Arkansas EB Benefits Breast Surgery- Reduction Mammoplasty

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1 Arkansas EB Benefits Breast Surgery- Reductin Mammplasty AUTH: AC-EBD92017 (AC) Link t Cdes Please nte: This guideline is t be used slely fr the Arkansas EB Benefits accunt serviced by AHM. Clinical Indicatins Breast reductin surgery is cnsidered csmetic unless breast hypertrphy is causing significant pain, paresthesias, r ulceratin (see selectin criteria belw). Reductin mammplasty fr asymptmatic members is cnsidered csmetic. Breast reductin surgery can be cnsidered medically necessary fr nn-csmetic indicatins fr wmen aged 18 r lder r fr whm grwth is cmplete (i.e., breast size stable ver ne year) when 1 r mre f the fllwing criteria is met. Nte: Medical review f breast reductin will require cntempraneus physician ffice ntes that include a histry f the cmplaint, a physical examinatin and ntes regarding previus evaluatins and testing. This dcumentatin shuld nte the patient s bra size, height, and weight. Frntal and side phtgraphs shwing macrmastia shuld be available fr review if requested. Macrmastia is dcumented - ALL f the fllwing are required Patient has persistent symptms in at least 2 r mre f the fllwing anatmical bdy areas belw, affecting daily activities fr at least ne year Headaches Pain in neck Pain in shulders Pain in upper back Painful kyphsis dcumented by X-rays Pain/discmfrt/ulceratin frm bra straps cutting int shulders ALL f the fllwing criteria are met Phtgraphic dcumentatin cnfirms severe breast hypertrphy Patient has undergne an evaluatin by a physician wh has determined that ALL f the fllwing criteria are met: There is a reasnable likelihd that the member's symptms are primarily due t macrmastia Reductin mammplasty is likely t result in imprvement f the chrnic pain Pain symptms persist as dcumented by the physician despite at least a 3- mnth trial f therapeutic measures such as ALL f the fllwing Analgesic/nn-steridal anti-inflammatry drugs (NSAIDs) interventins Physical therapy/exercises/psturing maneuvers Supprtive devices (e.g., prper bra supprt, wide bra straps) Wmen 40 years f age r lder are required t have a mammgram that was negative fr cancer perfrmed within the year prir t the date f the planned reductin mammplasty The surgen estimates that at least 1 r mre f the fllwing amunts (in grams) f breast tissue, nt fatty tissue, will be remved frm each breast, based n the patient's bdy surface area and the Mdified Schnur Sliding Scale that fllws. (T calculate bdy surface area, Msteller (BSA) see AC-EBD92017 Page 1 f 10

2 surface-area/bsa.htm OR the BSA may be calculated using BSA (m2 ) = ([height (cm) x weight (kg)]/3600)½ (½ dentes square rt) (weight is in kilgrams and the height is in centimeters.) [A] BSA is 1.35 m2: Lwer 5th Percentile is 127 and Lwer 22nd Percentile is 199 BSA is 1.40 m2: Lwer 5th Percentile is 139 and Lwer 22nd Percentile is 218 BSA is 1.45 m2: Lwer 5th Percentile is 152 and Lwer 22nd Percentile is 238 BSA is 1.50 m2: Lwer 5th Percentile is 166 and Lwer 22nd Percentile is 260 BSA is 1.55 m2: Lwer 5th Percentile is 181 and Lwer 22nd Percentile is 284 BSA is 1.60 m2: Lwer 5th Percentile is 198 and Lwer 22nd Percentile is 310 BSA is 1.65 m2: Lwer 5th Percentile is 216 and Lwer 22nd Percentile is 338 BSA is 1.70 m2: Lwer 5th Percentile is 236 and Lwer 22nd Percentile is 370 BSA is 1.75 m2: Lwer 5th Percentile is 258 and Lwer 22nd Percentile is 404 BSA is 1.80 m2: Lwer 5th Percentile is 282 and Lwer 22nd Percentile is 441 BSA is 1.85 m2: Lwer 5th Percentile is 308 and Lwer 22nd Percentile is 482 BSA is 1.90 m2: Lwer 5th Percentile is 336 and Lwer 22nd Percentile is 527 BSA is 2.00 m2: Lwer 5th Percentile is 401 and Lwer 22nd Percentile is 628 BSA is 2.05 m2: Lwer 5th Percentile is 439 and Lwer 22nd Percentile is 687 BSA is 2.10 m2: Lwer 5th Percentile is 479 and Lwer 22nd Percentile is 750 BSA is 2.15 m2: Lwer 5th Percentile is 523 and Lwer 22nd Percentile is 819 BSA is 2.20 m2: Lwer 5th Percentile is 572 and Lwer 22nd Percentile is 895 BSA is 2.25 m2: Lwer 5th Percentile is 625 and Lwer 22nd Percentile is 978 Breast reductin surgery will be cnsidered