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. } Medical reduction has been achieved with agents such as dihydrotestosterone, danazol, and clomiphene. The vacuum-assisted breast biopsy system is an effective strategy for the treatment of gynecomastia. However, the BRAVO study is not of sufficient quality to reach reliable conclusions about the effectiveness of breast reduction surgery as a pain intervention. text-decoration: underline; Oxford, UK: National Health Service (NHS); October 2008. Jones SA, Bain JR. Review of data describing outcomes that are used to assess changes in quality of life after reduction mammaplasty. 1995;95(6):1029-1032. 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). In contrast, tobacco use and BMI were associated with worse breast reduction outcomes. } padding-right: 18px; Fagerlund A, Lewin R, Rufolo G, et al. Surgical treatment of gynecomastia: Complications and outcomes. No necrosis, systemic infection, or muscle paralysis was reported. Level of Evidence = IV. These preliminary findings need to be validated by well-designed studies. Karamanos E, Wei B, Siddiqui A, Rubinfeld I. Variations in pattern of pubertal changes in girls. Nelson et al (2014a) analyzed population data from the 2005-2010 American College of Surgeons National Surgical Quality Improvement Program (NSQIP) database. This may justify an early use of tamoxifen in men with gynecomastia and a high digit ratio. Devalia HL, Layer GT. They concluded that higher resection weight, increased BMI, older age, and smoking are risk factors for complication and that patients should therefore be adequately counseled about losing weight and stopping smoking. Health insurance companies frequently have different criteria for whether breast reduction surgery is medically necessary. In a review on Surgical treatment of primary gynecomastia in children and adolescents, Fischer et al (2014b) concluded that surgical correction of gynecomastia remains a purely elective intervention. To calculate body surface area (BSA) see:BMI and BSA (Mosteller) Calculator;orBSA (m2) = ([height (in) x weight (lb)]/3131)(denotes square root), BSA (m2) = ([height (cm) x weight (kg)]/3600)(denotes square root). 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. Gland Surg. color: #FFF; #closethis { Seitchik (1995) reviewed the amount of breast tissue removed from a series of 100 patients that underwent breast reduction surgery. 2015;49(6):311-318. 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. 2007;356(5):479-485. margin-top: 38px; Reduction mammaplasty. 1993;91(7):1270-1276. Breast and aesthetic surgery. Breast reduction surgery, also known as reduction mammaplasty, removes fat, breast tissue and skin from the breasts. Clinical outcomes in reduction mammaplasty: A systemic review and meta-analysis of published studies. Ann Plast Surg. 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. 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. No new trials were identified for this first update. Brown MH, Weinberg M, Chong N, et al. Post-operative complications included 1 case of hematoma, but no nipple necrosis, local skin necrosis, or skin buttonhole occurred. Special Clinical Concerns. See Appendix for Table 1. Qu S, Zhang W, Li S, et al. Aetna considers associated nipple and areolar reconstruction and tattooing of the nipple area medically necessary. 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. 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. Liposuction assisted gynecomastia surgery with minimal periareolar incision: A systematic review. 2000;106(2):280-288. 0017 - Breast Reduction Surgery and Gynecomastia Surgery, are met. Although the BRAVO study nominally included a "control group", there was no comparison group of subjects selected from the same cohort, who were randomized or otherwise appropriately assigned to reduce bias, and treated with conservative management according to a protocol to ensure optimal conservative care. 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. } Secondary outcomes included subjective as well as objective assessments of pain and wound healing. display: none; .headerBar { Vacuum-assisted minimally invasive surgery was carried out under general anesthesia; subjects were followed-up with physical examination and ultrasonography (US). 1. 1997;100(4):875-883. A physician-supervised diet and exercise plan may be indicated in obese patients. Work-up of gynecomastia may include the following (GP Notebook, 2003): Treatment should be directed at correcting any underlying reversible causes. Grooving where the bra straps sit on the shoulder. 2019;8(4):431-440. 2005;55(3):227-231. Kerrigan CL, Collins ED, Kim HM, et al. Surgical management of gynecomastia--a 10-year analysis. OL OL OL LI { Hoyos and colleagues (2021) stated that male chest definition surgery and patients complaining of breast tissue over-growth have been increasing in recent decades. ol.numberedList LI { Patient demographics, surgical technique, and outcomes were analyzed. list-style-type: upper-roman; Endocrinol Metab Clin North Am. In addition, reduction mammoplasty needs to be compared with other established methods of relieving back, neck and shoulder pain. How to make Aetna pay for your breast reduction surgery Chemical peels (chemical exfoliation): Considered medically necessary when criteria in CPB 0251 - Dermabrasion, Chemical Peels, and Acne Annu Rev Med. outline: none; Risk factors for complications following breast reduction: Results from a randomized control trial. Gonzalez FG, Walton RL, Shafer B, et al. 