Coding Aesthet Surg J. 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. Causes may include testosterone-estrogen imbalance, increased prolactin levels, or abnormal serum binding protein levels. For those with large breasts, breast reduction surgery can ease discomfort and improve appearance. color: blue!important; There are alsoseveral earlier, smaller studies that found reductions in symptoms and improvements in quality of life after reduction mammoplasty (Glatt et al, 1999; Bruhlmannand Tschopp, 1998; Blomqvist et al, 2000; and Behmand et al, 2000). Clinical outcomes were measured by operative subjects' responses to a questionnaire about symptoms and quality of life. 2017;35:157-161. Patient demographics, surgical technique, and outcomes were analyzed. Because of their inherently subjective nature, pain symptoms are especially prone to placebo effects. Analysis was on an intention-to-treat basis. It should be noted that this study reported a strong correlation between the amount of tissue removed and pain amelioration. The median complication rate was 12.4 % with no major complications, such as neoplastic, pulmonary, or adverse cardiac outcomes. Of 110 subjects who were mailed questionnaires, approximately50 %(61 subjects) provided responses. A population-level analysis of bilateral breast reduction: does age affect early complications? Breast reduction for symptomatic macromastia. In a majority of boys with pubertal gynecomastia, the condition resolves within 18 months. #closethis { 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). 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. Schnur PL, Schnur DP, Petty PM, et al. Based largely upon these results, Nguyen et al (2004) reached the conclusion that a trial of conservative management is not an appropriate criterion for insurance coverage, even though responses to the BRAVO questionnaire indicated that operative candidates and hypertrophy controls received at least some pain relief from all of the conservative interventions, and for some conservative interventions, virtually all subjects reported at least some pain relief. 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. Aesthet Plastic Surg. It was also found that only 3 % of subjects reported that they had no aesthetic motivation for surgery. Brown MH, Weinberg M, Chong N, et al. Secondary outcomes included subjective as well as objective assessments of pain and wound healing. 2006;118(4):840-848. 1998;41(3):240-245. Collis N, McGuiness CM, Batchelor AG. Ann Plast Surg. 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. Breast re-reduction surgery was most commonly performed using a random pattern blood supply, rather than recreating the primary pedicle [n = 77 (86 %)]. Aesthetic Plast Surg. 2004;113(1):436-437. In a systematic review, these investigators examined the role of radiotherapy in this context. height:2px; Treatment of adolescent gynecomastia. As explained below, the studies used to support the arguments for the medical necessity of breast reduction surgery are poorly controlled and therefore subject to a substantial risk of bias in the interpretation of results. The average interval between primary and secondary surgery was 14 years (range of 0 to 42 years). list-style-type: upper-alpha; 2015;75(4):383-387. Gynecomastia Treatment through Open Resection and Pectoral High-Definition Liposculpture. 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. The vacuum-assisted breast biopsy system is an effective strategy for the treatment of gynecomastia. Harmonic scalpel versus electrocautery in breast reduction surgery: A randomized controlled trial. of the following criteria must be met: Aesthetic Plast Surg. A systematic search of the published literature was performed. The effectiveness of surgical and nonsurgical interventions in relieving the symptoms of macromastia. Patients undergoing surgery for gynecomastia should know that their scars may be visible when they are shirtless. list-style-type : square !important; Sood R, Mount DL, Coleman JJ 3rd, et al. They stated that in the light of these findings, contralateral reduction mammoplasty with histopathological evaluation in breast cancer patients offered a sophisticated tool to catch those patients whose contralateral breast needs increased attention. In other patients, excess skin and nipple and areola relocation are necessary. .newText { 2015;49(6):363-366. Reduction mammoplasty: Cosmetic or reconstructive procedure? Merkkola-von Schantz PA, Jahkola TA, Krogerus LA, Kauhanen SMC. If gynecomastia is idiopathic, reassurance of the common, transient and benign nature of the condition should be given. Is there a rationale behind pharmacotherapy in idiopathic gynecomastia? Bland KI, Copeland EM, eds. 1997;185(6):593-603. outline: none; Please check your insurance policy to see whether breast reduction is a covered procedure. This Clinical Policy Bulletin addresses breast reduction surgery and gynecomastia surgery. Breast reduction outcome study. Approximately 25 % of the 49 subjects included in this study did not return the post-operative questionnaire. 2008;121(4):1092-1100. The safety, efficacy, complications, and patient satisfactions were recorded during post-operative follow-up periods. 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]. Burdette TE, Kerrigan CL, Homa KA. 