Plast Reconstr Surg. Breast reduction surgery is considered reconstructive and medically necessary in certain circumstances . # font-weight: bold; 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. Furthermore, there is insufficient evidence that surgical removal is more effective than conservative management for pain due to gynecomastia. J Plast Reconstr Aesthet Surg. A detailed physical examination, including testicular examination. Mannu GS, Sudul M, Bettencourt-Silva JH, et al. 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). Dancey A, Khan M, Dawson J, Peart F. Gigantomastia--a classification and review of the literature. Tobacco use and body mass index as predictors of outcomes in patients undergoing breast reduction mammoplasty. Aesthetic Plast Surg. #closethis { Another set of breast pump supplies if you get pregnant . Kalliainen LK; ASPS Health Policy Committee. Khan SM, Smeulders MJ, Van der Horst CM. These researchers calculated the risk ratio (RR) for dichotomous outcomes and mean differences (MD) for continuous outcomes, with 95 % confidence intervals (CI). Breast and aesthetic surgery. 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. They evaluated the use of radiotherapy for the prevention and treatment of gynecomastia incidence or recurrence by plastic surgeons. 2 . 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. And if you are in Canada the surgeon decides. Fagerlund A, Lewin R, Rufolo G, et al. Last Review01/04/2023. Moreover, these researchers stated that further studies are needed within the common gynecomastia population managed by plastic surgeons to examine the clinical and economical utility of this intervention before a recommendation for its ubiquitous adoption in plastic surgery can be made to continue improving outcomes for high-risk gynecomastia patients. .fixedHeaderWrap { } Jones SA, Bain JR. Review of data describing outcomes that are used to assess changes in quality of life after reduction mammaplasty. } He Q, Zheng L, Zhuang D, et al. Breast Reduction Surgery and Gynecomastia Surgery - Medical Clinical Policy Bulletins | Aetna Page . Asian J Surg. Of these, 28.4 % were bilateral gynecomastia and 71.6 % were unilateral. Breast Concerns of Adolescents. Furthermore, no serious complications were observed in vacuum-assisted breast biopsy group. The NSQIP recorded two complication types: major complications (deep infection and return to operating room) and any complication (all surgical complications). It is universally believed by patients that if a surgery is considered reconstructive, it is medically indicated and covered by health insurance. In the case of breast reduction, however, for insurance purposes, it . 2015;10(8):e0136094. Morbidly obese patients are at the highest risk, with complications occurring in nearly 12% of this cohort. Srinivasaiah N, Iwuchukwu OC, Stanley PR, et al. top: 0px; OL OL OL OL LI { 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. Special Clinical Concerns. Beer GM, Kompatscher P, Hergan K. Diagnosis of breast tumors after breast reduction. } color:#eee; J Pediatr Surg. 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). Aesthet Surg J. Wound drainage after plastic and reconstructive surgery of the breast. 2021 Aug 11 [Online ahead of print]. Laituri CA, Garey CL, Ostlie DJ, et al. Plast Reconstr Surg. Surg Laparosc Endosc Percutan Tech. 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. background-color: #663399; /*margin-bottom: 43px;*/ Kasielska-Trojan A, Danilewicz M, Antoszewski B. However, the measuring method of satisfaction rate varied, resulting in difficulties to interpret the results. The study by Schnur et al was based on a survey of 92 plastic surgeons who reported on their care for 591 patients. 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. 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. Reduction mammaplasty: An outcome study. 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. 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. Cochrane Database Syst Rev. Guidelines for Adolescent Health Care. 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. The authors concluded that the incidences of malignant and high-risk lesions were doubled compared to patients without prior breast cancer. J Laparoendosc Adv Surg Tech A. Clinical Policy Bulletins are developed by Aetna to assist in administering plan benefits and constitute neither offers of coverage nor medical advice. In total there were 306 women in the 3 trials, and 505 breasts were studied (254 drained, and 251 who were not drained). Quality of life after breast reduction. 