Gynecomastia has been classified into2 types. See Appendix for Table 1. Karamanos et al (2015) noted that although breast reduction mammoplasty accounts for more than 60,000 procedures annually, the literature remains sparse on outcomes. of the following criteria must be met: No other operation-related complications were observed. Plast Reconstr Surg. It was also found that only 3 % of subjects reported that they had no aesthetic motivation for surgery. In these cases, breast reduction for men may take 2 to 3 hours. These preliminary findings need to be validated by well-designed studies. background: #5e9732; A detailed physical examination, including testicular examination. Gynecomastia, its etiologies and its surgical management: A difference between the bilateral and unilateral cases? For pain interventions, evidence of effectiveness is necessary from well controlled, randomized prospective clinical trials assessing effects on pain, disability, and function. Fischer S, Hirsch T, Hirche C, et al. } Choban PS, Heckler R, Burge JC, Flancbaum L. Increased incidence of nosocomial infections in obese surgical patients. Aesthetic Plast Surg. The safety, efficacy, complications, and patient satisfactions were recorded during post-operative follow-up periods. 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. Liposuction facilitated the easy handling to remove the breast tissue via small incisional design; showed consistent improved QOL in terms of satisfaction after surgery. Re-operation rate of liposuction-assisted surgery was between 0.6 % and 25 %. OL OL OL LI { Bruhlmann Y, Tschopp H. Breast reduction improves symptoms of macromastia and has a long-lasting effect. Subjects responses were compared to an age-matched comparison group of women, although no further details about how this comparison group were provided. 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 . Compared with the open surgery group, the vacuum-assisted breast biopsy group had significantly smaller scar sizes left after the operation (5.5 1.3 cm versus 0.8 0.2 cm, p < 0.001), and shorter hospital stay time (5.5 2.4 days versus 3.1 1.6 days, p < 0.001). padding-bottom: 4px; The traditional method of breast reduction requires an open incision around the areola extending downward to the crease beneath the breast. Laituri CA, Garey CL, Ostlie DJ, et al. Ann Plast Surg. Reduction mammaplasty. Gynecomastia: A systematic review. 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. Reduction mammoplasty also known as breast reduction surgery, is a surgical procedure in women to reduce the weight, mass, and size of the breast. In a majority of boys with pubertal gynecomastia, the condition resolves within 18 months. The effectiveness of surgical and nonsurgical interventions in relieving the symptoms of macromastia. Philadelphia, PA: WB Saunders Company; 2008; Ch 73. 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. No new trials were identified for this first update. Kalliainen LK; ASPS Health Policy Committee. Chemical peels (chemical exfoliation): Considered medically necessary when criteria in CPB 0251 - Dermabrasion, Chemical Peels, and Acne All the patients recovered well and were satisfied with the cosmetic outcomes. 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. The surgeon removes excess tissue, fat and skin before adjusting the placement of the nipple and areola appropriately. Doses examined ranged from 8 to 16 Gy, delivered between 1 and 11 fractions. 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. Study appraisal was carried out using MINORS to evaluate the methodological quality of the paper. Disproportionately large breasts can cause both physical and emotional . Drugs commonly associated with the development of gynecomastia include amphetamines, marijuana, mebrobamate, opiates, amitriptyline, chlordiazepoxide, chlorpromazine, cimetidine, diazepam, digoxin, fluphenazine, haloperidol, imipramine, isoniazid, mesoridazine, methyldopa, perphenazine, phenothiazines, reserpine, spironolactone, thiethylperazine, tricyclic antidepressants, tirfluoperazine, trimeparazine, busulfan, vincristine, tamoxifen, , methyltestosterone, human chorionic gonadotropins, and estrogens. It should be noted that this study reported a strong correlation between the amount of tissue removed and pain amelioration. Handschin AE, Bietry D, Hsler R, et al. } 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. Kasielska A, Antoszewski B. Surgical management of gynecomastia: An outcome analysis. Aetna does not provide health care services and, therefore, cannot guarantee any results or outcomes. right: 30px; It is universally believed by patients that if a surgery is considered reconstructive, it is medically indicated and covered by health insurance. 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. However, it is unclear if there is any evidence to support this practice. They reviewed their records on pectoral high-definition liposculpture between January of 2005 and October of 2019 in 4 surgical centers in Colombia. 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. 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. Plast Reconstr Surg. 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. 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. 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). Gynecomastia resection plus high-definition liposculpture was successfully performed in 436 consecutive men (open inverted-omega incision resection, n = 132; liposuction, n = 304). Minor complications (3.2 %) included prolonged swelling, bruising, asymmetries, and residual gynecomastia. Other just require 500 grams no matter what your height and weight. Blomqvist L, Eriksson A, Brandberg Y. Arlington Heights, IL: ASPRS; 1987. Annu Rev Med. 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. Of 291 subjects who were selected for inclusion in the study, only 179 completed follow-up. 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. Often times, insurance company will dictate how much breast tissue to be removed. 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. Links to various non-Aetna sites are provided for your convenience only. Level of Evidence = IV. Bland KI, Copeland EM, eds. This Clinical Policy Bulletin contains only a partial, general description of plan or program benefits and does not constitute a contract. Resolution of idiopathic gynecomastia may take several months to years. The authors concluded that high digit ratio in men with gynecomastia may tend to be a marker of over-expression of ER and PR. Plast Reconstr Surg. 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. list-style-type: decimal; Priorities Forum Policy Statement. 