Plast Reconstr Surg. 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. There were 18 out of 415 studies eligible to review. 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 . For the first update of this review, these investigators searched the Cochrane Wounds Group Specialised Register (searched March 4, 2015); the Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library 2015, Issue 2); Ovid Medline (2012 to March 3, 2015); Ovid Medline (In-Process & Other Non-Indexed Citations March 3, 2015); Ovid Embase(2012 to March 3, 2015); and EBSCO CINAHL (2012 to March 4, 2015). Br J Plast Surg. Iwuagwu OC, Stanley PW, Platt AJ, Drew PJ. Schnur PL, Schnur DP, Petty PM, et al. Among these domains were: vitality, emotional discomfort, limitations due to physical aspects and limitations due to pain. display: none; In Type I (idiopathic) gynecomastia, the adolescent presents with a tender, firm mass beneath the areola. Drugs whose mechanism of action is unknown: Others situations which can cause or lead to gynecomastia: The above policy is based on the following references: Last Review The authors concluded that vacuum-assisted, minimally invasive mastectomy was a feasible approach for the treatment of gynecomastia with acceptable complications. A systematic review of patient reported outcome measures for women with macromastia who have undergone breast reduction surgery. 1969;44(235):291-303. Kerrigan CL, Collins ED, Kneeland TS, et al. Mannu and colleagues (2018) stated that idiopathic gynecomastia is a benign breast disorder characterized by over-development of male breast tissue. Devalia HL, Layer GT. There were no restrictions on the basis of date or language of publication. 2005;58(3):286-289. These investigators presented their experience with pectoral high-definition liposculpture combined with inverted-omega incision resection for gynecomastia. 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. color: blue!important; 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. A lack of correlation between these variables may result from the fact that the analyzed group of men with idiopathic gynecomastia was small in number, but at the same time, it appeared to be homogenous in these aspects (positive ER and/or PR expression and high digit ratio). Washington, DC: ACOG; 2011:121-122. For medical OL OL OL OL OL LI { Refer to the member's specific plan document for applicable coverage. Note: Breast reduction surgery will be considered medically necessary for women meeting the symptomatic criteria specified above, regardless of BSA, with more than 1 kg of breast tissue to be removed per breast. All subjects were satisfied with their cosmetic outcome, graded as excellent by 22 patients (100 %). list-style-type: decimal; 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]. A retrospective review was conducted of patients who underwent bilateral breast re-reduction surgery performed by a single surgeon over a 12-year period. @media print { Aesthetic Plast Surg. Reduction mammaplasty in patients with history of breast cancer: The incidence of occult cancer and high-risk lesions. 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. Annu Rev Med. 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. of . No author listed. 1991;27(3):232-237. 2018;89(6):408-412. 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. Asian J Surg. 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. These preliminary findings need to be validated by well-designed studies. 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. 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). Treatment of adolescent gynecomastia. Marshall WA, Tanner JM. Another set of breast pump supplies if you get pregnant . Gynecomastia in patients with prostate cancer: A systematic review. 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. Klinefelters syndrome, testicular, adrenal, or pituitary tumors, and thyroid or hepatic dysfunction are also associated with gynecomastia. Evidence-based clinical practice guideline: Reduction mammaplasty. With the majority of BBRs performed as an inpatient procedure, there was a trend towards less drain usage in surgeons performing this procedure as an out-patient; however, this was not statistically significant (p = 0.07). Reduction mammoplasty: Cosmetic or reconstructive procedure? #backTop { Srinivasaiah N, Iwuchukwu OC, Stanley PR, et al. 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. Patient demographics, surgical technique, and outcomes were analyzed. Priorities Forum Policy Statement. Reduction mammaplasty provides long-term improvement in health status and quality of life. 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). 2nd ed. 2008;121(4):1092-1100. 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). American College of Obstetricians and Gynecologists (ACOG), Committee on Adolescent Health Care. The authorsleave the reader with the conclusionthat decisions about the medical necessity of breast reduction surgery in symptomatic women should be left entirely to the surgeon's discretion. It can cause discomfort and concern, resulting in patients seeking diagnosis and treatment. The health burden of breast hypertrophy. 2015;(10):CD007258. The operation was successfully performed in all 20 patients with a mean operating time of 51 mins and a hospital stay of 4 days. Arlington Heights, IL: ASPRS; 1987. An average of 320 specimens were excised from each side with mean blood loss of 34 ml. }. Vacuum-assisted minimally invasive surgery-An innovative method for the operative treatment of gynecomastia. Beer GM, Kompatscher P, Hergan K. Diagnosis of breast tumors after breast reduction. hr.separator { color: #FFF; Although the BRAVO study nominally included a "control group", there was no comparison group of subjects selected from the same cohort, who were randomized or otherwise appropriately assigned to reduce bias, and treated with conservative management according to a protocol to ensure optimal conservative care. Note: For breast surgeries pertaining to gender affirmation, refer to CP.MP.95 Gender Affirming Procedures. the nipple-areola complex can be elevated by de-epithelialization rather than recreating or developing a new pedicle; breast tissue is removed where it is in excess, usually inferiorly and laterally; the resection is complemented with liposuction to elevate the bottomed-out inframammary fold; and. 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. 