Of the responding surgeons, 71.6 % (151/211) routinely inserted post-operative drains, for a mean of 1.32 days. Special Clinical Concerns. Tang CL, Brown MH, Levine R, et al. Breast J. Morbidly obese patients are at the highest risk, with complications occurring in nearly 12% of this cohort. Gynecomastia resection plus high-definition liposculpture was successfully performed in 436 consecutive men (open inverted-omega incision resection, n = 132; liposuction, n = 304). 2008;61(5):493-502. 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. Reduction mammoplasty: Criteria for insurance coverage. font-size: 18px; 2006;118(4):840-848. Aesthetic Plast Surg. 2 . For pain interventions, evidence of effectiveness is necessary from well controlled, randomized prospective clinical trials assessing effects on pain, disability, and function. Reduction mammoplasty is among the most commonly performed cosmetic procedures in the United States. Glatt BS, Sarwer DB, O'Hara DE, et al. 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. In a Cochrane review, Khan and colleagues (2015) stated that wound drains are often used after plastic and reconstructive surgery of the breast in order to reduce potential complications. Emiroglu M, Salimoglu S, Karaali C, et al. 1969;44(235):291-303. Ann Plast Surg. } An average of 320 specimens were excised from each side with mean blood loss of 34 ml. Approximately 25 % of the 49 subjects included in this study did not return the post-operative questionnaire. Causes may include testosterone-estrogen imbalance, increased prolactin levels, or abnormal serum binding protein levels. Is there a rationale behind pharmacotherapy in idiopathic gynecomastia? Policy Statement 6d: Aesthetic surgery procedures. } Medical therapy should be aimed at correcting any reversible causes (e.g., drug discontinuance). Ann Plast Surg. American Society of Plastic Surgeons (ASPS). Policy. Brown MH, Weinberg M, Chong N, et al. 18th ed. Follow-up ranged from 2 months to 3 years. 2016;20(3):256-260. Gynecomastia, its etiologies and its surgical management: A difference between the bilateral and unilateral cases? A population-level analysis of bilateral breast reduction: does age affect early complications? 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). padding-bottom: 4px; The authors concluded that even with the high level of evidence demonstrating the safety of BBR without drains, they are still routinely utilized. 1997;100(4):875-883. 01/04/2023 padding: 10px; Anzarut A, Guenther CR, Edwards DC, Tsuyuki RT. Kalliainen LK; ASPS Health Policy Committee. Klinefelters syndrome, testicular, adrenal, or pituitary tumors, and thyroid or hepatic dysfunction are also associated with gynecomastia. For example, if the body surface area is 1.40 m2 , the estimated breast tissue to be removed should at least be 324 grams. 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: The article by Blomqvist et al (2000) is to another questionnaire study about health status and quality of life before and after surgery. Well-designed clinical trials provide reliable information about the effectiveness of an intervention, and provide valid information about the characteristics of patients who would benefit from that intervention. Cochrane Database Syst Rev. Most cases of type I gynecomastia are unilateral, and 20% of cases are bilateral. Abnormal histopathological findings were more frequent in patients with reduction mammoplasty performed prior to oncological treatment (p < 0.001), and in patients with immediate reconstruction (p = 0.0064). 2009;7(2):114-119. Reduction mammoplasty or breast reduction surgery reduces the volume and weight of the female breasts by removing excess fat, glandular tissue and skin. Philadelphia, PA: W.B. Drains were used significantly less by surgeons performing greater than or equal to 20 BBRs (p = 0.02). 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. Prostate Cancer Prostatic Dis. Health insurance companies frequently have different criteria for whether breast reduction surgery is medically necessary. ul.ur li{ Reduction mammoplasty for asymptomatic members is considered cosmetic. Vacuum-assisted minimally invasive surgery-An innovative method for the operative treatment of gynecomastia. Furthermore, no serious complications were observed in vacuum-assisted breast biopsy group. This study included 35 patients who underwent breast reduction due to the idiopathic form of gynecomastia. The NSQIP recorded two complication types: major complications (deep infection and return to operating room) and any complication (all surgical complications). Effects of reduction mammaplasty on pulmonary function and symptoms of macromastia. Several of the included studies reported improvement in QOL and several psychological domains after surgical treatment for gynecomastia. Srinivasaiah N, Iwuchukwu OC, Stanley PR, et al. Sollie M. Management of gynecomastia-changes in psychological aspects after surgery-a systematic review. 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. Preoperative patient factors and comorbidities, as well as intraoperative variables, were assessed. These researchers calculated the risk ratio (RR) for dichotomous outcomes and mean differences (MD) for continuous outcomes, with 95 % confidence intervals (CI). Prepubertal gynecomastia linked to lavender and tea tree oils. Ages ranged from 18 to 66 years. 