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. The median complication rate was 12.4 % with no major complications, such as neoplastic, pulmonary, or adverse cardiac outcomes. Clinical outcomes were measured by operative subjects' responses to a questionnaire about symptoms and quality of life. For the first update of this review, these investigators searched the Cochrane Wounds Group Specialised Register (searched March 4, 2015); the Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library 2015, Issue 2); Ovid Medline (2012 to March 3, 2015); Ovid Medline (In-Process & Other Non-Indexed Citations March 3, 2015); Ovid Embase(2012 to March 3, 2015); and EBSCO CINAHL (2012 to March 4, 2015). 1993;91(7):1270-1276. An 18-question survey was created evaluating various aspects of BBR practice; UK and Irish plastic and reconstructive and breast surgeons were invited to participate by an e-mail containing a link to a web-based survey. The authorsleave the reader with the conclusionthat decisions about the medical necessity of breast reduction surgery in symptomatic women should be left entirely to the surgeon's discretion. Blomqvist L, Eriksson A, Brandberg Y. Plast Reconstr Surg. OL OL OL OL OL LI { 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 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. 2005;58(3):286-289. margin-top: 38px; Is there a rationale behind pharmacotherapy in idiopathic gynecomastia? Please check your insurance policy to see whether breast reduction is a covered procedure. With the majority of BBRs performed as an inpatient procedure, there was a trend towards less drain usage in surgeons performing this procedure as an out-patient; however, this was not statistically significant (p = 0.07). 2008;61(5):493-502. list-style-type: decimal; Mizgala CL, MacKenzie KM. Seitchik (1995) reviewed the amount of breast tissue removed from a series of 100 patients that underwent breast reduction surgery. cursor: pointer; The mean incidence of gynecomastia was 70 % in the high-risk population examined representing prostate cancer patients on estrogen or anti-androgen therapy. No author listed. Iwuagwu OC, Stanley PW, Platt AJ, Drew PJ. Grooving where the bra straps sit on the shoulder. 2000;44(2):125-134. A population-level analysis of bilateral breast reduction: does age affect early complications? 2014b;48(5):334-339. bottom: 20px; Refer to the member's specific plan document for applicable coverage. Sixty to 70% of males develop a transient subareolar breast tissue during their adolescence (Tanner Stages II and III). Collins ED, Kerrigan CL, Kim M, et al. Sood R, Mount DL, Coleman JJ 3rd, et al. Ann Plast Surg. American Society of Plastic Surgeons (ASPS). Reduction mammoplasty specimens revealed abnormal findings in 68 (21.5 %) patients. Fat grafting volume ranged from 50 to 300 cc in each pectoral muscle. 1995;34(2):113-116. Breast asymmetries: A brief review and our experience. Principles of breast re-reduction: A reappraisal. If reduction mammoplasty was performed before oncological treatment, the incidence of abnormal findings was higher. 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. Plast Reconstr Surg. Miller AP, Zacher JB, Berggren RB, et al. Reduction mammoplasty: Cosmetic or reconstructive procedure? Approximately 25 % of the 49 subjects included in this study did not return the post-operative questionnaire. Insurers have commonly used the amount of breast tissue to be removed as a criterion for evaluating the medical necessity of breast reduction surgery. Aesthetic Plast Surg. 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. background-color:#eee; background-position: right 65%; padding-right: 18px; Copyright Aetna Inc. All rights reserved. Statistical analysis was performed with student t-test and chi-square test. Women's Health and Cancer Rights Act of 1998. With approval from the authors institutional ethics committee and written informed consent, a total of 22 patients with 33 abnormally hyperplastic breasts were enrolled at the First Affiliated Hospital with Nanjing Medical University between June 2016 and September 2018. Fischer JP, Cleveland EC, Shang EK, et al. Merkkola-von Schantz PA, Jahkola TA, Krogerus LA, Kauhanen SMC. 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. 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. Aetna considers breast reconstructive surgery to correct The study subjects were stratified into groups based on ages of <60 years and 60 years. All studies on the subject were evaluated for inclusion and 6 studies were included in the review. The Mammotome procedure represented another novel therapeutic option for gynecomastia. display: none; They stated that no data are available for breast augmentation or breast reconstruction, and this requires investigation. Plastic Reconstr Surg. Pseudo-gynecomastia refers to excessive fat tissue or prominent pectoralis muscles. } Surgical treatment of gynecomastia: Complications and outcomes. Re-operation rate of liposuction-assisted surgery was between 0.6 % and 25 %. 