} 40 . 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. Plast Reconstr Surg. 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). The study subjects were stratified into groups based on ages of <60 years and 60 years. Major complications (1.6 %) included unilateral hematoma and localized infection. The author average amount of breast tissue removed for women in 5 kg weight bands, ranging from 45-49 kg to 90+ kg. color: #FFF; Women's Health and Cancer Rights Act of 1998. Until now, most published research on the subject has focused on how effective surgical treatment is on correcting the cosmetic appearance of the breast. It is universally believed by patients that if a surgery is considered reconstructive, it is medically indicated and covered by health insurance. Mannu and colleagues (2018) stated that idiopathic gynecomastia is a benign breast disorder characterized by over-development of male breast tissue. Plastic Reconstruct Surg. } Washington, DC: ACOG; 2011:121-122. Tang CL, Brown MH, Levine R, et al. background: url('https://www.aetna.com/cpb/medical/data/assets/images/purplearrow.jpg') no-repeat; Clinical Policy Bulletins are developed by Aetna to assist in administering plan benefits and constitute neither offers of coverage nor medical advice. J Am Coll Surg. Arch Dis Child. Annu Rev Med. 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. They investigated effects of age on 30-day surgical outcomes for reduction mammoplasty with a goal of improving patient care, counseling, and risk stratification on 3537 patients. list-style-type: lower-alpha; Ann Plast Surg. Coding Collins ED, Kerrigan CL, Kim M, et al. For many patients the psychological impact of the disease is substantial. Also, there was no correlation between PR expression and 2D: 4D. 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. Reduction mammaplasty provides long-term improvement in health status and quality of life. Plast Reconstr Surg. Handschin AE, Bietry D, Hsler R, et al. After these researchers 1st report of pectoral etching in 2012, patients and surgeons became more aware regarding gynecomastia resection when performing pectoral enhancement. Drainage in breast reduction surgery: A prospective randomised intra-patient trail. Redundant skin was observed in 1 patient at 1 month post-operatively, whose breast, defined as grade-III, was the largest before operation. A retrospective review was conducted of patients who underwent bilateral breast re-reduction surgery performed by a single surgeon over a 12-year period. Surgical treatment of primary gynecomastia in children and adolescents. Other just require 500 grams no matter what your height and weight. Conversely, many patients believe if a procedure is considered cosmetic, it is not a medically indicated and covered procedure. Measurement of plasma gonadotrophins, human chorionic gonadotropin (hCG), testosterone, estradiol, and dehydroepiandosterone sulphate (DHEAS). The primary outcome was the difference in wound drainage over 24 hours. 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. Plast Reconstr Surg. Seitchik MW. 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. Plast Reconstr Surg. Saunders Co.; 1991. These preliminary findings need to be validated by well-designed studies. Aetna plans exclude coverage of cosmetic surgery that is not medically necessary, . Ann Plast Surg. Schnur PL, Hoehn JG, Ilstrup DM, et al. 2014a;34(3):409-416. Gland Surg. Participating providers are independent contractors in private practice and are neither employees nor agents of Aetna or its affiliates. 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. Reduction mammoplasty specimens revealed abnormal findings in 68 (21.5 %) patients. Furthermore, there is insufficient evidence that surgical removal is more effective than conservative management for pain due to gynecomastia. Minor complications (3.2 %) included prolonged swelling, bruising, asymmetries, and residual gynecomastia. 2012;130(4):785-789. Mayo Clin Proc. Dancey A, Khan M, Dawson J, Peart F. Gigantomastia--a classification and review of the literature. 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. Sollie (2018) noted that gynecomastia affects up to 2/3 of the male population. These investigators searched the literature on the treatment of Simon's grade I and II gynecomastia in PubMed, Scopus, Science Direct, and Cochrane using keywords "gynecomastia" and "liposuction". Thus, this study would not be considered of sufficient quality to provide reliable evidence of the effectiveness of a pain intervention. The study by Schnur et al was based on a survey of 92 plastic surgeons who reported on their care for 591 patients. 2014b;30(6):641-647. 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. 