Macromastia

Macromastia, or gigantomastia, is a condition that describes breast hyperplasia or hypertrophy. Macromastia may result in clinical symptoms such as shoulder, neck, or back pain, or recurrent intertrigo in the mammary folds. Also, macromastia may be associated with psychosocial or emotional disturbances related to the large breast size.

Treatment

Reduction mammaplasty is a surgical procedure designed to remove a variable proportion of breast tissue to address emotional and psychosocial issues and/or to relieve the associated clinical symptoms.

While literature searches have identified many articles that discuss the surgical technique of reduction mammaplasty and have documented that reduction mammaplasty is associated with relief of physical and psychosocial symptoms,^{1,2,3,4,5,6,7,8,9,} an important issue is whether reduction mammaplasty is a functional need or cosmetic. For some patients, the presence of medical indications is clear-cut: clear documentation of recurrent intertrigo or ulceration secondary to shoulder grooving. For some patients, the documentation differentiating between a cosmetic and a medically necessary procedure will be unclear. Criteria for medically necessary reduction mammaplasty are not well-addressed in the published medical literature.

Some protocols on the medical necessity of reduction mammaplasty are based on the weight of removed breast tissue. The basis of weight criteria is not related to the outcomes of surgery, but to surgeons retrospectively classifying cases as cosmetic or medically necessary. Schnur et al (1991) at the request of third-party payers, developed a sliding scale.^10, This scale was based on survey responses from 92 of 200 solicited plastic surgeons, who reported the height, weight, and amount of breast tissue removed from each a breast from the last 15 to 20 reduction mammaplasties they had performed. Surgeons were also asked if the procedures were performed for cosmetic or medically necessary reasons. The data were then used to create a chart relating the body surface area, and the cutoff weight of breast tissue removed that differentiated cosmetic and medically necessary procedures. Based on their estimates, those with a breast tissue removed weight above the 22nd percentile likely had the procedure for medical reasons, while those below the 5th percentile likely had the procedure performed for cosmetic reasons; those falling between the cutpoints had the procedure performed for mixed reasons.

Schnur (1999) reviewed the use of the sliding scale as a coverage criterion and reported that, while many payers had adopted it, many had also misused it.^11,Schnur pointed out that if a payer used weight of resected tissue as a coverage criterion, then if the weight fell below the 5th percentile, the reduction mammaplasty would be considered cosmetic; if above the 22nd percentile, it would be considered medically necessary; and if between these cutpoints, it would be considered on a case-by-case basis. Schnur also questioned the frequent requirement that a woman is within 20% of her ideal body weight. While weight loss might relieve symptoms, durable weight loss is notoriously difficult and might be unrealistic in many cases.

Regulatory Status

Reduction mammaplasty is a surgical procedure and, as such, is not subject to regulation by the U.S. Food and Drug Administration.

Related Policies

• None

A. Copies of original medical records submitted either hard copy or electronically from 2 physicians other than the operating surgeon (one of whom must specialize in musculoskeletal disorders, e.g., orthopedist, physiatrist, rheumatologist, osteopathic physician, chiropractor) indicating that shoulder, neck and/or back pain related to macromastia has not been responsive to at least a 6-month course of conservative therapy, such as support bra, exercises, heat/cold treatment and appropriate non-steroidal anti-inflammatory agents/muscle relaxants.

Note that letters of attestation alone will not fulfill this requirement.

B. The amount of breast tissue removed (projected, estimated, or actual) is 500 grams or more per breast. Photographs consisting of frontal and lateral views must be submitted.

When the amount of breast tissue is less than 500 grams, the following scale may be used alternatively to determine the minimum amount of breast tissue to be removed based on the member’s body surface area.




Body Surface Area (square meters)	Minimum Amount of Breast Tissue (grams)	Body Surface Area (square meters)	Minimum Amount of Breast Tissue (grams)
1.35	199	1.65	338
1.40	218	1.70	370
1.45	238	1.75	404
1.50	260	1.80	441
1.55	284	1.85	482
1.60	310	1.87	500

Schnur PL, Hoehn JG, Ilstrup DM, et al. Reduction Mammaplasty: Cosmetic or Reconstructive Procedure? Ann Plast Surg 1991;27(3):282-287.

To calculate body surface area, use any one of the following formulas:
• Body Surface Area (m2) = square root [{height (cm) x weight in (kg)} / 3600]
• Body Surface Area (m2) = square root [{height (in) x weight (lb)} / 3131]

To convert pounds to kilograms, multiply pounds by 0.45.
To convert inches to centimeters, multiply inches by 2.54.

