Breast J. } Reduction mammoplasty improves symptoms of macromastia. # font-weight: bold; OL OL OL OL LI { } No other operation-related complications were observed. They stated that no data are available for breast augmentation or breast reconstruction, and this requires investigation. li.bullet { First, the opinions and guidelines of medical professional organizations and consensus groups are considered according to the quality of the scientific evidence and supporting rationale. Last Review01/04/2023. Data were prospectively gathered on complications as a part of randomized control trial (RCT) examining psycho-socialand quality of life(QOL) benefits of reduction mammoplasty. 1995;34(2):113-116. Setala L, Papp A, Joukainen S, et al. font-size: 18px; 2nd ed. There are alsoseveral earlier, smaller studies that found reductions in symptoms and improvements in quality of life after reduction mammoplasty (Glatt et al, 1999; Bruhlmannand Tschopp, 1998; Blomqvist et al, 2000; and Behmand et al, 2000). 2001;107(5):1234-1240. Aetna considers breast reconstructive surgery to correct No new trials were identified for this first update. Can objective predictors for operative success be identified? Karamanos E, Wei B, Siddiqui A, Rubinfeld I. No author listed. Complications following reduction mammaplasty: A review of 3538 cases from the 2005-2010 NSQIP data sets. The authors (Nguyen et al, 2004) argue, based primarily on the results of the ASPS-funded BRAVO study (described below), that (with a single exception) no objective criteria for breast reduction surgery are supportable, including criteria based upon the presence of particular signs or symptoms, requirements based upon breast size or the amount of breast tissue removed, any minimum age limitations, any limitation based upon maximum body weight, requirements for a trial of conservative therapy, or the exclusion of certain procedures (liposuction). .headerBar { The mean age was 42.8 years (SD 19.5 years). Copyright Aetna Inc. All rights reserved. Aesthetic Plast Surg. There were only 2 studies of a total 25 patients that were considered as good in quality. If reduction mammoplasty was performed before oncological treatment, the incidence of abnormal findings was higher. 2014b;48(5):334-339. Surgical implications of obesity. Prasetyono TOH, Budhipramono AG, Andromeda I, et al. 2015;75(4):383-387. Aetna Inc. and its subsidiary companies are not responsible or liable for the content, accuracy, or privacy practices of linked sites, or for products or services described on these sites. Kerrigan CL, Collins ED, Kim HM, et al. Breast reduction surgery is considered reconstructive and medically necessary in certain circumstances .
Breast Reduction Surgery and Gynecomastia Surgery - Medical - Aetna Magnetic Resonance Imaging (MRI) of the Breast - Aetna Surgery. color: red } If breast growth has been completed, breast reduction surgery is an option. Marshall and Tanner (1969)shows that the final stage of breast maturityoccurs about age 15 on average, but there is wide variation. Level of Evidence = IV. The goal of medically necessary breast reduction surgery is to relieve symptoms of pain and disability. Mayo Clin Proc. Other just require 500 grams no matter what your height and weight. cursor: pointer; Saunders Co.; 1991. /*margin-bottom: 43px;*/ To get insurance coverage, you'll probably need . When seeking preauthorization for a breast reduction, your goal is generally twofold. Gonzalez FG, Walton RL, Shafer B, et al. Covered items may include: A manual or standard electric pump (non-hospital grade) while you are pregnant or for the duration of breastfeeding. 1999;103(1):76-82; discussion 83-85. Breast Reduction Surgery and Gynecomastia Surgery - Medical Clinical Policy Bulletins | Aetna Page . 2008;61(5):493-502. The following procedures are considered experimental and investigational because there is insufficient evidence of itseffectiveness or itseffectiveness has not been established: Aetna considers breast reduction, surgical mastectomy or liposuction for gynecomastia, either unilateral or bilateral, a cosmetic surgical procedure. Aetna considers associated nipple and areolar reconstruction and tattooing of the nipple area medically necessary. 1998;49:215-234. 2002;109(5):1556-1566. color:#eee; Hoyos AE, Perez ME, Dominguez-Millan R, et al. Surgical treatment of gynecomastia by vacuum-assisted biopsy device. 2019;8(4):431-440. Sixty to 70% of males develop a transient subareolar breast tissue during their adolescence (Tanner Stages II and III). He and associates (2011) examined the safety and feasibility of vacuum-assisted biopsy device in the treatment of gynecomastia. Devalia HL, Layer GT. Recommended criteria for insurance coverage of reduction mammoplasty. } OL LI { In Type I (idiopathic) gynecomastia, the adolescent presents with a tender, firm mass beneath the areola. background: #5e9732; 2006;9(2):109-114. 