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). A follow-up study of 105 women with breast cancer following reduction mammaplasty. In: Townsend CM, Beuchamp RD, Evers BM, eds. OL OL OL OL LI { 2006;30(3):309-319. This study included 35 patients who underwent breast reduction due to the idiopathic form of gynecomastia. Patients were randomized to receive the gel applied to the left or right breast after hemostasis was achieved; the other breast received no treatment. Plastic Reconstruct Surg. 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. Breast Reduction Surgery and Gynecomastia Surgery - Medical Clinical Policy Bulletins | Aetna Page . Gynaecomastia. padding: 10px; Qu and colleagues (2020) examined the effectiveness of vacuum-assisted breast biopsy systems for the treatment of gynecomastia. 2021;74(11):3128-3140. Reduction mammaplasty in patients with history of breast cancer: The incidence of occult cancer and high-risk lesions. 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. Srinivasaiahet al (2014) stated that although reduction mammoplasty has been shown to benefit physical, physiological, and psycho-social health there are recognized complications. These investigators concluded that their findings do not support the use of completely autologous platelet gel to improve outcomes after reduction mammoplasty. 2021;147(5):1072-1083. Please check your insurance policy to see whether breast reduction is a covered procedure. Collins ED, Kerrigan CL, Kim M, 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). Pain/discomfort/ulceration from bra straps cutting into shoulders; Skin breakdown (severe soft tissue infection, tissue necrosis, ulceration hemorrhage) from overlying breast tissue; There is a reasonable likelihood that the member's symptoms are primarily due to macromastia; Reduction mammoplasty (also spelled as 'mammaplasty') is likely to result in improvement of the chronic pain; Pain symptoms persist as documented by the physician despite at least a 3-month trial of therapeutic measures such as: Analgesic/non-steroidal anti-inflammatory drugs (NSAIDs) interventions and/or muscle relaxants, Dermatologic therapy of ulcers, necrosis and refractory infection, Physical therapy/exercises/posturing maneuvers, Supportive devices (e.g., proper bra support, wide bra straps), Chiropractic care or osteopathic manipulative treatment. The study by Schnur et al was based on a survey of 92 plastic surgeons who reported on their care for 591 patients. list-style-type: decimal; Drains were used significantly less by surgeons performing greater than or equal to 20 BBRs (p = 0.02). The Breast: Comprehensive Management of Benign and Malignant Diseases. 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). Plast Reconstr Surg. Gynecomastia: A systematic review. Surgical treatment of primary gynecomastia in children and adolescents. There were no restrictions on the basis of date or language of publication. 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). Plast Reconstr Surg. Autorino R, Perdona S, D'Armiento M, et al. } They evaluated the use of radiotherapy for the prevention and treatment of gynecomastia incidence or recurrence by plastic surgeons. 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. Reduction mammaplasty: A review of managed care medical policy coverage criteria. Surgical treatment of gynecomastia by vacuum-assisted biopsy device. Plast Reconstr Surg. 1999;103(6):1674-1681. Medical therapy should be aimed at correcting any reversible causes (e.g., drug discontinuance). Breast Reduction Surgery and Gynecomastia Surgery - Medical - Aetna Resolution of idiopathic gynecomastia may take several months to years. Treatment of adolescent gynecomastia. Breast reduction surgery might also help improve self-image and the ability to take part in physical activities. 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: The authors concluded that high digit ratio in men with gynecomastia may tend to be a marker of over-expression of ER and PR. 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). Yao and co-workers (2019) described an innovative method for the operative treatment of gynecomastia -- vacuum-assisted minimally invasive mastectomy. The end-point was the complete resolution of gynecomastia. 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). Gynecomastia has been classified into2 types. Gynecomastia surgery is the surgical correction of over-developed or enlarged breasts in men. The effectiveness of surgical and nonsurgical interventions in relieving the symptoms of macromastia. Minor complications (3.2 %) included prolonged swelling, bruising, asymmetries, and residual gynecomastia. }. 1995;95(1):77-83. } 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. American Society of Plastic and Reconstructive Surgery (ASPRS). right: 30px; Estrogens and estrogen like drugs,including: Drugsthat enhance estrogen formation, including: Drugs which inhibit testosterone synthesis, including, Drugs that inhibit testosterone action, including. 1995;61(11):1001-1005. 2012;130(4):785-789. 