The article by Blomqvist et al (2000) is to another questionnaire study about health status and quality of life before and after surgery. Gonzalez FG, Walton RL, Shafer B, et al. Socioeconomic Committee Position Paper. Reduction mammaplasty: Defining medical necessity. Abnormalities in Adolescent Breast Development. border: none; Surg Laparosc Endosc Percutan Tech. American Society of Plastic Surgeons (ASPS). Karamanos et al (2015) noted that although breast reduction mammoplasty accounts for more than 60,000 procedures annually, the literature remains sparse on outcomes. In the case of breast reduction, however, for insurance purposes, it . 2001;108(1):62-67. Subgroup analysis further stratified the younger cohort into those <50 years and 50-60 years of age. Brown MH, Weinberg M, Chong N, et al. 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. These investigators analyzed the incidence of occult breast cancer and high-risk lesions in reduction mammoplasty specimens of women with previous breast cancer. 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. .newText { padding-bottom: 4px; 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. Handschin AE, Bietry D, Hsler R, et al. 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]). } 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. 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. An 18-question survey was created evaluating various aspects of BBR practice; UK and Irish plastic and reconstructive and breast surgeons were invited to participate by an e-mail containing a link to a web-based survey. border-width:0; 2nd ed. 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. Srinivasaiah N, Iwuchukwu OC, Stanley PR, et al. } #backTop:hover { American College of Obstetricians and Gynecologists (ACOG), Committee on Adolescent Health Care. 1991;27(3):232-237. display: none; 2007;119(4):1159-1166. 1996;20(5):391-397. Plast Reconstr Surg. In a systematic review, Prasetyono and colleagues (2021) examined the quality of studies and re-visited liposuction-assisted gynecomastia surgery performed via minimal incision. 1995;34(2):113-116. Radiotherapy for prevention or management of gynecomastia recurrence: Future role for general gynecomastia patients in plastic surgery given current role in management of high-risk prostate cancer patients on anti-androgenic therapy. PLoS One. Here's what Aetna said in the denial: "We used the Clinical Policy Bulletin (CPB): Breast Reduction Surgery. Chadbourne EB, Zhang S, Gordon MJ, et al. 2002;109(5):1556-1566. Gynecomastia is a very common concern of male adolescence. The investigators found little difference between obese and non-obese women concerning patient's reports of resolution of symptoms and improvement in body image. Also, there was no correlation between PR expression and 2D: 4D. Breast asymmetries: A brief review and our experience. Refer to the member's specific plan document for applicable coverage. Washington, DC: ACOG; 2011:121-122. Schnur PL, Schnur DP, Petty PM, et al. Thus, this study would not be considered of sufficient quality to provide reliable evidence of the effectiveness of a pain intervention. Breast reduction outcome study. Participating providers are independent contractors in private practice and are neither employees nor agents of Aetna or its affiliates. A total of 90 patients underwent breast re-reduction surgery. A total of 211 responding surgeons were analyzed, including 80.1 % (171/211) plastic surgeons and 18.9 % (40/211) breast surgeons. The primary outcome was the difference in wound drainage over 24 hours. 1995;95(6):1029-1032. Patients were randomized to receive the gel applied to the left or right breast after hemostasis was achieved; the other breast received no treatment. It can cause discomfort and concern, resulting in patients seeking diagnosis and treatment. Preoperative patient factors and comorbidities, as well as intraoperative variables, were assessed. 1995;95(1):77-83. 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. 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. 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. Plast Reconstr Surg. Vacuum-assisted minimally invasive surgery was carried out under general anesthesia; subjects were followed-up with physical examination and ultrasonography (US). Jansen DA, Murphy M, Kind GM, Sands K. Breast cancer in reduction mammoplasty: Case reports and a survey of plastic surgeons. Plast Reconstr Surg. Quality of life after breast reduction. A systematic review of patient reported outcome measures for women with macromastia who have undergone breast reduction surgery. Risk factors for complications following breast reduction: Results from a randomized control trial. Medical therapy should be aimed at correcting any reversible causes (e.g., drug discontinuance). 2000;45(6):575-580. Aesthet Plastic Surg. 1998;101(2):361-364. Treating providers are solely responsible for medical advice and treatment of members. 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. Reduction mammoplasty also known as breast reduction surgery, is a surgical procedure in women to reduce the weight, mass, and size of the breast. Hello! breast augmentation with implant. 2013;71(5):471-475. font-size: 18px; The majority (87.7 %) of cases presented with accompanying mastalgia. 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). With approval from the authors institutional ethics committee and written informed consent, a total of 22 patients with 33 abnormally hyperplastic breasts were enrolled at the First Affiliated Hospital with Nanjing Medical University between June 2016 and September 2018. They have argued that removal of even a few hundred grams of breast tissue can result in substantial pain relief. 