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Variations in pattern of pubertal changes in girls. 1. Disproportionately large breasts can cause both physical and emotional . Removing the adipose tissue in pseudogynecomastia usually has no long term effect as adipose tissue reaccumulates unless the individual loses weight. 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. Aetna is the brand name used for products and services provided by one or more of the Aetna group of subsidiary companies, including Aetna . It should be noted that this study reported a strong correlation between the amount of tissue removed and pain amelioration. 1995;95(1):77-83. } of the following criteria must be met: Statistical analysis was performed with student t-test and chi-square test. 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 Tang CL, Brown MH, Levine R, et al. 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. Early complications were rare (6.1%), with superficial skin and soft tissue infections accounting for 45.8% of complications. 1997;100(4):875-883. Mizgala CL, MacKenzie KM. .newText { 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. The authors concluded that high digit ratio in men with gynecomastia may tend to be a marker of over-expression of ER and PR. Breast reduction for symptomatic macromastia. Grade II: Moderate breast enlargement exceeding areola boundaries with edges that are indistinct from the chest. 2001;108(6):1591-1599. All the patients recovered well and were satisfied with the cosmetic outcomes. 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. 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. Minor complications (3.2 %) included prolonged swelling, bruising, asymmetries, and residual 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. .arrowPurpleSmall, a:hover.arrowPurpleSmall { This may justify an early use of tamoxifen in men with gynecomastia and a high digit ratio. Here's what Aetna said in the denial: "We used the Clinical Policy Bulletin (CPB): Breast Reduction Surgery. 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 In Type I (idiopathic) gynecomastia, the adolescent presents with a tender, firm mass beneath the areola. padding: 15px; They stated that no data are available for breast augmentation or breast reconstruction, and this requires investigation. In addition, reduction mammoplasty needs to be compared with other established methods of relieving back, neck and shoulder pain. When seeking preauthorization for a breast reduction, your goal is generally twofold. 2006;118(4):840-848. Two review authors undertook independent data extraction of study characteristics, methodological quality and outcomes (e.g., infection, other wound complications, pain, and length of hospital stay [LOS]). @media print { All RCTs that compared the use of a wound drain with no wound drain following plastic and reconstructive surgery of the breast (breast augmentation, breast reduction and breast reconstruction) in women were eligible. Philadelphia, PA: W.B. Compared with the open surgery group, the vacuum-assisted breast biopsy group had significantly smaller scar sizes left after the operation (5.5 1.3 cm versus 0.8 0.2 cm, p < 0.001), and shorter hospital stay time (5.5 2.4 days versus 3.1 1.6 days, p < 0.001). Kerrigan CL, Collins ED, Striplin D, et al. /* aetna.com standards styles for templates */ 2007;36(2):497-519. background-color: #cc0066; Sixty to 70% of males develop a transient subareolar breast tissue during their adolescence (Tanner Stages II and III). 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). Ann Plastic Surg. Measurement of plasma gonadotrophins, human chorionic gonadotropin (hCG), testosterone, estradiol, and dehydroepiandosterone sulphate (DHEAS). Plastic Reconstruct Surg. Philadelphia, PA: WB Saunders Company; 2008; Ch 73. The mean volume of tissue resected was 250 g (range of 22 to 758 g) from the right breast and 244 g (range of 15 to 705 g) from the left breast. 1996;20(5):391-397. 2015;10(8):e0136094. Araco A, Gravante G, Araco F, et al. Policy. Other just require 500 grams no matter what your height and weight. 2001;108(1):62-67. 1995;95(6):1029-1032. Behmand et al (2000) reported on the results of a questionnaire pre- and post-surgery in 69 subjects from a single practice who underwent reduction mammoplasty. This may lead to additional scarring and additional operating time. Reduction mammoplasty: Cosmetic or reconstructive procedure? 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. The American Society of Plastic Surgeons' evidence-based clinical practice guideline on reduction mammoplasty (ASPS, 2011) states thatin standard reduction mammoplasty procedures, evidence indicates that the use of drains is not beneficial. Srinivasaiahet al (2014) stated that although reduction mammoplasty has been shown to benefit physical, physiological, and psycho-social health there are recognized complications. 