2001;76(5):503-510. The average amount of tissue removed from an average weight woman (within the 70 to 74.9 kg weight band) in this study was 600 g per breast, with a range of 502 g to 700 g of tissue removed per breast. height:2px; list-style-type: upper-roman; Macromastia: all . Minor complications (3.2 %) included prolonged swelling, bruising, asymmetries, and residual gynecomastia. Narula HS, Carlson HE. OL OL OL OL OL LI { Guidelines for Adolescent Health Care. list-style-type: decimal; 2001;108(6):1591-1599. The authors stated that operative subjects were told that their responses to the questionnaire were not to be used for insurance and thus the subjects had no motivation to exaggerate symptoms prior to surgery in questionnaire responses; however, it is not clear whether operative subjects would be willing to submit responses to a questionnaire from the doctor that differed substantially from the history that they provided to the doctor during their preoperative evaluation. Gland Surg. This will be computed based on your body area. color: red!important; } 2000;106(2):280-288. Conversely, many patients believe if a procedure is considered cosmetic, it is not a medically indicated and covered procedure. Fan L, Yang X, Zhang Y, Jiang J. Endoscopic subcutaneous mastectomy for the treatment of gynecomastia: A report of 65 cases. } Chemical peels (chemical exfoliation): Considered medically necessary when criteria in CPB 0251 - Dermabrasion, Chemical Peels, and Acne Nguyen JT, Wheatley MJ, Schnur PL, et al. Gynecomastia resection plus high-definition liposculpture was successfully performed in 436 consecutive men (open inverted-omega incision resection, n = 132; liposuction, n = 304). Surgical treatment is indicated when medical treatments fail. 1995;61(11):1001-1005. Of 291 subjects who were selected for inclusion in the study, only 179 completed follow-up. Glatt BS, Sarwer DB, O'Hara DE, et al. Until now, most published research on the subject has focused on how effective surgical treatment is on correcting the cosmetic appearance of the breast. You first need to demonstrate that the procedure is "medically necessary and therefore reconstructive rather than cosmetic," says board-certified New York City plastic surgeon Dr. Umbareen Mahmood. 1995;95(1):77-83. margin-top: 38px; Three review authors undertook independent screening of the search results. Principles of breast re-reduction: A reappraisal. Studies have suggested that 2.4% to 14% of breast reduction cases resulted in major complications and 2.4% . While 1 study showed high patient's satisfaction rate; both studies indicated high surgeon's satisfaction rate. Health insurance companies frequently have different criteria for whether breast reduction surgery is medically necessary. The authors concluded that gynecomastia treatment combining high-definition liposculpture to male breast tissue resection via a new, almost invisible incision allowed these researchers to achieve an athletic and natural appearance of the male pectoral area with a very low rate of complications. list-style-type : square !important; Medical therapy should be aimed at correcting any reversible causes (e.g., drug discontinuance). Autorino R, Perdona S, D'Armiento M, et al. Collis N, McGuiness CM, Batchelor AG. 2007;36(2):497-519. A lack of correlation between these variables may result from the fact that the analyzed group of men with idiopathic gynecomastia was small in number, but at the same time, it appeared to be homogenous in these aspects (positive ER and/or PR expression and high digit ratio). list-style-type: upper-alpha; Plast Reconstr Surg. Plastic Reconstr Surg. The operative group in the BRAVO study was drawn from a number of surgical practices that volunteered to participate in the study; no details are provided about how each center selected candidates for reduction mammoplasty, or how they chose patients who underwent mammoplasty for inclusion in the study. } hr.separator {
Aetna's Itty Bitty Titty Committee - by Libby Watson - Sick Note However, these medications should be reserved for those with no decrease in breast size after 2 years. If gynecomastia is idiopathic, reassurance of the common, transient and benign nature of the condition should be given. Bertin ML, Crowe J, Gordon SM. Sixteen (23%) patients had complications and higher resection weight, increased BMI, and older age were found to have statistically significant complication rates with p-values of p<0.001, p=0.034, and p=0.004, respectively.The investigators also found that the incidence of complications was highest among current smokers and lowest among those who had never smoked with a 37% difference in the occurrence of complication (p<0.01). Aetna does not provide health care services and, therefore, cannot guarantee any results or outcomes. The authors specified the value of these study results was in the identification of morbid obesity as a significant predictor of overall morbidity and active smoking as a strong predictor of major surgical morbidity. Morbidly obese patients are at the highest risk, with complications occurring in nearly 12% of this cohort. background: url('https://www.aetna.com/cpb/medical/data/assets/images/purplearrow.jpg') no-repeat; A total of 90 patients underwent breast re-reduction surgery. Disproportionately large breasts can cause both physical and emotional . Several important points should be considered in evaluating these challenges to insurers' criteria for breast reduction surgery. The study consisted of 329 breast cancer patients, who underwent symmetrizing reduction