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. It can cause discomfort and concern, resulting in patients seeking diagnosis and treatment. Plast Reconstr Surg. Khan SM, Smeulders MJ, Van der Horst CM. Liposuction was also used adjunctively in all cases (average of 455 cc; range, 50 to 1,750 cc). They reviewed their records on pectoral high-definition liposculpture between January of 2005 and October of 2019 in 4 surgical centers in Colombia. Within this study population, 54.4% of patients were obese (BMI > 30 kg/m2), of which 1308 (28.8%) were Class I (BMI = 30-34.9 kg/m2), 686 (15.1%) were Class II (BMI = 35-39.9 kg/m2), and 439 (9.7%) were Class III (BMI > 40 kg/m2). Merkkola-von Schantz and colleagues (2017) stated that contralateral reduction mammoplasty is regularly included in the treatment of breast cancer patients. All patients underwent routine investigations to exclude secondary causes of gynecomastia. Risk factors for complications following breast reduction: Results from a randomized control trial. 2012;69(5):510-515. 1998;26(1):61-65. No other operation-related complications were observed. Vacuum-assisted minimally invasive mastectomy was performed successfully in all cases, with no residual glands or adipose tissue observed on US. Wound drainage after plastic and reconstructive surgery of the breast. color: red Doses examined ranged from 8 to 16 Gy, delivered between 1 and 11 fractions. The authors concluded that the incidences of malignant and high-risk lesions were doubled compared to patients without prior breast cancer. 1990;24(1):61-67. 2010;45(3):650-654. Arlington Heights, IL: ASPS; 2011. Plast Reconstr Surg. Medical therapy should be aimed at correcting any reversible causes (e.g., drug discontinuance). Arch Dis Child. OL OL LI { 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. Gynecomastia may be drug-induced. These preliminary findings need to be validated by well-designed studies. Breast Concerns of Adolescents. Hoyos and colleagues (2021) stated that male chest definition surgery and patients complaining of breast tissue over-growth have been increasing in recent decades. The investigators reported that subjects who were of normal weight were as likely to report benefit from reduction mammoplasty as subjects who were over-weight. 2015;(10):CD007258. The mean age was 42.8 years (SD 19.5 years). Krieger LM, Lesavoy MA. The majority of patients had previously undergone primary breast reduction using an inferior pedicle [n = 37 (41 %)]. 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. Mannu and colleagues (2018) stated that idiopathic gynecomastia is a benign breast disorder characterized by over-development of male breast tissue. background: #5e9732; Breast J. Ann Plast Surg. Lonie S, Sachs R, Shen A, et al. Philadelphia, PA: WB Saunders Company; 2008; Ch 73. Fat grafting volume ranged from 50 to 300 cc in each pectoral muscle. A non-standardized survey showed a very high satisfaction index. list-style-type: upper-roman; Clinical outcomes in reduction mammaplasty: A systemic review and meta-analysis of published studies. color: blue .strikeThrough { Blomqvist L, Eriksson A, Brandberg Y. } Following treatment, 90.1 % (n = 73) had a complete response of their gynecomastia with tamoxifen therapy. 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. 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: 2007;356(5):479-485. World J Surg. 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. 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. However, if liposuction is used as an adjunctive technique, the decision to use drains should be left to the surgeon's discretion. Jansen DA, Murphy M, Kind GM, Sands K. Breast cancer in reduction mammoplasty: Case reports and a survey of plastic surgeons. Reduction mammoplasty also known as breast reduction surgery, is a surgical procedure in women to reduce the weight, mass, and size of the breast. 2001;108(6):1591-1599. Morbidly obese patients are at the highest risk, with complications occurring in nearly 12% of this cohort. It is universally believed by patients that if a surgery is considered reconstructive, it is medically indicated and covered by health insurance. 2005;58(3):286-289. Computed tomography scan of adrenal glands to identify adrenal lesions. 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. Gland Surg. 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%. 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. Aesthetic Plast Surg. list-style-image: url('https://www.aetna.com/cpb/medical/data/assets/images/purplearrow.jpg') !important; Klinefelters syndrome, testicular, adrenal, or pituitary tumors, and thyroid or hepatic dysfunction are also associated with gynecomastia. Kalliainen LK; ASPS Health Policy Committee. z-index: 99; Plast Reconstr Surg. The characteristics of patients as well as the curative effects between the 2 groups were analyzed. 2nd ed. Medical reduction has been achieved with agents such as dihydrotestosterone, danazol, and clomiphene. Beer GM, Kompatscher P, Hergan K. Diagnosis of breast tumors after breast reduction. For pain interventions, evidence of effectiveness is necessary from well controlled, randomized prospective clinical trials assessing effects on pain, disability, and function. Plastic Reconstr Surg. 2011;128(4):243e-249e. font-size: 18px; 2001;76(5):503-510. Other just require 500 grams no matter what your height and weight. Links to various non-Aetna sites are provided for your convenience only. He Q, Zheng L, Zhuang D, et al. The article by Blomqvist et al (2000) is to another questionnaire study about health status and quality of life before and after surgery. 