The traditional method of breast reduction requires an open incision around the areola extending downward to the crease beneath the breast. Jansen DA, Murphy M, Kind GM, Sands K. Breast cancer in reduction mammoplasty: Case reports and a survey of plastic surgeons. 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 Mental health care professionals may be consulted to address psychological distress from gynecomastia. 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. Ann Plastic Surg. The average age of the studied individuals was 25.7 years (SD = 7.8); ER and PR expression was detected in breasts, and digit ratios were calculated in patients with idiopathic gynecomastia. Of the responding surgeons, 71.6 % (151/211) routinely inserted post-operative drains, for a mean of 1.32 days. 2009;62(2):195-199. Plast Reconstr Surg. Gynecomastia has been classified into2 types. 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. Beer GM, Kompatscher P, Hergan K. Diagnosis of breast tumors after breast reduction. Sollie M. Management of gynecomastia-changes in psychological aspects after surgery-a systematic review. There were 18 out of 415 studies eligible to review. 2019;8(4):431-440. Arch Dis Child. While 1 study showed high patient's satisfaction rate; both studies indicated high surgeon's satisfaction rate. }. If gynecomastia is idiopathic, reassurance of the common, transient and benign nature of the condition should be given. Nelson et al (2014a) analyzed population data from the 2005-2010 American College of Surgeons National Surgical Quality Improvement Program (NSQIP) database. This may lead to additional scarring and additional operating time. 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. } A total of 15 articles met the inclusion criteria for review. For these reasons, there is insufficient evidence to support the use of reduction mammoplasty, without regard to the size of the breasts or amount of breast tissue to be removed, as a method of relieving chronic back, neck, or shoulder pain. Medical therapy should be aimed at correcting any reversible causes (e.g., drug discontinuance). A follow-up study of 105 women with breast cancer following reduction mammaplasty. A systematic search of the published literature was performed. The end-point was the complete resolution of gynecomastia. Harmonic scalpel versus electrocautery in breast reduction surgery: A randomized controlled trial. Sixty to 70% of males develop a transient subareolar breast tissue during their adolescence (Tanner Stages II and III). J Am Coll Surg. font-size: 18px; In other patients, excess skin and nipple and areola relocation are necessary. While the efficacy of radiotherapy as a therapeutic modality for gynecomastia was also established, it was shown to be less effective than other available options. The operation was successfully performed in all 20 patients with a mean operating time of 51 mins and a hospital stay of 4 days. 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. Townsend: Sabiston Textbook of Surgery. 1995;95(1):77-83. No new trials were identified for this first update. Impact of surgical treatment for gynecomastia appeared to be beneficial for several psychological domains. Third, reliable evidence is especially important for pain interventions, because of the waxing and waning nature of pain and the susceptibility of this symptom to placebo effects and other biases that may confound interpretation of study results. No other operation-related complications were observed. Schnur PL, Hoehn JG, Ilstrup DM, et al. Obesity and complications in breast reduction surgery: Are restrictions justified? /* aetna.com standards styles for templates */ 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: 1990;24(1):61-67. Seitchik MW. 1969;44(235):291-303. list-style-type: upper-alpha; 2014b;48(5):334-339. Aesthetic Plast Surg. You may be able to buy a breast pump and supplies from one of our medical equipment suppliers at no charge or at a discounted rate. 2003;111(2):688-694. Kasielska-Trojan and associates (2018) analyzed digit ratio in relation to estrogen receptor (ER) and progesterone receptor (PR) expression and verified digit ratio (2D: 4D) as a marker of ER and PR over-expression in the male breast. Aesthet Surg J. Surgery. padding-bottom: 4px; @media print { In total there were 306 women in the 3 trials, and 505 breasts were studied (254 drained, and 251 who were not drained). 2021;74(11):3128-3140. Plast Reconstr Surg. The safety, efficacy, complications, and patient satisfactions were recorded during post-operative follow-up periods. list-style-type: lower-roman; 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). /*margin-bottom: 43px;*/ The following procedures are considered experimental and investigational because there is insufficient evidence of itseffectiveness or itseffectiveness has not been established: Aetna considers breast reduction, surgical mastectomy or liposuction for gynecomastia, either unilateral or bilateral, a cosmetic surgical procedure. z-index: 99; Reduction mammaplasty: Defining medical necessity. Breast reduction surgery is considered cosmetic for all indications not listed in section I, A. Srinivasaiahet al (2014) stated that although reduction mammoplasty has been shown to benefit physical, physiological, and psycho-social health there are recognized complications. See Appendix for Table 1. li.bullet { Each surgeon who participated in the study reported on the height, weight, and volume of reduction of their last 15 to 20 patients, and each surgeon provided their intuitive sense regarding the motivation