A. Improper fitting clothing.
B. Claims of inability to exercise.
C. Psychological or social reasons.
D. Fibrocystic breast disease.

· The signs or symptoms have been present for at least six months.
· Medical treatment or physical interventions have not adequately alleviated symptoms.

FIDE-SNP:

For members enrolled in a Fully Integrated Dual Eligible Special Needs Plan (FIDE-SNP): (1) to the extent the service is covered under the Medicare portion of the member’s benefit package, the above Medicare Coverage statement applies; and (2) to the extent the service is not covered under the Medicare portion of the member’s benefit package, the above Medicaid Coverage statement applies.

[RATIONALE: This policy was created in 1993 and has been updated regularly with searches of the MEDLINE database. The most recent literature review was performed through December 6, 2018.

Evidence reviews assess the clinical evidence to determine whether the use of a technology improves the net health outcome. Broadly defined, health outcomes are length of life, quality of life, and ability to function¾including benefits and harms. Every clinical condition has specific outcomes that are important to patients and to managing the course of that condition. Validated outcome measures are necessary to ascertain whether a condition improves or worsens; and whether the magnitude of that change is clinically significant. The net health outcome is a balance of benefits and harms.

To assess whether the evidence is sufficient to draw conclusions about the net health outcome of a technology, 2 domains are examined: the relevance and the quality and credibility. To be relevant, studies must represent one or more intended clinical use of the technology in the intended population and compare an effective and appropriate alternative at a comparable intensity. For some conditions, the alternative will be supportive care or surveillance. The quality and credibility of the evidence depend on study design and conduct, minimizing bias and confounding that can generate incorrect findings. The randomized controlled trial is preferred to assess efficacy; however, in some circumstances, nonrandomized studies may be adequate. Randomized controlled trials are rarely large enough or long enough to capture less common adverse events and long-term effects. Other types of studies can be used for these purposes and to assess generalizability to broader clinical populations and settings of clinical practice.

Reduction mammAplasty for Macromastia-Efficacy in Reducing Symptoms

Clinical Context and Therapy Purpose

The purpose of reduction mammaplasty is to provide a treatment option that is an alternative to or an improvement on existing therapies, such as nonsurgical treatment, in patients with symptomatic macromastia.

The question addressed in this policy is: does reduction mammoplasty improve the net health outcome for women with symptomatic macromastia?

The following PICOTS were used to select literature to inform this review.

Patients

The relevant population of interest is women with symptomatic macromastia, or gigantomastia, a condition that describes breast hyperplasia or hypertrophy.

Interventions

The therapy being considered is reduction mammaplasty, a surgical procedure that removes a variable proportion of breast tissue to relieve the associated clinical symptoms and address emotional and psychosocial issue related to large breast size.

Comparators

Comparators of interest include nonsurgical treatment which primarily involves analgesia, clothing modifications, physical therapy and other measures to address symptoms.

Outcomes

The general outcomes of interest are symptoms and functional outcomes. Symptoms of symptomatic macromastia can include mastalgia, pain in the shoulders, back, and neck, recurrent intertrigo in the mammary fold. The condition may also be associated with psychosocial or emotional disturbances.

Timing

The existing literature evaluating reduction mammaplasty as a treatment for symptomatic macromastia has varying lengths of follow-up, ranging from 6 to 18 months. While studies described below all reported at least one outcome of interest, longer follow-up was necessary to fully observe outcomes. Therefore, at least one year of follow-up is considered necessary to demonstrate efficacy.

Setting

Patients with symptomatic macromastia are managed by general or plastic surgeons in an inpatient clinical setting.

Study Selection Criteria

Methodologically credible studies were selected using the following principles: 

a.     To assess efficacy outcomes, comparative controlled prospective trials were sought, with a preference for RCTs;

b.     In the absence of such trials, comparative observational studies were sought, with a preference for prospective studies.

c.     To assess longer term outcomes and adverse events, single-arm studies that capture longer periods of follow-up and/or larger populations were sought.

d.     Studies with duplicative or overlapping populations were excluded.

