Clinical outcomes in reduction mammaplasty: A systemic review and meta-analysis of published studies. Plast Reconstr Surg. Cochrane Database Syst Rev. This may lead to additional scarring and additional operating time. color:#eee; Sugrue and associates (2015) evaluated the current practice patterns of drains usage by plastic and reconstructive and breast surgeons in United kingdom (UK) and Ireland performing bilateral breast reduction (BBR). background: #5e9732; The risks included infection, wound breakdown, scarring, and the need for re-operating. Refer to the member's specific plan document for applicable coverage. In a majority of boys with pubertal gynecomastia, the condition resolves within 18 months. A total of 90 patients underwent breast re-reduction surgery. Marshall WA, Tanner JM. 2005;55(3):227-231. Plastic Reconstruct Surg. Plastic Reconstruct Surg. Level of Evidence = IV. 1998;101(2):361-364. Managed care's methods for determining coverage of plastic surgery procedures: The example of reduction mammaplasty. 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). 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. Reduction mammoplasty: Criteria for insurance coverage. 2014b;30(6):641-647. He Q, Zheng L, Zhuang D, et al. ul.ur li{ The surgeon removes excess tissue, fat and skin before adjusting the placement of the nipple and areola appropriately. 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". Two review authors undertook independent data extraction of study characteristics, methodological quality and outcomes (e.g., infection, other wound complications, pain, and length of hospital stay [LOS]). 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). 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. 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). Reduction mammaplasty. Plast Reconstr Surg. Fagerlund A, Cormio L, Palangi L, et al. } Reduction mammoplasty improves symptoms of macromastia. 1994;21(3):539-543. Ann Plastic Surg. Surgeon. 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. Post-operative complications included 1 case of hematoma, but no nipple necrosis, local skin necrosis, or skin buttonhole occurred. Determinants of surgical site infection after breast surgery. Reduction mammoplasty is among the most commonly performed cosmetic procedures in the United States. 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. Thus, this study would not be considered of sufficient quality to provide reliable evidence of the effectiveness of a pain intervention. Plast Reconstr Surg. Plast Reconstr Surg. There were no statistically significant differences between the 2 vacuum-assisted breast biopsy systems according to the mean age, the mean operation time, sites, or grade. Drainage in breast reduction surgery: A prospective randomised intra-patient trail. 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. Am J Infect Control. Sollie (2018) noted that gynecomastia affects up to 2/3 of the male population. Among these domains were: vitality, emotional discomfort, limitations due to physical aspects and limitations due to pain. Often, you'll be eligible for Blue Cross Blue Shield breast reduction coverage if your surgeon plans to remove at least 500 grams of breast tissue per breast. Jansen DA, Murphy M, Kind GM, Sands K. Breast cancer in reduction mammoplasty: Case reports and a survey of plastic surgeons. 1997;100(4):875-883. display: block; In addition, reduction mammoplasty needs to be compared with other established methods of relieving back, neck and shoulder pain. Patients with abnormal histopathology could not be pre-operatively identified based on demographics. Type II gynecomastia is more generalized breast enlargement. It can cause discomfort and concern, resulting in patients seeking diagnosis and treatment. text-decoration: underline; Choban PS, Heckler R, Burge JC, Flancbaum L. Increased incidence of nosocomial infections in obese surgical patients. z-index: 99; border: none; 2011;21(5):431-434. Henley DV, Lipson N, Korach KS, Bloch CA. 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. Iwuagwu OC, Stanley PW, Platt AJ, Drew PJ. Li CC, Fu JP, Chang SC, et al. Plast Reconstr Surg. They evaluated the use of radiotherapy for the prevention and treatment of gynecomastia incidence or recurrence by plastic surgeons. Satisfactory chest contour was gained in all cases without any abnormality, skin redundancy, or recurrence during the follow-up of 6 to 48 months. 2001;76(5):503-510. 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. Patients in vacuum-assisted breast biopsy group had a better cosmetic outcome than those in open surgery group. Kasielska A, Antoszewski B. Surgical management of gynecomastia: An outcome analysis. PLoS One. .fixedHeaderWrap { Plast Reconstr Surg. Gynecomastia in patients with prostate cancer: Update on treatment options. Surgical treatment of gynecomastia by vacuum-assisted biopsy device. Wound drainage after plastic and reconstructive surgery of the breast. Principles of breast re-reduction: A reappraisal. Breast Reduction Surgery and Gynecomastia Surgery - Medical Clinical Policy Bulletins | Aetna Page . 