of each patient for breast reduction surgery. ol.numberedList LI { Gynecomastia in patients with prostate cancer: A systematic review. In fact, according to the American Society of Plastic Surgeons, more than 46,000 breast reduction procedures were performed in 2019, a six percent increase compared to 2018; but in recent years, insurance companies have become more likely to deny coverage for this medically recommended procedure. Grade II: Moderate breast enlargement exceeding areola boundaries with edges that are indistinct from the chest. Surg Laparosc Endosc Percutan Tech. Howrigan P. Reduction and augmentation mammoplasty. color: red!important; Two patients experienced unilateral minor partial necrosis of the areolar edge but not of the nipple itself (2 %). The primary outcome was the difference in wound drainage over 24 hours. Arlington Heights, IL: ASPS; March 9, 2002. This conclusion is based primarily upon the Breast Reduction Assessment of Value and Outcomes (BRAVO) study, which is described in several articles (Kerrigan et al, 2001; Kerrigan et al, 2002; Collins et al, 2002). Many men with breast enlargement are found to have pseudo-gynecomastia. Study appraisal was carried out using MINORS to evaluate the methodological quality of the paper. Transient pain that may occur as the breast enlarges and the capsule is stretched; these symptoms may be managed with analgesics. } The Mammotome procedure represented another novel therapeutic option for gynecomastia. Plast Reconstr Surg. Major complications (1.6 %) included unilateral hematoma and localized infection. No data were provided on loss to follow-up. 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%. } A retrospective study of changes in physical symptoms and body image after reduction mammaplasty. 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). 2006;30(3):309-319. 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. Safran T, Abi-Rafeh J, Alabdulkarim A, et al. These investigators stated that in an era of evidence-based medicine, surgeons performing breast reductions must adopt the results from scientific research into their clinical practice. Completely autologous platelet gel in breast reduction surgery: A blinded, randomized, controlled trial. Nelson et al (2014b) separately conducted a population level analysis of the 2005-2011 NSQIP datasets, identifying patient who underwent reduction mammoplasty, to determine the impact of obesity on early complications after reduction mammoplasty. 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. 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. Administration of Benefits and Transition Responsibilities These investigators retrospectively examined 83 patients with gynecomastia between January 2015 and December 2019. Other just require 500 grams no matter what your height and weight. top: 0px; These investigators support its use for idiopathic gynecomastia in eligible men following the careful discussion of its risks and benefits. } .arrowPurpleSmall, a:hover.arrowPurpleSmall { Plastic Reconstr Surg. Ann Plast Surg. Breast reduction surgery might also help improve self-image and the ability to take part in physical activities. Krieger LM, Lesavoy MA. Aesthet Plastic Surg. list-style-type: decimal; Blomqvist L, Eriksson A, Brandberg Y. The goal of medically necessary breast reduction surgery is to relieve symptoms of pain and disability. Breast and aesthetic surgery. 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. Breast reduction outcome study. 2017;139(6):1313-1322. Breast reduction for symptomatic macromastia. padding: 10px; Plastic Reconstruct Surg. Anzarut A, Guenther CR, Edwards DC, Tsuyuki RT. Liposuction assisted gynecomastia surgery with minimal periareolar incision: A systematic review. 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 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. 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). Endocrinol Metab Clin North Am. Yao and co-workers (2019) described an innovative method for the operative treatment of gynecomastia -- vacuum-assisted minimally invasive mastectomy. ER expression did not correlate with the right (p = 0.51) and left 2D: 4D (p = 0.97). Schnur PL, Schnur DP, Petty PM, et al. Dancey A, Khan M, Dawson J, Peart F. Gigantomastia--a classification and review of the literature. Other referencesto smaller studies published prior to the BRAVO study have been cited,examining symptoms before and after reduction mammoplasty; each of these studies suffer from limitations similar to those identified with the BRAVO study. A total of 81 patients were included in this study. A total of 2779 patients were identified with a mean age of 42.7 (14.1) years and BMI of 31.6 (7.0) kg/m. Tobacco use and body mass index as predictors of outcomes in patients undergoing breast reduction mammoplasty. 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). Gynaecomastia. Fischer et al (2014a) evaluated predictors of postoperative complications following reduction mammoplasty using the NSQIP) data sets. ASPS clinical practice guideline summary on reduction mammaplasty. 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. Evidence-based clinical practice guideline: Reduction mammaplasty. Drainage in breast reduction surgery: A prospective randomised intra-patient trail. } World J Surg. Abnormalities in Adolescent Breast Development. Minor complications (3.2 %) included prolonged swelling, bruising, asymmetries, and residual gynecomastia. These investigators searched the literature on the treatment of Simon's grade I and II gynecomastia in PubMed, Scopus, Science Direct, and Cochrane using keywords "gynecomastia" and "liposuction". 