2009;62(2):195-199. All the patients recovered well and were satisfied with the cosmetic outcomes. OL OL OL OL OL LI { Plast Reconstr Surg. #backTop:hover { Secondary outcomes included subjective as well as objective assessments of pain and wound healing. Causes may include testosterone-estrogen imbalance, increased prolactin levels, or abnormal serum binding protein levels. Gynecomastia resection plus high-definition liposculpture was successfully performed in 436 consecutive men (open inverted-omega incision resection, n = 132; liposuction, n = 304). border: none; Disproportionately large breasts can cause both physical and emotional . #closethis { Srinivasaiah N, Iwuchukwu OC, Stanley PR, et al. 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. Estrogens and estrogen like drugs,including: Drugsthat enhance estrogen formation, including: Drugs which inhibit testosterone synthesis, including, Drugs that inhibit testosterone action, including. Surgical management of gynecomastia--a 10-year analysis. A detailed physical examination, including testicular examination. 2009;7(2):114-119. Reduction mammoplasty performed solely for cosmetic indications is considered by insurers to be not medically necessary treatment of disease and subject to the standard cosmetic surgery plan exclusion. Fischer et al (2014a) evaluated predictors of postoperative complications following reduction mammoplasty using the NSQIP) data sets. Ann Plast Surg. A total of 211 responding surgeons were analyzed, including 80.1 % (171/211) plastic surgeons and 18.9 % (40/211) breast surgeons. 1998;26(1):61-65. 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. Aetna considers magnetic resonance imaging (MRI), with or without contrast materials, of the breast medically necessary for members who have had a recent (within the past year) conventional mammogram and/or breast sonogram, in any of the following circumstances where MRI of the breast may affect their clinical management:. 0017 - Breast Reduction Surgery and Gynecomastia Surgery, are met. He and associates (2011) examined the safety and feasibility of vacuum-assisted biopsy device in the treatment of gynecomastia. Completely autologous platelet gel in breast reduction surgery: A blinded, randomized, controlled trial. J Plast Surg Hand Surg. Early complications were rare (6.1%), with superficial skin and soft tissue infections accounting for 45.8% of complications. 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). 2001;108(1):62-67. Removing the adipose tissue in pseudogynecomastia usually has no long term effect as adipose tissue reaccumulates unless the individual loses weight. The requirement for coverage is that the amount of breast tissue to be removed has to be enough to improve your symptoms or function. Breast cancer found at the time of breast reduction. 1995;95(1):77-83. Subgroup analysis further stratified the younger cohort into those <50 years and 50-60 years of age. Plastic surgery for teenagers briefing paper. Radiotherapy for prevention or management of gynecomastia recurrence: Future role for general gynecomastia patients in plastic surgery given current role in management of high-risk prostate cancer patients on anti-androgenic therapy. 2004;113(1):436-437. 1969;44(235):291-303. Reduction mammoplasty has also been used for relief of pain in the back, neck and shoulders. .strikeThrough { Most cases of type I gynecomastia are unilateral, and 20% of cases are bilateral. Reduction mammoplasty is among the most commonly performed cosmetic procedures in the United States. I have recently met with my primary doctor after speaking to my insurance company (aetna) for months about getting a breast reduction. Srinivasaiahet al (2014) stated that although reduction mammoplasty has been shown to benefit physical, physiological, and psycho-social health there are recognized complications. 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. 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. Merkkola-von Schantz and colleagues (2017) stated that contralateral reduction mammoplasty is regularly included in the treatment of breast cancer patients. OL OL LI { Swelstad MR, Swelstad BB, Rao VK, Gutowski KA. Breast hypertrophy. Reduction mammoplasty improves symptoms of macromastia. Following treatment, 90.1 % (n = 73) had a complete response of their gynecomastia with tamoxifen therapy. There were only 2 studies of a total 25 patients that were considered as good in quality. 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. 1996;20(5):391-397. Aetna considers associated nipple and areolar reconstruction and tattooing of the nipple area medically necessary. Gynecomastia: A systematic review. Breast Reduction Surgery and Gynecomastia Surgery - Medical Clinical Policy Bulletins | Aetna Page . ER expression did not correlate with the right (p = 0.51) and left 2D: 4D (p = 0.97). Vacuum-assisted minimally invasive surgery-An innovative method for the operative treatment of gynecomastia. However, if liposuction is used as an adjunctive technique, the decision to use drains should be left to the surgeon's discretion. Aetna does not provide health care services and, therefore, cannot guarantee any results or outcomes. 