Oncoplastic reduction mammoplasty for breast cancer in women with macromastia: Oncological long-term outcomes. 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. OL OL LI { 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. Level of Evidence = IV. Most cases of type I gynecomastia are unilateral, and 20% of cases are bilateral. color: blue 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). position: fixed; 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. PLoS One. There are alsoseveral earlier, smaller studies that found reductions in symptoms and improvements in quality of life after reduction mammoplasty (Glatt et al, 1999; Bruhlmannand Tschopp, 1998; Blomqvist et al, 2000; and Behmand et al, 2000). Laituri CA, Garey CL, Ostlie DJ, 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. Gynecomastia resection plus high-definition liposculpture was successfully performed in 436 consecutive men (open inverted-omega incision resection, n = 132; liposuction, n = 304). These individuals cite evidence from observational studies to support this position (e.g., Chadbourne et al, 2001; Kerrigan et al, 2001). Qu S, Zhang W, Li S, et al. In a systematic review, Prasetyono and colleagues (2021) examined the quality of studies and re-visited liposuction-assisted gynecomastia surgery performed via minimal incision. Gynecomastia in patients with prostate cancer: A systematic review. Schnur PL, Schnur DP, Petty PM, et al. The traditional method of breast reduction requires an open incision around the areola extending downward to the crease beneath the breast. 2010;45(3):650-654. 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). 1999;103(6):1682-1686. 2007;36(2):497-519. } 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. J Plast Reconstr Aesthet Surg. 2000;106(2):280-288. Townsend: Sabiston Textbook of Surgery. Little is known about the effect of surgical treatment on the psychological aspects of the disease. The authors concluded that with proper patient selection, reduction mammoplasty can be performed safely on older patients. Orthopedic or spine surgeon evaluation of spinal pain; Radiotherapy (for the prevention or management of gynecomastia recurrence); Vacuum-assisted breast biopsy system for treament of gynecomastia. J Plast Surg Hand Surg. 2021 Aug 11 [Online ahead of print]. Of the responding surgeons, 71.6 % (151/211) routinely inserted post-operative drains, for a mean of 1.32 days. J Plast Surg Hand Surg. list-style-type: decimal; Surgical implications of obesity. .newText { 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. } I have recently met with my primary doctor after speaking to my insurance company (aetna) for months about getting a breast reduction. Data was then analyzed for surgical complications, wound complications, and medical complications within 30 days of surgery on 4545 patients. Plast Reconstr Surg. The average age of the studied individuals was 25.7 years (SD = 7.8); ER and PR expression was detected in breasts, and digit ratios were calculated in patients with idiopathic gynecomastia. Plastic Reconstr Surg. Nelson JA, Fischer JP, Wink JD, Kovach SJ 3rd. Lonie S, Sachs R, Shen A, et al. Reduction mammoplasty has also been used for relief of pain in the back, neck and shoulders. The characteristics of patients as well as the curative effects between the 2 groups were analyzed. /* aetna.com standards styles for templates */ 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. Evidence-based clinical practice guideline: Reduction mammaplasty. Kasielska-Trojan A, Danilewicz M, Antoszewski B. A study reporting on a survey of health insurer policies on breast reduction surgery (Nguyen et al, 2004) found that no insurer medical policies could be supported by the medical literature. Type II gynecomastia is more generalized breast enlargement. Breast reconstruction/breast enlargement Breast reduction/mammoplasty Excision of excessive skin due to weight loss Gastroplasty/gastric bypass 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. This study included 35 patients who underwent breast reduction due to the idiopathic form of gynecomastia. Mistry RM, MacLennan SE, Hall-Findlay EJ. The study by Schnur et al was based on a survey of 92 plastic surgeons who reported on their care for 591 patients. Role of tamoxifen in idiopathic gynecomastia: A 10-year prospective cohort study. It's important to note that CPT 19324 - mammaplasty, augmentation without pros-thetic implant - has been deleted. 2005;58(3):286-289. 