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. 2015;49(6):311-318. 0017 - Breast Reduction Surgery and Gynecomastia Surgery, are met. Little is known about the effect of surgical treatment on the psychological aspects of the disease. 1999;103(6):1687-1690. Med Decis Making. Ann Plast Surg. 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. The operation was successfully performed in all 20 patients with a mean operating time of 51 mins and a hospital stay of 4 days. Clinical Policy Bulletins are developed by Aetna to assist in administering plan benefits and constitute neither offers of coverage nor medical advice. Complication rates were inconsistent throughout the studies, ranging from 0.06 % to 26.67 %. Tobacco use and body mass index as predictors of outcomes in patients undergoing breast reduction mammoplasty. Based on CPB criteria and the information we have, we're denying coverage for breast reduction surgery. The 2 studies, which discussed laser-assisted liposuction technique, showed minor complication of seroma in 2 patients. Mizgala CL, MacKenzie KM. 2019;166(5):934-939. 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. Devalia HL, Layer GT. 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). While 1 study showed high patient's satisfaction rate; both studies indicated high surgeon's satisfaction rate. Kasielska A, Antoszewski B. Surgical management of gynecomastia: An outcome analysis. There were 18 out of 415 studies eligible to review. Qu and colleagues (2020) examined the effectiveness of vacuum-assisted breast biopsy systems for the treatment of gynecomastia. 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. Lonie S, Sachs R, Shen A, et al. Marshall WA, Tanner JM. Prepubertal gynecomastia linked to lavender and tea tree oils. background: #5e9732; The mean incidence of gynecomastia was 70 % in the high-risk population examined representing prostate cancer patients on estrogen or anti-androgen therapy. 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. 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". Gynecomastia has been classified into2 types. A total of 244 out of 1,628 patients with the average age of 23.13 years. If an insufficient amount of breast tissue is removed, the surgery is less likely to be successful in relieving pain and any related symptoms from excessive breast weight (e.g., excoriations, rash). list-style-type: upper-roman; 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. Thus, more than 1/3of operative subjects selected for inclusion in the study did not complete it; most of the operative subjects who did not complete the study were lost to follow-up. The vacuum-assisted breast biopsy system is an effective strategy for the treatment of gynecomastia. Breast hypertrophy. Ages ranged from 18 to 66 years. skin should not be excised horizontally below the inframammary fold. Furthermore, the lack of an expected "dose-response" relationship between the amount of breast tissue removed and the magnitude of symptomatic relief in these studies raises questions about the validity of these studies and the effectiveness of breast reduction as a method of relieving shoulder and back pain. 2001;107(5):1234-1240. @media print { Resolution of idiopathic gynecomastia may take several months to years. 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). 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. 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. Sollie M. Management of gynecomastia-changes in psychological aspects after surgery-a systematic review. It was also found that only 3 % of subjects reported that they had no aesthetic motivation for surgery. Seitchik (1995) reviewed the amount of breast tissue removed from a series of 100 patients that underwent breast reduction surgery. Pseudo-gynecomastia refers to excessive fat tissue or prominent pectoralis muscles. 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). Medical reduction has been achieved with agents such as dihydrotestosterone, danazol, and clomiphene. Aetna plans exclude coverage of cosmetic surgery that is not medically necessary, . Aesthet Surg J. # font-weight: bold; Reduction mammoplasty for asymptomatic members is considered cosmetic. Seitchik MW. This Clinical Policy Bulletin contains only a partial, general description of plan or program benefits and does not constitute a contract. In a Cochrane review, Khan and colleagues (2015) stated that wound drains are often used after plastic and reconstructive surgery of the breast in order to reduce potential complications. Analysis was on an intention-to-treat basis. Kerrigan CL, Collins ED, Kneeland TS, et al. Follow-up ranged from 2 months to 3 years. Raispis T, Zehring RD, Downey DL. The authors concluded that treatment of gynecomastia by the Mammotome device was distinctive, practicable in manipulation, safe, and could achieve excellent cosmetic results. If gynecomastia is idiopathic, reassurance of the common, transient and benign nature of the condition should be given. In contrast, tobacco use and BMI were associated with worse breast reduction outcomes. Plast Reconstr Surg. color:#eee; } Open surgery was performed in 56 patients, and vacuum-assisted breast biopsy was performed in 27 patients. Nguyen JT, Wheatley MJ, Schnur PL, et al. 1997;100(4):875-883. Gynecomastia Treatment through Open Resection and Pectoral High-Definition Liposculpture. 