My back hurts all the time, I have tried pt with no luck so I was referred for a breast reduction. Based on my frame the doctor wanted to remove 543 grams my insurance denied it stating they wanted 840 grams removed. I could care less if the other 300 grams is removed but I am assuming there is some type of a formula the dr uses to determine how much to remove. Does anyone know what that is so I can try to lose weight to achieve that goal. Thank you
How Does the Doctore Determine What to Remove in a Breast Reduction?
Doctor Answers (10)
Determine what to remove in a breast reduction
First of all we DO NOT operate upon a patient based on an insurance expectation. Plastic surgery has an artistic component. We wish to improve the appearance. And if I determine to remove only 500 gms but the insurance wants 501 gms to pay for the surgery and hospital and anesthesia, well to bad. What if I removed 1,000 gms and the insurance only wanted 500 gms, do I get paid double? OF course NOT!. I recommend you ask for a review and get 2 more PS letters to support the claim or predetermination letter.
In regards to where I remove the tissue, YES there is a standard pattern used but as PS we adapt to the exact individual patients' dimensions, appearance, and anatomic issues. This is the old McKissock "key hole" pattern, all recent ADAPTIONS ARE BASED ON THIS CONCEPT.
From MIAMI Dr. B
Determination of Volume Reduction in Breast Reduction
I think we can all agree that the actual weight of large breasts on a 5 foot 95 pound woman may not appear very large on a 6'1" 195 pound woman. And yet for years insurers insisted that for a breast reduction to be distinguished from a breast lift at least 500 grams had to be reduced from each breast. Totally illogical since in the petite woman that could represent a almost complete breast removal while in the large woman the volume may not be sufficient to correct the symptoms of large breasts.
In the 1990's many insurance company adopted Dr. P. Schnur's formula which related the patient's body surface area to the amount of breast weight that would need to be removed to provide relief. This made the weight request less arbitrary and more dependent on the size of the woman. I SUSPECT your surgeon picked his numbers from this scale. However, some insurers do not want to pay up on "breast benefits" and simply raise their required breast removal weights to levels which would greatly flatten the breasts to dissuade women from having the operation done. Before agreeing to lose over >800 grams from each breast make sure your Plastic surgeon feels the weight is reasonable and would not deform you (A or B cup breast).
Breast Reduction and Tissue Removed?
Congratulations on your decision to proceed with breast reduction surgery. It is one of the most patient pleasing operations we performed. It will likely be in your best interest to reach a long-term stable weight prior to proceeding with the surgery.
Unfortunately, there is no direct correlation between the amount of tissue removed and the ultimate cup size that a patient will wear after breast reduction surgery.
Before undergoing the breast reduction procedure it is very important to communicate your size goals with your surgeon. In my practice, the use of photographs of “goal” pictures (and breasts that are too big or too small) is very helpful. I have found that the use of words such as “natural” or “C cup” or "fake looking" means different things to different people and therefore prove unhelpful. Also, as you know, cup size varies depending on who makes the bra; therefore, discussing desired cup size may also be inaccurate.
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Determining breast reduction volume...
There are really three issues here-
1. The amount of breast tissue your insurance company wants you to have removed in order for them to pay for it.
2. The maximum amount that a well-qualified and Board Certified Plastic Surgeon believes could be removed.
3. The amount that such a qualified surgeon RECOMMENDS you have removed in order for you to achieve both symptomatic improvement AND an aesthetically pleasing appearance.
It is unfortunately very rare nowadays for insurance companies to pay for breast reduction.
Web reference: http://www.DrArmandoSoto.com
Unfortunately more and more insurance companies do not want to pay for breast reduction anymore whether or not patients have actual symptoms of very large breasts.
Breast reduction amounts
It is disturbing that the insurance company is mandating a certain amount of tisse be removed based on your size, etc. They used to have a minimum or 500 grams of tissue removed to be covered, but most insurance carriers did away with this since each patient is different with regards to how much weight makes a difference.
Before surgery, during the planning, and then during surgery, the surgeon has three goals - remove excess tissue, reshape the breast to the appropriate size for the patient's frame, and do this all while being safe and keeping as much blood supply and sensation to the nipple. This is what really determines how much gets removed.
How much breast tissue should be removed in a reduction
There is actually no formula that we use to determine this. It is based on the patient's size, height, frame, weight, and on the surgeon's experience. We can guess how much we will be removing, but that is truly a guess. We can never really tell until we are in the operating room. A very important part of this is a long discussion with the patient to determine their wishes. However, it would be unwise to remove more breast tissue just to satisfy an insurance company. For that reason, and that reason alone, many surgeons and patients do the procedure outside of insurance and pay for it just like any other "cosmetic" procedure. Good luck.
How much to remove in breast reduction
The way a surgeon determines how much to remove in a breast is an art, not a science. The art is to shape the breast down to a size than balances with the rest of your body. This comes with experience and some have more sculpting talent than others. You don't want to over-reduce the patient because it won't look right and you may lose too much blood supply to the tissues that they might not survive.
Web reference: http://www.randcosmeticsurgery.com
Breast reduction is really sculpture.
During a breast reduction, we remove the amount of tissue that will give your breasts the look you want. You may be upset if you end up too flat chested. But if you are sure you don't mind being small, you can ask your surgeon to take more tissue out.
I personally would not remove too much tissue just to meet insurance criteria. I don't think it is in your best interest.
Breast reduction formula
There is no formula for volume removal. Much is dependent on what the patient wants to end up with. Some patients have been so disabled by large breast they they would even consent to a mastectomy just to get the weight and bulk off. We usually prefer to leave the patient with what she might consider to an attractive breast. It is nit so much what we take off but what we leave behind. The insurance companies like to quantify the volume removed because it indicates to them whether it was a significant volume to cause symptoms. They may have a "quota" but it is used only as a guide after the surgery, not as a mandate for surgeons.
As far a weight loss is concerned., I would recommend trying to lose what weight you want and get into the best fitness level possible before surgery.
These answers are for educational purposes and should not be relied upon as a substitute for medical advice you may receive from your physician. If you have a medical emergency, please call 911. These answers do not constitute or initiate a patient/doctor relationship.