medically necessary fr wmen meeting the symptmatic criteria specified abve, regardless f BSA, with mre than 1 kg f breast tissue t be remved per breast. The BSA plts n the Sliding Schnur Scale int 1 r mre f the fllwing parameters: If the amunt plts abve the 22nd percentile, and ther c-criteria are met, breast reductin is medically necessary If the amunt plts belw the 5th percentile, breast reductin fr macrmastia is cnsidered csmetic -Refer t the Medical Directr If the amunt plts between the 5th and 22nd percentiles, the prcedure requires review t determine medical necessity-refer t the Medical Directr The patient has gigantmastia f pregnancy accmpanied by 1 r mre f the fllwing cmplicatins, and delivery is nt imminent: Massive infectin Significant hemrrhage AC-EBD92017 Page 2 f 10

3 Tissue necrsis with slugh Ulceratin f breast tissue Breast reductin, surgical mastectmy r lipsuctin fr gynecmastia, either unilateral r bilateral, is cnsidered a csmetic surgical prcedure. Medical therapy shuld be aimed at crrecting any reversible causes (e.g., drug discntinuance). Furthermre, there is insufficient evidence that surgical remval is mre effective than cnservative management fr pain due t gynecmastia. Evidence Summary Backgrund Reductin mammaplasty is amng the mst cmmnly perfrmed csmetic prcedures in the United States. Reductin mammaplasty perfrmed slely fr csmetic indicatins is cnsidered nt medically necessary. Reductin mammaplasty has als been used fr relief f pain in the back, neck and shulders. Because reductin mammaplasty may be used fr bth medically necessary and csmetic indicatins, The bjective criteria are cnsidered medically necessary reductin mammaplasty frm csmetic reductin mammaplasty. Reductin mammaplasty has been perfrmed t relieve back and shulder pain n the thery that reducing breast weight will relieve this pain. Fr pain interventins, evidence f effectiveness is necessary frm well cntrlled, randmized prspective clinical trials assessing effects n pain, disability, and functin. Well designed trials are especially imprtant in assessing pain management interventins t islate the cntributin f the interventin frm placeb effects, the effects f ther cncurrently administered pain management interventins, and the natural histry f the medical cnditin. Because f their inherently subjective nature, pain symptms are especially prne t placeb effects. In the case f reductin mammaplasty fr relief f back, neck and shulder pain, This prcedure medically is cnsidered necessary in wmen with excessively large breasts because it seems lgical, even in the absence f firm clinical trial evidence, that this excessive weight wuld cntribute t back and shulder pain, and that remval f this excessive breast tissue wuld prvide substantial pain relief, reductins in disability, and imprvements in functin. The gal f medically necessary breast reductin surgery is t relieve symptms f pain and disability. If an insufficient amunt f breast tissue is remved, the surgery is less likely t be successful in relieving pain and any related symptms frm excessive breast weight (e.g., excriatins, rash). Sme individuals, hwever, have argued that reductin mammaplasty may be indicated in any wman wh suffers frm back and shulder pain, regardless f hw small her breasts are r hw little tissue is t be remved (ASPS, 2002). They have argued that remval f even a few hundred grams f breast tissue can result in substantial pain relief. These individuals cite evidence frm bservatinal studies t supprt this psitin (e.g., Chadburne, et al., 2001; Kerrigan, et al., 2001). These studies did nt find a relatinship between breast weight r amunt f breast tissue remved and the likelihd f respnse r magnitude f relief f pain after reductin mammaplasty. It is nt intuitively bvius, hwever, that breast weight wuld substantially cntribute t back, neck and shulder pain in wmen with nrmal r small breasts. Nr is it intuitively bvius that remval f smaller amunts f breast tissue wuld ffer significant relief f back, shulder r neck pain. Criteria fr reductin mammaplasty surgery frm the American Sciety f Plastic Surgens (ASPS, 2002) states, amng ther things, that breast weight r breast vlume is nt a legitimate criterin upn which t distinguish csmetic frm functinal indicatins. This cnclusin is based primarily upn the Breast Reductin Assessment f Value and Outcmes (BRAVO) study, which is described in several articles (Kerrigan, et al., 2001; Kerrigan, et al., 2002; Cllins, et al., 2002). There are als several earlier, smaller studies that fund reductins in symptms and AC-EBD92017 Page 3 f 10