mammoplasty between 1/2007 and 12/2011. This study included 35 patients who underwent breast reduction due to the idiopathic form of gynecomastia. Qu and colleagues (2020) examined the effectiveness of vacuum-assisted breast biopsy systems for the treatment of gynecomastia. The authors concluded that low-dose radiotherapy to the male breast might be a safe and effective strategy to prevent gynecomastia incidence or recurrence in high-risk patients. Some individuals, however, have argued that reduction mammoplasty may be indicated in any woman who suffers from back and shoulder pain, regardless of how small her breasts are or how little tissue is to be removed (ASPS, 2002). For pain interventions, evidence of effectiveness is necessary from well controlled, randomized prospective clinical trials assessing effects on pain, disability, and function. Healing balms, scented soaps, skin lotions, shampoos and styling gels containing lavender oilor tea tree oil. Removing the adipose tissue in pseudogynecomastia usually has no long term effect as adipose tissue reaccumulates unless the individual loses weight. (This refers to actual breast tissue only; any fatty tissue removed doesn't count.) The operation was successfully performed in all 20 patients with a mean operating time of 51 mins and a hospital stay of 4 days. 2002;33:208-217. Estrogens and estrogen like drugs,including: Drugsthat enhance estrogen formation, including: Drugs which inhibit testosterone synthesis, including, Drugs that inhibit testosterone action, including.
My Experience of Having Breast Reduction Surgery - Health Obesity and complications in breast reduction surgery: Are restrictions justified? Reduction mammoplasty specimens revealed abnormal findings in 68 (21.5 %) patients. Gland Surg. Secondary outcomes included subjective as well as objective assessments of pain and wound healing. 2000;106(5):991-997. Results illustrated that 3050 patients were <60 years of age (39.7 11.8 years) and 487 were 60 years of age (65.1 4.7 years). The condition not only must be unresponsive to dermatological treatments (e.g., antibiotics or antifungal therapy) and conservative measures (e.g., good skin hygiene, adequate nutrition) for a period of 6 months or longer, but also must satisfy criteria stated insection I above. The authors concluded that small incisional design for breast parenchymal removal in gynecomastia assisted by liposuction showed a good technical approach for consistent improvement in QOL; however, only 2 studies reported good quality methods of non-randomized case-series urging for a better quality of studies in the future. Breast and aesthetic surgery. A systematic search of the published literature was performed. Plast Reconstr Surg. Prostate Cancer Prostatic Dis. Following treatment, 90.1 % (n = 73) had a complete response of their gynecomastia with tamoxifen therapy. ASPS Recommended Coverage Criteria for Third Party Payors. Plastic Reconstruct Surg. Schnur et al (1991) reported on a sliding scale assigns a weight of breast tissue to be removed based on body weight and surface area. For individuals who received radiation treatment to the chest . Drains were used significantly less by surgeons performing greater than or equal to 20 BBRs (p = 0.02). All the patients recovered well and were satisfied with the cosmetic outcomes. } Gynecomastia surgery is the surgical correction of over-developed or enlarged breasts in men. Nelson et al (2014b) separately conducted a population level analysis of the 2005-2011 NSQIP datasets, identifying patient who underwent reduction mammoplasty, to determine the impact of obesity on early complications after reduction mammoplasty. While the efficacy of radiotherapy as a therapeutic modality for gynecomastia was also established, it was shown to be less effective than other available options. skin should not be excised horizontally below the inframammary fold. .strikeThrough { Abnormal histopathology correlated with higher age (p = 0.0053), heavier specimen (p = 0.0491), and with no previous breast surgery (p < 0.001). These researchers compared the safety and effectiveness of the use of wound drains following elective plastic and reconstructive surgery procedures of the breast. The authors concluded that the vacuum-assisted breast biopsy system could be used as a feasible and minimally invasive approach for the treatment of gynecomastia. 2009;62(2):195-199. The authors concluded that high digit ratio in men with gynecomastia may tend to be a marker of over-expression of ER and PR. 2021 Aug 11 [Online ahead of print]. It can cause discomfort and concern, resulting in patients seeking diagnosis and treatment. Arlington Heights, IL: ASPRS; 1987. Plast Reconstr Surg. Annu Rev Med. These individuals cite evidence from observational studies to support this position (e.g., Chadbourne et al, 2001; Kerrigan et al, 2001). Inclusion criteria were as follows: men diagnosed with gynecomastia and BMI of less than or equal to 32 kg/m2, adequate skin elasticity, and general good health. An 18-question survey was created evaluating various aspects of BBR practice; UK and Irish plastic and reconstructive and breast surgeons were invited to participate by an e-mail containing a link to a web-based survey.
