18th ed. } Oxford, UK: National Health Service (NHS); October 2008. margin-top: 38px; Alternatively, you may qualify if your breast size causes significant symptoms, such as: Long-term neck, shoulder or neck pain. Complications following radiotherapy were minor and self-limiting in all cases, restricted to minor skin reactions, and associated with larger radiotherapy doses delivered in fewer fractions. Breast J. Vacuum-assisted minimally invasive surgery-An innovative method for the operative treatment of gynecomastia. 1. The author identified the psychological domains affected by the disease and the effect of surgical treatment on these. hr.separator { 2012;69(5):510-515. } Leclere FM, Spies M, Gohritz A, Vogt PM. Yao and co-workers (2019) described an innovative method for the operative treatment of gynecomastia -- vacuum-assisted minimally invasive mastectomy. Plast Reconstr Surg. .arrowPurpleSmall, a:hover.arrowPurpleSmall { 1995;95(1):77-83. Fat grafting volume ranged from 50 to 300 cc in each pectoral muscle. Gynecomastia is a very common concern of male adolescence. Coding 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). The investigators found little difference between obese and non-obese women concerning patient's reports of resolution of symptoms and improvement in body image. These researchers compared the safety and effectiveness of the use of wound drains following elective plastic and reconstructive surgery procedures of the breast. The 2 vacuum-assisted breast biopsy systems (Mammotome and Encor) were used for the patients with gynecomastia. The operation had a mean duration of 73.5 mins per side, ranging from 40 to 102 mins. Completely autologous platelet gel in breast reduction surgery: A blinded, randomized, controlled trial. 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. They have argued that removal of even a few hundred grams of breast tissue can result in substantial pain relief. Reduction mammaplasty: A review of managed care medical policy coverage criteria. Breast pumps. 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. } 2021;74(11):3128-3140. Morbidly obese patients are at the highest risk, with complications occurring in nearly 12% of this cohort. 1995;34(2):113-116. The NSQIP recorded two complication types: major complications (deep infection and return to operating room) and any complication (all surgical complications). Priorities Forum Policy Statement. @media print { Srinivasaiahet al (2014) stated that although reduction mammoplasty has been shown to benefit physical, physiological, and psycho-social health there are recognized complications. A retrospective study of changes in physical symptoms and body image after reduction mammaplasty. 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. Often times, insurance company will dictate how much breast tissue to be removed. A non-standardized survey showed a very high satisfaction index. Plastic Reconstruct Surg. Breast reconstruction/breast enlargement Breast reduction/mammoplasty Excision of excessive skin due to weight loss Gastroplasty/gastric bypass Clinical Policy Bulletins are developed by Aetna to assist in administering plan benefits and constitute neither offers of coverage nor medical advice. 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. 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. Gonzalez FG, Walton RL, Shafer B, et al. Sollie (2018) noted that gynecomastia affects up to 2/3 of the male population. A systematic review of patient reported outcome measures for women with macromastia who have undergone breast reduction surgery. N Engl J Med. Patients with abnormal histopathology could not be pre-operatively identified based on demographics. .strikeThrough { Annu Rev Med. 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. Petty PM, Solomon M, Buchel EW, Tran NV. It was also found that only 3 % of subjects reported that they had no aesthetic motivation for surgery. 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). In a systematic review, these investigators examined the role of radiotherapy in this context. In these cases, breast reduction for men may take 2 to 3 hours. cursor: pointer; Furthermore, no serious complications were observed in vacuum-assisted breast biopsy group. 1996;20(5):391-397. The authors also noted that patients with BMI greater than 40 kg/m were significantly more likely to develop postoperative wound complications (p = 0.02). Marshall WA, Tanner JM. ASPS Recommended Coverage Criteria for Third Party Payors. #backTop { Guidelines for Adolescent Health Care. Aesthet Surg J. 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. There were 18 out of 415 studies eligible to review. Flancbaum L, Choban PS. --> The authors concluded that with proper patient selection, reduction mammoplasty can be performed safely on older patients. 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: list-style-type: lower-alpha; Nguyen JT, Wheatley MJ, Schnur PL, et al. 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. The risks included infection, wound breakdown, scarring, and the need for re-operating. 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. The authors concluded that the incidences of malignant and high-risk lesions were doubled compared to patients without prior breast cancer. background-color:#eee; Imahiyerobo TA, Pharmer LA, Swistel AJ, Talmor M. A comparative retrospective analysis of complications after oncoplastic breast reduction and breast reduction for benign macromastia: Are these procedures equally safe? Chemical peels (chemical exfoliation): Considered medically necessary when criteria in CPB 0251 - Dermabrasion, Chemical Peels, and Acne Scand J Plast Reconstr Hand Surg. 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. 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. 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. Surgical treatment of gynecomastia by vacuum-assisted biopsy device. top: 0px; Surgeon. 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. The end-point was the complete resolution of gynecomastia. Type II gynecomastia is more generalized breast enlargement. Role of tamoxifen in idiopathic gynecomastia: A 10-year prospective cohort study. cursor: pointer; 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. No data were provided on loss to follow-up. There were no restrictions on the basis of date or language of publication. Liposuction was also used adjunctively in all cases (average of 455 cc; range, 50 to 1,750 cc). 