|Comments from Faculty and Members
E. Dale Collins, MD Associate Professor of Surgery
and Director, Comprehensive Breast Program One Medical Center
Drive, Dartmouth Hitchcock Medical Center, Lebanon, NH, USA
on Nov 29, 2004
This woman looks like someone who would benefit significantly
from breast reduction. I suspect that if you ask, she will report
having breast-related pain all or most of time in her neck,
upper back and shoulder area. This is directly linked to the
weight of her breasts. Insurer's often underestimate the degree
of pain these women live with on a daliy basis. I hope she will
be able to obtain coverage for the surgical procedure.
Phung Huynh, MD, Department of Dermatology, NY Medical
College, New York, NY, USA on Nov 29, 2004
You can fight the insurance company on this. I know that patients
have had their insurance companies pay for breast reduction
in the past because it was causing medical problems. She may
need to see orthopaedics to fight for the breast reduction surgery.
Caroline Koblenzer M.D., Professor of Dermatology
and Psychiatry, University of Pennsylvania, Philadelphia, PA,
USA on November 29, 2004
This is indeed a tragic case. It is, in my opinion, a medical
necessity for this young woman to undergo breast reduction surgery.
Indeed I have had, in my practice, woman for whom breast-reduction
surgery was covered by insurance, whose breasts were not as
significantly enlarged as in this case.
Not only is surgery a medical necessity, but there is no question
that it would also be cost-effective.
Such macromastia as we see in this case, causes chronic strain
on the back and shoulder muscles, and ultimately damage to the
The quality of life for these patients is significantly diminished.
Not only is there chronic pain, but activities are severely
limited---for example, this patient could not engage in sports,
dancing, or many forms of physical exercise, because not only
are the breasts are in the way,but the weight of their movement
up and down increases the already severe strain on the back.
Similarly, many of the commonly practised sexual activities
would be strictly limited by the intrusion of the massive volume
of the breasts.
Apart from the devastating psychological impact of all these
factors, the inevitable increase in weight that follows on the
imposed lack of exercise will ensue, and all the well-know co-morbidities
that go along with that.
Clothing is strictly limited in both size and style for these
patients, while the distortion of body image, the sense of being
"different" from others, and the inevitable lowering
of self-esteem has a very negative psychological impact, and
undoubtedly contributes to this patient's depression.
Anatoli Freiman MD, Montreal, Canada on Nov
As the patient's main complaint is the back pain, which I imagine
can be quite severe, perhaps the orthopedic morbidity of such
degree of macromastia would be an important medical indication
for surgery, and should be considered by the insurance company.
Monroe Richman MD, Koloa, USA on Nov 29, 2004
Sad commentary that in this ? age of enlightment the insurance
carrier does not approve of surgery.
Benjamin Barankin MD, Department of Dermatology, University
of Alberta, Edmonton, Canada on Nov 29, 2004
There is no doubt that she would greatly benefit from a reduction
mammoplasty for her psyche, musculoskeletal/back, and ulcerations
which occur not uncommonly in those with pendulous breasts;
because of gravity and poor circulation & lymphatic drainage,
she is likely to have repeated ulcerative episodes on her breasts
irrespective of her Crohn's.
Stephen Glinick M.D., Providence, RI, USA
on Nov 29, 2004
It is absolutely ridiculous that the insurance company in this
case refuses to pay for a reduction mammoplasty. If I ever saw
a better candidate I can't recall it. She should fight ever
step of the way.
Jole Bamford MD, USA, on Nov 29, 2004
Patient may want to share experiences with insurance carriers
and/or patients with similar problems. Google "blogumentary",
an open source documentary film about how anyone (pt, citizen,
dr, insurance agent) can possibly have an effect by networking
on line with others. One well known, main example was related
to how Dan Rather was exposed for presenting false documents
on TV - people doubted, then talked and figured out the font
used in the paper was not available when the paper was said
to be written >>> the rest is history.
Gregory Herbich MD, Honolulu, HI, USA on Nov
These cases are usually covered by health insurance provided
the patients have back pain, bra straps cutting the skin and
The surgical procedure would probably entail amputation and
a free nipple graft due to the enormous size. Complications
includ fat necrosis, skin breakdown, loss of sensation, graft
slough but otherwise the patients are generally pleased with
Doug Johnson MD, Dept of Medicine, University of Hawaii
School of Medicine, Honolulu, HI, USA on Dec 1, 2004
This patient would obviously benefit from the procedure and
the approval is usually done by the plastic sturgeon. The carrier
probably has a policy that is available with criteria necessary
to complete the procedure. My previous nurse had the procedure
done and it was covered by her insurance. Find a reconstructive
surgeon who has experience in the area and let them carry the
ball. Your photos and a letter of appeal would be strong evidence
for doing the procedure.
Judith J Petry MD, FACS, Westminster, VT, USA on
Dec 1, 2004
There is a large body of scientific documentation in the peer-reviewed
medical literature demonstrating the efficacy of reduction mammaplasty
for women suffering from macromastia. Statistically significant
improvement in back, neck and shoulder pain, shoulder grooving,
posture, pulmonary function, body image, emotional well-being
and quality of life are proven outcomes and have been shown
to persist for at least 3 years post-op in one long-term study.
(1-4) Any disease entity that caused a symptom complex similar
to that caused by macromastia would never be denied insurance
coverage for treatment unless there were an irrational argument
used to do so. That is the usual cause of denial of coverage
for macromastia; the irrational argument that the surgery is
cosmetic in nature. As defined by the American Society of Plastic
Surgery, “Cosmetic surgery is performed to reshape normal
structures of the body in order to improve the patient's appearance
and self-esteem….. Reconstructive surgery is performed
on abnormal structures of the body, caused by congenital defects,
developmental abnormalities, trauma, infection, tumors or disease.
It is generally performed to improve function, but may also
be done to approximate a normal appearance.”
There can be no question that the woman pictured in your “Current
Case” suffers from a developmental deformity that is causing
physical and emotional symptoms that seriously interfere with
normal function and quality of her life. Her experience of daily
life is hampered by a situation that could be reproduced by
carrying a heavily weighted knapsack hung from the shoulders
and strapped to the chest, day after day, year after year. The
results are predictable: poor posture, shoulder grooving, neck
pain, shoulder pain, back pain, decreased pulmonary function,
poor body image, decreased social function, and depression.
All worsening with time.
If the surgery to correct such a problem were particularly dangerous
or fraught with high morbidity, the decision to deny insurance
coverage might be easier to understand. The surgery is not any
more dangerous than other reconstructive surgery. It rarely
requires transfusion, does not require invasion of a body cavity
and most patients are discharged from hospital after 24 hours.
The patients are consistently delighted with the results in
spite of significant permanent scars.
I am convinced that the most frequent cause for insurance denial
in cases of true macromastia is a complete lack of knowledge
and absence of compassion.
1. Blomqvist L, Brandberg Y. Three-year follow-up on clinical
symptoms and health-related quality of life after reduction
mammaplasty. Plast Reconstr Surg. 2004 Jul;114(1):49-54.
2. Sood R, et al. Effects of reduction mammaplasty on pulmonary
function and symptoms of macromastia. Plast Reconstr Surg. 2003
3. Behmand RA, Tang DH, Smith DJ Jr. Outcomes in breast reduction
surgery. Ann Plast Surg. 2000 Dec;45(6):575-80.
4. Glatt BS, Sarwer DB, O'Hara DE, Hamori C, Bucky LP, LaRossa
A retrospective study of changes in physical symptoms and body
image after reduction mammaplasty. Plast Reconstr Surg. 1999