Will Aetna Insurance Cover my Breast Reduction? - RealSelf.com Level of Evidence = IV. Sollie M. Management of gynecomastia-changes in psychological aspects after surgery-a systematic review.
What can I do if my insurance denies coverage for breast reduction? Kerrigan CL, Collins ED, Kneeland TS, et al. American College of Obstetricians and Gynecologists (ACOG), Committee on Adolescent Health Care. breast augmentation with implant. 1993;91(7):1270-1276. Breast reduction surgery might also help improve self-image and the ability to take part in physical activities. In a liposuction-only reduction mammoplasty, a small access incision is made in one of the following locations: axillary (under the arm), periareolar (around the nipple) or in the inframammary fold (under the breast). 2004;113(1):436-437. The authors concluded that with proper patient selection, reduction mammoplasty can be performed safely on older patients. The operation had a mean duration of 73.5 mins per side, ranging from 40 to 102 mins. Links to various non-Aetna sites are provided for your convenience only. Anzarut A, Guenther CR, Edwards DC, Tsuyuki RT. For example, if the body surface area is 1.40 m2 , the estimated breast tissue to be removed should at least be 324 grams. top: 0px; Kerrigan CL, Collins ED, Striplin D, et al. border-width:0; Karamanos et al (2015) identified their study as the largest sample on breast reduction in the literature, in which age and surgeon specialty did not correlate with negative results. 2 . The primary outcome was the difference in wound drainage over 24 hours. Brown DM, Young VL. # color: white; .strikeThrough { Gynecomastia Treatment through Open Resection and Pectoral High-Definition Liposculpture.
Breast Reduction | American Society of Plastic Surgeons The control group was not followed longitudinally or treated according to any protocol to ensure that they received optimal conservative management; conclusions about the lack of effectiveness of conservative management were based on their responses to a questionnaire about whether subjects tried any of 15 conservative interventions, and whether or not they thought these interventions provided relief of symptoms. Completely autologous platelet gel in breast reduction surgery: A blinded, randomized, controlled trial. Reduction mammoplasty performed solely for cosmetic indications is considered by insurers to be not medically necessary treatment of disease and subject to the standard cosmetic surgery plan exclusion. They investigated effects of age on 30-day surgical outcomes for reduction mammoplasty with a goal of improving patient care, counseling, and risk stratification on 3537 patients. @media print { #backTop { Oxfordshire NHS Trust. High-risk lesions (atypical ductal hyperplasia [ADH], atypical lobular hyperplasia [ALH], and lobular carcinoma in situ [LCIS]) were revealed in 37 (11.7 %), and cancer in 6 (1.9 %) patients. Other referencesto smaller studies published prior to the BRAVO study have been cited,examining symptoms before and after reduction mammoplasty; each of these studies suffer from limitations similar to those identified with the BRAVO study.
