Aesthetic Plast Surg. Reduction mammaplasty provides long-term improvement in health status and quality of life. Plast Reconstr Surg. Imahiyerobo TA, Pharmer LA, Swistel AJ, Talmor M. A comparative retrospective analysis of complications after oncoplastic breast reduction and breast reduction for benign macromastia: Are these procedures equally safe? 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. Krieger LM, Lesavoy MA. Secondary outcomes included subjective as well as objective assessments of pain and wound healing. The authors concluded that the incidences of malignant and high-risk lesions were doubled compared to patients without prior breast cancer. 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 . 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). 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. 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). However, if liposuction is used as an adjunctive technique, the decision to use drains should be left to the surgeon's discretion. Breast reduction surgery is considered cosmetic for all indications not listed in section I, A. High-risk lesions (atypical ductal hyperplasia [ADH], atypical lobular hyperplasia [ALH], and lobular carcinoma in situ [LCIS]) were revealed in 37 (11.7 %), and cancer in 6 (1.9 %) patients. 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. Mental health care professionals may be consulted to address psychological distress from gynecomastia. The investigators reported that subjects who were of normal weight were as likely to report benefit from reduction mammoplasty as subjects who were over-weight. Arlington Heights, IL: ASPRS; 1987. 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. World J Surg. Marshall WA, Tanner JM. 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. These investigators retrospectively examined 83 patients with gynecomastia between January 2015 and December 2019. Patients with abnormal histopathology could not be pre-operatively identified based on demographics. Following treatment, 90.1 % (n = 73) had a complete response of their gynecomastia with tamoxifen therapy. Reduction mammoplasty for macromastia. 2021 Aug 11 [Online ahead of print]. } A non-standardized survey showed a very high satisfaction index. li.bullet { Arlington Heights, IL: ASPS; March 9, 2002. The operation was successfully performed in all 20 patients with a mean operating time of 51 mins and a hospital stay of 4 days. border: none; # font-weight: bold; }. However, the measuring method of satisfaction rate varied, resulting in difficulties to interpret the results. Priorities Forum Policy Statement. This will be computed based on your body area. The control group was not followed longitudinally or treated according to any protocol to ensure that they received optimal conservative management; conclusions about the lack of effectiveness of conservative management were based on their responses to a questionnaire about whether subjects tried any of 15 conservative interventions, and whether or not they thought these interventions provided relief of symptoms. While 1 study showed high patient's satisfaction rate; both studies indicated high surgeon's satisfaction rate. Completely autologous platelet gel in breast reduction surgery: A blinded, randomized, controlled trial. Mannu and colleagues (2018) stated that idiopathic gynecomastia is a benign breast disorder characterized by over-development of male breast tissue. Mizgala CL, MacKenzie KM. 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. Open surgery was performed in 56 patients, and vacuum-assisted breast biopsy was performed in 27 patients. The average interval between primary and secondary surgery was 14 years (range of 0 to 42 years). #closethis { 1995;95(1):77-83. Breast pumps. The health burden of breast hypertrophy. Surgical implications of obesity. z-index: 99; See Appendix for Table 1. Hoyos AE, Perez ME, Dominguez-Millan R, et al. 2nd ed. Glatt BS, Sarwer DB, O'Hara DE, et al. } 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. 1. Aesthetic Plast Surg. 2015;10(8):e0136094. 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. 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. N Engl J Med. Other referencesto smaller studies published prior to the BRAVO study have been cited,examining symptoms before and after reduction mammoplasty; each of these studies suffer from limitations similar to those identified with the BRAVO study. American College of Obstetricians and Gynecologists (ACOG), Committee on Adolescent Health Care. All patients underwent routine investigations to exclude secondary causes of gynecomastia. CPT Codes 19316 & 19318 - Mastopexy & Reduction No significant changes have been made to the Copyright Aetna Inc. All rights reserved. A systematic search of the published literature was performed. A retrospective review was conducted of patients who underwent bilateral breast re-reduction surgery performed by a single surgeon over a 12-year period. Data was then analyzed for surgical complications, wound complications, and medical complications within 30 days of surgery on 4545 patients. Please check your insurance policy to see whether breast reduction is a covered procedure. Nguyen JT, Wheatley MJ, Schnur PL, et al. 2018;89(6):408-412. --> Obstet Gynecol Clin North Am. } 1998;49:215-234. Computed tomography scan of adrenal glands to identify adrenal lesions. 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. Well-designed, prospective, controlled clinical studies have not been performed to assess the effectiveness of surgical removal of modest amounts of breast tissue in reducing neck, shoulder, and back pain and related disability in women. 2000;106(2):280-288. 