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. border: none; Klinefelters syndrome, testicular, adrenal, or pituitary tumors, and thyroid or hepatic dysfunction are also associated with gynecomastia. Seitchik (1995) reviewed the amount of breast tissue removed from a series of 100 patients that underwent breast reduction surgery. Surgical treatment of primary gynecomastia in children and adolescents. 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). Swelstad MR, Swelstad BB, Rao VK, Gutowski KA. Administration of Benefits and Transition Responsibilities Kerrigan CL, Collins ED, Kim HM, et al. .newText { Disproportionately large breasts can cause both physical and emotional . Bertin ML, Crowe J, Gordon SM. background-color: #cc0066; 2007;356(5):479-485. 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). Special Clinical Concerns. J Am Coll Surg. Philadelphia, PA: WB Saunders Company; 2008; Ch 73. A population-level analysis of bilateral breast reduction: does age affect early complications? color: red 2002;33:208-217. text-decoration: line-through; The authors of the BRAVO study reached several conclusions about reduction mammoplasty, most notably that breast size or the amount of breast tissue removed does not have any relationship to the outcome of breast reduction surgery (Kerrigan et al, 2002; Collins et al, 2002). Ann Plast Surg. list-style-type: decimal; 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. } For many patients the psychological impact of the disease is substantial. .headerBar { 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. 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. 2005;55(3):227-231. Resolution of idiopathic gynecomastia may take several months to years. list-style-type: upper-roman; OL OL OL OL LI { J Laparoendosc Adv Surg Tech A. background: url('https://www.aetna.com/cpb/medical/data/assets/images/purplearrow.jpg') no-repeat; Secondary outcomes included subjective as well as objective assessments of pain and wound healing. Complication rates were inconsistent throughout the studies, ranging from 0.06 % to 26.67 %. 2006;30(3):309-319. 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.. Fagerlund A, Lewin R, Rufolo G, et al. The surgeon removes excess tissue, fat and skin before adjusting the placement of the nipple and areola appropriately. For pain interventions, evidence of effectiveness is necessary from well controlled, randomized prospective clinical trials assessing effects on pain, disability, and function. of . Mizgala CL, MacKenzie KM. The 2 studies, which discussed laser-assisted liposuction technique, showed minor complication of seroma in 2 patients. OL OL LI { 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. 1999;103(6):1687-1690. Study appraisal was carried out using MINORS to evaluate the methodological quality of the paper. 2011;21(5):431-434. Henley DV, Lipson N, Korach KS, Bloch CA. Chadbourne EB, Zhang S, Gordon MJ, et al. There were only 2 studies of a total 25 patients that were considered as good in quality. The study consisted of 329 breast cancer patients, who underwent symmetrizing reduction mammoplasty between 1/2007 and 12/2011. Three review authors undertook independent screening of the search results. Reduction mammoplasty has also been used for relief of pain in the back, neck and shoulders. Plast Reconstr Surg. Patients in vacuum-assisted breast biopsy group had a better cosmetic outcome than those in open surgery group. Merkkola-von Schantz PA, Jahkola TA, Krogerus LA, Kauhanen SMC. 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. list-style-type: upper-alpha; 1993;17(3):211-223. For example, if the body surface area is 1.40 m2 , the estimated breast tissue to be removed should at least be 324 grams. However, the BRAVO study is not of sufficient quality to reach reliable conclusions about the effectiveness of breast reduction surgery as a pain intervention. Br J Plast Surg. 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. and areola. These investigators analyzed the incidence of occult breast cancer and high-risk lesions in reduction mammoplasty specimens of women with previous breast cancer. Conversely, many patients believe if a procedure is considered cosmetic, it is not a medically indicated and covered procedure. Many men with breast enlargement are found to have pseudo-gynecomastia. 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. Seitchik MW. 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). 2012;130(4):785-789. Ann Plast Surg. Aesthetic Plast Surg. 2009;7(2):114-119. margin-bottom: 38px; Drugs commonly associated with the development of gynecomastia include amphetamines, marijuana, mebrobamate, opiates, amitriptyline, chlordiazepoxide, chlorpromazine, cimetidine, diazepam, digoxin, fluphenazine, haloperidol, imipramine, isoniazid, mesoridazine, methyldopa, perphenazine, phenothiazines, reserpine, spironolactone, thiethylperazine, tricyclic antidepressants, tirfluoperazine, trimeparazine, busulfan, vincristine, tamoxifen, , methyltestosterone, human chorionic gonadotropins, and estrogens. Fagerlund A, Cormio L, Palangi L, et al. list-style-type: lower-roman; 2009;62(2):195-199. Reduction mammaplasty: Defining medical necessity. Jansen DA, Murphy M, Kind GM, Sands K. Breast cancer in reduction mammoplasty: Case reports and a survey of plastic surgeons. Aetna has their own sliding scale which requires more from smaller patients relative to the Schnur scale, but maxes out at 1000 gms per breast. Preoperative patient factors and comorbidities, as well as intraoperative variables, were assessed. Brown MH, Weinberg M, Chong N, et al. Breast. } Management of gestational gigantomastia. Kasielska-Trojan A, Danilewicz M, Antoszewski B. OL LI { Surgical implications of obesity. Surgical management of gynecomastia--a 10-year analysis. 2018;24(6):1043-1045. Ann Plastic Surg. Fischer JP, Cleveland EC, Shang EK, et al. color:#eee; 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. Reduction mammoplasty or breast reduction surgery reduces the volume and weight of the female breasts by removing excess fat, glandular tissue and skin. Tang CL, Brown MH, Levine R, et al. The study by Schnur et al was based on a survey of 92 plastic surgeons who reported on their care for 591 patients. OL OL OL OL OL LI { Examining any complication, a significant increase was noted with increasing obesity class (p < 0.001). skin should not be excised horizontally below the inframammary fold. Am Surg. Thus, this study would not be considered of sufficient quality to provide reliable evidence of the effectiveness of a pain intervention. Med Decis Making. American Society of Plastic and Reconstructive Surgery (ASPRS). 1995;95(6):1029-1032. Handschin AE, Bietry D, Hsler R, et al. Prostate Cancer Prostatic Dis.
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