All patients underwent routine investigations to exclude secondary causes of gynecomastia. Plast Reconstr Surg. Gynecomastia in patients with prostate cancer: Update on treatment options. 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. Determinants of surgical site infection after breast surgery. background-color:#eee; hr.separator { J Plast Surg Hand Surg. Srinivasaiah N, Iwuchukwu OC, Stanley PR, et al. Clinical outcomes in reduction mammaplasty: A systemic review and meta-analysis of published studies. 1997;100(4):875-883. Gynecomastia may be drug-induced. 2009;19(3):e85-e90. Examining any complication, a significant increase was noted with increasing obesity class (p < 0.001). Liposuction was also used adjunctively in all cases (average of 455 cc; range, 50 to 1,750 cc). Khan SM, Smeulders MJ, Van der Horst CM. Measurement of plasma gonadotrophins, human chorionic gonadotropin (hCG), testosterone, estradiol, and dehydroepiandosterone sulphate (DHEAS). Gynecomastia: A systematic review. There were 18 out of 415 studies eligible to review. Last Review01/04/2023. Computed tomography scan of adrenal glands to identify adrenal lesions. 2021;74(11):3128-3140. Insurers have commonly used the amount of breast tissue to be removed as a criterion for evaluating the medical necessity of breast reduction surgery. American College of Obstetricians and Gynecologists (ACOG), Committee on Adolescent Health Care. Thus, this study would not be considered of sufficient quality to provide reliable evidence of the effectiveness of a pain intervention. Grade II: Moderate breast enlargement exceeding areola boundaries with edges that are indistinct from the chest. The median complication rate was 12.4 % with no major complications, such as neoplastic, pulmonary, or adverse cardiac outcomes. Raispis T, Zehring RD, Downey DL. 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. list-style-type : square !important; Hoyos AE, Perez ME, Dominguez-Millan R, et al. The 2 studies, which discussed laser-assisted liposuction technique, showed minor complication of seroma in 2 patients. Surgeon. The safety, efficacy, complications, and patient satisfactions were recorded during post-operative follow-up periods. Glatt BS, Sarwer DB, O'Hara DE, et al. No other operation-related complications were observed. } Swelstad MR, Swelstad BB, Rao VK, Gutowski KA. Vacuum-assisted minimally invasive surgery was carried out under general anesthesia; subjects were followed-up with physical examination and ultrasonography (US). 1995;61(11):1001-1005. 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. The primary outcome was the difference in wound drainage over 24 hours. If gynecomastia is idiopathic, reassurance of the common, transient and benign nature of the condition should be given. These investigators concluded that their findings do not support the use of completely autologous platelet gel to improve outcomes after reduction mammoplasty. The end-point was the complete resolution of gynecomastia. Aetna and the City shall each abide by all applicable laws, regulations and government requirements regarding the confidentiality and the safeguarding of individually identifiable health and other personal information, including the privacy and security requirements of HIPAA. top: 0px; 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. The operation had a mean duration of 73.5 mins per side, ranging from 40 to 102 mins. 40 . If reduction mammoplasty was performed before oncological treatment, the incidence of abnormal findings was higher. Plast Reconstr Surg. Klinefelters syndrome, testicular, adrenal, or pituitary tumors, and thyroid or hepatic dysfunction are also associated with gynecomastia. Kasielska-Trojan A, Danilewicz M, Antoszewski B. } Morbidly obese patients are at the highest risk, with complications occurring in nearly 12% of this cohort. Initial breast reconstruction including augmentation with implants 15771-15772 (when specific to breast), 19325, 19340, 19342, C1789 Fat grafting (alone, or with implant based feminization) 15771, 15772 *Note: CPT 19318 (breast reduction) includes the work necessary to reposition and reshape the nipple . No necrosis, systemic infection, or muscle paralysis was reported. Pain/discomfort/ulceration from bra straps cutting into shoulders; Skin breakdown (severe soft tissue infection, tissue necrosis, ulceration hemorrhage) from overlying breast tissue; There is a reasonable likelihood that the member's symptoms are primarily due to macromastia; Reduction mammoplasty (also spelled as 'mammaplasty') is likely to result in improvement of the chronic pain; Pain symptoms persist as documented by the physician despite at least a 3-month trial of therapeutic measures such as: Analgesic/non-steroidal anti-inflammatory drugs (NSAIDs) interventions and/or muscle relaxants, Dermatologic therapy of ulcers, necrosis and refractory infection, Physical therapy/exercises/posturing maneuvers, Supportive devices (e.g., proper bra support, wide bra straps), Chiropractic care or osteopathic manipulative treatment. Reduction mammoplasty is among the most commonly performed cosmetic procedures in the United States. text-decoration: underline; Several important points should be considered in evaluating these challenges to insurers' criteria for breast reduction surgery. Current concepts in gynaecomastia. border-width:0; 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). 