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. 1995;61(11):1001-1005. Anzarut A, Guenther CR, Edwards DC, Tsuyuki RT. Quality of life after breast reduction. A physician-supervised diet and exercise plan may be indicated in obese patients. Kasielska-Trojan A, Danilewicz M, Antoszewski B. 2011;128(4):243e-249e. It is not intuitively obvious, however, that breast weight would substantially contribute to back, neck and shoulder pain in women with normal or small breasts. background-position: right 65%; These investigators stated that in an era of evidence-based medicine, surgeons performing breast reductions must adopt the results from scientific research into their clinical practice. N Engl J Med. Two patients experienced unilateral minor partial necrosis of the areolar edge but not of the nipple itself (2 %). padding: 15px; of the following criteria must be met: The author identified the psychological domains affected by the disease and the effect of surgical treatment on these. Follow-up ranged from 2 months to 3 years. 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. Fischer JP, Cleveland EC, Shang EK, et al. In total there were 306 women in the 3 trials, and 505 breasts were studied (254 drained, and 251 who were not drained). .headerBar { list-style-type: upper-alpha; Long-term functional results after reduction mammoplasty. 2008;61(5):493-502. Patients undergoing surgery for gynecomastia should know that their scars may be visible when they are shirtless. A lack of correlation between these variables may result from the fact that the analyzed group of men with idiopathic gynecomastia was small in number, but at the same time, it appeared to be homogenous in these aspects (positive ER and/or PR expression and high digit ratio). Second, it is the burden of the proponent of an intervention to provide reliable evidence of its effectiveness, not the burden of ones whoquestion the effectivenessan intervention to provide definitive proof of ineffectiveness. 2001;108(6):1591-1599. Breast reduction for symptomatic macromastia. Grade IV: Marked breast enlargement with skin redundancy and feminization of the breast. This investigators stated that these studies should include data from older individuals affected by gynecomastia and utilize valid tools of psychological measurement in order to better quantify the effect; elderly patients affected by the disease have been over-looked in the current research; more data on this subject could improve the pre-operative evaluation of these patients and help identify the patients who will benefit from treatment. Aesthet Plastic Surg. Doses examined ranged from 8 to 16 Gy, delivered between 1 and 11 fractions. ol.numberedList LI { 2002;109(5):1556-1566. Breast reduction surgery is considered cosmetic and not medically necessary for the following conditions: poor posture, breast asymmetry, pendulousness, problems with clothes fitting properly and nipple-areola distortion. Is there a rationale behind pharmacotherapy in idiopathic gynecomastia? Hello! 2017;139(6):1313-1322. Narula HS, Carlson HE. Here's what Aetna said in the denial: "We used the Clinical Policy Bulletin (CPB): Breast Reduction Surgery. The vacuum-assisted breast biopsy system is an effective strategy for the treatment of gynecomastia. ul.ur li{ border-radius: 4px; 2011;21(5):431-434. Henley DV, Lipson N, Korach KS, Bloch CA. Plastic Reconstr Surg. These researchers calculated the risk ratio (RR) for dichotomous outcomes and mean differences (MD) for continuous outcomes, with 95 % confidence intervals (CI). You may be able to buy a breast pump and supplies from one of our medical equipment suppliers at no charge or at a discounted rate. 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. A study by Glatt et al (1999) was a retrospective analysis of responses to questionnaires sent to patients who underwent reduction mammoplasty regarding physical symptoms and body image. Links to various non-Aetna sites are provided for your convenience only. .newText { 1995;95(6):1029-1032. Policy Statement 6d: Aesthetic surgery procedures. Please check your insurance policy to see whether breast reduction is a covered procedure. The authors concluded that low-dose radiotherapy to the male breast might be a safe and effective strategy to prevent gynecomastia incidence or recurrence in high-risk patients. Grade III: Moderate breast enlargement exceeding areola boundaries with edges that are indistinct from the chest with skin redundancy present. 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). Gynecomastia. This may lead to additional scarring and additional operating time. background-color: #cc0066; Gynecomastia surgery is the surgical correction of over-developed or enlarged breasts in men. } 2006;118(4):840-848. American College of Obstetricians and Gynecologists (ACOG), Committee on Adolescent Health Care. 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). Risk factors for complications following breast reduction: Results from a randomized control trial. Bertin ML, Crowe J, Gordon SM. 