2017;35:157-161. N Engl J Med. After these researchers 1st report of pectoral etching in 2012, patients and surgeons became more aware regarding gynecomastia resection when performing pectoral enhancement. and areola. The condition not only must be unresponsive to dermatological treatments (e.g., antibiotics or antifungal therapy) and conservative measures (e.g., good skin hygiene, adequate nutrition) for a period of 6 months or longer, but also must satisfy criteria stated insection I above. Of 291 subjects who were selected for inclusion in the study, only 179 completed follow-up. 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. 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. 40 . 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. 1994;21(3):539-543. 2001;107(5):1234-1240. High-risk lesions (atypical ductal hyperplasia [ADH], atypical lobular hyperplasia [ALH], and lobular carcinoma in situ [LCIS]) were revealed in 37 (11.7 %), and cancer in 6 (1.9 %) patients. Macromastia: all . A cohort study of breast cancer risk in breast reduction patients. 2014;20(3):274-278. A systematic search of the published literature was performed. Removing the adipose tissue in pseudogynecomastia usually has no long term effect as adipose tissue reaccumulates unless the individual loses weight. 2011;21(5):431-434. Henley DV, Lipson N, Korach KS, Bloch CA. 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. Hello! The data were retrospectively analyzed for demographics, operative and histopathology reports, oncological treatment, and post-operative follow-up. In a prospective, cohort study, these investigators evaluated the efficacy of tamoxifen therapy in resolving this condition. Henley et al (2007) reported that repeated topical exposure to lavender and tea tree oils may be linked to prepubertal gynecomastia (idiopathic gynecomastia). 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). They evaluated the use of radiotherapy for the prevention and treatment of gynecomastia incidence or recurrence by plastic surgeons. Plast Reconstr Surg. Transient pain that may occur as the breast enlarges and the capsule is stretched; these symptoms may be managed with analgesics. Plastic Reconstr Surg. Health insurance companies frequently have different criteria for whether breast reduction surgery is medically necessary. In contrast, tobacco use and BMI were associated with worse breast reduction outcomes. color: red!important; Examining any complication, a significant increase was noted with increasing obesity class (p < 0.001). list-style-image: url('https://www.aetna.com/cpb/medical/data/assets/images/purplearrow.jpg') !important; background: #5e9732; Howrigan P. Reduction and augmentation mammoplasty. Current concepts in gynaecomastia. 2005;55(3):227-231. However, these medications should be reserved for those with no decrease in breast size after 2 years. Merkkola-von Schantz and colleagues (2017) stated that contralateral reduction mammoplasty is regularly included in the treatment of breast cancer patients. .strikeThrough { Liposuction was also used adjunctively in all cases (average of 455 cc; range, 50 to 1,750 cc). J Laparoendosc Adv Surg Tech A. 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: Management of gestational gigantomastia. 1990;24(1):61-67. 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. 2009;19(3):e85-e90. color: white; Surgical treatment of gynecomastia by vacuum-assisted biopsy device. 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. 2014b;48(5):334-339. These investigators retrospectively examined 83 patients with gynecomastia between January 2015 and December 2019. .fixedHeaderWrap { Subjects were compared to age-matched norms from another study cohort. 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. Seitchik MW. Autorino R, Perdona S, D'Armiento M, et al. Surg Laparosc Endosc Percutan Tech. In addition, reduction mammoplasty needs to be compared with other established methods of relieving back, neck and shoulder pain. 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. Nelson JA, Fischer JP, Wink JD, Kovach SJ 3rd. Gynecomastia Treatment through Open Resection and Pectoral High-Definition Liposculpture. 2004;113(1):436-437. Am J Infect Control. Oxford, UK: National Health Service (NHS); October 2008. 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). The majority (87.7 %) of cases presented with accompanying mastalgia. Analysis was on an intention-to-treat basis. Major complications (1.6 %) included unilateral hematoma and localized infection. background-color: #663399; No necrosis, systemic infection, or muscle paralysis was reported. Plast Reconstr Surg. 2014a;34(3):409-416. Petty PM, Solomon M, Buchel EW, Tran NV. Gynecomastia. This may justify an early use of tamoxifen in men with gynecomastia and a high digit ratio. No new trials were identified for this first update. Fischer et al (2014a) evaluated predictors of postoperative complications following reduction mammoplasty using the NSQIP) data sets. 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. padding-bottom: 4px; 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. Plastic surgery for teenagers briefing paper. Ann Plast Surg. Aetna is the brand name used for products and services provided by one or more of the Aetna group of subsidiary companies, including Aetna . The safety, efficacy, complications, and patient satisfactions were recorded during post-operative follow-up periods. Reduction mammoplasty for asymptomatic members is considered cosmetic. A physician-supervised diet and exercise plan may be indicated in obese patients. Long-term functional results after reduction mammoplasty. 1999;103(6):1682-1686. Wound drainage after plastic and reconstructive surgery of the breast. 2015;49(6):363-366. 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. Gynecomastia, its etiologies and its surgical management: A difference between the bilateral and unilateral cases? .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. 2012;130(4):785-789. Of these, 28.4 % were bilateral gynecomastia and 71.6 % were unilateral. Nguyen JT, Wheatley MJ, Schnur PL, et al. Aesthet Surg J. Policy. /*margin-bottom: 43px;*/ 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. Gland Surg. 1999;103(6):1674-1681. } .arrowPurpleSmall, a:hover.arrowPurpleSmall { Burdette TE, Kerrigan CL, Homa KA. From January 2006 to January 2010, a total of 20 men with gynecomastia were treated by an 8-G vacuum-assisted biopsy device. Reduction (or some cases augmentation) mammoplasty and related reconstructive procedures on the unaffected side for symmetry are also considered medically necessary.
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