1. Aetna considers reconstructive breast surgery medically necessary after a medically necessary mastectomy or a medically necessary lumpectomy that results in a significant deformity (i.e., mastectomy or lumpectomy for treatment of or prophylaxis for breast cancer and mastectomy or lumpectomy performed for chronic, severe fibrocystic breast disease, also known as cystic mastitis, unresponsive to medical therapy).  Medically necessary procedures include mastopexy, insertion of breast prostheses, the use of tissue expanders, or reconstruction with a transverse rectus abdominis myocutaneous (TRAM) flap, deep inferior epigastric perforator (DIEP) flap, or similar procedure.

2. Aetna considers associated nipple and areolar reconstruction and tattooing of the nipple area medically necessary. Reduction (or some cases augmentation) mammoplasty and related reconstructive procedures on the unaffected side for symmetry are also considered medically necessary.

3. Aetna considers breast reconstructive surgery to correct breast asymmetry cosmetic except for: (i) surgical correction of chest wall deformity causing functional deficit in Poland syndrome when criteria are met in CPB 272 - Pectus Excavatum and Poland’s Syndrome: Surgical Correction; or (ii) repair of breast asymmetry due to a medically necessary mastectomy or a medically necessary lumpectomy that results in a significant deformity; or (iii) prompt* repair of breast asymmetry due to trauma. (*Note: See CPB 031 - Cosmetic Surgery for criteria related to surgical repair of cosmetic disfigurement due to trauma).

See also CPB 017 - Breast Reduction Surgery and Gynecomastia Surgery.

Breast reconstruction using autologous tissue is most commonly performed using the TRAM flap. This flap has been in use for 20 years and has provided excellent aesthetic results. However, a drawback of the TRAM flap is related to donor site morbidity of the abdomen. The pedicle TRAM flap frequently requires use of the entire rectus abdominis muscle, while the free TRAM flap requires use of as little as a postage-stamp size portion of the muscle. Abdominal complications resulting from a sacrifice of all or a portion of the rectus abdominis muscle include a reduction in abdominal strength (10-50%), abdominal bulge (5-20%), and hernia (< 5%).

Perforator flaps have gained increasing attention with the realization that the muscle component of the TRAM flap does not add to the quality of the reconstruction and serves only as a carrier for the blood supply to the flap. Thus, the concept of separating the flap (skin, fat, artery, and vein) from the muscle was realized as a means of minimizing the morbidity related to the abdominal wall and maintaining the aesthetic quality of the reconstruction. The deep inferior epigastric perforator (DIEP) flap was introduced in the early 1990's and is identical to the free TRAM flap except that it contains no muscle or fascia. Use of this flap has been popular in the Europe for a number of years and is now gaining popularity in the United States. The DIEP flap has been performed at Johns Hopkins for several years. Candidates for this operation are similar to those for the free TRAM in that there must be adequate abdominal fat to create a new breast. However, caution must be exercised in performing this technique in women who require large volume reconstruction to prevent the occurrence of fat necrosis or hardening of the new breast. The operation can be performed immediately following mastectomy or on a delayed basis. Performance of this operation is slightly more difficult than the free TRAM flap because it requires meticulous dissection of the perforating vessels from the muscle.

DIEP flaps tend to have less robust blood flow than is typical with a standard TRAM reconstruction, so careful patient selection is important. In patients who are nonsmokers, who require no more than 70% of the TRAM flap skin paddle to make a breast of adequate size, and who have at least one perforating vessel >1 mm in diameter with a detectable pulse, the incidence of flap complications reportedly is similar to that seen in standard free TRAM flap reconstruction.

Superior gluteal artery perforator (SGAP) flaps may be performed on women who are not candidates for a TRAM flap or who have had a failed TRAM flap. Thin women who may not have much tissue in the lower abdominal area often have an adequate amount of tissue in the gluteal region. The inferior gluteal artery perforator (SGAP) flap shares the same indications as the superior gluteal flap, namely the inability to use the TRAM flap and an abundance of soft tissue in the gluteal region.

Poland Syndrome is an extremely rare developmental disorder that is present at birth (congenital). It is characterized by absence (agenesis) or underdevelopment (hypoplasia) of certain muscles of the chest (e.g., pectoralis major, pectoralis minor, and/or other nearby muscles), and abnormally short, webbed fingers (symbrachydactyly). Additional findings may include underdevelopment or absence of one nipple (including the darkened area around the nipple [areola]) and/or patchy hair growth under the arm (axilla). In females, one breast may also be underdeveloped (hypoplastic) or absent (amastia). In some cases, affected individuals may also exhibit underdeveloped upper ribs and/or an abnormally short arm with underdeveloped forearm bones (i.e., ulna and radius) on the affected side. In most cases, physical abnormalities are confined to one side of the body (unilateral). In approximately 75 percent of the cases, the right side of the body is affected. The range and severity of symptoms may vary from case to case. The exact cause of Poland Syndrome is not known.