4 imprvements in quality f life after reductin mammaplasty (Glatt, et al., 1999; Bruhlmann & Tschpp, 1998; Blmqvist, et al., 2000; Behmand, et al., 2000). As explained belw, the studies used t supprt the arguments fr the medical necessity f breast reductin surgery are prly cntrlled and therefre subject t a substantial risk f bias in the interpretatin f results. Furthermre, the lack f an expected "dse-respnse" relatinship between the amunt f breast tissue remved and the magnitude f symptmatic relief in these studies raises questins abut the validity f these studies and the effectiveness f breast reductin as a methd f relieving shulder and back pain. A study reprting n a survey f health insurer plicies n breast reductin surgery (Nguyen, et al., 2004) fund that n insurer medical plicies culd be supprted by the medical literature. The authrs (Nguyen, et al., 2004) argue, based primarily n the results f the ASPS-funded BRAVO study (described belw), that (with a single exceptin) n bjective criteria fr breast reductin surgery are supprtable, including criteria based upn the presence f particular signs r symptms, requirements based upn breast size r the amunt f breast tissue remved, any minimum age limitatins, any limitatin based upn maximum bdy weight, requirements fr a trial f cnservative therapy, r the exclusin f certain prcedures (lipsuctin). The nly criterin that the authrs fund supprtable was a requirement fr a preperative mammgram fr wmen age 40 years and lder. The authrs leave the reader with the cnclusin that decisins abut the medical necessity f breast reductin surgery in symptmatic wmen shuld be left entirely t the surgen's discretin. Several imprtant pints shuld be cnsidered in evaluating these challenges t insurers' criteria fr breast reductin surgery. First, the pinins and guidelines f medical prfessinal rganizatins and cnsensus grups are cnsidered accrding t the quality f the scientific evidence and supprting ratinale. Secnd, it is the burden f the prpnent f an interventin t prvide reliable evidence f its effectiveness, nt the burden f nes wh questin the effectiveness an interventin t prvide definitive prf f ineffectiveness. Third, reliable evidence is especially imprtant fr pain interventins, because f the waxing and waning nature f pain and the susceptibility f this symptm t placeb effects and ther biases that may cnfund interpretatin f study results. Furth, insurers have prvided cverage fr reductin mammaplasty in wmen with excessively large breasts; thus, the debate is abut the effectiveness f remval f smaller amunts f breast tissue frm wmen whse breast size mst persns wuld cnsider within the nrmal range. The authrs f the BRAVO study reached several cnclusins abut reductin mammaplasty, mst ntably that breast size r the amunt f breast tissue remved des nt have any relatinship t the utcme f breast reductin surgery (Kerrigan, et al., 2002; Cllins, et al., 2002). The authrs reach the remarkable cnclusin that a wman with nrmal sized breasts wh has nly a few unces f breast tissue remved is as likely t receive as much benefit frm breast reductin surgery as wmen with large breasts that has substantially mre breast tissue remved. Hwever, the BRAVO study is nt f sufficient quality t reach reliable cnclusins abut the effectiveness f breast reductin surgery as a pain interventin. Althugh the BRAVO study is described as a cntrlled study, the "cntrl" grup is btained, nt frm the same chrt, but frm a separate chrt f individuals recruited frm newspaper advertisements and slicitatins at meetings fr inclusin in a study f the ppulatin burden f breast hypertrphy; three-quarters f this cntrl grup were btained frm tw centers, but the characteristics f thse tw centers were nt described. The