Oxfordshire NHS Trust. 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. Policy. Reduction (or some cases augmentation) mammoplasty and related reconstructive procedures on the unaffected side for symmetry are also considered medically necessary. Macromastia: all . Exposure to partners using estrogen containing vaginal creams; Cancer chemotherapy (alkylating agents, methotrexate, vinca alkaloids, imatinib, combination chemotherapy), Androgen receptor blockers - bicalutamide, 5 reductase inhibitors - finasteride, dutasteride, Angiotensin converting enzyme inhibitors (captopril, enalapril), Calcium channelblockers(diltiazem, nifedipine, verapamil), Anabolic steroids(e.g., in body builders). background: url('https://www.aetna.com/cpb/medical/data/assets/images/purplearrow.jpg') no-repeat; Bruhlmann Y, Tschopp H. Breast reduction improves symptoms of macromastia and has a long-lasting effect. 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. After these researchers 1st report of pectoral etching in 2012, patients and surgeons became more aware regarding gynecomastia resection when performing pectoral enhancement. American Society of Plastic Surgeons (ASPS). 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. Patients with abnormal histopathology could not be pre-operatively identified based on demographics. Mannu and colleagues (2018) stated that idiopathic gynecomastia is a benign breast disorder characterized by over-development of male breast tissue. 2015;(10):CD007258. Plastic Reconstruct Surg. First, the opinions and guidelines of medical professional organizations and consensus groups are considered according to the quality of the scientific evidence and supporting rationale. 2001;76(5):503-510. Of these 33 operative sides, 2 complications occurred, but satisfactory chest contour was attained in all subjects. Kasielska A, Antoszewski B. Surgical management of gynecomastia: An outcome analysis. J Plast Reconstr Aesthet Surg. All studies on the subject were evaluated for inclusion and 6 studies were included in the review. Henley et al (2007) reported that repeated topical exposure to lavender and tea tree oils may be linked to prepubertal gynecomastia (idiopathic 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. Asian J Surg. background-color: #663399; In a systematic review, Prasetyono and colleagues (2021) examined the quality of studies and re-visited liposuction-assisted gynecomastia surgery performed via minimal incision. A cohort study of breast cancer risk in breast reduction patients. Reduction mammoplasty has also been used for relief of pain in the back, neck and shoulders. Mizgala CL, MacKenzie KM. Socioeconomic Committee Position Paper. Impact of surgical treatment for gynecomastia appeared to be beneficial for several psychological domains. } Priorities Forum Policy Statement. Of these, 28.4 % were bilateral gynecomastia and 71.6 % were unilateral. The majority (87.7 %) of cases presented with accompanying mastalgia. Health insurance companies frequently have different criteria for whether breast reduction surgery is medically necessary. Plast Reconstr Surg. --> J Plast Reconstr Aesthet Surg. Ann Plast Surg. Morbidly obese patients are at the highest risk, with complications occurring in nearly 12% of this cohort. 2008;121(4):1092-1100. Pediatr Surg Int. Current practice patterns of drain usage amongst UK and Irish surgeons performing bilateral breast reductions: Evidence down the drain. The authors concluded that this study was the largest to-date examining the role of tamoxifen in idiopathic gynecomastia, and these findings showed approximately 9 in every 10 men treated with tamoxifen therapy had successful resolution of their symptoms. list-style-type: decimal; 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 Note: For breast surgeries pertaining to gender affirmation, refer to CP.MP.95 Gender Affirming Procedures. 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. 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]. The vacuum-assisted breast biopsy system is an effective strategy for the treatment of gynecomastia. 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. Aesthetic Plast Surg. breast augmentation with implant. Gynecomastia: A systematic review. Reduction mammaplasty: An outcome study. 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. Kerrigan CL, Collins ED, Kim HM, et al. Flancbaum L, Choban PS. list-style-type: upper-roman; 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. This will be computed based on your body area. The data were retrospectively analyzed for demographics, operative and histopathology reports, oncological treatment, and post-operative follow-up. N Engl J Med. list-style-type: decimal; For pain interventions, evidence of effectiveness is necessary from well controlled, randomized prospective clinical trials assessing effects on pain, disability, and function. Most cases of type I gynecomastia are unilateral, and 20% of cases are bilateral. 