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. } Mistry and associates (2017) examined outcomes following breast re-reduction surgery using a random pattern blood supply to the nipple and vertical scar reduction. OL OL OL OL OL LI { Patients with abnormal histopathology could not be pre-operatively identified based on demographics. } 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. It can cause discomfort and concern, resulting in patients seeking diagnosis and treatment. Arlington Heights, IL: ASPS; May 2011. Yao Y, Yang Y, Liu J, et al. 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. Mental health care professionals may be consulted to address psychological distress from gynecomastia. GP Notebook. Plast Reconstr Surg. This study included 35 patients who underwent breast reduction due to the idiopathic form of gynecomastia. No data were provided on loss to follow-up. While 1 study showed high patient's satisfaction rate; both studies indicated high surgeon's satisfaction rate. 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. Treating providers are solely responsible for medical advice and treatment of members. Clinical outcomes in reduction mammaplasty: A systemic review and meta-analysis of published studies. A retrospective study of changes in physical symptoms and body image after reduction mammaplasty. Please check your insurance policy to see whether breast reduction is a covered procedure. A systematic search of the published literature was performed. Drainage in breast reduction surgery: A prospective randomised intra-patient trail. For example, at a body surface area of 1.5m, Aetna requires a minimum weight of 385 grams removed from each breast, whereas the Schnur scale would only require 260g. The effectiveness of surgical and nonsurgical interventions in relieving the symptoms of macromastia. padding-bottom: 4px; Arch Dis Child. Last Review01/04/2023. 2005;58(3):286-289. Plast Reconstr Surg. 2021;147(5):1072-1083. /*margin-bottom: 43px;*/ Safran and colleagues (2021) noted that several technologies and innovative approaches continue to emerge for the optimal management of gynecomastia by plastic surgeons. Breast cancer found at the time of breast reduction. Re-operation rate of liposuction-assisted surgery was between 0.6 % and 25 %. 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. #closethis { 2014b;30(6):641-647. These investigators concluded that their findings do not support the use of completely autologous platelet gel to improve outcomes after reduction mammoplasty. Kasielska A, Antoszewski B. Surgical management of gynecomastia: An outcome analysis. Studies have suggested that 2.4% to 14% of breast reduction cases resulted in major complications and 2.4% . 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. 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). 2015;(10):CD007258. The goal of medically necessary breast reduction surgery is to relieve symptoms of pain and disability. background: #5e9732; background-color: #663399; Fischer JP, Cleveland EC, Shang EK, et al. Dancey A, Khan M, Dawson J, Peart F. Gigantomastia--a classification and review of the literature. .fixedHeaderWrap { Administration of Benefits and Transition Responsibilities American Society of Plastic and Reconstructive Surgery (ASPRS). The data were retrospectively analyzed for demographics, operative and histopathology reports, oncological treatment, and post-operative follow-up. Aetna Inc. and its subsidiary companies are not responsible or liable for the content, accuracy, or privacy practices of linked sites, or for products or services described on these sites. After these researchers 1st report of pectoral etching in 2012, patients and surgeons became more aware regarding gynecomastia resection when performing pectoral enhancement. Plast Reconstr Surg. Grade IV: Marked breast enlargement with skin redundancy and feminization of the breast. Satisfactory chest contour was gained in all cases without any abnormality, skin redundancy, or recurrence during the follow-up of 6 to 48 months. Li CC, Fu JP, Chang SC, et al. Howrigan P. Reduction and augmentation mammoplasty. In a systematic review, Prasetyono and colleagues (2021) examined the quality of studies and re-visited liposuction-assisted gynecomastia surgery performed via minimal incision. Jansen DA, Murphy M, Kind GM, Sands K. Breast cancer in reduction mammoplasty: Case reports and a survey of plastic surgeons. Harmonic scalpel versus electrocautery in breast reduction surgery: A randomized controlled trial. He and associates (2011) examined the safety and feasibility of vacuum-assisted biopsy device in the treatment of gynecomastia. 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. Scand J Plast Reconstr Hand Surg. These investigators analyzed the incidence of occult breast cancer and high-risk lesions in reduction mammoplasty specimens of women with previous breast cancer. Reduction (or some cases augmentation) mammoplasty and related reconstructive procedures on the unaffected side for symmetry are also considered medically necessary. The health burden of breast hypertrophy. No author listed. Plast Reconstr Surg. Complication rates were inconsistent throughout the studies, ranging from 0.06 % to 26.67 %. The author average amount of breast tissue removed for women in 5 kg weight bands, ranging from 45-49 kg to 90+ kg. Krieger LM, Lesavoy MA. 