Randomized Controlled Trials

Sabino Neto et al (2008) assessed functional capacity for 100 patients, ages 18 to 55 years, who were randomized to reduction mammaplasty or to waiting list control.^7,Forty-six patients from each group completed the study. At baseline and 6 months later, patients were assessed for functional capacity using the Roland-Morris Disability Questionnaire (0=best performance, 24=worst performance) and for pain using a visual analog scale. The reduction mammaplasty group showed improvement in functional status, with an average score of 5.9 preoperatively and 1.2 within 6 months postoperatively (p<0.001 for pre-post comparison within the mammaplasty group) vs an unchanged average score of 6.2 in the control group on the first and second evaluations. Additionally, pain in the lower back decreased on the visual analog scale from an average of 5.7 preoperatively to 1.3 postoperatively (p<0.001 for pre-post comparison within the mammaplasty group) vs visual analog scale average scores in the control group of 6.0 and 5.3 on the first and second evaluations, respectively (p=NS).

Saariniemi et al (2008) reported on quality of life (QOL) and pain in 82 patients randomized to reduction mammaplasty or a nonoperative group and evaluated at baseline and 6 months later.^9,The authors reported that the mammaplasty group had significant improvements in QOL from baseline to 6 months, as measured by the Physical Component Summary score of the 36-Item Short-Form Health Survey (SF-36; change, +9.7 vs +0.7, p<0.001), the Utility Index score (SF-6D; change, +17.5 vs +0.6), the index score of QOL (SF-15D; change, +8.6 vs +0.06, p<0.001), and SF-36 Mental Component Summary score (change, +7.8 vs -1.0, p<0.002). There were also improvements in breast-related symptoms from baseline to 6 months, as measured by Finnish Breast-Associated Symptoms questionnaire scores (-47.9 vs -3.5, p<0.001), and Finnish Pain Questionnaire scores (-21.5 vs -1.0, p<0.001).

Iwuagwu et al (2006) reported on 73 patients randomized to reduction mammaplasty within 6 weeks or after a 6-month waiting period to assess lung function.^8, All patients had symptoms related to macromastia. Postoperative lung function correlated with the weight of breast tissue removed, but there were no significant improvements in any lung function parameters for the mammaplasty group compared with the control group.

Key trials are reported in Tables 1 and 2 below.

Table 1. Summary of Key RCT Characteristics

Study; Trial	Countries	Sites	Dates	Participants	Interventions
					Active	Comparator
Sabino Neto (2008)7,	Brazil	1	2002-2004	Female patients (age 18-55 yrs) with breast hypertrophy (n=100)	Reduction mammaplasty (n=50)	Waiting list control (n=50)
Saariniemi (2008)9,	Finland	1	NR	Female patients with symptomatic breast hypertrophy (n=82)	Reduction mammaplasty (n=40)	Non-operative control (n=42)

RCT: randomized controlled trial; NR: not reported.

Table 2. Summary of Key RCT Results

Study	Change (Pre- to Postoperative) in RSES	Change (Pre- to Postoperative) in RMDQ	Change (Pre- to Postoperative) in VAS	Change (Pre- to Postoperative) in SF-36 Utility Index Score	Change (Pre- to Postoperative) in Mental Summary Score	Change (Pre- to Postoperative) in Pain Score
Sabino Neto (2008)
Mammaplasty	8.9 to 4.9 (p<0.001)	5.9 to 1.2 (p<0 001)	5.7 to 1.3 (p<0.001)
Control	9.1 to 9.0 (p>0.999)	6.2 to 6.2 (NR)	6.0 to 5.3 (p<0.001)
Saariniemi (2008)
Mammaplasty				0.645 to 0.820	46.0 to 53.8	28.5 to 7.0
Control				0.657 to 0.663	47.2 to 46.2	27.5 to 26.5
P-value				<0.001	<0.002	<0.001

RSES: Rosenberg Self-Esteem Scale; RMDQ: Roland-Morris Disability Questionnaire; VAS: visual analog scale; NR: not reported; RCT: randomized controlled trial.

 The purpose of the gaps table (Table 4) is to display notable gaps identified in each study. This information is synthesized as a summary of the body of evidence following each table and provides the conclusions on the sufficiency of evidence supporting the position statement.  

Table 3.  Study Design and Conduct Gaps

Study	Allocationa	Blindingb	Selective Reportingc	Follow-Upd	Powere	Statisticalf
Sabino Neto (2008)		1,2,3. No blinding				3. Some p-values not reported
Saariniemi (2008)		1,2,3. No blinding		1. 22% of patients lost to follow-up

The evidence gaps stated in this table are those notable in the current review; this is not a comprehensive gaps assessment.