1969;44(235):291-303. Fischer S, Hirsch T, Hirche C, et al. In: Townsend CM, Beuchamp RD, Evers BM, eds. The authors concluded that breast re-reduction can be performed safely and predictably, even when the previous technique is not known; and 4 key principles were developed: Language services can be provided by calling the number on your member ID card. Determinants of surgical site infection after breast surgery. However, these medications should be reserved for those with no decrease in breast size after 2 years. .fixedHeaderWrap { Statistical analysis was performed with student t-test and chi-square test. 2014;20(3):274-278. A non-standardized survey showed a very high satisfaction index. Breast Concerns of Adolescents. 2000;106(2):280-288. Oncoplastic reduction mammoplasty for breast cancer in women with macromastia: Oncological long-term outcomes. Reduction mammoplasty is among the most commonly performed cosmetic procedures in the United States. Arlington Heights, IL: ASPS; May 2011. Petty PM, Solomon M, Buchel EW, Tran NV. OL OL OL OL OL LI { Reduction mammoplasty has also been used for relief of pain in the back, neck and shoulders. OL OL LI { Brown DM, Young VL. Approximately 25 % of the 49 subjects included in this study did not return the post-operative questionnaire. Answer: Aetna Insurance Breast reduction may or may not be covered depending on your insurance carrier and your breast size. Am Surg. 1998;49:215-234. Plast Reconstr Surg. 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. Morbidly obese patients are at the highest risk, with complications occurring in nearly 12% of this cohort. Key takeaways: Health insurance does not cover cosmetic breast reduction, but it usually does cover breast reduction surgery that is considered medically necessary. Merkkola-von Schantz and colleagues (2017) stated that contralateral reduction mammoplasty is regularly included in the treatment of breast cancer patients. 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. 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. These researchers compared the safety and effectiveness of the use of wound drains following elective plastic and reconstructive surgery procedures of the breast. A total of 15 articles met the inclusion criteria for review. Ann Plast Surg. The study by Schnur et al was based on a survey of 92 plastic surgeons who reported on their care for 591 patients. Miller AP, Zacher JB, Berggren RB, et al. Of these 33 operative sides, 2 complications occurred, but satisfactory chest contour was attained in all subjects. Subjects responses were compared to an age-matched comparison group of women, although no further details about how this comparison group were provided. Several of the included studies reported improvement in QOL and several psychological domains after surgical treatment for gynecomastia. However, the BRAVO study is not of sufficient quality to reach reliable conclusions about the effectiveness of breast reduction surgery as a pain intervention. } Ann Plast Surg. 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. Reduction mammoplasty for macromastia. Tang CL, Brown MH, Levine R, et al. }. The operation had a mean duration of 73.5 mins per side, ranging from 40 to 102 mins. I have recently met with my primary doctor after speaking to my insurance company (aetna) for months about getting a breast reduction. Data was then analyzed for surgical complications, wound complications, and medical complications within 30 days of surgery on 4545 patients. 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. Patients with abnormal histopathology could not be pre-operatively identified based on demographics. Obstet Gynecol Clin North Am. Management of gestational gigantomastia. Safran T, Abi-Rafeh J, Alabdulkarim A, et al. There were only 2 studies of a total 25 patients that were considered as good in quality. 2009;7(2):114-119. 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 . 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. An average of 320 specimens were excised from each side with mean blood loss of 34 ml. Reduction mammoplasty: Criteria for insurance coverage. These researchers calculated the risk ratio (RR) for dichotomous outcomes and mean differences (MD) for continuous outcomes, with 95 % confidence intervals (CI). Surgical treatment of gynecomastia by vacuum-assisted biopsy device. 2017;139(6):1313-1322. The surgeon must also certify that a certain weight of breast tissue (based on Aetna's table) will be removed in every breast, and not entirely fatty tissue. 2008;32(1):38-44. Gynecomastia in patients with prostate cancer: Update on treatment options. Type II gynecomastia is more generalized breast enlargement. 2021;147(5):1072-1083. list-style-type: decimal; Each surgeon who participated in the study reported on the height, weight, and volume of reduction of their last 15 to 20 patients, and each surgeon provided their intuitive sense regarding the motivation of each patient for breast reduction surgery. Breast reconstruction/breast enlargement Breast reduction/mammoplasty Excision of excessive skin due to weight loss Gastroplasty/gastric bypass 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. 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. } The health burden of breast hypertrophy. Grade IV: Marked breast enlargement with skin redundancy and feminization of the breast. cursor: pointer; 2005;55(3):227-231. Horm Res Paediatr. Scand J Plast Reconstr Hand Surg. 