2nd ed. Tobacco use and body mass index as predictors of outcomes in patients undergoing breast reduction mammoplasty. 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). } Risk factors for complications following breast reduction: Results from a randomized control trial. Determinants of surgical site infection after breast surgery. Fagerlund A, Lewin R, Rufolo G, et al. Resolution of idiopathic gynecomastia may take several months to years. Arlington Heights, IL: ASPS; March 9, 2002. 2006;9(2):109-114. These investigators retrospectively examined 83 patients with gynecomastia between January 2015 and December 2019. Of 110 subjects who were mailed questionnaires, approximately50 %(61 subjects) provided responses. Sollie (2018) noted that gynecomastia affects up to 2/3 of the male population. Aetna considers associated nipple and areolar reconstruction and tattooing of the nipple area medically necessary. cursor: pointer; 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. 2004;113(1):436-437. Choban PS, Flancbaum L. The impact of obesity on surgical outcomes: A review. Karamanos et al (2015) noted that although breast reduction mammoplasty accounts for more than 60,000 procedures annually, the literature remains sparse on outcomes. No necrosis, systemic infection, or muscle paralysis was reported. Thus, this study would not be considered of sufficient quality to provide reliable evidence of the effectiveness of a pain intervention. They have argued that removal of even a few hundred grams of breast tissue can result in substantial pain relief. 1999;103(1):76-82; discussion 83-85. This Clinical Policy Bulletin contains only a partial, general description of plan or program benefits and does not constitute a contract. In a liposuction-only reduction mammoplasty, a small access incision is made in one of the following locations: axillary (under the arm), periareolar (around the nipple) or in the inframammary fold (under the breast). @media print { } Bertin ML, Crowe J, Gordon SM. Major complications (1.6 %) included unilateral hematoma and localized infection. Brown DM, Young VL. Oncoplastic reduction mammoplasty for breast cancer in women with macromastia: Oncological long-term outcomes. A total of 15 articles met the inclusion criteria for review. } Hoyos and colleagues (2021) stated that male chest definition surgery and patients complaining of breast tissue over-growth have been increasing in recent decades. Breast pumps. Gynecomastia in patients with prostate cancer: A systematic review. In a prospective, cohort study, these investigators evaluated the efficacy of tamoxifen therapy in resolving this condition. OL LI { Henley et al (2007) reported that repeated topical exposure to lavender and tea tree oils may be linked to prepubertal gynecomastia (idiopathic gynecomastia). 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. Plast Reconstr Surg. Collins ED, Kerrigan CL, Kim M, et al. } Plast Reconstr Surg. Reduction mammaplasty: A review of managed care medical policy coverage criteria. 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. Mayo Clin Proc. 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. A physician-supervised diet and exercise plan may be indicated in obese patients. The mean incidence of gynecomastia was 70 % in the high-risk population examined representing prostate cancer patients on estrogen or anti-androgen therapy. The median complication rate was 12.4 % with no major complications, such as neoplastic, pulmonary, or adverse cardiac outcomes. } These investigators analyzed the incidence of occult breast cancer and high-risk lesions in reduction mammoplasty specimens of women with previous breast cancer. Pediatr Surg Int. 2003;111(2):688-694. Breast and aesthetic surgery. 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. /* aetna.com standards styles for templates */ 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. Little is known about the effect of surgical treatment on the psychological aspects of the disease. 2002;109(5):1556-1566. 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. 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. The average interval between primary and secondary surgery was 14 years (range of 0 to 42 years). Principles of breast re-reduction: A reappraisal. .headerBar { 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. OL OL OL OL OL LI { These individuals cite evidence from observational studies to support this position (e.g., Chadbourne et al, 2001; Kerrigan et al, 2001). Analysis was on an intention-to-treat basis. Reduction (or some cases augmentation) mammoplasty and related reconstructive procedures on the unaffected side for symmetry are also considered medically necessary. 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. A detailed physical examination, including testicular examination. 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. J Plast Reconstr Aesthet Surg. Reduction mammoplasty has also been used for relief of pain in the back, neck and shoulders. Plast Reconstr Surg. The effectiveness of surgical and nonsurgical interventions in relieving the symptoms of macromastia. 1999;103(6):1687-1690. 2008;53(3):255-261. ER expression did not correlate with the right (p = 0.51) and left 2D: 4D (p = 0.97). Breast reduction surgery might also help improve self-image and the ability to take part in physical activities. Clinical Policy Bulletins are developed by Aetna to assist in administering plan benefits and constitute neither offers of coverage nor medical advice. Here's what Aetna said in the denial: "We used the Clinical Policy Bulletin (CPB): Breast Reduction Surgery. 