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. Administration of Benefits and Transition Responsibilities 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). Drainage in breast reduction surgery: A prospective randomised intra-patient trail. This may lead to additional scarring and additional operating time. A total of 211 responding surgeons were analyzed, including 80.1 % (171/211) plastic surgeons and 18.9 % (40/211) breast surgeons. The authors concluded that even with the high level of evidence demonstrating the safety of BBR without drains, they are still routinely utilized. 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. CPT Codes 19316 & 19318 - Mastopexy & Reduction No significant changes have been made to the Ann Plastic Surg. Am Surg. li.bullet { Plast Reconstr Surg. The Breast: Comprehensive Management of Benign and Malignant Diseases. Study appraisal was carried out using MINORS to evaluate the methodological quality of the paper. 1993;17(3):211-223. Policy. Aetna considers breast reconstructive surgery to correct 1999;103(6):1674-1681. Examining any complication, a significant increase was noted with increasing obesity class (p < 0.001). Fan L, Yang X, Zhang Y, Jiang J. Endoscopic subcutaneous mastectomy for the treatment of gynecomastia: A report of 65 cases. Brown DM, Young VL. 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. 2014b;48(5):334-339. The end-point was the complete resolution of gynecomastia. color: blue!important; display: block; 2005;58(3):286-289. 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. He and associates (2011) examined the safety and feasibility of vacuum-assisted biopsy device in the treatment of gynecomastia. OL LI { 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. All subjects were satisfied with their cosmetic outcome, graded as excellent by 22 patients (100 %). 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. Management of gynecomastia should include evaluation, including laboratory testing, to identify underlying etiologies. Gynecomastia is a very common concern of male adolescence. } 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. Nguyen JT, Wheatley MJ, Schnur PL, et al. Macromastia: all . Gynecomastia may be drug-induced. American College of Obstetricians and Gynecologists (ACOG), Committee on Adolescent Health Care. Henley et al (2007) reported that repeated topical exposure to lavender and tea tree oils may be linked to prepubertal gynecomastia (idiopathic gynecomastia). Plast Reconstr Surg. A total of 81 patients were included in this study. Women's Health and Cancer Rights Act of 1998. background-position: right 65%; Araco A, Gravante G, Araco F, et al. Doses examined ranged from 8 to 16 Gy, delivered between 1 and 11 fractions. 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. Computed tomography scan of adrenal glands to identify adrenal lesions. padding: 10px; Re-operation rate of liposuction-assisted surgery was between 0.6 % and 25 %. 2006;118(4):840-848. 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. Level of Evidence = IV. Aetna does not provide health care services and, therefore, cannot guarantee any results or outcomes. 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. Li CC, Fu JP, Chang SC, et al. 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. Measuring health state preferences in women with breast hypertrophy. PLoS One. skin should not be excised horizontally below the inframammary fold. Abnormal histopathology correlated with higher age (p = 0.0053), heavier specimen (p = 0.0491), and with no previous breast surgery (p < 0.001). The authors concluded that vacuum-assisted, minimally invasive mastectomy was a feasible approach for the treatment of gynecomastia with acceptable complications. They stated that no data are available for breast augmentation or breast reconstruction, and this requires investigation. Fat grafting to the breast can now be reported with CPT codes 15771 and 15772. background: url('https://www.aetna.com/cpb/medical/data/assets/images/purplearrow.jpg') no-repeat; list-style-type: upper-roman; Plast Reconstr Surg. 2015;75(4):383-387. } The risks included infection, wound breakdown, scarring, and the need for re-operating. Brown MH, Weinberg M, Chong N, et al. Breast J. Collins ED, Kerrigan CL, Kim M, et al. Hello! Several important points should be considered in evaluating these challenges to insurers' criteria for breast reduction surgery. 2014a;34(3):409-416. Clinical outcomes were measured by operative subjects' responses to a questionnaire about symptoms and quality of life. .arrowPurpleSmall, a:hover.arrowPurpleSmall { 2009;19(3):e85-e90. Secondary outcomes included subjective as well as objective assessments of pain and wound healing. Plast Reconstr Surg. Nor is it intuitively obvious that removal of smaller amounts of breast tissue would offer significant relief of back, shoulder or neck pain. 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. border-radius: 4px; Medical reduction has been achieved with agents such as dihydrotestosterone, danazol, and clomiphene. 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. Ann Plast Surg. 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. 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. 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. Breast reduction surgery (also called reduction mammaplasty) is a type of invasive procedure that involves incisions (cuts) in your skin to decrease the size and weight of your breasts . Schnur et al (1991) reported on a sliding scale assigns a weight of breast tissue to be removed based on body weight and surface area. Ages ranged from 18 to 66 years. For individuals who received radiation treatment to the chest . Effects of reduction mammaplasty on pulmonary function and symptoms of macromastia. 2000;44(2):125-134. 2015;75(4):370-375. 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. You first need to demonstrate that the procedure is "medically necessary and therefore reconstructive rather than cosmetic," says board-certified New York City plastic surgeon Dr. Umbareen Mahmood. padding-right: 18px; list-style-type: decimal; The mean incidence of gynecomastia was 70 % in the high-risk population examined representing prostate cancer patients on estrogen or anti-androgen therapy. Breast re-reduction surgery was most commonly performed using a random pattern blood supply, rather than recreating the primary pedicle [n = 77 (86 %)]. color: #FFF; Wound drainage after plastic and reconstructive surgery of the breast. 1998;26(1):61-65. 