2010;125(5):1301-1308. 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. 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. They stated that no data are available for breast augmentation or breast reconstruction, and this requires investigation. The surgeon removes excess tissue, fat and skin before adjusting the placement of the nipple and areola appropriately. Kerrigan CL, Collins ED, Kneeland TS, et al. 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? Variations in pattern of pubertal changes in girls. } Blomqvist L, Eriksson A, Brandberg Y. In a survey of managed care policies regarding breast reduction surgery, Krieger and colleagues reported (2001)found that mostof the respondentsstated that they use weight of excised tissue as the main criterion for allowing the procedure, with anaverage cut-off value of 472 grams for a typicalwoman. The American Society for Plastic Surgery (2011) advises to delay surgery until breast growth ceases: Although waiting may prolong the psychological awkwardness, it is advisable to delay surgery until breast growth ceases in order to achieve the best result. This is similar tothe American College of Obstetricians and Gynaecologists'2011 Guidelines forAdolescent Health Care chapter on breast concerns in adolescents, which states regarding breast hypertrophy: Preferably, treatment should be deferred until breast growth has been completed. A total of 244 out of 1,628 patients with the average age of 23.13 years. In these cases, breast reduction for men may take 2 to 3 hours. 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). A retrospective study of changes in physical symptoms and body image after reduction mammaplasty. Breast Reduction Surgery and Gynecomastia Surgery - Medical Clinical Policy Bulletins | Aetna Page . Dancey A, Khan M, Dawson J, Peart F. Gigantomastia--a classification and review of the literature. Policy Statement 6d: Aesthetic surgery procedures. Breast cancer found at the time of breast reduction. Liposuction assisted gynecomastia surgery with minimal periareolar incision: A systematic review. Obesity and complications in breast reduction surgery: Are restrictions justified? This investigators stated that these studies should include data from older individuals affected by gynecomastia and utilize valid tools of psychological measurement in order to better quantify the effect; elderly patients affected by the disease have been over-looked in the current research; more data on this subject could improve the pre-operative evaluation of these patients and help identify the patients who will benefit from treatment. Completely autologous platelet gel in breast reduction surgery: A blinded, randomized, controlled trial. background-color: #cc0066; 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. 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. Cambridge, UK: Oxbridge Solutions, Ltd.; 2003. Effects of reduction mammaplasty on pulmonary function and symptoms of macromastia. background: #5e9732; In a prospective, cohort study, these investigators evaluated the efficacy of tamoxifen therapy in resolving this condition. A non-standardized survey showed a very high satisfaction index. 2006;9(2):109-114. Arch Dis Child. 40 . For many patients the psychological impact of the disease is substantial. Treatment of adolescent gynecomastia. Subgroup analysis further stratified the younger cohort into those <50 years and 50-60 years of age. Breast J. Among these domains were: vitality, emotional discomfort, limitations due to physical aspects and limitations due to pain. Br J Plast Surg. Gynecomastia, its etiologies and its surgical management: A difference between the bilateral and unilateral cases? Aetna considers associated nipple and areolar reconstruction and tattooing of the nipple area medically necessary. 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. From January 2006 to January 2010, a total of 20 men with gynecomastia were treated by an 8-G vacuum-assisted biopsy device. Other just require 500 grams no matter what your height and weight. li.bullet { Gynecomastia has been classified into2 types. Patients were randomized to receive the gel applied to the left or right breast after hemostasis was achieved; the other breast received no treatment. 1997;100(4):875-883. Klinefelters syndrome, testicular, adrenal, or pituitary tumors, and thyroid or hepatic dysfunction are also associated with gynecomastia. Subjects were compared to age-matched norms from another study cohort. Disproportionately large breasts can cause both physical and emotional . Risk factors for complications following breast reduction: Results from a randomized control trial. margin-bottom: 38px; 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. Early complications were rare (6.1%), with superficial skin and soft tissue infections accounting for 45.8% of complications. Plast Reconstr Surg. In contrast, tobacco use and BMI were associated with worse breast reduction outcomes. Lonie S, Sachs R, Shen A, et al. Fagerlund A, Lewin R, Rufolo G, et al. .headerBar { 1993;91(7):1270-1276. Townsend: Sabiston Textbook of Surgery. World J Surg. Ann Plast Surg. 