Reduction Mammoplasty:

Aetna considers breast reduction surgery cosmetic unless breast hypertrophy is causing significant pain, paresthesias, or ulceration (see selection criteria below). Reduction mammoplasty for asymptomatic members is considered cosmetic.

Aetna considers breast reduction surgery medically necessary for non-cosmetic indications for women aged 18 or older or for whom growth is complete when any of the following criteria (I, II, or III) is met:

1. Macromastia: all of the following criteria must be met:

   1. Member has persistent symptoms in at least two of the anatomical body areas below, affecting daily activities for at least one year:

      • Pain in upper back
      • Pain in neck
      • Pain in shoulders
      • Headaches
      • Painful kyphosis documented by X-rays

      • Pain / discomfort / ulceration from bra straps cutting into shoulders;

      and

   2. All of the following criteria are met:

      1. Photographic documentation confirms severe breast hypertrophy; and

      2. Member has undergone an evaluation by a physician who has determined that all of the following criteria are met:

         1. There is a reasonable likelihood that the member's symptoms are primarily due to macromastia; and
         2. Reduction mammoplasty is likely to result in improvement of the chronic pain; and

         3. Pain symptoms persist as documented by the physician despite at least a 3-month trial of therapeutic measures such as:

            • Supportive devices (e.g., proper bra support, wide bra straps)
            • Analgesic / non-steroidal anti-inflammatory drugs (NSAIDs) interventions
            • Physical therapy / exercises / posturing maneuvers;

         and

      3. Women 40 years of age or older are required to have a mammogram that was negative for cancer performed within the year prior to the date of the planned reduction mammoplasty;

      and

   3. The surgeon estimates that at least the following amounts (in grams) of breast tissue, not fatty tissue, will be removed from each breast, based on the member's body surface area:

      Table: Weight of breast tissue removed, per breast, as a function of body surface area

      Body Surface Area (m2)

      Weight of tissue removed per breast (grams)

      1.40 1.41 1.42 1.43 1.44 1.45 1.46 1.47 1.48 1.49 1.50 1.51 1.52 1.53 1.54 1.55 1.56 1.57 1.58 1.59 1.60 1.61 1.62 1.63 1.64 1.65 1.66 1.67 1.68 1.69 1.70 1.71 1.72 1.73 1.74 1.75 1.76 1.77 1.78 1.79 1.80 1.81 1.82 1.83 1.84 1.85 1.86 1.87 1.88 1.89 1.90 1.91 1.92 1.93 1.94 1.95 1.96 1.97 1.98 1.99 2.00 2.01 2.02 2.03 2.04 2.05 2.06 2.07 2.08 2.09 2.10 2.11 2.12 2.13 2.14 2.15 2.16 2.17 2.18 2.19 2.20

      324.3 330 335 340 350 355 360 365 375 380 385 395 400 405 415 420 430 435 445 455 460 470 480 485 495 505 510 520 530 540 550 560 570 580 590 600 610 620 635 645 655 665 680 690 705 715 730 740 755 770 780 795 810 825 840 855 870 885 900 915 935 950 965 985 1000 1000 1000 1000 1000 1000 1000 1000 1000 1000 1000 1000 1000 1000 1000 1000 1000

      To calculate body surface area (BSA) see http://www-users.med.cornell.edu/~spon/picu/calc/bsacalc.htm

      OR
      
      BSA (m2 ) = ([height (in) x weight (lb)]/3131)½

      BSA (m2 ) = ([height (cm) x weight (kg)]/3600)^½

   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.

   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. 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 six months or longer, but also must satisfy criteria stated in I above.

2. Gigantomastia of Pregnancy:

   The member has gigantomastia of pregnancy accompanied by any of the following complications, and delivery is not imminent:

   • Ulceration of breast tissue;
   • Massive infection;
   • Tissue necrosis with slough;

   • Significant hemorrhage.

3. Asymmetry:

   For medical necessity criteria for surgery to correct breast asymmetry, see CPB 185 - Breast Reconstructive Surgery.

Gynecomastia Surgery:

Aetna considers breast reduction, surgical mastectomy or liposuction for gynecomastia, either unilateral or bilateral, a cosmetic surgical procedure. Medical therapy should be aimed at correcting any reversible causes (e.g., drug discontinuance).  Furthermore, there is insufficient evidence that surgical removal is more effective than conservative management for pain due to gynecomastia.

See also CPB 031 - Cosmetic Surgery, and CPB 185 - Breast Reconstructive Surgery.

Reduction Mammaplasty

Reduction mammaplasty is among the most commonly performed cosmetic procedures in the United States.  Reduction mammaplasty performed solely for cosmetic indications is considered not medically necessary.

Reduction mammaplasty has also been used for relief of pain in the back, neck and shoulders.  Because reduction mammaplasty may be used for both medically necessary and cosmetic indications, Aetna has set forth above objective criteria to distinguish medically necessary reduction mammaplasty from cosmetic reduction mammaplasty.

Reduction mammaplasty has been performed to relieve back and shoulder pain on the theory that reducing breast weight will relieve this pain.  For pain interventions, evidence of effectiveness is necessary from well controlled, randomized prospective clinical trials assessing effects on pain, disability, and function.  Well designed trials are especially important in assessing pain management interventions to isolate the contribution of the intervention from placebo effects, the effects of other concurrently administered pain management interventions, and the natural history of the medical condition.  Because of their inherently subjective nature, pain symptoms are especially prone to placebo effects.