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. Plast Reconstr Surg. J Plast Reconstr Aesthet Surg. All subjects were satisfied with their cosmetic outcome, graded as excellent by 22 patients (100 %). Policy Statement 6d: Aesthetic surgery procedures. breast augmentation with implant. Until now, most published research on the subject has focused on how effective surgical treatment is on correcting the cosmetic appearance of the breast. Fagerlund A, Lewin R, Rufolo G, et al. The study subjects were stratified into groups based on ages of <60 years and 60 years. Gynecomastia is a very common concern of male adolescence. Patient demographics, surgical technique, and outcomes were analyzed. A total of 3 RCTs were identified and included in the review out of 190 studies that were initially screened; all evaluated wound drainage after breast reduction surgery. Aetna considers breast reconstructive surgery to correct Plastic Reconstr Surg. Reduction mammoplasty has also been used for relief of pain in the back, neck and shoulders. 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. Removing the adipose tissue in pseudogynecomastia usually has no long term effect as adipose tissue reaccumulates unless the individual loses weight. .fixedHeaderWrap { 2014a;34(1):66-73. 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. Photographs were taken pre-operatively and 1, 3, 6, and 12 months post-operatively. Harmonic scalpel versus electrocautery in breast reduction surgery: A randomized controlled trial. Principles of breast re-reduction: A reappraisal. Sood R, Mount DL, Coleman JJ 3rd, et al. Two patients experienced unilateral minor partial necrosis of the areolar edge but not of the nipple itself (2 %). Behmand RA, Tang DH, Smith DJ Jr. Outcomes in breast reduction surgery. 2001;108(6):1591-1599. 2011;128(4):243e-249e. Khan SM, Smeulders MJ, Van der Horst CM. Tang CL, Brown MH, Levine R, et al. Clinical outcomes in reduction mammaplasty: A systemic review and meta-analysis of published studies. They have argued that removal of even a few hundred grams of breast tissue can result in substantial pain relief. To get insurance coverage, you'll probably need . } 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. Initial breast reconstruction including augmentation with implants 15771-15772 (when specific to breast), 19325, 19340, 19342, C1789 Fat grafting (alone, or with implant based feminization) 15771, 15772 *Note: CPT 19318 (breast reduction) includes the work necessary to reposition and reshape the nipple . 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. } Aetna does not provide health care services and, therefore, cannot guarantee any results or outcomes. This may justify an early use of tamoxifen in men with gynecomastia and a high digit ratio. Plast Reconstr Surg. 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. display: none; 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. 2009;19(3):e85-e90. No author listed. 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. OL OL LI { .newText { Fat grafting to the breast can now be reported with CPT codes 15771 and 15772. 1995;34(2):113-116. } Aetna is the brand name used for products and services provided by one or more of the Aetna group of subsidiary companies, including Aetna . Am Surg. Breast reduction surgery is considered reconstructive and medically necessary in certain circumstances . Health insurance companies frequently have different criteria for whether breast reduction surgery is medically necessary. 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). 18th ed. padding-bottom: 4px; Cambridge, UK: Oxbridge Solutions, Ltd.; 2003. OL OL OL OL LI { Abnormalities in Adolescent Breast Development. In: Townsend CM, Beuchamp RD, Evers BM, eds. Of these, 28.4 % were bilateral gynecomastia and 71.6 % were unilateral. Variations in pattern of pubertal changes in girls. # color: white; 2002;109(5):1556-1566. 2018;7(Suppl 1):S70-S76. 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. This study included 35 patients who underwent breast reduction due to the idiopathic form of gynecomastia. 2019;8(4):431-440. 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. The authors (Nguyen et al, 2004) argue, based primarily on the results of the ASPS-funded BRAVO study (described below), that (with a single exception) no objective criteria for breast reduction surgery are supportable, including criteria based upon the presence of particular signs or symptoms, requirements based upon breast size or the amount of breast tissue removed, any minimum age limitations, any limitation based upon maximum body weight, requirements for a trial of conservative therapy, or the exclusion of certain procedures (liposuction). This may lead to additional scarring and additional operating time. Plastic Reconstr Surg. Only 8 (9.9 %) patients did not have a complete resolution following tamoxifen therapy, of which 2 underwent subsequent surgical resection of their symptomatic gynecomastia. Henley et al (2007) reported that repeated topical exposure to lavender and tea tree oils may be linked to prepubertal gynecomastia (idiopathic gynecomastia). Breast reconstruction/breast enlargement Breast reduction/mammoplasty Excision of excessive skin due to weight loss Gastroplasty/gastric bypass 2013;71(5):471-475. Surgical treatment of primary gynecomastia in children and adolescents. If gynecomastia is idiopathic, reassurance of the common, transient and benign nature of the condition should be given. The surgeon estimates that at least the following amounts (in grams) of breast tissue, not fatty tissue, will be removed from each breast, based on the member's body surface area (BSA) calculated using theMosteller formula. Among these domains were: vitality, emotional discomfort, limitations due to physical aspects and limitations due to pain. ASPS clinical practice guideline summary on reduction mammaplasty. Grade IV: Marked breast enlargement with skin redundancy and feminization of the breast. height:2px; Choban PS, Flancbaum L. The impact of obesity on surgical outcomes: A review. However, the BRAVO study is not of sufficient quality to reach reliable conclusions about the effectiveness of breast reduction surgery as a pain intervention. 