^a Allocation key: 1. Participants not randomly allocated; 2. Allocation not concealed; 3. Allocation concealment unclear; 4. Inadequate control for selection bias.

^b Blinding key: 1. Not blinded to treatment assignment; 2. Not blinded outcome assessment; 3. Outcome assessed by treating physician.

^c Selective Reporting key: 1. Not registered; 2. Evidence of selective reporting; 3.  Evidence of selective publication.

^d Follow-Up key: 1. High loss to follow-up or missing data; 2. Inadequate handling of missing data; 3. High number of crossovers; 4. Inadequate handling of crossovers; 5. Inappropriate exclusions; 6. Not intent to treat analysis (per protocol for noninferiority trials).

^e Power key: 1. Power calculations not reported; 2. Power not calculated for primary outcome; 3. Power not based on clinically important difference.

^f Statistical key: 1. Intervention is not appropriate for outcome type: (a) continuous; (b) binary; (c) time to event; 2. Intervention is not appropriate for multiple observations per patient; 3. Confidence intervals and/or p values not reported; 4.Comparative treatment effects not calculated.

Observational Studies

Singh and Losken (2012) reported on a systematic review of studies reporting outcomes after reduction mammaplasty.^12, In 7 studies reporting on physical symptoms (n range, 11-92 patients), reviewers found reduction mammaplasty improved functional outcomes including pain, breathing, sleep, and headaches. Additional psychological outcomes noted included improvements in self-esteem, sexual function, and QOL.

Hernanz et al (2016) reported on a descriptive cohort study of 37 consecutive obese patients who underwent reduction mammoplasty for symptomatic macromastia, along with 37 age-matched women hospitalized for short-stay surgical procedures.^13, In the preoperative state, SF-36 physical health component subscore was significantly lower for patients with symptomatic macromastia (40) than for age-matched controls (53; p<0.001), with differences in 5 of the 8 subscales. At 18 months postprocedure, there were no significant differences in any SF-36 subscores except the body pain subscale between patients who had undergone reduction mammoplasty and age-matched controls.

Kerrigan et al (2002) published the results of the BRAVO (Breast Reduction: Assessment of Value and Outcomes) study, a registry of 179 women undergoing reduction mammaplasty.^14, Women were asked to complete QOL questionnaires and a physical symptom count both before and after surgery. The physical symptom count focused on the number of symptoms present that were specific to breast hypertrophy and included upper back pain, rashes, bra strap grooves, neck pain, shoulder pain, numbness, and arm pain. Also, the weight and volume of resected tissue were recorded. Results were compared with a control group of patients with breast hypertrophy, defined as size DD bra cup, and normal-sized breasts, who were recruited from the general population. The authors proposed that the presence of 2 physical symptoms might be an appropriate cutoff for determining medical necessity for breast reduction. For example, while 71.6% of the hypertrophic controls reported none or 1 symptom, only 12.4% of those considered surgical candidates reported none or 1 symptom. This observation is difficult to evaluate because the study did not report how surgical candidacy was determined. The authors also reported that none of the traditional criteria for determining medical necessity for breast reduction surgery (height, weight, body mass index, bra cup size, or weight of resected breast tissue) had a statistically significant relation with outcome improvement. The authors concluded that the determination of medical necessity should be based on patients’ self-reported symptoms rather than more objectively measured criteria (eg, the weight of excised breast tissue).

Adverse Events

Thibaudeau et al (2010) conducted a systematic review to evaluate breastfeeding after reduction mammaplasty.^15, After a review of literature from 1950 through 2008, reviewers concluded that reduction mammaplasty does not reduce the ability to breastfeed. In women who had reduction mammaplasty, breastfeeding rates were comparable in the first month postpartum to rates in the general population in North America.

Chen et al (2011) reported on a review of claims data to compare complication rates after breast surgery in 2403 obese and 5597 nonobese patients.^16, Of these patients, breast reduction was performed in 1939 (80.7%) in the study group and 3569 (63.8%) in the control group. Obese patients had significantly more claims for complications within 30 days after breast reduction surgery (14.6%) than nonobese patients (1.7%; p<0.001). Complications included inflammation, infection, pain, and seroma/hematoma development. Shermak et al (2011) also reported on a review of claims data comparing complication rates by age after breast reduction surgery in 1192 patients.^17, Infection occurred more frequently in patients older than 50 years of age (odds ratio, 2.7; p=0.003). Additionally, women older than 50 years experienced more wound healing problems (odds ratio, 1.6; p=0.09) and reoperative wound débridement (odds ratio, 5.1; p=0.07). Other retrospective evaluations (2013, 2014) of large population datasets have reported increased incidences of perioperative and postoperative complications with high body mass index.^18,19,

Section Summary: Reduction Mammaplasty for Macromastia-Efficacy in Reducing Symptoms

Systematic reviews, randomized trials, and observational studies have shown that several measures of function and QOL improve after reduction mammaplasty.