cntrl grup was nt fllwed lngitudinally r treated accrding t any prtcl t ensure that they received ptimal cnservative management; cnclusins abut the lack f effectiveness f cnservative management were based n their respnses t a questinnaire abut whether subjects tried any f 15 cnservative interventins, and whether r nt they thught these interventins prvided relief f symptms. Based largely upn these results, Nguyen, et al. (2004) reached the cnclusin that a trial f cnservative management is nt an apprpriate criterin fr insurance cverage, even thugh respnses t the BRAVO questinnaire indicated that perative candidates and hypertrphy cntrls received at least sme pain relief frm all f the cnservative interventins, and fr sme cnservative interventins, virtually all AC-EBD92017 Page 4 f 10

5 subjects reprted at least sme pain relief. In additin, Nguyen, et al. (2004) ignred a wealth f published evidence f the effectiveness f physical therapy, analgesics and ther cnservative measures n back and neck pain generally. The perative grup in the BRAVO study was drawn frm a number f surgical practices that vlunteered t participate in the study; n details are prvided abut hw each center selected candidates fr reductin mammaplasty, r hw they chse patients wh underwent mammaplasty fr inclusin in the study. Of 291 subjects wh were selected fr inclusin in the study, nly 179 cmpleted fllwup. Thus, mre than ne-third f perative subjects selected fr inclusin in the study did nt cmplete it; mst f the perative subjects wh did nt cmplete the study were lst t fllwup. Althugh the BRAVO study nminally included a "cntrl grup", there was n cmparisn grup f subjects selected frm the same chrt, wh were randmized r therwise apprpriately assigned t reduce bias, and treated with cnservative management accrding t a prtcl t ensure ptimal cnservative care. Clinical utcmes were measured by perative subjects' respnses t a questinnaire abut symptms and quality f life. The authrs stated that perative subjects were tld that their respnses t the questinnaire were nt t be used fr insurance and thus the subjects had n mtivatin t exaggerate symptms prir t surgery in questinnaire respnses; hwever, it is nt clear whether perative subjects wuld be willing t submit respnses t a questinnaire frm the dctr that differed substantially frm the histry that they prvided t the dctr during their preperative evaluatin. Althugh perative subjects were examined befre and after surgery, there was n attempt t emply any blinded r bjective measures f disability and functin t verify these self-reprt. Operative subjects wh cmpleted the study reprted reductins in pain and imprvements in quality f life; hwever, these imprvements may be attributable t placeb effects, the natural histry f back pain, ther cncurrent interventins, regressin t the mean, imprvements in csmesis (fr quality f life measures), r ther cnfunding variables that may bias in interpretatin f results. Thus, this study wuld nt be cnsidered f sufficient quality t prvide reliable evidence f the effectiveness f a pain interventin. Other references t smaller studies published prir t the BRAVO study have been cited, examining symptms befre and after reductin mammaplasty; each f these studies suffer frm limitatins similar t thse identified with the BRAVO study. A study by Glatt, et al. (1999) was a retrspective analysis f respnses t questinnaires sent t patients wh underwent reductin mammaplasty regarding physical symptms and bdy image. Of 110 subjects wh were mailed questinnaires, apprximately half (61 subjects) prvided respnses. The investigatrs fund little difference between bese and nnbese wmen cncerning patient's reprts f reslutin f symptms and imprvement in bdy image. A study by Bruhlmann and Tschpp (1998) was a retrspective study f 246 patients frm a surgical practice, apprximately half (132) f whm returned a questinnaire abut their symptms and satisfactin with aesthetic results, and their recllectin f symptms prir t surgery. It shuld be nted that this study reprted a strng crrelatin between the amunt f tissue remved and pain ameliratin. It was als fund that nly three percent f subjects reprted