1999;103(6):1687-1690. There were 18 out of 415 studies eligible to review. Bruhlmann Y, Tschopp H. Breast reduction improves symptoms of macromastia and has a long-lasting effect. Answer: Aetna Insurance Breast reduction may or may not be covered depending on your insurance carrier and your breast size. The authors concluded that with proper patient selection, reduction mammoplasty can be performed safely on older patients. Am J Infect Control. Transient pain that may occur as the breast enlarges and the capsule is stretched; these symptoms may be managed with analgesics. In total there were 306 women in the 3 trials, and 505 breasts were studied (254 drained, and 251 who were not drained). The characteristics of patients as well as the curative effects between the 2 groups were analyzed. Khan SM, Smeulders MJ, Van der Horst CM. Guidelines for Adolescent Health Care. } And if you are in Canada the surgeon decides. Rising Rates of Insurance Denial for Breast Reduction Surgery Fat grafting volume ranged from 50 to 300 cc in each pectoral muscle. The 2 vacuum-assisted breast biopsy systems (Mammotome and Encor) were used for the patients with gynecomastia. } The surgeon removes excess tissue, fat and skin before adjusting the placement of the nipple and areola appropriately. Schnur PL, Hoehn JG, Ilstrup DM, et al. Mannu GS, Sudul M, Bettencourt-Silva JH, et al. 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). Laituri CA, Garey CL, Ostlie DJ, et al. In these cases, breast reduction for men may take 2 to 3 hours. Of these, 28.4 % were bilateral gynecomastia and 71.6 % were unilateral. 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. 2011;128(4):243e-249e. The investigators found that comorbid conditions increased across obesity classifications (p < 0.001), with significant differences noted in all cohort comparisons except when comparing class I to class II (p = 0.12). Reduction mammoplasty has also been used for relief of pain in the back, neck and shoulders. 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). J Laparoendosc Adv Surg Tech A. 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. 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. Study appraisal was carried out using MINORS to evaluate the methodological quality of the paper. breast augmentation with implant. Burdette TE, Kerrigan CL, Homa KA. Will Aetna Insurance Cover my Breast Reduction? - RealSelf.com 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. These researchers compared the safety and effectiveness of the use of wound drains following elective plastic and reconstructive surgery procedures of the breast. list-style-type: upper-alpha; Harmonic scalpel versus electrocautery in breast reduction surgery: A randomized controlled trial. Plastic surgery for teenagers briefing paper. 1998;49:215-234. Karamanos et al (2015) noted that although breast reduction mammoplasty accounts for more than 60,000 procedures annually, the literature remains sparse on outcomes. A total of 211 responding surgeons were analyzed, including 80.1 % (171/211) plastic surgeons and 18.9 % (40/211) breast surgeons. @media print { Does Aetna Cover Breast Reduction? | HelpAdvisor.com Raispis T, Zehring RD, Downey DL. The authors concluded that treatment of gynecomastia by the Mammotome device was distinctive, practicable in manipulation, safe, and could achieve excellent cosmetic results. These individuals cite evidence from observational studies to support this position (e.g., Chadbourne et al, 2001; Kerrigan et al, 2001). 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. A total of 182 thirty-day postoperative surgical complications were documented, but stratifying patients into 2 age groups did not reveal an association between age and any surgical complication (P = .26). } Clinical Policy Bulletins are developed by Aetna to assist in administering plan benefits and constitute neither offers of coverage nor medical advice. Ann Plast Surg. 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). Inclusion criteria were as follows: men diagnosed with gynecomastia and BMI of less than or equal to 32 kg/m2, adequate skin elasticity, and general good health. top: 0px; Cambridge, UK: Oxbridge Solutions, Ltd.; 2003. 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. Because of their inherently subjective nature, pain symptoms are especially prone to placebo effects. } list-style-type: lower-alpha; Plastic Reconstruct Surg. For many patients the psychological impact of the disease is substantial. Breast re-reduction surgery was most commonly performed using a random pattern blood supply, rather than recreating the primary pedicle [n = 77 (86 %)]. 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. list-style-type : square !important; The author identified the psychological domains affected by the disease and the effect of surgical treatment on these. 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. Aesthetic Plast Surg. 2010;45(3):650-654. 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:. Gynecomastia, its etiologies and its surgical management: A difference between the bilateral and unilateral cases? These researchers calculated the risk ratio (RR) for dichotomous outcomes and mean differences (MD) for continuous outcomes, with 95 % confidence intervals (CI). Reduction mammoplasty improves symptoms of macromastia. While 1 study showed high patient's satisfaction rate; both studies indicated high surgeon's satisfaction rate. 2000;45(6):575-580. Grade III: Moderate breast enlargement exceeding areola boundaries with edges that are indistinct from the chest with skin redundancy present. } 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.

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