Summary of Evidence

For individuals who have symptomatic macromastia who receive reduction mammaplasty, the evidence includes systematic reviews, randomized controlled trials, cohort studies, and case series. Relevant outcomes are symptoms and functional outcomes. Studies have indicated that reduction mammaplasty is effective at decreasing breast-related symptoms such as pain and discomfort. There is also evidence that functional limitations related to breast hypertrophy are improved after reduction mammaplasty. These outcomes are achieved with acceptable complication rates. The evidence is sufficient to determine that the technology results in a meaningful improvement in the net health outcome.

SUPPLEMENTAL INFORMATION

Practice Guidelines and Position Statements

American Society of Plastic Surgeons

In 2011, The American Society of Plastic Surgeons issued practice guidelines and a companion document on criteria for third-party payers for reduction mammaplasty.^20,21, The Society found that level I evidence has shown reduction mammaplasty is effective in treating symptomatic breast hypertrophy, which “is defined as a syndrome of persistent neck and shoulder pain, painful shoulder grooving from brassiere straps, chronic intertriginous rash of the inframammary fold, and frequent episodes of headache, backache, and neuropathies caused by heavy breasts caused by an increase in the volume and weight of breast tissue beyond normal proportions.” The Society also indicated the volume or weight of breast tissue resection should not be criteria for reduction mammaplasty. If two or more symptoms are present all or most of the time, reduction mammaplasty is appropriate. This practice guideline has been officially archived and an update is scheduled for 2019.

U.S. Preventive Services Task Force Recommendations

Not applicable.

Ongoing and Unpublished Clinical Trials

A search of ClinicalTrials.gov in December 2018 did not identify any ongoing or unpublished trials that would likely influence this review.]
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Horizon BCBSNJ Medical Policy Development Process:

This Horizon BCBSNJ Medical Policy (the “Medical Policy”) has been developed by Horizon BCBSNJ’s Medical Policy Committee (the “Committee”) consistent with generally accepted standards of medical practice, and reflects Horizon BCBSNJ’s view of the subject health care services, supplies or procedures, and in what circumstances they are deemed to be medically necessary or experimental/ investigational in nature. This Medical Policy also considers whether and to what degree the subject health care services, supplies or procedures are clinically appropriate, in terms of type, frequency, extent, site and duration and if they are considered effective for the illnesses, injuries or diseases discussed. Where relevant, this Medical Policy considers whether the subject health care services, supplies or procedures are being requested primarily for the convenience of the covered person or the health care provider. It may also consider whether the services, supplies or procedures are more costly than an alternative service or sequence of services, supplies or procedures that are at least as likely to produce equivalent therapeutic or diagnostic results as to the diagnosis or treatment of the relevant illness, injury or disease. In reaching its conclusion regarding what it considers to be the generally accepted standards of medical practice, the Committee reviews and considers the following: all credible scientific evidence published in peer-reviewed medical literature generally recognized by the relevant medical community, physician and health care provider specialty society recommendations, the views of physicians and health care providers practicing in relevant clinical areas (including, but not limited to, the prevailing opinion within the appropriate specialty) and any other relevant factor as determined by applicable State and Federal laws and regulations.

___________________________________________________________________________________________________________________________

Index:
Reduction Mammaplasty
Mammaplasty, Reduction

References:
1. Dabbah A, Lehman JA, Jr., Parker MG, et al. Reduction mammaplasty: an outcome analysis. Ann Plast Surg. Oct 1995;35(4):337-341. PMID 8585673

2. Schnur PL, Schnur DP, Petty PM, et al. Reduction mammaplasty: an outcome study. Plast Reconstr Surg. Sep 1997;100(4):875-883. PMID 9290655

3. Hidalgo DA, Elliot LF, Palumbo S, et al. Current trends in breast reduction. Plast Reconstr Surg. Sep 1999;104(3):806-815; quiz 816; discussion 817-808. PMID 10456536