that they had n aesthetic mtivatin fr surgery. Behmand, et al. (2000) reprted n the results f a questinnaire pre- and pst-surgery in 69 subjects frm a single practice that underwent reductin mammaplasty. Subjects were cmpared t age-matched nrms frm anther study chrt. N data were prvided n lss t fllw up. The article by Blmqvist, et al. (2000) is t anther questinnaire study abut health status and quality f life befre and after surgery. Apprximately ne quarter f the 49 subjects included in this study did nt return the pstperative questinnaire. Subject s respnses were cmpared t an agematched cmparisn grup f wmen, althugh n further details abut hw this cmparisn grup was prvided. The investigatrs reprted that subjects wh were f nrmal weight were as likely t reprt benefit frm reductin mammaplasty as subjects wh were verweight. The studies used t supprt the arguments fr the medical necessity f breast reductin surgery are prly cntrlled and therefre subject t a substantial risk f bias in the interpretatin f results. Well-designed, prspective, cntrlled clinical studies have nt been perfrmed t assess the effectiveness f surgical remval f mdest amunts f breast tissue in reducing neck, AC-EBD92017 Page 5 f 10

6 shulder, and back pain and related disability in wmen. In additin, reductin mammaplasty needs t be cmpared with ther established methds f relieving back, neck and shulder pain. Well designed clinical trials prvide reliable infrmatin abut the effectiveness f an interventin, and prvide valid infrmatin abut the characteristics f patients wh wuld benefit frm that interventin. Fr these reasns, there is insufficient evidence t supprt the use f reductin mammaplasty, withut regard t the size f the breasts r amunt f breast tissue t be remved, as a methd f relieving chrnic back, neck, r shulder pain. The American Sciety f Plastic Surgens' evidence-based clinical practice guideline n reductin mammaplasty (ASPS, 2011) states that in standard reductin mammaplasty prcedures, evidence indicates that the use f drains is nt beneficial. Hwever, if lipsuctin is used as an adjunctive technique, the decisin t use drains shuld be left t the surgen's discretin. The American Sciety fr Plastic Surgery (2011) advises t delay surgery until breast grwth ceases: "Althugh waiting may prlng the psychlgical awkwardness, it is advisable t delay surgery until breast grwth ceases in rder t achieve the best result." This is similar t the American Cllege f Obstetricians and Gynaeclgists' 2011 Guidelines fr Adlescent Health Care chapter n breast cncerns in adlescents, which states regarding breast hypertrphy: "Preferably, treatment shuld be deferred until breast grwth has been cmpleted. If breast grwth has been cmpleted, breast reductin surgery is an ptin." Marshall and Tanner (1969) shws that the final stage f breast maturity ccurs abut age 15 n average, but there is wide variatin. The average amunt f breast tissue remved ranged frm 430 g per breast t 1.6 kg per breast, with increased bdy weight assciated with an increased amunt f breast tissue t be remved. The average amunt f tissue remved frm an average weight wman (within the 70 t 74.9 kg weight band) in this study was 60 g per breast, with a range f 502 g t 700 g f tissue remved per breast. Schnur, et al. (1991) reprted n a sliding scale assigns a weight f breast tissue t be remved based n bdy weight and surface area. The study by Schnur, et al. was based n a survey f 92 plastic surgens wh reprted n their care fr 591 patients. Each surgen wh participated in the study reprted n the height, weight, and vlume f reductin f their last 15 t 20 patients, and each surgen prvided their "intuitive sense" regarding the mtivatin f each patient fr breast reductin surgery. Schnur subsequently refuted the validity f the Schnur sliding scale and stated that the scale shuld n lnger be used as a criterin fr the determinatin f insurance cverage fr breast reductin surgery (Nguyen, et al., 1999). The American Sciety f Plastic Surgens' evidence-based clinical practice guideline n reductin mammaplasty (ASPS, 2011) states that in standard reductin mammaplasty prcedures, evidence indicates that the use f