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. Beer GM, Kompatscher P, Hergan K. Diagnosis of breast tumors after breast reduction. 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. Breast reduction outcome study. 2014a;34(3):409-416. Mannu GS, Sudul M, Bettencourt-Silva JH, et al. They have argued that removal of even a few hundred grams of breast tissue can result in substantial pain relief. 2012;69(5):510-515. Iwuagwu OC, Stanley PW, Platt AJ, Drew PJ. Ann Plastic Surg. These investigators analyzed the incidence of occult breast cancer and high-risk lesions in reduction mammoplasty specimens of women with previous breast cancer. background: #5e9732; 2014a;34(1):66-73. Managed care's methods for determining coverage of plastic surgery procedures: The example of reduction mammaplasty. Second, it is the burden of the proponent of an intervention to provide reliable evidence of its effectiveness, not the burden of ones whoquestion the effectivenessan intervention to provide definitive proof of ineffectiveness. A detailed physical examination, including testicular examination. Emiroglu M, Salimoglu S, Karaali C, et al. 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. 2021 Aug 11 [Online ahead of print]. Plast Reconstr Surg. Sood R, Mount DL, Coleman JJ 3rd, et al. padding: 15px; Redundant skin was observed in 1 patient at 1 month post-operatively, whose breast, defined as grade-III, was the largest before operation. li.bullet { 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. 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. From January 2006 to January 2010, a total of 20 men with gynecomastia were treated by an 8-G vacuum-assisted biopsy device. 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. The only criterion that the authors found supportable wasa requirementfor a pre-operative mammogram for women aged 40 years and older. Gynecomastia. outline: none; Post-operative complications included 1 case of hematoma, but no nipple necrosis, local skin necrosis, or skin buttonhole occurred. Principles of breast re-reduction: A reappraisal. Breast and aesthetic surgery. Aesthet Plastic Surg. They evaluated the use of radiotherapy for the prevention and treatment of gynecomastia incidence or recurrence by plastic surgeons. 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? 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. All the patients recovered well and were satisfied with the cosmetic outcomes. Of these, 28.4 % were bilateral gynecomastia and 71.6 % were unilateral. Autorino R, Perdona S, D'Armiento M, et al. Chemical peels (chemical exfoliation): Considered medically necessary when criteria in CPB 0251 - Dermabrasion, Chemical Peels, and Acne background: url('https://www.aetna.com/cpb/medical/data/assets/images/purplearrow.jpg') no-repeat; Reduction mammoplasty for macromastia. 1994;21(3):539-543. Reduction (or some cases augmentation) mammoplasty and related reconstructive procedures on the unaffected side for symmetry are also considered medically necessary. Kasielska A, Antoszewski B. Surgical management of gynecomastia: An outcome analysis. Breast. Mental health care professionals may be consulted to address psychological distress from gynecomastia. 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). Grade III: Moderate breast enlargement exceeding areola boundaries with edges that are indistinct from the chest with skin redundancy present. 2000;45(6):575-580. Nor is it intuitively obvious that removal of smaller amounts of breast tissue would offer significant relief of back, shoulder or neck pain. Dancey A, Khan M, Dawson J, Peart F. Gigantomastia--a classification and review of the literature. Approximately 25 % of the 49 subjects included in this study did not return the post-operative questionnaire. Plastic Reconstr Surg. Socioeconomic Committee Position Paper. Furthermore, no serious complications were observed in vacuum-assisted breast biopsy group. 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. Breast reduction surgery is considered cosmetic and not medically necessary for the following conditions: poor posture, breast asymmetry, pendulousness, problems with clothes fitting properly and nipple-areola distortion. Arlington Heights, IL: ASPS; 2011. 