NEW YORK — Reduction mammoplasty (RM) remains the gold standard treatment for patients with macromastia-associated complaints. These include neck pain, headaches, mastodynia, difficulty sleeping, upper and lower back pain that can radiate to the shoulders and hands, and painful deep shoulder grooves caused by bra straps.
Not all insurance plans cover RM, however, as many companies cite weight loss as the primary approach to treatment.
"Overweight patients are correlated with larger breast size, and being overweight is a disqualifier for RM in some insurance plans," says Jason A. Spector, M.D., F.A.C.S., assistant professor of plastic surgery and director, Laboratory of Bioregenerative Medicine and Surgery, Weill Cornell Medical College, New York. "As macromastia can be a direct result of being overweight, they claim that weight loss should be the primary treatment goal and not RM. This is, of course, a catch-22, because patients cannot effectively lose weight if they cannot run or exercise properly due to their large breast size."The physical symptoms associated with macromastia can be severe and can significantly impact the patient's quality of life (QoL). Improvement of macromastia-related symptoms can be achieved in those patients who experience a decrease in breast size if they lose weight in a proportional fashion. However, this is not always the case, and, according to Dr. Spector, RM is the best — and sometimes only — solution for macromastia-related pain and QoL-related factors.
DEFINING BREAST HYPERTROPHY The definition of breast hypertrophy differs from patient to patient, because the proportion of body size and weight-to-breast size can vary greatly. Size D-cup breasts in a 5-foot-2-inch woman weighing 120 pounds may be too large and cumbersome for her and interfere with her QoL, compared to a 5-foot-8-inch woman weighing 160 pounds with the same size breasts.
"The problem is that insurance companies try to group all patients under one umbrella, regardless of their size or weight," Dr. Spector says. "Most insurance companies will say that the surgeon needs to remove at least 500 grams of breast tissue for the procedure to qualify as RM. Otherwise, it is a mastopexy, a cosmetic breast-lifting procedure." In other words, sometimes it is unclear where a reduction mammoplasty ends and a "cosmetic" mastopexy begins.
Some physicians recommend that resection weights should be based on the patient's total body surface area, an approach many insurance companies adopt in their policy (Schnur PL, et al. Ann Plast Surg. 1991;27(3):232-237). However, other insurance companies categorically consider breast reduction a "contractual exclusion," and patients have little to no recourse if this is the policy.
BREAST REDUCTION STUDY In a recent study (Spector JA, et al. Ann Plast Surg. 2008;60(5):505-509), Dr. Spector compared large- versus small-breast reduction in a series of patients to determine whether improvement in symptoms can be correlated to the amount of breast tissue removed. The 188 patients included in the study were stratified by the total weight of breast tissue resected and divided into four cohorts: 1,000 g or less (66 patients), 1,001 g to 1,500 g (55 patients), 1,501 g to 2,000 g (30 patients) and greater than 2,000 g (37 patients). Patients completed questionnaires evaluating their macromastia-related symptoms and other macromastia-related QoL issues prior to surgery and at final follow-up, which occurred anywhere between three and 12 months post-procedure.
Results showed that RM significantly improved all macromastia-related symptoms and QoL factors analyzed in all patients. However, the quantitative improvement in patients' symptoms from their pre- to postoperative status was no different between women who had large breast reductions (greater than 1,000 g per breast) and women who had small breast reductions (less than 500 g per breast).
"Women of varying breast sizes equally benefited from RM, regardless of the amount of breast tissue removed. This corroborates what we as plastic surgeons already know from experience," Dr. Spector says.