PDF Breast Reduction Surgery and Gynecomastia Surgery - Aetna Reduction mammaplasty provides long-term improvement in health status and quality of life. Evidence-based clinical practice guideline: Reduction mammaplasty. Although operative subjects were examined before and after surgery, there was no attempt to employ any blinded or objective measures of disability and function to verify these self-reports. Plast Reconstr Surg. The authors concluded that treatment of gynecomastia by the Mammotome device was distinctive, practicable in manipulation, safe, and could achieve excellent cosmetic results. Drugs commonly associated with the development of gynecomastia include amphetamines, marijuana, mebrobamate, opiates, amitriptyline, chlordiazepoxide, chlorpromazine, cimetidine, diazepam, digoxin, fluphenazine, haloperidol, imipramine, isoniazid, mesoridazine, methyldopa, perphenazine, phenothiazines, reserpine, spironolactone, thiethylperazine, tricyclic antidepressants, tirfluoperazine, trimeparazine, busulfan, vincristine, tamoxifen, , methyltestosterone, human chorionic gonadotropins, and estrogens. Criteria for reduction mammoplasty surgery from the American Society of Plastic Surgeons (ASPS, 2002; ASPS, 2011) states, among other things, that breast weight or breast volume is not a legitimate criterion upon which to distinguish cosmetic from functional indications. Grooving where the bra straps sit on the shoulder. The authorsleave the reader with the conclusionthat decisions about the medical necessity of breast reduction surgery in symptomatic women should be left entirely to the surgeon's discretion. } Plast Reconstr Surg. 1999;103(6):1687-1690. In a systematic review, Prasetyono and colleagues (2021) examined the quality of studies and re-visited liposuction-assisted gynecomastia surgery performed via minimal incision. Breast reduction, also known as reduction mammaplasty, is a procedure to remove excess breast fat, glandular tissue and skin to achieve a breast size more in proportion with your body and to alleviate the discomfort associated with excessively large breasts (macromastia). bottom: 20px; In these cases, breast reduction for men may take 2 to 3 hours. Ann Plast Surg. These investigators presented their experience with pectoral high-definition liposculpture combined with inverted-omega incision resection for gynecomastia. 2018;7(Suppl 1):S70-S76. American Society of Plastic Surgeons (ASPS). Fagerlund A, Lewin R, Rufolo G, et al. Transient pain that may occur as the breast enlarges and the capsule is stretched; these symptoms may be managed with analgesics. CPT Codes 19316 & 19318 - Mastopexy & Reduction No significant changes have been made to the Doses examined ranged from 8 to 16 Gy, delivered between 1 and 11 fractions. Aetna considers breast reduction surgery medically necessary for non-cosmetic indications for women aged 18 or older or for whom growth is complete (i.e., breast size stable over one year) when any of the following criteria (A, B, or C) is met: Macromastia: all of the following criteria must be met: Breast Concerns of Adolescents. Reduction mammoplasty: Cosmetic or reconstructive procedure? No necrosis, systemic infection, or muscle paralysis was reported. Choban PS, Heckler R, Burge JC, Flancbaum L. Increased incidence of nosocomial infections in obese surgical patients. Level of Evidence = IV. Mistry and associates (2017) examined outcomes following breast re-reduction surgery using a random pattern blood supply to the nipple and vertical scar reduction. The risks included infection, wound breakdown, scarring, and the need for re-operating. } Treatment of adolescent gynecomastia. 2015;(10):CD007258. Abnormalities in Adolescent Breast Development. background-position: right 65%;
PDF Gender Dysphoria Treatment - Cigna Aesthetic Plast Surg. Socioeconomic Committee Position Paper. Grade II: Moderate breast enlargement exceeding areola boundaries with edges that are indistinct from the chest. Breast asymmetries: A brief review and our experience. Aetna considers breast reduction surgery medically necessary for non-cosmetic indications for women aged 18 or older or for whom growth is complete (i.e., breast size stable over one year) when any of the following criteria (A, B, or C) is met: Macromastia: all of the following criteria must be met: Post-operative complications included 1 case of hematoma, but no nipple necrosis, local skin necrosis, or skin buttonhole occurred. .newText { The mean volume of tissue resected was 250 g (range of 22 to 758 g) from the right breast and 244 g (range of 15 to 705 g) from the left breast. of . color: blue A total of 211 responding surgeons were analyzed, including 80.1 % (171/211) plastic surgeons and 18.9 % (40/211) breast surgeons. Aesthet Surg J. Kinell I, Baeusang-Linder M, Ohlsen L. The effect on the preoperative symptoms and the late results of Skoog's reduction mammoplasty: A follow-up study on 149 patients. 2000;44(2):125-134. Plast Reconstr Surg.