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. In the case of breast reduction, however, for insurance purposes, it . 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. Surg Laparosc Endosc Percutan Tech. Cambridge, UK: Oxbridge Solutions, Ltd.; 2003. Can objective predictors for operative success be identified? Among these domains were: vitality, emotional discomfort, limitations due to physical aspects and limitations due to pain. 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. If reduction mammoplasty was performed before oncological treatment, the incidence of abnormal findings was higher. Analysis was on an intention-to-treat basis. Exposure to partners using estrogen containing vaginal creams; Cancer chemotherapy (alkylating agents, methotrexate, vinca alkaloids, imatinib, combination chemotherapy), Androgen receptor blockers - bicalutamide, 5 reductase inhibitors - finasteride, dutasteride, Angiotensin converting enzyme inhibitors (captopril, enalapril), Calcium channelblockers(diltiazem, nifedipine, verapamil), Anabolic steroids(e.g., in body builders). The authors concluded that high digit ratio in men with gynecomastia may tend to be a marker of over-expression of ER and PR. list-style-type: lower-alpha; Subgroup analysis further stratified the younger cohort into those <50 years and 50-60 years of age. Plast Reconstr Surg. Brown MH, Weinberg M, Chong N, et al. 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. Treatment of adolescent gynecomastia. bottom: 20px; Breast pumps. Plast Reconstr Surg. 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 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. 2004;113(1):436-437. Am Surg. The 2 vacuum-assisted breast biopsy systems (Mammotome and Encor) were used for the patients with gynecomastia. 2011;21(5):431-434. Henley DV, Lipson N, Korach KS, Bloch CA. These investigators presented their experience with pectoral high-definition liposculpture combined with inverted-omega incision resection for 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. For medical 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 1994;21(3):539-543. OL OL OL OL LI { However, if liposuction is used as an adjunctive technique, the decision to use drains should be left to the surgeon's discretion. Washington, DC: ACOG; 2011:121-122. Liposuction assisted gynecomastia surgery with minimal periareolar incision: A systematic review. Wound drainage after plastic and reconstructive surgery of the breast. Photographs were taken pre-operatively and 1, 3, 6, and 12 months post-operatively. display: none; Ages ranged from 18 to 66 years. The mean incidence of gynecomastia was 70 % in the high-risk population examined representing prostate cancer patients on estrogen or anti-androgen therapy. Complication rates were inconsistent throughout the studies, ranging from 0.06 % to 26.67 %. 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). 2015;(10):CD007258. Liposuction was also used adjunctively in all cases (average of 455 cc; range, 50 to 1,750 cc). Breast reduction for symptomatic macromastia. Of 291 subjects who were selected for inclusion in the study, only 179 completed follow-up. The operation had a mean duration of 73.5 mins per side, ranging from 40 to 102 mins. The nipple-areola complex was re-positioned in 60 % of patients (n = 54). 2002;33:208-217. #closethis { Reduction mammaplasty: An outcome study. 1998;26(1):61-65. Several important points should be considered in evaluating these challenges to insurers' criteria for breast reduction surgery. Karamanos E, Wei B, Siddiqui A, Rubinfeld I. Horm Res Paediatr. A total of 244 out of 1,628 patients with the average age of 23.13 years. The study consisted of 329 breast cancer patients, who underwent symmetrizing reduction mammoplasty between 1/2007 and 12/2011. All the patients recovered well and were satisfied with the cosmetic outcomes. Sugrue CM, McInerney N, Joyce CW, et al. Ann Plast Surg. American College of Obstetricians and Gynecologists (ACOG), Committee on Adolescent Health Care. Reduction mammoplasty also known as breast reduction surgery, is a surgical procedure in women to reduce the weight, mass, and size of the breast. No data were provided on loss to follow-up. Ann Chir Plast Esthet. Nelson et al (2014b) separately conducted a population level analysis of the 2005-2011 NSQIP datasets, identifying patient who underwent reduction mammoplasty, to determine the impact of obesity on early complications after reduction mammoplasty. Abnormal histopathology correlated with higher age (p = 0.0053), heavier specimen (p = 0.0491), and with no previous breast surgery (p < 0.001). Please check your insurance policy to see whether breast reduction is a covered procedure. 