4. Glatt BS, Sarwer DB, O'Hara DE, et al. A retrospective study of changes in physical symptoms and body image after reduction mammaplasty. Plast Reconstr Surg. Jan 1999;103(1):76-82; discussion 83-75. PMID 9915166

5. Collins ED, Kerrigan CL, Kim M, et al. The effectiveness of surgical and nonsurgical interventions in relieving the symptoms of macromastia. Plast Reconstr Surg. Apr 15 2002;109(5):1556-1566. PMID 11932597

6. Iwuagwu OC, Walker LG, Stanley PW, et al. Randomized clinical trial examining psychosocial and quality of life benefits of bilateral breast reduction surgery. Br J Surg. Mar 2006;93(3):291-294. PMID 16363021

7. Sabino Neto M, Dematte MF, Freire M, et al. Self-esteem and functional capacity outcomes following reduction mammaplasty. Aesthet Surg J. Jul-Aug 2008;28(4):417-420. PMID 19083555

8. Iwuagwu OC, Platt AJ, Stanley PW, et al. Does reduction mammaplasty improve lung function test in women with macromastia? Results of a randomized controlled trial. Plast Reconstr Surg. Jul 2006;118(1):1-6; discussion 7. PMID 16816661

9. Saariniemi KM, Keranen UH, Salminen-Peltola PK, et al. Reduction mammaplasty is effective treatment according to two quality of life instruments. A prospective randomised clinical trial. J Plast Reconstr Aesthet Surg. Dec 2008;61(12):1472-1478. PMID 17983882

10. Schnur PL, Hoehn JG, Ilstrup DM, et al. Reduction mammaplasty: cosmetic or reconstructive procedure? Ann Plast Surg. Sep 1991;27(3):232-237. PMID 1952749

11. Schnur PL. Reduction mammaplasty-the schnur sliding scale revisited. Ann Plast Surg. Jan 1999;42(1):107-108. PMID 9972729

12. Singh KA, Losken A. Additional benefits of reduction mammaplasty: a systematic review of the literature. Plast Reconstr Surg. Mar 2012;129(3):562-570. PMID 22090252

13. Hernanz F, Fidalgo M, Munoz P, et al. Impact of reduction mammoplasty on the quality of life of obese patients suffering from symptomatic macromastia: A descriptive cohort study. J Plast Reconstr Aesthet Surg. Aug 2016;69(8):e168-173. PMID 27344408

14. Kerrigan CL, Collins ED, Kim HM, et al. Reduction mammaplasty: defining medical necessity. Med Decis Making. May-Jun 2002;22(3):208-217. PMID 12058778

15. Thibaudeau S, Sinno H, Williams B. The effects of breast reduction on successful breastfeeding: a systematic review. J Plast Reconstr Aesthet Surg. Oct 2010;63(10):1688-1693. PMID 19692299

16. Chen CL, Shore AD, Johns R, et al. The impact of obesity on breast surgery complications. Plast Reconstr Surg. Nov 2011;128(5):395e-402e. PMID 21666541

17. Shermak MA, Chang D, Buretta K, et al. Increasing age impairs outcomes in breast reduction surgery. Plast Reconstr Surg. Dec 2011;128(6):1182-1187. PMID 22094737

18. Gust MJ, Smetona JT, Persing JS, et al. The impact of body mass index on reduction mammaplasty: a multicenter analysis of 2492 patients. Aesthet Surg J. Nov 01 2013;33(8):1140-1147. PMID 24214951

19. Nelson JA, Fischer JP, Chung CU, et al. Obesity and early complications following reduction mammaplasty: An analysis of 4545 patients from the 2005-2011 NSQIP datasets. J Plast Surg Hand Surg. Oct 2014;48(5):334-339. PMID 24506446

20. American Society of Plastic Surgeons. Evidence-based Clinical Practice Guideline: Reduction Mammaplasty. 2011; http://www.plasticsurgery.org/Documents/medical-professionals/health-policy/evidence-practice/Reduction_Mammaplasty_Evidence_Based_Guideline%20%282%29%282%29.pdf. Accessed January 17, 2019.

21. Kalliainen LK, ASPS Health Policy Committee. ASPS clinical practice guideline summary on reduction mammaplasty. Plast Reconstr Surg. Oct 2012;130(4):785-789. PMID 23018692

Codes:
(The list of codes is not intended to be all-inclusive and is included below for informational purposes only. Inclusion or exclusion of a procedure, diagnosis, drug or device code(s) does not constitute or imply authorization, certification, approval, offer of coverage or guarantee of payment.)

CPT*

19318