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. Grooving where the bra straps sit on the shoulder. Breast reduction surgery is considered cosmetic for all indications not listed in section I, A. Fat grafting volume ranged from 50 to 300 cc in each pectoral muscle. text-decoration: line-through; J Plast Reconstr Aesthet Surg. Reduction mammoplasty also known as breast reduction surgery, is a surgical procedure in women to reduce the weight, mass, and size of the breast. color:#eee; Plastic Reconstr Surg. The traditional method of breast reduction requires an open incision around the areola extending downward to the crease beneath the breast. They evaluated the use of radiotherapy for the prevention and treatment of gynecomastia incidence or recurrence by plastic surgeons. Oxford, UK: National Health Service (NHS); October 2008. 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. } (This refers to actual breast tissue only; any fatty tissue removed doesn't count.) 2018;24(6):1043-1045. Ann Plastic Surg. width: 100%; Because of their inherently subjective nature, pain symptoms are especially prone to placebo effects. Plast Reconstr Surg. 2010;45(3):650-654. It should be noted that this study reported a strong correlation between the amount of tissue removed and pain amelioration. Note: For breast surgeries pertaining to gender affirmation, refer to CP.MP.95 Gender Affirming Procedures. Aesthetic Plast Surg. The authors concluded that the incidences of malignant and high-risk lesions were doubled compared to patients without prior breast cancer. 1999;103(6):1674-1681. bottom: 20px; A total of 81 patients were included in this study. This will be computed based on your body area. Med Decis Making. This population-wide analysis - the largest and most heterogeneous study to date - has demonstrated that increasing obesity class is associated with increased early postoperative complications. Ann Chir Plast Esthet. 2000;106(5):991-997. Krieger LM, Lesavoy MA. All patients underwent routine investigations to exclude secondary causes of gynecomastia. 2013;71(5):471-475. Role of tamoxifen in idiopathic gynecomastia: A 10-year prospective cohort study. 2019;8(4):431-440. No other operation-related complications were observed. Gland Surg. breast augmentation with implant. In a systematic review, these investigators examined the role of radiotherapy in this context. Reduction mammoplasty or breast reduction surgery reduces the volume and weight of the female breasts by removing excess fat, glandular tissue and skin. There were 18 out of 415 studies eligible to review. Ages ranged from 18 to 66 years. Breast. 1999;103(1):76-82; discussion 83-85. Alternatively, you may qualify if your breast size causes significant symptoms, such as: Long-term neck, shoulder or neck pain. An average of 320 specimens were excised from each side with mean blood loss of 34 ml. Obstet Gynecol Clin North Am. } OL OL OL OL LI { Breast reduction surgery might also help improve self-image and the ability to take part in physical activities. They reviewed their records on pectoral high-definition liposculpture between January of 2005 and October of 2019 in 4 surgical centers in Colombia. top: 0px; 2000;45(6):575-580. Liposuction facilitated the easy handling to remove the breast tissue via small incisional design; showed consistent improved QOL in terms of satisfaction after surgery. 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 .fixedHeaderWrap { Breast pumps. The majority of patients had previously undergone primary breast reduction using an inferior pedicle [n = 37 (41 %)]. Gynecomastia, its etiologies and its surgical management: A difference between the bilateral and unilateral cases? Another set of breast pump supplies if you get pregnant . Burdette TE, Kerrigan CL, Homa KA. 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. Tobacco use and body mass index as predictors of outcomes in patients undergoing breast reduction mammoplasty. Devalia HL, Layer GT. Plast Reconstr Surg. 1999;103(6):1687-1690. American Society of Plastic and Reconstructive Surgery (ASPRS). 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. Apart from a significantly shorter LOS for those participants who did not have drains (MD 0.77; 95 % CI: 0.40 to 1.14), there was no statistically significant impact of the use of drains on outcomes. The 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. 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. Sollie M. Management of gynecomastia-changes in psychological aspects after surgery-a systematic review. 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. ASPS Recommended Coverage Criteria for Third Party Payors. 2018;7(Suppl 1):S70-S76. 1993;91(7):1270-1276. The surgeon must also certify that a certain weight of breast tissue (based on Aetna's table) will be removed in every breast, and not entirely fatty tissue.
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