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]. 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:. right: 30px; OL OL LI { } In total there were 306 women in the 3 trials, and 505 breasts were studied (254 drained, and 251 who were not drained). Seitchik (1995) reviewed the amount of breast tissue removed from a series of 100 patients that underwent breast reduction surgery. J Plast Reconstr Aesthet Surg. Ann Plast Surg. Med Decis Making. Yao and co-workers (2019) described an innovative method for the operative treatment of gynecomastia -- vacuum-assisted minimally invasive mastectomy. Ages ranged from 18 to 66 years. 2008;121(4):1092-1100. Asian J Surg. Most cases of type I gynecomastia are unilateral, and 20% of cases are bilateral. 2018;24(6):1043-1045. Brown DM, Young VL. 2015;49(6):311-318. 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. 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 Note: Chronic intertrigo, eczema, dermatitis, and/or ulceration in the infra-mammary fold in and of themselves are not considered medically necessary indications for reduction mammoplasty. Gynecomastia resection plus high-definition liposculpture was successfully performed in 436 consecutive men (open inverted-omega incision resection, n = 132; liposuction, n = 304). The surgeon estimates that at least the following amounts (in grams) of breast tissue, not fatty tissue, will be removed from each breast, based on the member's body surface area (BSA) calculated using theMosteller formula. Vacuum-assisted minimally invasive surgery-An innovative method for the operative treatment of gynecomastia. Plast Reconstr Surg. Redundant skin was observed in 1 patient at 1 month post-operatively, whose breast, defined as grade-III, was the largest before operation. 2009;19(3):e85-e90. 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. 1995;95(6):1029-1032. Karamanos et al (2015) noted that although breast reduction mammoplasty accounts for more than 60,000 procedures annually, the literature remains sparse on outcomes. American College of Obstetricians and Gynecologists (ACOG), Committee on Adolescent Health Care. Gynecomastia has been classified into2 types. and areola. 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. padding-right: 18px; Sugrue CM, McInerney N, Joyce CW, et al. 1991;27(3):232-237. 0017 - Breast Reduction Surgery and Gynecomastia Surgery, are met. The operation had a mean duration of 73.5 mins per side, ranging from 40 to 102 mins. The study subjects were stratified into groups based on ages of <60 years and 60 years. list-style-type: upper-roman; 1997;185(6):593-603. Reduction mammoplasty specimens revealed abnormal findings in 68 (21.5 %) patients. Ann Plast Surg. They reviewed their records on pectoral high-definition liposculpture between January of 2005 and October of 2019 in 4 surgical centers in Colombia. J Am Coll Surg. The control group was not followed longitudinally or treated according to any protocol to ensure that they received optimal conservative management; conclusions about the lack of effectiveness of conservative management were based on their responses to a questionnaire about whether subjects tried any of 15 conservative interventions, and whether or not they thought these interventions provided relief of symptoms. color: white; Special Clinical Concerns. Aetna considers breast reduction surgery medically necessary for non-cosmetic indications for women aged 18 or older or for whom growth is complete (i.e., breastsize stable over one year) when any of the following criteria (A, B, or C) is met: Member has persistent symptoms in at leasttwoof the anatomical body areas below, directly attributed to macromastia and affecting daily activities for at least1 year: Member has severe breast hypertrophy, documented by high-quality color frontal-view and side-view photographs;and, Women50 years of age or older are required to have a mammogram that was negative for cancer performed within the twoyears prior to the date of the planned reduction mammoplasty;and. Removing the adipose tissue in pseudogynecomastia usually has no long term effect as adipose tissue reaccumulates unless the individual loses weight. Karamanos et al (2015) identified their study as the largest sample on breast reduction in the literature, in which age and surgeon specialty did not correlate with negative results. A total of 81 patients were included in this study. In other patients, excess skin and nipple and areola relocation are necessary. Flancbaum L, Choban PS. The average amount of breast tissue removed ranged from 430 g per breast to 1.6 kg per breast, with increased body weight associated with an increased amount of breast tissue to be removed. 