1994;21(3):539-543. Secondary outcomes included subjective as well as objective assessments of pain and wound healing. Treating providers are solely responsible for medical advice and treatment of members. 2015;75(4):370-375. They also analyzed if timing of reduction mammoplasty in relation to oncological treatment influenced the incidence of abnormal findings, and compared if patients with abnormal contralateral histopathology differed from the study population in terms of demographics. Jansen DA, Murphy M, Kind GM, Sands K. Breast cancer in reduction mammoplasty: Case reports and a survey of plastic surgeons. text-decoration: underline; 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. Qu S, Zhang W, Li S, et al. Surgical management of gynecomastia--a 10-year analysis. Management of gynecomastia should include evaluation, including laboratory testing, to identify underlying etiologies. Gonzalez FG, Walton RL, Shafer B, et al. Aesthet Plastic Surg. Nor is it intuitively obvious that removal of smaller amounts of breast tissue would offer significant relief of back, shoulder or neck pain. Abnormalities in Adolescent Breast Development. 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. 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. Safran and colleagues (2021) noted that several technologies and innovative approaches continue to emerge for the optimal management of gynecomastia by plastic surgeons. 2018;89(6):408-412. The authors concluded that vacuum-assisted, minimally invasive mastectomy was a feasible approach for the treatment of gynecomastia with acceptable complications. Gynecomastia has been classified into2 types. 1998;41(3):240-245. It can cause discomfort and concern, resulting in patients seeking diagnosis and treatment. 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). 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. Subjects were compared to age-matched norms from another study cohort. Priorities Forum Policy Statement. OL OL OL OL LI { 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. Ann Plast Surg. Links to various non-Aetna sites are provided for your convenience only. Annu Rev Med. Evidence-based clinical practice guideline: Reduction mammaplasty. and areola. It was also found that only 3 % of subjects reported that they had no aesthetic motivation for surgery. Women's Health and Cancer Rights Act of 1998. 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. Plast Reconstr Surg. } No other operation-related complications were observed. Re-operation rate of liposuction-assisted surgery was between 0.6 % and 25 %. Reduction mammoplasty for macromastia. The investigators found that comorbid conditions increased across obesity classifications (p < 0.001), with significant differences noted in all cohort comparisons except when comparing class I to class II (p = 0.12). Level of Evidence = IV. 2012;69(5):510-515. Patient demographics, surgical technique, and outcomes were analyzed. 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). The goals of the surgery are to relieve symptoms caused by heavy breasts, to create a natural, balanced appearance with normal location of the nipple and areola, to maintain the capacity for lactation and allow for future breast exams/mammograms with minimal scarring or decreased sensation. Subgroup analysis further stratified the younger cohort into those <50 years and 50-60 years of age. hr.separator { Level of Evidence = IV. 2017;35:157-161. Howrigan P. Reduction and augmentation mammoplasty. height:2px; 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. Removing the adipose tissue in pseudogynecomastia usually has no long term effect as adipose tissue reaccumulates unless the individual loses weight. The surgeon removes excess tissue, fat and skin before adjusting the placement of the nipple and areola appropriately. Grooving where the bra straps sit on the shoulder. 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. Khan SM, Smeulders MJ, Van der Horst CM. Raispis T, Zehring RD, Downey DL. Ann Plast Surg. You must be at least 18 years old or show completed breast growth (no change in breast size over at least a year) to qualify for Aetna breast reduction coverage. list-style-type: decimal; border-radius: 4px; 2006;30(3):309-319. Behmand RA, Tang DH, Smith DJ Jr. Outcomes in breast reduction surgery. list-style-type : square !important; 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. text-decoration: line-through; 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. 2021 Aug 11 [Online ahead of print]. 2014;20(3):274-278. Risk of bias was assessed independently by 2review authors. Healing balms, scented soaps, skin lotions, shampoos and styling gels containing lavender oilor tea tree oil. } To get insurance coverage, you'll probably need . 2001;107(5):1234-1240. These investigators concluded that their findings do not support the use of completely autologous platelet gel to improve outcomes after reduction mammoplasty. Level of Evidence = III. 2020 Sep 4 [Online ahead of print]. Drainage in breast reduction surgery: A prospective randomised intra-patient trail. padding: 15px; The mean age was 42.8 years (SD 19.5 years). Breast J. Aetna does not provide health care services and, therefore, cannot guarantee any results or outcomes. 