2016;20(3):256-260. Karamanos E, Wei B, Siddiqui A, Rubinfeld I. 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. Lonie S, Sachs R, Shen A, et al. 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. 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. PLoS One. He Q, Zheng L, Zhuang D, et al. Ann Chir Plast Esthet. The requirement for coverage is that the amount of breast tissue to be removed has to be enough to improve your symptoms or function. 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. Arlington Heights, IL: ASPS; May 2011. For individuals who received radiation treatment to the chest . } The authors concluded that vacuum-assisted, minimally invasive mastectomy was a feasible approach for the treatment of gynecomastia with acceptable complications. In contrast, tobacco use and BMI were associated with worse breast reduction outcomes. Results illustrated that 3050 patients were <60 years of age (39.7 11.8 years) and 487 were 60 years of age (65.1 4.7 years). Reduction mammoplasty specimens revealed abnormal findings in 68 (21.5 %) patients. Breast Concerns of Adolescents. } } This Clinical Policy Bulletin contains only a partial, general description of plan or program benefits and does not constitute a contract. 1998;26(1):61-65. Prostate Cancer Prostatic Dis. 2006;118(4):840-848. These preliminary findings need to be validated by well-designed studies. Bruhlmann Y, Tschopp H. Breast reduction improves symptoms of macromastia and has a long-lasting effect. Liposuction assisted gynecomastia surgery with minimal periareolar incision: A systematic review. 2009;7(2):114-119. Ann Plast Surg. 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. 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. The surgeon removes excess tissue, fat and skin before adjusting the placement of the nipple and areola appropriately. Burdette TE, Kerrigan CL, Homa KA. Breast J. 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. 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. Conversely, many patients believe if a procedure is considered cosmetic, it is not a medically indicated and covered procedure. Schnur PL, Schnur DP, Petty PM, et al. Because of their inherently subjective nature, pain symptoms are especially prone to placebo effects. 1990;24(1):61-67. 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. margin-top: 38px; Subgroup analysis further stratified the younger cohort into those <50 years and 50-60 years of age. In: Townsend CM, Beuchamp RD, Evers BM, eds. Gynaecomastia. 2005;55(3):227-231. bottom: 20px; For many patients the psychological impact of the disease is substantial. The author identified the psychological domains affected by the disease and the effect of surgical treatment on these. 2008;32(1):38-44. Sabistons Textbook of Surgery (Burns & Blackwell, 2008)states that breast size should be stable for one year: There is no set lower age limit but, for the adolescent with breast hypertrophy, reduction is deferred until the breasts have stopped growing and are stable in size for at least 12 months before surgery.. color: blue Fischer JP, Cleveland EC, Shang EK, et al. height:2px; 2017;139(6):1313-1322. 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). There were only 2 studies of a total 25 patients that were considered as good in quality. } Plast Reconstr Surg. These investigators support its use for idiopathic gynecomastia in eligible men following the careful discussion of its risks and benefits. 2018;89(6):408-412. 2008;61(5):493-502. 2008;121(4):1092-1100. of . Asian J Surg. Merkkola-von Schantz and colleagues (2017) stated that contralateral reduction mammoplasty is regularly included in the treatment of breast cancer patients. 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. Study appraisal was carried out using MINORS to evaluate the methodological quality of the paper. 1999;103(6):1687-1690. Schnur PL, Hoehn JG, Ilstrup DM, et al. } Tang CL, Brown MH, Levine R, et al. Plast Reconstr Surg. and areola. Reduction mammoplasty improves symptoms of macromastia. GP Notebook. Araco A, Gravante G, Araco F, et al. The authors reach the remarkable conclusion that a woman with normal sized breasts who has only a few ounces of breast tissue removed is as likely to receive as much benefit from breast reduction surgery as a women with large breasts who has substantially more breast tissue removed. padding-bottom: 4px; Narula HS, Carlson HE. 1995;34(2):113-116. 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. Obesity and complications in breast reduction surgery: Are restrictions justified? 2004;113(1):436-437.
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