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. Liposuction facilitated the easy handling to remove the breast tissue via small incisional design; showed consistent improved QOL in terms of satisfaction after surgery. Macromastia: all . Breast re-reduction surgery was most commonly performed using a random pattern blood supply, rather than recreating the primary pedicle [n = 77 (86 %)]. .strikeThrough { Complications following reduction mammaplasty: A review of 3538 cases from the 2005-2010 NSQIP data sets. Several of the included studies reported improvement in QOL and several psychological domains after surgical treatment for gynecomastia. Hello! Reduction mammoplasty or breast reduction surgery reduces the volume and weight of the female breasts by removing excess fat, glandular tissue and skin. list-style-image: url('https://www.aetna.com/cpb/medical/data/assets/images/purplearrow.jpg') !important; 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). American Society of Plastic Surgeons (ASPS). Prasetyono TOH, Budhipramono AG, Andromeda I, et al. In these cases, breast reduction for men may take 2 to 3 hours. Reduction mammoplasty: Criteria for insurance coverage. Plast Reconstr Surg. Causes may include testosterone-estrogen imbalance, increased prolactin levels, or abnormal serum binding protein levels. J Laparoendosc Adv Surg Tech A. Early complications were rare (6.1%), with superficial skin and soft tissue infections accounting for 45.8% of complications. Scand J Plast Reconstr Hand Surg. 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. Sollie (2018) noted that gynecomastia affects up to 2/3 of the male population. Most cases of type I gynecomastia are unilateral, and 20% of cases are bilateral. The NSQIP recorded two complication types: major complications (deep infection and return to operating room) and any complication (all surgical complications). 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 Plast Surg. Patients undergoing surgery for gynecomastia should know that their scars may be visible when they are shirtless. Level of Evidence = IV. Ann Plastic Surg. Qu S, Zhang W, Li S, et al. Conversely, many patients believe if a procedure is considered cosmetic, it is not a medically indicated and covered procedure. 2001;108(1):62-67. I have recently met with my primary doctor after speaking to my insurance company (aetna) for months about getting a breast reduction. Furthermore, no serious complications were observed in vacuum-assisted breast biopsy group. Yao and co-workers (2019) described an innovative method for the operative treatment of gynecomastia -- vacuum-assisted minimally invasive mastectomy. 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. 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. 2015;75(4):370-375. Many men with breast enlargement are found to have pseudo-gynecomastia. 2016;20(3):256-260. Covered items may include: A manual or standard electric pump (non-hospital grade) while you are pregnant or for the duration of breastfeeding. 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: 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. No data were provided on loss to follow-up. Risk factors for complications following breast reduction: Results from a randomized control trial. Autorino R, Perdona S, D'Armiento M, et al. Resolution of idiopathic gynecomastia may take several months to years. #backTop:hover { Estrogens and estrogen like drugs,including: Drugsthat enhance estrogen formation, including: Drugs which inhibit testosterone synthesis, including, Drugs that inhibit testosterone action, including. Kerrigan CL, Collins ED, Striplin D, et al. 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]. These individuals cite evidence from observational studies to support this position (e.g., Chadbourne et al, 2001; Kerrigan et al, 2001). 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. Ann Plastic Surg. } The article by Blomqvist et al (2000) is to another questionnaire study about health status and quality of life before and after surgery. 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. The authors concluded that vacuum-assisted, minimally invasive mastectomy was a feasible approach for the treatment of gynecomastia with acceptable complications. J Am Coll Surg. A total of 244 out of 1,628 patients with the average age of 23.13 years. 1999;103(1):76-82; discussion 83-85. If reduction mammoplasty was performed before oncological treatment, the incidence of abnormal findings was higher. In a systematic review, these investigators examined the role of radiotherapy in this context. Preoperative patient factors and comorbidities, as well as intraoperative variables, were assessed. 1995;61(11):1001-1005. 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. display: block; Mannu GS, Sudul M, Bettencourt-Silva JH, et al. These researchers compared the safety and effectiveness of the use of wound drains following elective plastic and reconstructive surgery procedures of the breast. Minor complications (3.2 %) included prolonged swelling, bruising, asymmetries, and residual gynecomastia. Often times, insurance company will dictate how much breast tissue to be removed. 2014;20(3):274-278. Nelson JA, Fischer JP, Wink JD, Kovach SJ 3rd. 2001;76(5):503-510. This Clinical Policy Bulletin addresses breast reduction surgery and gynecomastia surgery. Merkkola-von Schantz PA, Jahkola TA, Krogerus LA, Kauhanen SMC. 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. of . } Lonie S, Sachs R, Shen A, et al. .strikeThrough { American Society of Plastic Surgeons (ASPS). padding-right: 18px; cursor: pointer; 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. Drains were used significantly less by surgeons performing greater than or equal to 20 BBRs (p = 0.02). Redundant skin was observed in 1 patient at 1 month post-operatively, whose breast, defined as grade-III, was the largest before operation.
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