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. After these researchers 1st report of pectoral etching in 2012, patients and surgeons became more aware regarding gynecomastia resection when performing pectoral enhancement. height:2px; Three review authors undertook independent screening of the search results. Surgical management of gynecomastia--a 10-year analysis. Leclere FM, Spies M, Gohritz A, Vogt PM. Plast Reconstr Surg. .arrowPurpleSmall, a:hover.arrowPurpleSmall { 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. No data were provided on loss to follow-up. 2010;45(3):650-654. 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: The Mammotome procedure represented another novel therapeutic option for gynecomastia. Araco A, Gravante G, Araco F, et al. All studies on the subject were evaluated for inclusion and 6 studies were included in the review. 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. 2011;21(5):431-434. Henley DV, Lipson N, Korach KS, Bloch CA. Yao Y, Yang Y, Liu J, et al. Merkkola-von Schantz PA, Jahkola TA, Krogerus LA, Kauhanen SMC. 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. Aetna considers breast reconstructive surgery to correct Breast. 2015;10(8):e0136094. 1998;26(1):61-65. Plast Reconstr Surg. Plast Reconstr Surg. Guidelines for Adolescent Health Care. Ann Plast Surg. However, if liposuction is used as an adjunctive technique, the decision to use drains should be left to the surgeon's discretion. 1997;185(6):593-603. Plast Reconstr Surg. Re-operation rate of liposuction-assisted surgery was between 0.6 % and 25 %. 2016;20(3):256-260. J Plast Surg Hand Surg. Nelson et al (2014b) separately conducted a population level analysis of the 2005-2011 NSQIP datasets, identifying patient who underwent reduction mammoplasty, to determine the impact of obesity on early complications after reduction mammoplasty. 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. 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 Flancbaum L, Choban PS. Can objective predictors for operative success be identified? Reduction mammaplasty: A review of managed care medical policy coverage criteria. z-index: 99; Fat grafting volume ranged from 50 to 300 cc in each pectoral muscle. The authors concluded that even with the high level of evidence demonstrating the safety of BBR without drains, they are still routinely utilized. These investigators concluded that their findings do not support the use of completely autologous platelet gel to improve outcomes after reduction mammoplasty. ER expression did not correlate with the right (p = 0.51) and left 2D: 4D (p = 0.97). Reduction mammoplasty or breast reduction surgery reduces the volume and weight of the female breasts by removing excess fat, glandular tissue and skin. 2014b;48(5):334-339. The study consisted of 329 breast cancer patients, who underwent symmetrizing reduction mammoplasty between 1/2007 and 12/2011. The risks included infection, wound breakdown, scarring, and the need for re-operating. The mean age was 42.8 years (SD 19.5 years). .strikeThrough { 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 Breast: Comprehensive Management of Benign and Malignant Diseases. li.bullet { Subjects were compared to age-matched norms from another study cohort. 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. Plast Reconstr Surg. J Plast Reconstr Aesthet Surg. 2009;19(3):e85-e90. ASPS clinical practice guideline summary on reduction mammaplasty. In Type I (idiopathic) gynecomastia, the adolescent presents with a tender, firm mass beneath the areola. The 2 vacuum-assisted breast biopsy systems (Mammotome and Encor) were used for the patients with gynecomastia. Obesity and complications in breast reduction surgery: Are restrictions justified? Surgeon. Choban PS, Flancbaum L. The impact of obesity on surgical outcomes: A review. Level of Evidence = IV. 1. Nor is it intuitively obvious that removal of smaller amounts of breast tissue would offer significant relief of back, shoulder or neck pain. Gland Surg. 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 authors (Nguyen et al, 2004) argue, based primarily on the results of the ASPS-funded BRAVO study (described below), that (with a single exception) no objective criteria for breast reduction surgery are supportable, including criteria based upon the presence of particular signs or symptoms, requirements based upon breast size or the amount of breast tissue removed, any minimum age limitations, any limitation based upon maximum body weight, requirements for a trial of conservative therapy, or the exclusion of certain procedures (liposuction). Anzarut A, Guenther CR, Edwards DC, Tsuyuki RT. (25 y/o female with a 38J bra size) according to aetna, I should more than qualify for a reduction as I have back, neck, shoulder pain, chest pain and pressure, arm numbness while laying on sides, etc. Until now, most published research on the subject has focused on how effective surgical treatment is on correcting the cosmetic appearance of the breast. Photographs were taken pre-operatively and 1, 3, 6, and 12 months post-operatively. and areola. Special Clinical Concerns. The average interval between primary and secondary surgery was 14 years (range of 0 to 42 years). Risk of bias was assessed independently by 2review authors. This Clinical Policy Bulletin addresses breast reduction surgery and gynecomastia surgery. } Plastic Reconstruct Surg. Abnormal histopathology correlated with higher age (p = 0.0053), heavier specimen (p = 0.0491), and with no previous breast surgery (p < 0.001).