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. Arlington Heights, IL: ASPS; March 9, 2002. 1. The authors concluded that even with the high level of evidence demonstrating the safety of BBR without drains, they are still routinely utilized. Am Surg. 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). It was also found that only 3 % of subjects reported that they had no aesthetic motivation for surgery. Operative subjects who completed the study reported reductions in pain and improvements in quality of life; however, these improvements may be attributable to placebo effects, the natural history of back pain, other concurrent interventions, regression to the mean, improvements in cosmesis (for quality of life measures), or other confounding variables that may bias in interpretation of results. /* aetna.com standards styles for templates */ 2009;7(2):114-119. Reduction mammaplasty: Defining medical necessity. Estrogens and estrogen like drugs,including: Drugsthat enhance estrogen formation, including: Drugs which inhibit testosterone synthesis, including, Drugs that inhibit testosterone action, including. 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). 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. 2007;356(5):479-485. outline: none; (This refers to actual breast tissue only; any fatty tissue removed doesn't count.) 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. Based on CPB criteria and the information we have, we're denying coverage for breast reduction surgery. No data were provided on loss to follow-up. Breast reduction surgery is considered reconstructive and medically necessary in certain circumstances . The authors concluded that the vacuum-assisted breast biopsy system could be used as a feasible and minimally invasive approach for the treatment of gynecomastia. Gynaecomastia. 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 2014;20(3):274-278. Kalliainen LK; ASPS Health Policy Committee. Tobacco use and body mass index as predictors of outcomes in patients undergoing breast reduction mammoplasty. Plast Reconstr Surg. Pseudo-gynecomastia refers to excessive fat tissue or prominent pectoralis muscles. These preliminary findings need to be validated by well-designed studies. 2009;62(2):195-199. American Society of Plastic Surgeons (ASPS). Horm Res Paediatr. In addition, Nguyen et al (2004) ignored a wealth of published evidence of the effectiveness of physical therapy, analgesics and other conservative measures on back and neck pain generally. There were 18 out of 415 studies eligible to review. 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:. background-color:#eee; Autorino R, Perdona S, D'Armiento M, et al. Harmonic scalpel versus electrocautery in breast reduction surgery: A randomized controlled trial. Arlington Heights, IL: ASPRS; 1987. Healing balms, scented soaps, skin lotions, shampoos and styling gels containing lavender oilor tea tree oil. # color: white; Collins ED, Kerrigan CL, Kim M, et al. Furthermore, no serious complications were observed in vacuum-assisted breast biopsy group. .newText { Breast J. font-size: 18px; 1999;103(6):1682-1686. Petty PM, Solomon M, Buchel EW, Tran NV. I have recently met with my primary doctor after speaking to my insurance company (aetna) for months about getting a breast reduction. 2020 Sep 4 [Online ahead of print]. 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). Two patients experienced unilateral minor partial necrosis of the areolar edge but not of the nipple itself (2 %). For those with large breasts, breast reduction surgery can ease discomfort and improve appearance. 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. 1998;26(1):61-65. This population-wide analysis - the largest and most heterogeneous study to date - has demonstrated that increasing obesity class is associated with increased early postoperative complications. The 2 studies, which discussed laser-assisted liposuction technique, showed minor complication of seroma in 2 patients. Another set of breast pump supplies if you get pregnant . 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. Burdette TE, Kerrigan CL, Homa KA. Please check your insurance policy to see whether breast reduction is a covered procedure. Measurement of plasma gonadotrophins, human chorionic gonadotropin (hCG), testosterone, estradiol, and dehydroepiandosterone sulphate (DHEAS). Brown MH, Weinberg M, Chong N, et al. 1995;34(2):113-116. 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. J Plast Reconstr Aesthet Surg. Grade II: Moderate breast enlargement exceeding areola boundaries with edges that are indistinct from the chest. 