2014;20(3):274-278. Chemical peels (chemical exfoliation): Considered medically necessary when criteria in CPB 0251 - Dermabrasion, Chemical Peels, and Acne Am Surg. Photographs were taken pre-operatively and 1, 3, 6, and 12 months post-operatively. The 2 studies, which discussed laser-assisted liposuction technique, showed minor complication of seroma in 2 patients. 2021 Aug 11 [Online ahead of print]. margin-bottom: 38px; Major complications (1.6 %) included unilateral hematoma and localized infection. 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. If gynecomastia is idiopathic, reassurance of the common, transient and benign nature of the condition should be given. Handschin AE, Bietry D, Hsler R, et al. color: blue!important; Complication rates were inconsistent throughout the studies, ranging from 0.06 % to 26.67 %. These preliminary findings need to be validated by well-designed studies. Liposuction facilitated the easy handling to remove the breast tissue via small incisional design; showed consistent improved QOL in terms of satisfaction after surgery. Schnur subsequently refuted the validity of the Schnursliding scaleand stated that thescale should no longer be used as a criterion for the determination of insurance coverage for breast reduction surgery (Nguyen et al, 1999). 1999;103(6):1674-1681. Glatt BS, Sarwer DB, O'Hara DE, et al. Evidence-based clinical practice guideline: Reduction mammaplasty. 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. 1969;44(235):291-303. 2005;58(3):286-289. Data was then analyzed for surgical complications, wound complications, and medical complications within 30 days of surgery on 4545 patients. 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. Arlington Heights, IL: ASPS; 2011. 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. Narula HS, Carlson HE. display: none; Sollie M. Management of gynecomastia-changes in psychological aspects after surgery-a systematic review. Because of their inherently subjective nature, pain symptoms are especially prone to placebo effects. The vacuum-assisted breast biopsy system is an effective strategy for the treatment of gynecomastia. Work-up of gynecomastia may include the following (GP Notebook, 2003): Treatment should be directed at correcting any underlying reversible causes. } 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. For many patients the psychological impact of the disease is substantial. } Estrogens and estrogen like drugs,including: Drugsthat enhance estrogen formation, including: Drugs which inhibit testosterone synthesis, including, Drugs that inhibit testosterone action, including. } Gynaecomastia. Risk of bias was assessed independently by 2review authors. The study consisted of 329 breast cancer patients, who underwent symmetrizing reduction mammoplasty between 1/2007 and 12/2011. 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. The effectiveness of surgical and nonsurgical interventions in relieving the symptoms of macromastia. background-color: #cc0066; } Kerrigan CL, Collins ED, Kim HM, et al. J Plast Surg Hand Surg. For medical Current practice patterns of drain usage amongst UK and Irish surgeons performing bilateral breast reductions: Evidence down the drain. 1. Follow-up ranged from 2 months to 3 years. American Society of Plastic Surgeons (ASPS). Is there a rationale behind pharmacotherapy in idiopathic gynecomastia? Klinefelters syndrome, testicular, adrenal, or pituitary tumors, and thyroid or hepatic dysfunction are also associated with gynecomastia. 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. 2 . For those with large breasts, breast reduction surgery can ease discomfort and improve appearance. Mizgala CL, MacKenzie KM. width: 100%; Schnur PL, Schnur DP, Petty PM, et al. World J Surg. Reduction mammoplasty for asymptomatic members is considered cosmetic. list-style-type: decimal; list-style-type: decimal; 2008;53(3):255-261. Other just require 500 grams no matter what your height and weight. However, if liposuction is used as an adjunctive technique, the decision to use drains should be left to the surgeon's discretion. 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 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. 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. Emiroglu M, Salimoglu S, Karaali C, et al. hr.separator { Most UnitedHealthcare plans have a specific exclusion for breast reduction surgery except as required by the . The investigators reported that subjects who were of normal weight were as likely to report benefit from reduction mammoplasty as subjects who were over-weight. They have argued that removal of even a few hundred grams of breast tissue can result in substantial pain relief. 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.

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