Rising Rates of Insurance Denial for Breast Reduction Surgery 2015;10(8):e0136094. Resolution of idiopathic gynecomastia may take several months to years.
PDF 0185 Breast Reconstructive Surgery (1) - Aetna Plast Reconstr Surg. Medical reduction has been achieved with agents such as dihydrotestosterone, danazol, and clomiphene. The traditional method of breast reduction requires an open incision around the areola extending downward to the crease beneath the breast. Breast reduction for symptomatic macromastia. Moreover, these researchers stated that further studies are needed within the common gynecomastia population managed by plastic surgeons to examine the clinical and economical utility of this intervention before a recommendation for its ubiquitous adoption in plastic surgery can be made to continue improving outcomes for high-risk gynecomastia patients. For medical Safran and colleagues (2021) noted that several technologies and innovative approaches continue to emerge for the optimal management of gynecomastia by plastic surgeons. With the majority of BBRs performed as an inpatient procedure, there was a trend towards less drain usage in surgeons performing this procedure as an out-patient; however, this was not statistically significant (p = 0.07). Several of the included studies reported improvement in QOL and several psychological domains after surgical treatment for gynecomastia. A study by Bruhlmann and Tschopp (1998) was a retrospective study of 246 patients from a surgical practice, approximately 50 % (132) of whom returned a questionnaire about their symptoms and satisfaction with aesthetic results, and their recollection of symptoms prior to surgery. After these researchers 1st report of pectoral etching in 2012, patients and surgeons became more aware regarding gynecomastia resection when performing pectoral enhancement. Plast Reconstr Surg. They also analyzed if timing of reduction mammoplasty in relation to oncological treatment influenced the incidence of abnormal findings, and compared if patients with abnormal contralateral histopathology differed from the study population in terms of demographics. Nor is it intuitively obvious that removal of smaller amounts of breast tissue would offer significant relief of back, shoulder or neck pain. The author average amount of breast tissue removed for women in 5 kg weight bands, ranging from 45-49 kg to 90+ kg. Behmand et al (2000) reported on the results of a questionnaire pre- and post-surgery in 69 subjects from a single practice who underwent reduction mammoplasty. The surgeon must also certify that a certain weight of breast tissue (based on Aetna's table) will be removed in every breast, and not entirely fatty tissue. Gynecomastia: A systematic review. Based on CPB criteria and the information we have, we're denying coverage for breast reduction surgery. The majority of patients had previously undergone primary breast reduction using an inferior pedicle [n = 37 (41 %)]. The only criterion that the authors found supportable wasa requirementfor a pre-operative mammogram for women aged 40 years and older. OL OL LI { Howrigan P. Reduction and augmentation mammoplasty. Note: For breast surgeries pertaining to gender affirmation, refer to CP.MP.95 Gender Affirming Procedures. Re-operation rate of liposuction-assisted surgery was between 0.6 % and 25 %. From January 2006 to January 2010, a total of 20 men with gynecomastia were treated by an 8-G vacuum-assisted biopsy device. In other patients, excess skin and nipple and areola relocation are necessary. Plast Reconstr Surg. 1997;185(6):593-603. Many men with breast enlargement are found to have pseudo-gynecomastia. background-color: #663399;
How to make Aetna pay for your breast reduction surgery See Appendix for Table 1. Fat grafting volume ranged from 50 to 300 cc in each pectoral muscle.
Breast Reduction Surgery | Johns Hopkins Medicine Aetna considers molecular susceptibility testing for breast and/or epithelial ovarian cancer ("BRCA testing") medically necessary once per lifetime in any of the following categories of high-risk adults with breast or epithelial ovarian cancer (adapted from guidelines from the U.S. Preventive Services Task Force (for 1995;95(6):1029-1032. text-decoration: underline; I have recently met with my primary doctor after speaking to my insurance company (aetna) for months about getting a breast reduction. Raispis T, Zehring RD, Downey DL. padding: 15px; Is there a rationale behind pharmacotherapy in idiopathic gynecomastia? 2007;356(5):479-485. Breast reduction surgery, also known as reduction mammaplasty, removes fat, breast tissue and skin from the breasts.