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. It is universally believed by patients that if a surgery is considered reconstructive, it is medically indicated and covered by health insurance. Drains were used significantly less by surgeons performing greater than or equal to 20 BBRs (p = 0.02). 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. width: 100%; Policy Statement 6d: Aesthetic surgery procedures. Grade III: Moderate breast enlargement exceeding areola boundaries with edges that are indistinct from the chest with skin redundancy present. Medical reduction has been achieved with agents such as dihydrotestosterone, danazol, and clomiphene. Br J Plast Surg. 1998;26(1):61-65. padding-right: 18px; The risks included infection, wound breakdown, scarring, and the need for re-operating. Collins ED, Kerrigan CL, Kim M, et al. The requirement for coverage is that the amount of breast tissue to be removed has to be enough to improve your symptoms or function. 2020 Sep 4 [Online ahead of print]. Risk factors for complications following breast reduction: Results from a randomized control trial. padding: 10px; Washington, DC: ACOG; 2011:121-122. 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. However, it is unclear if there is any evidence to support this practice. 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]. Subgroup analysis further stratified the younger cohort into those <50 years and 50-60 years of age. 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. These investigators presented their experience with pectoral high-definition liposculpture combined with inverted-omega incision resection for gynecomastia. } Kerrigan CL, Collins ED, Kim HM, et al. Management of gynecomastia should include evaluation, including laboratory testing, to identify underlying etiologies. Reduction mammaplasty in patients with history of breast cancer: The incidence of occult cancer and high-risk lesions. Abnormal histopathology correlated with higher age (p = 0.0053), heavier specimen (p = 0.0491), and with no previous breast surgery (p < 0.001). Swelstad MR, Swelstad BB, Rao VK, Gutowski KA. list-style-type: decimal; Reduction mammoplasty is among the most commonly performed cosmetic procedures in the United States. A non-standardized survey showed a very high satisfaction index. 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. Sollie (2018) noted that gynecomastia affects up to 2/3 of the male population. There were only 2 studies of a total 25 patients that were considered as good in quality. Major complications (1.6 %) included unilateral hematoma and localized infection. Health insurance companies frequently have different criteria for whether breast reduction surgery is medically necessary. color: blue Mannu GS, Sudul M, Bettencourt-Silva JH, et al. Plastic Reconstruct Surg. border-width:0; 2000;106(2):280-288. Am Surg. 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). Level of Evidence = IV. display: none; # font-weight: bold; Plast Reconstr Surg. This Clinical Policy Bulletin may be updated and therefore is subject to change. Narula HS, Carlson HE. 2004;113(1):436-437. 2006;9(2):109-114. Also, there was no correlation between PR expression and 2D: 4D. Aesthet Plastic Surg. 2001;107(5):1234-1240. Aesthetic Plast Surg. Liposuction was also used adjunctively in all cases (average of 455 cc; range, 50 to 1,750 cc). Hello! Reduction mammaplasty: The need for prospective randomized studies. Reduction mammaplasty provides long-term improvement in health status and quality of life. Of these 33 operative sides, 2 complications occurred, but satisfactory chest contour was attained in all subjects. Level of Evidence = III. The nipple-areola complex was re-positioned in 60 % of patients (n = 54). Brown MH, Weinberg M, Chong N, et al. The vacuum-assisted breast biopsy system is an effective strategy for the treatment of gynecomastia. Long-term functional results after reduction mammoplasty. Prostate Cancer Prostatic Dis. Breast reduction surgery is considered reconstructive and medically necessary in certain circumstances . All subjects were satisfied with their cosmetic outcome, graded as excellent by 22 patients (100 %). Study subjects included 3538 patients with an average age of 43 years and body mass index of 31.6 kg/m(2) and most patients underwent outpatient surgery (80.5%) with an average operative time of 180 minutes.The incidence of overall surgical complications was 5.1% and the incidence of major surgical complications was 2.1%. Aesthetic Plast Surg. The article by Blomqvist et al (2000) is to another questionnaire study about health status and quality of life before and after surgery. Based on CPB criteria and the information we have, we're denying coverage for breast reduction surgery. The only criterion that the authors found supportable wasa requirementfor a pre-operative mammogram for women aged 40 years and older. } Resolution of idiopathic gynecomastia may take several months to years. The safety, efficacy, complications, and patient satisfactions were recorded during post-operative follow-up periods. Gynecomastia, its etiologies and its surgical management: A difference between the bilateral and unilateral cases? 