drains is nt beneficial. Hwever, if lipsuctin is used as an adjunctive technique, the decisin t use drains shuld be left t the surgen's discretin. The American Sciety fr Plastic Surgery (2011) advises t delay surgery until breast grwth ceases: "Althugh waiting may prlng the psychlgical awkwardness, it is advisable t delay surgery until breast grwth ceases in rder t achieve the best result." This is similar t the American Cllege f Obstetricians and Gynaeclgists' 2011 Guidelines fr Adlescent Health Care chapter n breast cncerns in adlescents, which states regarding breast hypertrphy: "Preferably, treatment shuld be deferred until breast grwth has been cmpleted. If breast grwth has been cmpleted, breast reductin surgery is an ptin." Marshall and Tanner (1969) shws that the final stage f breast maturity ccurs abut age 15 n average, but there is wide variatin. Sabistn's Textbk f Surgery (Burns & Blackwell, 2008) states that breast size shuld be stable fr ne year: "There is n set lwer age limit but, fr the adlescent with breast hypertrphy, reductin is deferred until the breasts have stpped grwing and are stable in size fr at least 12 mnths befre surgery." Fischer et al (2014a) evaluated predictrs f pstperative cmplicatins fllwing reductin mammaplasty using the NSQIP) data sets. The NSQIP recrded tw cmplicatin types: majr cmplicatins (deep infectin and return t perating rm) and any cmplicatin (all surgical cmplicatins). Preperative patient factrs and cmrbidities, as well as AC-EBD92017 Page 6 f 10

7 intraperative variables, were assessed. Study subjects included 3538 patients with an average age f 43 years and bdy mass index f 31.6 kg/m(2) and mst patients underwent utpatient surgery (80.5%) with an average perative time f 180 minutes. Karamans et al (2014) nted that althugh breast reductin mammplasty accunts fr mre than 60,000 prcedures annually, the literature remains sparse n utcmes. In this study the Natinal Surgical Quality Imprvement Prgram data set was queried fr the Current Prcedural Terminlgy cde frm the years 2005 t 2010, with principal utcme measurements f wund cmplicatins, surgical site infectins, and reperatins. A ttal f 2779 patients were identified with a mean age f 42.7 (14.1) years and BMI f 31.6 (7.0) kg/m. Tbacc use was shwn t have a higher rate f reperatin (p= 0.02) and BMI was identified as an independent risk factr fr wund cmplicatins (dds rati, 1.85, P = 0.005). Karamans et al identified their study as the largest sample n breast reductin in the literature, in which age and surgen specialty did nt crrelate with negative results. In cntrast, tbacc use and BMI were assciated with wrse breast reductin utcmes. Nelsn et al (2014a) analyzed ppulatin data frm the American Cllege f Surgens Natinal Surgical Quality Imprvement Prgram (NSQIP) database. They investigated effects f age n 30-day surgical utcmes fr reductin mammaplasty with a gal f imprving patient care, cunseling, and risk stratificatin n 3537 patients. The study subjects were stratified int grups based n ages f <60 years and > r = 60 years. Subgrup analysis further stratified the yunger chrt int thse <50 years and years f age. Results illustrated that 3050 patients were <60 years f age ( r years) and 487 were > r = 60 years f age ( r years). A ttal f 182 thirty-day pstperative surgical cmplicatins were dcumented, but stratifying patients int 2 age grups did nt reveal an assciatin between age and any surgical cmplicatin (P =.26). The authrs cncluded that with prper patient selectin, reductin mammplasty can be perfrmed safely n lder patients. Nelsn et al (2014b) separately cnducted a ppulatin level analysis f the NSQIP datasets, identifying patient wh underwent reductin mammplasty, t determine the impact f besity n early cmplicatins after reductin mammaplasty. Data was then analyzed fr surgical cmplicatins, wund cmplicatins, and medical cmplicatins within 30 days f surgery n 4545 patients. Within this study ppulatin, 54.4% f patients were bese (BMI > 30 kg/m2), f which 1308 (28.8%) were Class I (BMI = kg/m2), 686 (15.1%) were Class II (BMI = kg/m2), and 439 (9.7%) were Class III (BMI > 40 kg/m2). The investigatrs fund that cmrbid