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. If gynecomastia is idiopathic, reassurance of the common, transient and benign nature of the condition should be given. The authors concluded that treatment of gynecomastia by the Mammotome device was distinctive, practicable in manipulation, safe, and could achieve excellent cosmetic results. Hello! right: 30px; Breast reduction surgery, also known as reduction mammaplasty, removes fat, breast tissue and skin from the breasts. Plast Reconstr Surg. Med Decis Making. 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. Complication rates were inconsistent throughout the studies, ranging from 0.06 % to 26.67 %. Gynecomastia: A systematic review. Work-up of gynecomastia may include the following (GP Notebook, 2003): Treatment should be directed at correcting any underlying reversible causes. Merkkola-von Schantz and colleagues (2017) stated that contralateral reduction mammoplasty is regularly included in the treatment of breast cancer patients. Arlington Heights, IL: ASPRS; 1987. 1995;34(2):113-116. (This refers to actual breast tissue only; any fatty tissue removed doesn't count.) 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. cursor: pointer; OL OL OL LI { This was further isolated when comparing morbidly obese patients to non-obese (p < 0.001), class I (p < 0.001), and class II (p = 0.01) patients. color: blue!important; Surgical treatment of gynecomastia: Complications and outcomes. color:#eee; Reduction mammaplasty in patients with history of breast cancer: The incidence of occult cancer and high-risk lesions. Aesthetic Plast Surg. The end-point was the complete resolution of gynecomastia. Aesthet Surg J. Saunders Co.; 1991. border: none; These investigators support its use for idiopathic gynecomastia in eligible men following the careful discussion of its risks and benefits. 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. Schnur PL, Schnur DP, Petty PM, et al. The author identified the psychological domains affected by the disease and the effect of surgical treatment on these. Dancey A, Khan M, Dawson J, Peart F. Gigantomastia--a classification and review of the literature. list-style-image: url('https://www.aetna.com/cpb/medical/data/assets/images/purplearrow.jpg') !important; These studies did not find a relationship between breast weight or amount of breast tissue removed and the likelihood of response or magnitude of relief of pain after reduction mammoplasty. The majority (87.7 %) of cases presented with accompanying mastalgia. Macromastia: all . A study by Bruhlmann and Tschopp (1998) was a retrospective study of 246 patients from a surgical practice, approximately 50 % (132) of whom returned a questionnaire about their symptoms and satisfaction with aesthetic results, and their recollection of symptoms prior to surgery. Long-term functional results after reduction mammoplasty. OL OL LI { Reduction mammoplasty also known as breast reduction surgery, is a surgical procedure in women to reduce the weight, mass, and size of the breast. 2018;24(6):1043-1045. Gynecomastia Treatment through Open Resection and Pectoral High-Definition Liposculpture. Endocrinol Metab Clin North Am. Insurers have commonly used the amount of breast tissue to be removed as a criterion for evaluating the medical necessity of breast reduction surgery. Reduction mammaplasty: Defining medical necessity. 2015;49(6):363-366. Nguyen JT, Wheatley MJ, Schnur PL, et al. 2001;76(5):503-510. Plast Reconstr Surg. Obesity and complications in breast reduction surgery: Are restrictions justified? Surgical treatment of gynecomastia by vacuum-assisted biopsy device. 2018;7(Suppl 1):S70-S76. The author average amount of breast tissue removed for women in 5 kg weight bands, ranging from 45-49 kg to 90+ kg. 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. All studies on the subject were evaluated for inclusion and 6 studies were included in the review. There were only 2 studies of a total 25 patients that were considered as good in quality. The health burden of breast hypertrophy. 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. Other just require 500 grams no matter what your height and weight. 1999;103(6):1674-1681. Plastic Reconstr Surg. Guidelines for Adolescent Health Care. This trial included all male patients who presented to the authors breast clinic who were diagnosed with primary gynecomastia, and were treated with a trial of tamoxifen 10 mg daily therapy, over a 10-year period from October 2004 to October 2015. 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. Townsend: Sabiston Textbook of Surgery. Mannu GS, Sudul M, Bettencourt-Silva JH, et al. list-style-type: upper-alpha; These researchers compared the safety and effectiveness of the use of wound drains following elective plastic and reconstructive surgery procedures of the breast. background: #5e9732; The operation had a mean duration of 73.5 mins per side, ranging from 40 to 102 mins. Breast Reduction Surgery and Gynecomastia Surgery - Medical Clinical Policy Bulletins | Aetna Page . Reduction mammoplasty: Cosmetic or reconstructive procedure? Plast Reconstr Surg. American College of Obstetricians and Gynecologists (ACOG), Committee on Adolescent Health Care. 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.
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