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. An average of 320 specimens were excised from each side with mean blood loss of 34 ml. A study reporting on a survey of health insurer policies on breast reduction surgery (Nguyen et al, 2004) found that no insurer medical policies could be supported by the medical literature. Estrogens and estrogen like drugs,including: Drugsthat enhance estrogen formation, including: Drugs which inhibit testosterone synthesis, including, Drugs that inhibit testosterone action, including. 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. Arlington Heights, IL: ASPS; March 9, 2002. # color: white; Emiroglu M, Salimoglu S, Karaali C, et al. Surg Laparosc Endosc Percutan Tech. 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. breast augmentation with implant. Surgeon. American Society of Plastic Surgeons (ASPS). 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). Philadelphia, PA: W.B. Srinivasaiahet al (2014) stated that although reduction mammoplasty has been shown to benefit physical, physiological, and psycho-social health there are recognized complications. The authors concluded that high digit ratio in men with gynecomastia may tend to be a marker of over-expression of ER and PR. Aetna and the City shall each abide by all applicable laws, regulations and government requirements regarding the confidentiality and the safeguarding of individually identifiable health and other personal information, including the privacy and security requirements of HIPAA. Choban PS, Heckler R, Burge JC, Flancbaum L. Increased incidence of nosocomial infections in obese surgical patients. Recommended criteria for insurance coverage of reduction mammoplasty. Aesthetic Plast Surg. Three review authors undertook independent screening of the search results. J Plast Reconstr Aesthet Surg. 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. Sollie (2018) noted that gynecomastia affects up to 2/3 of the male population. Administration of Benefits and Transition Responsibilities list-style-type: decimal; color: red!important; 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). } Breast J. There were only 2 studies of a total 25 patients that were considered as good in quality. Scand J Plast Reconstr Hand Surg. For many patients the psychological impact of the disease is substantial. 2021 Aug 11 [Online ahead of print]. Devalia HL, Layer GT. right: 30px; 2009;62(2):195-199. Breast cancer found at the time of breast reduction. Work-up of gynecomastia may include the following (GP Notebook, 2003): Treatment should be directed at correcting any underlying reversible causes. 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). 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. ASPS clinical practice guideline summary on reduction mammaplasty. Sabistons Textbook of Surgery (Burns & Blackwell, 2008)states that breast size should be stable for one year: There is no set lower age limit but, for the adolescent with breast hypertrophy, reduction is deferred until the breasts have stopped growing and are stable in size for at least 12 months before surgery.. 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. Mistry and associates (2017) examined outcomes following breast re-reduction surgery using a random pattern blood supply to the nipple and vertical scar reduction. /*margin-bottom: 43px;*/ Reduction mammoplasty for asymptomatic members is considered cosmetic. 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. Little is known about the effect of surgical treatment on the psychological aspects of the disease. No data were provided on loss to follow-up. Tobacco use and body mass index as predictors of outcomes in patients undergoing breast reduction mammoplasty. } Oxford, UK: National Health Service (NHS); October 2008. 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). 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 ASPS Recommended Coverage Criteria for Third Party Payors. Post-operative complications included 1 case of hematoma, but no nipple necrosis, local skin necrosis, or skin buttonhole occurred. Yao and co-workers (2019) described an innovative method for the operative treatment of gynecomastia -- vacuum-assisted minimally invasive mastectomy. Vacuum-assisted minimally invasive surgery was carried out under general anesthesia; subjects were followed-up with physical examination and ultrasonography (US). Patients were randomized to receive the gel applied to the left or right breast after hemostasis was achieved; the other breast received no treatment. Impact of surgical treatment for gynecomastia appeared to be beneficial for several psychological domains. 2008;32(1):38-44. Measuring health state preferences in women with breast hypertrophy. } Plast Reconstr Surg. Gynaecomastia. Minor complications (3.2 %) included prolonged swelling, bruising, asymmetries, and residual gynecomastia. 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. 2006;30(3):309-319. Thus, this study would not be considered of sufficient quality to provide reliable evidence of the effectiveness of a pain intervention. 2000;44(2):125-134. 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. Ann Plast Surg. The risks included infection, wound breakdown, scarring, and the need for re-operating. 01/04/2023 Type II gynecomastia is more generalized breast enlargement. In a prospective, cohort study, these investigators evaluated the efficacy of tamoxifen therapy in resolving this condition. Policy Statement 6d: Aesthetic surgery procedures.