cnditins increased acrss besity classificatins (p < 0.001), with significant differences nted in all chrt cmparisns except when cmparing class I t class II (p = 0.12). Early cmplicatins were rare (6.1%), with superficial skin and sft tissue infectins accunting fr 45.8% f cmplicatins. Examining any cmplicatin, a significant increase was nted with increasing besity class (p < 0.001). This was further islated when cmparing mrbidly bese patients t nn-bese (p < 0.001), class I (p < 0.001), and class II (p = 0.01) patients. This ppulatin-wide analysis - the largest and mst hetergeneus study t date - has demnstrated that increasing besity class is assciated with increased early pstperative cmplicatins. Mrbidly bese patients are at the highest risk, with cmplicatins ccurring in nearly 12% f this chrt. Srinivasaiah et al (2014) stated that althugh reductin mammplasty has been shwn t benefit physical, physilgical, and psych-scial health there are recgnized cmplicatins. The authrs recruited 67 cnsecutive female patients wh underwent inferir pedicle reductin mammplasty in rder t determine the effects f resectin weight, BMI, age, and smking n cmplicatin rates fllwing reductin mammplasty. Data were prspectively gathered n cmplicatins as a part f randmized cntrl trial (RCT) examining psych-scial & QOL benefits f reductin mammplasty. Sixteen (23%) patients had cmplicatins and higher resectin weight, increased BMI, and lder age were fund t AC-EBD92017 Page 7 f 10

8 have statistically significant cmplicatin rates with p-values f p < 0.001, p = 0.034, and p = 0.004, respectively. The investigatrs als fund that the incidence f cmplicatins was highest amng current smkers and lwest amng thse wh had never smked with a 37% difference in the ccurrence f cmplicatin (p < 0.01). They cncluded that higher resectin weight, increased BMI, lder age, and smking are risk factrs fr cmplicatin and that patients shuld therefre be adequately cunseled abut lsing weight and stpping smking. Gynecmastia Surgery Gynecmastia is a very cmmn cncern f male adlescence. Sixty t 70 % f males develp a transient subarelar breast tissue during their adlescence (Tanner Stages II and III). Causes may include teststerne-estrgen imbalance, increased prlactin levels, r abnrmal serum binding prtein levels. Gynecmastia has been classified int 2 types. In Type I (idipathic) gynecmastia, the adlescent presents with a tender, firm mass beneath the arela. Mst cases f type I gynecmastia are unilateral, and 20 % f cases are bilateral. Type II gynecmastia is mre generalized breast enlargement. Pseud-gynecmastia refers t excessive fat tissue r prminent pectralis muscles. Gynecmastia may be drug-induced. Drugs cmmnly assciated with the develpment f gynecmastia include amphetamines, marijuana, mebrbamate, piates, amitriptyline, chlrdiazepxide, chlrprmazine, cimetidine, diazepam, digxin, fluphenazine, halperidl, imipramine, isniazid, mesridazine, methyldpa, perphenazine, phenthiazines, reserpine, spirnlactne, thiethylperazine, tricyclic antidepressants, tirfluperazine, trimeparazine, busulfan, vincristine, tamxifen,, methylteststerne, human chrinic gnadtrpins, and estrgens. Klinefelter's syndrme, testicular, adrenal, r pituitary tumrs, and thyrid r hepatic dysfunctin are als assciated with gynecmastia. Henley et al (2007) reprted that repeated tpical expsure t lavender and tea tree ils may be linked t prepubertal gynecmastia (idipathic gynecmastia). Management f gynecmastia shuld include evaluatin, including labratry testing, t identify underlying etilgies. Wrk-up f gynecmastia may include the fllwing (GP Ntebk, 2003): A detailed drug histry, including list f medicatins, an assessment f indirect r envirnmental expsure t estrgenic cmpunds, and recreatinal drug use. A detailed physical examinatin, including testicular examinatin. Liver and thyrid functin tests. Measurement f plasma gnadtrphins, human chrinic gnadtrpin (hcg), teststerne, estradil, and dehydrepiandsterne sulphate (DHEAS) An ultrasund scan f testicular masses Cmputed tmgraphy scan f adrenal glands t identify adrenal lesins. Treatment shuld be directed at crrecting any underlying reversible causes. If