Certain patient subsets can benefit greatly from lift component of red

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Pursuit of scientific data justifying this reconstructive procedure is imperative.

MOST PLASTIC SURGEONS have had the experience of performing reduction mammaplasty with minimal tissue removal but significant lift, and achieving dramatic symptom relief. There seems to be a subset of patients with significant breast ptosis and large, but not gigantic breasts, who benefit greatly from the lift component of reduction mammaplasty. Kerrigan and others have demonstrated that symptomatic improvement does not correlate with the weight of breast tissue removed.¹ So what physical attribute does it correlate with? Why do third-party payers continue insisting on a minimal weight of tissue removal when the lift component of reduction mammaplasty probably contributes significantly to efficacy of the operation² ?

Dr. Laverson

SEMANTICS MATTER Part of the problem, I believe, is semantic. When we augment breasts with an implant and perform simultaneous mastopexy, the procedure is named "augmentation-mastopexy." When we reduce breast size and perform simultaneous mastopexy, the procedure is named incompletely and inaccurately, simply "reduction." For both research and reimbursement purposes, attention has therefore been myopically focused on the reduction component of the procedure.

The exact definition of breast hypertrophy is unclear, especially its lower limit. The etiology, other than "genetic" and "hormonal" is ill defined. Why two women with identical breast weight have different clinical presentations is unknown. Biomechanical variables, including degree of ptosis, likely play a role, but the system of breast suspension from the human musculoskeletal frame is devoid of scientific understanding. Reduction mammaplasty reduces size and weight of the breasts, but also lifts the breasts to a higher position on the chest wall. Because lowest ribs are also longer in the antero-posterior dimension, women with significant ptosis are carrying the weight of their breasts further away from the supporting spine. Thus the lever arm of breast support is longer. Lifting breasts to a higher position on the anterior chest likely moves breast weight closer to muscular and vertebral structural supporting elements. The lift component and the reduction component of reduction mammaplasty probably therefore both contribute to efficacy of the procedure, although the importance of each surgical maneuver is not known, and has never been researched.

MEDICAL NECESSITY Faced with patients with breast hypertrophy enumerating chronic complaints and disability, practicing plastic surgeons frequently appeal to third parties to pay for breast reduction surgery. Without quantitative data to explain a clearly effective intervention, it will become increasingly difficult to substantiate the "medical necessity" of this costly procedure. Our responsibility to practice evidence-based medicine is becoming greater, and thus, pursuit of scientific data justifying this reconstructive procedure is more imperative. This is a line of research that begs plastic surgery community interest.

Steve Laverson, M.D., F.A.C.S., is a board-certified plastic surgeon in Encinitas, Calif.

REFERENCES

1.Kerrigan CL, Collins ED, Striplin D, et al. The health burden of breast hypertrophy. Plast Reconstr Surg. 2001;108:1591-1599.

2.Insurance companies deny medically necessary breast reductions based on random, unproven coverage criteria [press release]. American Society of Plastic Surgeons; October 8, 2006.

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Certain patient subsets can benefit greatly from lift component of reduction mammaplasty

Article-Certain patient subsets can benefit greatly from lift component of reduction mammaplasty

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