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. Prasetyono TOH, Budhipramono AG, Andromeda I, et al. Plast Reconstr Surg. 2000;106(2):280-288. 2015;75(4):383-387. The author identified the psychological domains affected by the disease and the effect of surgical treatment on these. Of the responding surgeons, 71.6 % (151/211) routinely inserted post-operative drains, for a mean of 1.32 days. An average of 320 specimens were excised from each side with mean blood loss of 34 ml. Emiroglu M, Salimoglu S, Karaali C, 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? Special Clinical Concerns. Scand J Plast Reconstr Hand Surg. Health insurance companies frequently have different criteria for whether breast reduction surgery is medically necessary. Medical reduction has been achieved with agents such as dihydrotestosterone, danazol, and clomiphene. Post-operative complications included 1 case of hematoma, but no nipple necrosis, local skin necrosis, or skin buttonhole occurred. American Society of Plastic Surgeons (ASPS). Women's Health and Cancer Rights Act of 1998. Also, there was no correlation between PR expression and 2D: 4D. A systematic review of patient reported outcome measures for women with macromastia who have undergone breast reduction surgery. PLoS One. Fagerlund A, Lewin R, Rufolo G, et al. Hermans, BJ, Boeckx, WD, De Lorenzi, F, Vand der Hulst, RR. Asian J Surg. padding: 15px; 2001;108(1):62-67. Washington, DC: ACOG; 2011:121-122. Qu S, Zhang W, Li S, et al. Aetna plans exclude coverage of cosmetic surgery that is not medically necessary, . GP Notebook. color: white; Aetna has their own sliding scale which requires more from smaller patients relative to the Schnur scale, but maxes out at 1000 gms per breast. 2006;118(4):840-848. 1. There are alsoseveral earlier, smaller studies that found reductions in symptoms and improvements in quality of life after reduction mammoplasty (Glatt et al, 1999; Bruhlmannand Tschopp, 1998; Blomqvist et al, 2000; and Behmand et al, 2000). 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). Surgical management of gynecomastia--a 10-year analysis. 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. ol.numberedList LI { 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. 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. margin-bottom: 38px; } Patient demographics, surgical technique, and outcomes were analyzed. Fan L, Yang X, Zhang Y, Jiang J. Endoscopic subcutaneous mastectomy for the treatment of gynecomastia: A report of 65 cases. This may justify an early use of tamoxifen in men with gynecomastia and a high digit ratio. Ages ranged from 18 to 66 years. Ann Plast Surg. Lonie S, Sachs R, Shen A, et al. /* aetna.com standards styles for templates */ Plastic Reconstr Surg. 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. From January 2006 to January 2010, a total of 20 men with gynecomastia were treated by an 8-G vacuum-assisted biopsy device. 2015;75(4):370-375. ul.ur li{ American Society of Plastic Surgeons (ASPS). Furthermore, there is insufficient evidence that surgical removal is more effective than conservative management for pain due to gynecomastia. Vacuum-assisted minimally invasive surgery-An innovative method for the operative treatment of gynecomastia. Mizgala CL, MacKenzie KM. Examining any complication, a significant increase was noted with increasing obesity class (p < 0.001). 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:. 2nd ed. Horm Res Paediatr. 2014b;30(6):641-647. Is there a rationale behind pharmacotherapy in idiopathic gynecomastia? 2016;20(3):256-260. Surgical implications of obesity. 2002;109(5):1556-1566. For individuals who received radiation treatment to the chest . outline: none; top: 0px; Clinical Policy Bulletins are developed by Aetna to assist in administering plan benefits and constitute neither offers of coverage nor medical advice. 2019;8(4):431-440. skin should not be excised horizontally below the inframammary fold. The only criterion that the authors found supportable wasa requirementfor a pre-operative mammogram for women aged 40 years and older. list-style-type: lower-alpha; For those with large breasts, breast reduction surgery can ease discomfort and improve appearance. list-style-image: url('https://www.aetna.com/cpb/medical/data/assets/images/purplearrow.jpg') !important; 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. The authors concluded that treatment of gynecomastia by the Mammotome device was distinctive, practicable in manipulation, safe, and could achieve excellent cosmetic results. This may lead to additional scarring and additional operating time. Subgroup analysis further stratified the younger cohort into those <50 years and 50-60 years of age. Plast Reconstr Surg. Healing balms, scented soaps, skin lotions, shampoos and styling gels containing lavender oilor tea tree oil. Note: For breast surgeries pertaining to gender affirmation, refer to CP.MP.95 Gender Affirming Procedures. 1998;41(3):240-245. 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. Aetna is the brand name used for products and services provided by one or more of the Aetna group of subsidiary companies, including Aetna . Subjects were compared to age-matched norms from another study cohort. World J Surg. 1997;100(4):875-883. Nguyen JT, Wheatley MJ, Schnur PL, et al. cursor: pointer; The study subjects were stratified into groups based on ages of <60 years and 60 years. The mean age was 42.8 years (SD 19.5 years). American College of Obstetricians and Gynecologists (ACOG), Committee on Adolescent Health Care. There were only 2 studies of a total 25 patients that were considered as good in quality. } Reduction mammoplasty: Criteria for insurance coverage. 2015;49(6):311-318. In Type I (idiopathic) gynecomastia, the adolescent presents with a tender, firm mass beneath the areola. He Q, Zheng L, Zhuang D, et al. Autorino R, Perdona S, D'Armiento M, et al. Reduction mammaplasty: An outcome study. 40 . Gland Surg. #backTop { Li CC, Fu JP, Chang SC, 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. Impact of surgical treatment for gynecomastia appeared to be beneficial for several psychological domains. Aesthet Surg J. 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). Key takeaways: Health insurance does not cover cosmetic breast reduction, but it usually does cover breast reduction surgery that is considered medically necessary. Kasielska-Trojan and associates (2018) analyzed digit ratio in relation to estrogen receptor (ER) and progesterone receptor (PR) expression and verified digit ratio (2D: 4D) as a marker of ER and PR over-expression in the male breast.