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. Leclere FM, Spies M, Gohritz A, Vogt PM. Plast Reconstr Surg. A total of 15 articles met the inclusion criteria for review. Plast Reconstr Surg. No necrosis, systemic infection, or muscle paralysis was reported. 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). 2005;55(3):227-231. Ann Plastic Surg. Measurement of plasma gonadotrophins, human chorionic gonadotropin (hCG), testosterone, estradiol, and dehydroepiandosterone sulphate (DHEAS). Gynecomastia Treatment through Open Resection and Pectoral High-Definition Liposculpture. 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. } 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). Reduction mammoplasty for macromastia. 2018;89(6):408-412. There were only 2 studies of a total 25 patients that were considered as good in quality. .arrowPurpleSmall, a:hover.arrowPurpleSmall { Gynecomastia, its etiologies and its surgical management: A difference between the bilateral and unilateral cases? Many men with breast enlargement are found to have pseudo-gynecomastia. For many patients the psychological impact of the disease is substantial. Removing the adipose tissue in pseudogynecomastia usually has no long term effect as adipose tissue reaccumulates unless the individual loses weight. The average interval between primary and secondary surgery was 14 years (range of 0 to 42 years). 2003;111(2):688-694. Henley et al (2007) reported that repeated topical exposure to lavender and tea tree oils may be linked to prepubertal gynecomastia (idiopathic gynecomastia). Yao Y, Yang Y, Liu J, et al. list-style-image: url('https://www.aetna.com/cpb/medical/data/assets/images/purplearrow.jpg') !important; Araco A, Gravante G, Araco F, et al. Of 110 subjects who were mailed questionnaires, approximately50 %(61 subjects) provided responses. However, it is unclear if there is any evidence to support this practice. --> The data were retrospectively analyzed for demographics, operative and histopathology reports, oncological treatment, and post-operative follow-up. Reduction mammoplasty has been performed to relieve back and shoulder pain on the theory that reducing breast weight will relieve this pain. 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. Reduction mammaplasty: A review of managed care medical policy coverage criteria. Ann Plast Surg. Mental health care professionals may be consulted to address psychological distress from gynecomastia. margin-bottom: 38px; A non-standardized survey showed a very high satisfaction index. It can cause discomfort and concern, resulting in patients seeking diagnosis and treatment. Plast Reconstr Surg. Saunders Co.; 1991. text-decoration: line-through; Examining any complication, a significant increase was noted with increasing obesity class (p < 0.001). Li CC, Fu JP, Chang SC, et al. 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. 2002;33:208-217. color: red!important; Autorino R, Perdona S, D'Armiento M, et al. For individuals who received radiation treatment to the chest . Breast reduction surgery is considered cosmetic for all indications not listed in section I, A. Aetna is the brand name used for products and services provided by one or more of the Aetna group of subsidiary companies, including Aetna . Ann Plast Surg. Schnur PL, Hoehn JG, Ilstrup DM, et al. 2017;35:157-161. Gynecomastia in patients with prostate cancer: A systematic review. Complication rates were inconsistent throughout the studies, ranging from 0.06 % to 26.67 %. 2014a;34(3):409-416. } The operation had a mean duration of 73.5 mins per side, ranging from 40 to 102 mins. OL LI { 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 Work-up of gynecomastia may include the following (GP Notebook, 2003): Treatment should be directed at correcting any underlying reversible causes. Safran T, Abi-Rafeh J, Alabdulkarim A, et al. Horm Res Paediatr. Plastic Reconstruct Surg. Level of Evidence = III. 18th ed. The only criterion that the authors found supportable wasa requirementfor a pre-operative mammogram for women aged 40 years and older. font-size: 18px; Preoperative patient factors and comorbidities, as well as intraoperative variables, were assessed. ER expression did not correlate with the right (p = 0.51) and left 2D: 4D (p = 0.97). Risk of bias was assessed independently by 2review authors. 2001;108(6):1591-1599. Photographs were taken pre-operatively and 1, 3, 6, and 12 months post-operatively. Treating providers are solely responsible for medical advice and treatment of members. Hoyos and colleagues (2021) stated that male chest definition surgery and patients complaining of breast tissue over-growth have been increasing in recent decades. 