40 . color: white; This was further isolated when comparing morbidly obese patients to non-obese (p < 0.001), class I (p < 0.001), and class II (p = 0.01) patients. Furthermore, there is insufficient evidence that surgical removal is more effective than conservative management for pain due to gynecomastia. Autorino R, Perdona S, D'Armiento M, et al. } 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. 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. Two patients experienced unilateral minor partial necrosis of the areolar edge but not of the nipple itself (2 %). 2002;109(5):1556-1566. 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. Approximately 25 % of the 49 subjects included in this study did not return the post-operative questionnaire. Of 291 subjects who were selected for inclusion in the study, only 179 completed follow-up. Although the BRAVO study is described as a controlled study, the "control" group is obtained, not from the same cohort, but from a separate cohort of individuals recruited from newspaper advertisements and solicitations at meetings for inclusion in a study of the population burden of breast hypertrophy; 75 % of this control group were obtained from2 centers, but the characteristics of those2 centers were not described. #backTop { 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. 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 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). In the case of breast reduction, however, for insurance purposes, it . J Plast Surg Hand Surg. 1995;61(11):1001-1005. If breast growth has been completed, breast reduction surgery is an option. Marshall and Tanner (1969)shows that the final stage of breast maturityoccurs about age 15 on average, but there is wide variation. 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 . J Plast Reconstr Aesthet Surg. skin should not be excised horizontally below the inframammary fold. Type II gynecomastia is more generalized breast enlargement. 2018;7(Suppl 1):S70-S76. Gynecomastia surgery is the surgical correction of over-developed or enlarged breasts in men. Surgical treatment is indicated when medical treatments fail. Ann Plast Surg. 2008;32(1):38-44. Radiotherapy was shown to significantly reduce the incidence to a median of 23 %, with all 6 RCTs assessed demonstrating a statistically significant decrease in incidence following radiotherapy prophylaxis. For medical Setala L, Papp A, Joukainen S, et al. 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:. Tang CL, Brown MH, Levine R, et al. color: #FFF; 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. J Laparoendosc Adv Surg Tech A. Plast Reconstr Surg. The traditional method of breast reduction requires an open incision around the areola extending downward to the crease beneath the breast. Marshall WA, Tanner JM. Kalliainen LK; ASPS Health Policy Committee. Aetna considers molecular susceptibility testing for breast and/or epithelial ovarian cancer ("BRCA testing") medically necessary once per lifetime in any of the following categories of high-risk adults with breast or epithelial ovarian cancer (adapted from guidelines from the U.S. Preventive Services Task Force (for Collis N, McGuiness CM, Batchelor AG. The study by Schnur et al was based on a survey of 92 plastic surgeons who reported on their care for 591 patients. Breast J. Data were prospectively gathered on complications as a part of randomized control trial (RCT) examining psycho-socialand quality of life(QOL) benefits of reduction mammoplasty. Flancbaum L, Choban PS. Fan L, Yang X, Zhang Y, Jiang J. Endoscopic subcutaneous mastectomy for the treatment of gynecomastia: A report of 65 cases. Following treatment, 90.1 % (n = 73) had a complete response of their gynecomastia with tamoxifen therapy. 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, you must test negative for breast cancer on a mammogram a maximum of two years before your surgery if you are 50 or older. Plastic surgery for teenagers briefing paper. Note: For breast surgeries pertaining to gender affirmation, refer to CP.MP.95 Gender Affirming Procedures. Hoyos AE, Perez ME, Dominguez-Millan R, et al. Fat grafting volume ranged from 50 to 300 cc in each pectoral muscle. The authors concluded that treatment of gynecomastia by the Mammotome device was distinctive, practicable in manipulation, safe, and could achieve excellent cosmetic results. For those with large breasts, breast reduction surgery can ease discomfort and improve appearance. .strikeThrough { Abnormalities in Adolescent Breast Development. Gynecomastia Treatment through Open Resection and Pectoral High-Definition Liposculpture. #backTop:hover { Subjects responses were compared to an age-matched comparison group of women, although no further details about how this comparison group were provided.