In the case of reduction mammaplasty for relief of back, neck and shoulder pain, Aetna has considered this procedure medically necessary in women with excessively large breasts because it seems logical, even in the absence of firm clinical trial evidence, that this excessive weight would contribute to back and shoulder pain, and that removal of this excessive breast tissue would provide substantial pain relief, reductions in disability, and improvements in function.

The goal of medically necessary breast reduction surgery is to relieve symptoms of pain and disability.  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).

Some individuals, however, have argued that reduction mammaplasty may be indicated in any woman who suffers from back and shoulder pain, regardless of how small her breasts are or how little tissue is to be removed (ASPS, 2002).  They have argued that removal of even a few hundred grams of breast tissue can result in substantial pain relief.  These individuals cite evidence from observational studies to support this position (e.g., Chadbourne, et al., 2001; Kerrigan, et al., 2001).  These studies did not find a relationship between breast weight or amount of breast tissue removed and the likelihood of response or magnitude of relief of pain after reduction mammaplasty.

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.   Nor is it intuitively obvious that removal of smaller amounts of breast tissue would offer significant relief of back, shoulder or neck pain.  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.

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.  Well-designed, prospective, controlled clinical studies have not been performed to assess the effectiveness of surgical removal of modest amounts of breast tissue in reducing neck, shoulder, and back pain and related disability in women.  In addition, reduction mammaplasty needs to be compared with other established methods of relieving back, neck and shoulder pain.  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.

For these reasons, there is insufficient evidence to support the use of reduction mammaplasty, without regard to the size of the breasts or amount of breast tissue to be removed, as a method of relieving chronic back, neck, or shoulder pain.

Gynecomastia Surgery

Gynecomastia is a very common concern of male adolescence.  Sixty to 70 percent of males develop a transient subareolar breast tissue during their adolescence (Tanner Stages II & III).  Causes may include testosterone-estrogen imbalance, increased prolactin levels, or abnormal serum binding protein levels.

Gynecomastia has been classified into two types.  In Type I (idiopathic) gynecomastia, the adolescent presents with a tender, firm mass beneath the areola.   Most cases of type I gynecomastia are unilateral, and 20 percent of cases are bilateral.  Type II gynecomastia is more generalized breast enlargement.  Pseudogynecomastia refers to excessive fat tissue or prominent pectoralis muscles.

Gynecomastia may be drug-induced.  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.  Klinefelter’s syndrome, testicular, adrenal, or pituitary tumors, and thyroid or hepatic dysfunction are also associated with gynecomastia.

Henley et al (2007) reported that repeated topical exposure to lavender and tea tree oils may be linked to prepubertal gynecomastia (idiopathic gynecomastia).

Management of gynecomastia should include evaluation, including laboratory testing, to identify underlying etiologies.  Workup of gynecomastia may include the following (GP Notebook, 2003):

• A detailed drug history, including list of medications, an assessment of indirect or environmental exposure to estrogenic compounds, and recreational drug use.
• A detailed physical examination, including testicular examination.
• Liver and thyroid function tests.
• Measurement of plasma gonadotrophins, human chorionic gonadotropin (hCG), testosterone, estradiol, and dehydroepiandosterone sulphate (DHEAS)
• An ultrasound scan of testicular masses
• Computed tomography scan of adrenal glands to identify adrenal lesions.

Treatment should be directed at correcting any underlying reversible causes.  If gynecomastia is idiopathic, reassurance of the common, transient and benign nature of the condition should be given.  Resolution of idiopathic gynecomastia may take several months to years.  In a majority of boys with pubertal gynecomastia, the condition resolves within 18 months.  Medical reduction has been achieved with agents such as dihydrotestosterone, danazol, and clomiphene.   However, these medications should be reserved for those with no decrease in breast size after 2 years.  Surgical removal is rarely indicated and the vast majority of the time is for cosmetic reasons, as there is no functional impairment associated with this disorder.

Many men with breast enlargement are found to have pseudogynecomastia.  Removing the adipose tissue in pseudogynecomastia usually has no long term effect as adipose tissue reaccumulates unless the individual loses weight.   A physician-supervised diet and exercise plan may be indicated in obese patients.

Transient pain that may occur as the breast enlarges and the capsule is stretched; these symptoms may be managed with analgesics.  Mental health care professionals may be consulted to address psychological distress from gynecomastia.

Autologous Platelet Gel During Breast Surgery

In a within-patient, randomized, patient- and assessor-blinded, controlled study, Anzarut et al (2007) evaluated the use of completely autologous platelet gel in 111 patients undergoing bilateral reduction mammaplasty to reduce post-operative wound drainage. Patients were randomized to receive the gel applied to the left or right breast after hemostasis was achieved; the other breast received no treatment. The primary outcome was the difference in wound drainage over 24 hours. Secondary outcomes included subjective as well as objective assessments of pain and wound healing. 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. These investigators concluded that their findings do not support the use of completely autologous platelet gel to improve outcomes after reduction mammaplasty.