gynecmastia is idipathic, reassurance f the cmmn, transient and benign nature f the cnditin shuld be given. Reslutin f idipathic gynecmastia may take several mnths t years. In a majrity f bys with pubertal gynecmastia, the cnditin reslves within 18 mnths. Medical reductin has been achieved with agents such as dihydrteststerne, danazl, and clmiphene. Hwever, these medicatins shuld be reserved fr thse with n decrease in breast size after 2 years. Surgical remval is rarely indicated and the vast majrity f the time is fr csmetic reasns, as there is n functinal impairment assciated with this disrder. Many men with breast enlargement are fund t have pseud-gynecmastia. Remving the adipse tissue in pseudgynecmastia usually has n lng term effect as adipse tissue reaccumulates unless the individual lses weight. A physician-supervised diet and exercise plan may be indicated in bese patients. Transient pain that may ccur as the breast enlarges and the capsule is stretched; these symptms may be managed with analgesics. Mental health care prfessinals may be cnsulted t address psychlgical distress frm gynecmastia. AC-EBD92017 Page 8 f 10

9 In a review n "Surgical treatment f primary gynecmastia in children and adlescents", Fischer et al (2014b) cncluded that surgical crrectin f gynecmastia remains a purely elective interventin. Autlgus Platelet Gel During Breast Surgery In a within-patient, randmized, patient- and assessr-blinded, cntrlled study, Anzarut et al (2007) evaluated the use f cmpletely autlgus platelet gel in 111 patients underging bilateral reductin mammaplasty t reduce pst-perative wund drainage. Patients were randmized t receive the gel applied t the left r right breast after hemstasis was achieved; the ther breast received n treatment. The primary utcme was the difference in wund drainage ver 24 hurs. Secndary utcmes included subjective as well as bjective assessments f pain and wund healing. N statistically significant differences in the drainage, level f pain, size f pen areas, clinical appearance, degree f scar pliability, r scar erythema were nted. These investigatrs cncluded that their findings d nt supprt the use f cmpletely autlgus platelet gel t imprve utcmes after reductin mammaplasty. Drugs assciated with gynecmastia: Estrgens and estrgen like drugs, including: diethylstibestrl expsure t partners using estrgen cntaining vaginal creams csmetics cntaining estrgens digitxin Drugs that enhance estrgen frmatin, including: gnadtrphins such as hcg fllwing withdrawal f clmiphene Drugs which inhibit teststerne synthesis, including ketcnazle metrnidazle spirnlactne cancer chemtherapy (alkylating agents, methtrexate, vinca alkalids, imatinib, cmbinatin chemtherapy) Drugs that inhibit teststerne actin, including andrgen receptr blckers - bicalutamide 5 alpha reductase inhibitrs - finasteride, dutasteride H2 blckers and prtn pump inhibitrs marijuana Drugs whse mechanism f actin is unknwn: tricyclic antidepressants angitensin cnverting enzyme inhibitrs (captpril, enalapril) herin amidarne busulfan methyldpa captpril grwth hrmne reserpine highly active antiretrviral therapy calcium channel blckers (diltiazem, nifedipine, verapamil) isniazid American Sciety f Plastic Surgens' gynecmastia scale: Grade II: Mderate breast enlargement exceeding arela bundaries with edges that are indistinct frm the chest. Grade III: Mderate breast enlargement exceeding arela bundaries with edges that are indistinct frm the chest with skin redundancy present. Grade IV: Marked breast enlargement with skin redundancy and feminizatin f the breast AC-EBD92017 Page 9 f 10

10 References This guideline was develped based n EBD client requirements. Reviewed by a Bard Certified Internist Reviewed by David Evans, MD, Medical Directr, Active Health Management- Oct 2017 ACTIVEHEALTH MANAGEMENT. Ftntes [A] Table and nmgram were riginally published in Schnur PL et al. Reductin mammaplasty: csmetic r recnstructive prcedure? Ann Plast Surg Sep;27(3): [ A in Cntext Link 1 ] Cdes CPT : 19316, CPT cpyright 2016 American Medical Assciatin. All rights reserved. AC-EBD92017 Page 10 f 10

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