2016;20(3):256-260. 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. Covered items may include: A manual or standard electric pump (non-hospital grade) while you are pregnant or for the duration of breastfeeding. Brown MH, Weinberg M, Chong N, et al. 2014a;34(1):66-73. Complications following reduction mammaplasty: A review of 3538 cases from the 2005-2010 NSQIP data sets. Iwuagwu OC, Stanley PW, Platt AJ, Drew PJ. 2002;109(5):1556-1566. 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. Priorities Forum Policy Statement. The study subjects were stratified into groups based on ages of <60 years and 60 years. Hello! 2000;106(5):991-997. background-color: #cc0066; border-radius: 4px; list-style-type: upper-roman; Reduction mammaplasty. Furthermore, no serious complications were observed in vacuum-assisted breast biopsy group. This Clinical Policy Bulletin contains only a partial, general description of plan or program benefits and does not constitute a contract. Aetna considers breast reconstructive surgery to correct Grade IV: Marked breast enlargement with skin redundancy and feminization of the breast. Plast Reconstr Surg. No necrosis, systemic infection, or muscle paralysis was reported. 2009;19(3):e85-e90. Ann Plast Surg. 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. Nguyen JT, Wheatley MJ, Schnur PL, et al. 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. #backTop { Mizgala CL, MacKenzie KM. Plastic surgery for teenagers briefing paper. 1999;103(1):76-82; discussion 83-85. 2018;89(6):408-412. Flancbaum L, Choban PS. 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. 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. Because of their inherently subjective nature, pain symptoms are especially prone to placebo effects. Tang CL, Brown MH, Levine R, et al. Surgical treatment is indicated when medical treatments fail. J Plast Reconstr Aesthet Surg. Reduction mammoplasty for macromastia. Raispis T, Zehring RD, Downey DL. Choban PS, Flancbaum L. The impact of obesity on surgical outcomes: A review. 0017 - Breast Reduction Surgery and Gynecomastia Surgery, are met. Causes may include testosterone-estrogen imbalance, increased prolactin levels, or abnormal serum binding protein levels. This will be computed based on your body area. Reduction mammoplasty: Cosmetic or reconstructive procedure? Thus, this study would not be considered of sufficient quality to provide reliable evidence of the effectiveness of a pain intervention. The authors concluded that the limited evidence available showed no significant benefit of using post-operative wound drains in reduction mammoplasty, although LOS may be shorter when drains are not used. He and associates (2011) examined the safety and feasibility of vacuum-assisted biopsy device in the treatment of gynecomastia. Surgical treatment of gynecomastia: Complications and outcomes. Philadelphia, PA: WB Saunders Company; 2008; Ch 73. Mistry RM, MacLennan SE, Hall-Findlay EJ. Miller AP, Zacher JB, Berggren RB, et al. Refer to the member's specific plan document for applicable coverage. Mannu and colleagues (2018) stated that idiopathic gynecomastia is a benign breast disorder characterized by over-development of male breast tissue. Glatt BS, Sarwer DB, O'Hara DE, et al. 2008;32(1):38-44. Washington, DC: ACOG; 2011:121-122. 1998;101(2):361-364. Plast Reconstr Surg. Br J Plast Surg. J Plast Reconstr Aesthet Surg. Yao Y, Yang Y, Liu J, et al. Petty PM, Solomon M, Buchel EW, Tran NV. It should be noted that this study reported a strong correlation between the amount of tissue removed and pain amelioration. Schnur et al (1991) reported on a sliding scale assigns a weight of breast tissue to be removed based on body weight and surface area. 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. 2000;44(2):125-134. 2008;53(3):255-261. padding: 15px; 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). Patients undergoing surgery for gynecomastia should know that their scars may be visible when they are shirtless. Reduction mammaplasty: The need for prospective randomized studies. Am J Infect Control. Links to various non-Aetna sites are provided for your convenience only. Breast 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. Clinical Policy Bulletins are developed by Aetna to assist in administering plan benefits and constitute neither offers of coverage nor medical advice. Karamanos et al (2015) noted that although breast reduction mammoplasty accounts for more than 60,000 procedures annually, the literature remains sparse on outcomes. Note: Breast reduction surgery will be considered medically necessary for women meeting the symptomatic criteria specified above, regardless of BSA, with more than 1 kg of breast tissue to be removed per breast. 2020 Sep 4 [Online ahead of print]. The authors concluded that small incisional design for breast parenchymal removal in gynecomastia assisted by liposuction showed a good technical approach for consistent improvement in QOL; however, only 2 studies reported good quality methods of non-randomized case-series urging for a better quality of studies in the future. 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. 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). The authors concluded that with proper patient selection, reduction mammoplasty can be performed safely on older patients. 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. color: red Reduction mammoplasty: Criteria for insurance coverage. 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.