2008;61(5):493-502. Hoyos AE, Perez ME, Dominguez-Millan R, et al. Here's what Aetna said in the denial: "We used the Clinical Policy Bulletin (CPB): Breast Reduction Surgery. .headerBar { Two patients experienced unilateral minor partial necrosis of the areolar edge but not of the nipple itself (2 %). The health burden of breast hypertrophy. Transient pain that may occur as the breast enlarges and the capsule is stretched; these symptoms may be managed with analgesics. Treating providers are solely responsible for medical advice and treatment of members. Health insurance companies frequently have different criteria for whether breast reduction surgery is medically necessary. Fagerlund A, Lewin R, Rufolo G, et al. Burns JL, Blackwell SJ. Breast J. Risk factors for complications following breast reduction: Results from a randomized control trial. 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. Jones SA, Bain JR. Review of data describing outcomes that are used to assess changes in quality of life after reduction mammaplasty. Risk of bias was assessed independently by 2review authors. 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. Howrigan P. Reduction and augmentation mammoplasty. No author listed. @media print { Gonzalez FG, Walton RL, Shafer B, et al. 2009;19(3):e85-e90. 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. In a prospective, cohort study, these investigators evaluated the efficacy of tamoxifen therapy in resolving this condition. Socioeconomic Committee Position Paper. Narula HS, Carlson HE. J Pediatr Surg. 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 . } In: Townsend CM, Beuchamp RD, Evers BM, eds. Surgical management of gynecomastia--a 10-year analysis. 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. Reduction mammoplasty: Cosmetic or reconstructive procedure? Surgical treatment of gynecomastia: Complications and outcomes. They have argued that removal of even a few hundred grams of breast tissue can result in substantial pain relief. Aetna is the brand name used for products and services provided by one or more of the Aetna group of subsidiary companies, including Aetna . 2010;125(5):1301-1308. Drainage in breast reduction surgery: A prospective randomised intra-patient trail. 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 No new trials were identified for this first update. Karamanos et al (2015) noted that although breast reduction mammoplasty accounts for more than 60,000 procedures annually, the literature remains sparse on outcomes. 1999;103(6):1687-1690. Fischer S, Hirsch T, Hirche C, et al. 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. Reduction mammoplasty for asymptomatic members is considered cosmetic. 2008;32(1):38-44. The following factors were independently associated with any surgical complications: morbid obesity (odds ratio [OR], 2.1; P < .001), active smoking (OR, 1.7; P < .001), history of dyspnea (OR, 2.0; P < .001), and resident participation (OR, 1.8; P = .01) while factors associated with major complications included active smoking (OR, 2.7; P < .001), dyspnea (OR, 2.6; P < .001), resident participation (OR, 2.1; P < .001), and inpatient surgery (OR, 1.8; P = .01). 2001;76(5):503-510. Because of their inherently subjective nature, pain symptoms are especially prone to placebo effects. Asian J Surg. Fat grafting to the breast can now be reported with CPT codes 15771 and 15772. J Am Coll Surg. Plastic Reconstruct Surg. 2005;55(3):227-231. Causes may include testosterone-estrogen imbalance, increased prolactin levels, or abnormal serum binding protein levels. Plast Reconstr Surg. The authors concluded that this study was the largest to-date examining the role of tamoxifen in idiopathic gynecomastia, and these findings showed approximately 9 in every 10 men treated with tamoxifen therapy had successful resolution of their symptoms. Surgical treatment is indicated when medical treatments fail. Subjects were compared to age-matched norms from another study cohort. margin-top: 38px; .strikeThrough { 1995;61(11):1001-1005. 2000;106(5):991-997. 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. Special Clinical Concerns. Yao Y, Yang Y, Liu J, et al. The average age was 24.7 years (range of 18 to 47 years). 2002;109(5):1556-1566. 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.
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