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]. Qu and colleagues (2020) examined the effectiveness of vacuum-assisted breast biopsy systems for the treatment of gynecomastia. Drains were used significantly less by surgeons performing greater than or equal to 20 BBRs (p = 0.02). Fagerlund A, Cormio L, Palangi L, 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. Sugrue CM, McInerney N, Joyce CW, et al. Macromastia: all . Breast reconstruction/breast enlargement Breast reduction/mammoplasty Excision of excessive skin due to weight loss Gastroplasty/gastric bypass Reduction mammaplasty in patients with history of breast cancer: The incidence of occult cancer and high-risk lesions. 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. Gynecomastia. Med Decis Making. 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. American Society of Plastic Surgeons (ASPS). In addition, reduction mammoplasty needs to be compared with other established methods of relieving back, neck and shoulder pain. The majority (87.7 %) of cases presented with accompanying mastalgia. 2007;36(2):497-519. Of 291 subjects who were selected for inclusion in the study, only 179 completed follow-up. The author identified the psychological domains affected by the disease and the effect of surgical treatment on these. Kerrigan CL, Collins ED, Kneeland TS, et al. PLoS One. Arlington Heights, IL: ASPS; 2011. 2012;130(4):785-789. Arlington Heights, IL: ASPS; May 2011. # color: white; Two patients experienced unilateral minor partial necrosis of the areolar edge but not of the nipple itself (2 %). 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. Surgeon. Managed care's methods for determining coverage of plastic surgery procedures: The example of reduction mammaplasty. .newText { 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. 1995;95(6):1029-1032. #backTop { Resolution of idiopathic gynecomastia may take several months to years. Breast J. A total of 211 responding surgeons were analyzed, including 80.1 % (171/211) plastic surgeons and 18.9 % (40/211) breast surgeons. breast augmentation with implant. Reduction (or some cases augmentation) mammoplasty and related reconstructive procedures on the unaffected side for symmetry are also considered medically necessary. 1995;61(11):1001-1005. Plast Reconstr Surg. Links to various non-Aetna sites are provided for your convenience only. Grade III: Moderate breast enlargement exceeding areola boundaries with edges that are indistinct from the chest with skin redundancy present. 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). The Breast: Comprehensive Management of Benign and Malignant Diseases. 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. Aesthet Surg J. Based on CPB criteria and the information we have, we're denying coverage for breast reduction surgery. 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. .headerBar { For pain interventions, evidence of effectiveness is necessary from well controlled, randomized prospective clinical trials assessing effects on pain, disability, and function. Gland Surg. Nelson JA, Fischer JP, Wink JD, Kovach SJ 3rd. ul.ur li{ } } 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. 2001;108(1):62-67. The requirement for coverage is that the amount of breast tissue to be removed has to be enough to improve your symptoms or function. 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. 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. 2008;53(3):255-261. Sixteen (23%) patients had complications and higher resection weight, increased BMI, and older age were found to have statistically significant complication rates with p-values of p<0.001, p=0.034, and p=0.004, respectively.The investigators also found that the incidence of complications was highest among current smokers and lowest among those who had never smoked with a 37% difference in the occurrence of complication (p<0.01). Annu Rev Med. Glatt BS, Sarwer DB, O'Hara DE, et al. Level of Evidence = IV. li.bullet { For those with large breasts, breast reduction surgery can ease discomfort and improve appearance. 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. Hello! J Plast Surg Hand Surg. (This refers to actual breast tissue only; any fatty tissue removed doesn't count.) Medical reduction has been achieved with agents such as dihydrotestosterone, danazol, and clomiphene. Note: For breast surgeries pertaining to gender affirmation, refer to CP.MP.95 Gender Affirming Procedures. The 2 studies, which discussed laser-assisted liposuction technique, showed minor complication of seroma in 2 patients. Reduction mammoplasty or breast reduction surgery reduces the volume and weight of the female breasts by removing excess fat, glandular tissue and skin. In Type I (idiopathic) gynecomastia, the adolescent presents with a tender, firm mass beneath the areola. There were 18 out of 415 studies eligible to review. Vacuum-assisted minimally invasive surgery-An innovative method for the operative treatment of gynecomastia. 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).