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. Examining any complication, a significant increase was noted with increasing obesity class (p < 0.001). These investigators support its use for idiopathic gynecomastia in eligible men following the careful discussion of its risks and benefits. The mean incidence of gynecomastia was 70 % in the high-risk population examined representing prostate cancer patients on estrogen or anti-androgen therapy. The authors concluded that the incidences of malignant and high-risk lesions were doubled compared to patients without prior breast cancer. Resolution of idiopathic gynecomastia may take several months to years. 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. Chadbourne EB, Zhang S, Gordon MJ, et al. No new trials were identified for this first update. Although operative subjects were examined before and after surgery, there was no attempt to employ any blinded or objective measures of disability and function to verify these self-reports. } Plastic Reconstruct Surg. 2002;109(5):1556-1566. Vacuum-assisted minimally invasive surgery was carried out under general anesthesia; subjects were followed-up with physical examination and ultrasonography (US). } border: none; 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. An average of 320 specimens were excised from each side with mean blood loss of 34 ml. padding-bottom: 4px; To get insurance coverage, you'll probably need . 2010;45(3):650-654. Plast Reconstr Surg. Reduction mammoplasty for macromastia. Key takeaways: Health insurance does not cover cosmetic breast reduction, but it usually does cover breast reduction surgery that is considered medically necessary. Grade IV: Marked breast enlargement with skin redundancy and feminization of the breast. These researchers calculated the risk ratio (RR) for dichotomous outcomes and mean differences (MD) for continuous outcomes, with 95 % confidence intervals (CI). 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. 2005;58(3):286-289. He Q, Zheng L, Zhuang D, et al. Evidence-based clinical practice guideline: Reduction mammaplasty. The average amount of tissue removed from an average weight woman (within the 70 to 74.9 kg weight band) in this study was 600 g per breast, with a range of 502 g to 700 g of tissue removed per breast. Aetna plans exclude coverage of cosmetic surgery that is not medically necessary, . Obstet Gynecol Clin North Am. Fischer S, Hirsch T, Hirche C, et al. No statistically significant differences in the drainage, level of pain, size of open areas, clinical appearance, degree of scar pliability, or scar erythema were noted. Nelson JA, Fischer JP, Wink JD, Kovach SJ 3rd. Treating providers are solely responsible for medical advice and treatment of members. Furthermore, there is insufficient evidence that surgical removal is more effective than conservative management for pain due to gynecomastia. Kinell I, Baeusang-Linder M, Ohlsen L. The effect on the preoperative symptoms and the late results of Skoog's reduction mammoplasty: A follow-up study on 149 patients. Anzarut A, Guenther CR, Edwards DC, Tsuyuki RT. 2002;33:208-217. Data was then analyzed for surgical complications, wound complications, and medical complications within 30 days of surgery on 4545 patients. These researchers compared the safety and effectiveness of the use of wound drains following elective plastic and reconstructive surgery procedures 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. } list-style-type: lower-alpha; height:2px; It can cause discomfort and concern, resulting in patients seeking diagnosis and treatment. The authors stated that operative subjects were told that their responses to the questionnaire were not to be used for insurance and thus the subjects had no motivation to exaggerate symptoms prior to surgery in questionnaire responses; however, it is not clear whether operative subjects would be willing to submit responses to a questionnaire from the doctor that differed substantially from the history that they provided to the doctor during their preoperative evaluation. Sood R, Mount DL, Coleman JJ 3rd, et al. Plast Reconstr Surg. 1995;95(6):1029-1032. } 2015;10(8):e0136094. Removing the adipose tissue in pseudogynecomastia usually has no long term effect as adipose tissue reaccumulates unless the individual loses weight. For individuals who received radiation treatment to the chest . Choban PS, Heckler R, Burge JC, Flancbaum L. Increased incidence of nosocomial infections in obese surgical patients. J Pediatr Surg. Nguyen JT, Wheatley MJ, Schnur PL, et al. Gynecomastia: Evolving paradigm of management and comparison of techniques. A total of 211 responding surgeons were analyzed, including 80.1 % (171/211) plastic surgeons and 18.9 % (40/211) breast surgeons.
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