1999;103(6):1687-1690. Breast reduction outcome study. Petty PM, Solomon M, Buchel EW, Tran NV. A study by Glatt et al (1999) was a retrospective analysis of responses to questionnaires sent to patients who underwent reduction mammoplasty regarding physical symptoms and body image. } A study reporting on a survey of health insurer policies on breast reduction surgery (Nguyen et al, 2004) found that no insurer medical policies could be supported by the medical literature. Aesthet Plastic Surg. right: 30px; Plastic Reconstr Surg. These investigators presented their experience with pectoral high-definition liposculpture combined with inverted-omega incision resection for gynecomastia. Kerrigan CL, Collins ED, Kim HM, et al. Redundant skin was observed in 1 patient at 1 month post-operatively, whose breast, defined as grade-III, was the largest before operation. In a review on Surgical treatment of primary gynecomastia in children and adolescents, Fischer et al (2014b) concluded that surgical correction of gynecomastia remains a purely elective intervention. Arlington Heights, IL: ASPS; May 2011. 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. Until now, most published research on the subject has focused on how effective surgical treatment is on correcting the cosmetic appearance of the breast. These researchers compared the safety and effectiveness of the use of wound drains following elective plastic and reconstructive surgery procedures of the breast. Reduction mammoplasty for asymptomatic members is considered cosmetic. 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. Anzarut A, Guenther CR, Edwards DC, Tsuyuki RT. Aetna plans exclude coverage of cosmetic surgery that is not medically necessary, . Collis N, McGuiness CM, Batchelor AG. Links to various non-Aetna sites are provided for your convenience only. The operative group in the BRAVO study was drawn from a number of surgical practices that volunteered to participate in the study; no details are provided about how each center selected candidates for reduction mammoplasty, or how they chose patients who underwent mammoplasty for inclusion in the study. OL OL LI { 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. Based largely upon these results, Nguyen et al (2004) reached the conclusion that a trial of conservative management is not an appropriate criterion for insurance coverage, even though responses to the BRAVO questionnaire indicated that operative candidates and hypertrophy controls received at least some pain relief from all of the conservative interventions, and for some conservative interventions, virtually all subjects reported at least some pain relief. To calculate body surface area (BSA) see:BMI and BSA (Mosteller) Calculator;orBSA (m2) = ([height (in) x weight (lb)]/3131)(denotes square root), BSA (m2) = ([height (cm) x weight (kg)]/3600)(denotes square root). These individuals cite evidence from observational studies to support this position (e.g., Chadbourne et al, 2001; Kerrigan et al, 2001). 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). color: red!important; 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. Reduction mammoplasty improves symptoms of macromastia. A total of 182 thirty-day postoperative surgical complications were documented, but stratifying patients into 2 age groups did not reveal an association between age and any surgical complication (P = .26). Breast reconstruction/breast enlargement Breast reduction/mammoplasty Excision of excessive skin due to weight loss Gastroplasty/gastric bypass Reduction mammoplasty: Cosmetic or reconstructive procedure? /* aetna.com standards styles for templates */ Surgeon. Chadbourne EB, Zhang S, Gordon MJ, et al. 2019;166(5):934-939. Coding Studies have suggested that 2.4% to 14% of breast reduction cases resulted in major complications and 2.4% . It should be noted that this study reported a strong correlation between the amount of tissue removed and pain amelioration. Level of Evidence = III. position: fixed; It is universally believed by patients that if a surgery is considered reconstructive, it is medically indicated and covered by health insurance. The NSQIP recorded two complication types: major complications (deep infection and return to operating room) and any complication (all surgical complications). 2018;24(6):1043-1045. Philadelphia, PA: W.B. 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. Mistry and associates (2017) examined outcomes following breast re-reduction surgery using a random pattern blood supply to the nipple and vertical scar reduction. 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. Plast Reconstr Surg. Post-operative complications included 1 case of hematoma, but no nipple necrosis, local skin necrosis, or skin buttonhole occurred. 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). 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.. Merkkola-von Schantz and colleagues (2017) stated that contralateral reduction mammoplasty is regularly included in the treatment of breast cancer patients. .newText { If gynecomastia is idiopathic, reassurance of the common, transient and benign nature of the condition should be given. # color: white; A total of 15 articles met the inclusion criteria for review. 2005;55(3):227-231. All patients underwent routine investigations to exclude secondary causes of gynecomastia. Merkkola-von Schantz PA, Jahkola TA, Krogerus LA, Kauhanen SMC. However, the measuring method of satisfaction rate varied, resulting in difficulties to interpret the results. 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. Management of gestational gigantomastia. Devalia HL, Layer GT. In contrast, tobacco use and BMI were associated with worse breast reduction outcomes. The characteristics of patients as well as the curative effects between the 2 groups were analyzed. } 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. Breast. ul.ur li{ Chemical peels (chemical exfoliation): Considered medically necessary when criteria in CPB 0251 - Dermabrasion, Chemical Peels, and Acne 1990;24(1):61-67. Analysis was on an intention-to-treat basis. GP Notebook. 2003;111(2):688-694. There were no restrictions on the basis of date or language of publication. .newText { Work-up of gynecomastia may include the following (GP Notebook, 2003): Treatment should be directed at correcting any underlying reversible causes. Br J Plast Surg. 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. 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). 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).
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