How do surgeons determine how much breast tissue is to be removed in a breast reduction?

Question

Are there guidelines? Are there measurements? What’s this thing called the Schnur scale?

John Michael Thomassen, MD · Answer

The Schnur scale sets the amount of tissue to be removed for a breast reduction to be covered by insurance depending on a patient's BMI.  Roughly 500 gm per side minimum is required for insurance coverage.  Otherwise insurances consider these smaller reductions more as lifts and will not cover the procedures.

Caner Kacmaz, MD · Answer

The amount depends on your anatomy and your expectations for the results. During the consultation, we estimate the weight of breast tissue to be removed based on your physical examination and your measurements.

Derek Fletcher, MD · Answer

In practice, the following elements determine how much tissue is removed during an insurance-covered breast reduction: existing breast size, breast tissue density, patient goal size, and insurance minimum specimen weight. Surgeon skill and judgement is a critical part of this equation as well. Generally speaking, I spend the time to gain a detailed understanding of the breast size/shape my patient wants to achieve with surgery using before and after photos to guide discussion. 
The Schnur scale is a method for determining how much tissue should be removed during an insurance breast reduction based on body surface area. It is not a very useful tool for planning surgery except to the extent that it may influence the minimum amount of tissue to be removed to make sure your procedure is covered by your insurance plan.

Irena Karanetz, MD · Answer

Hello,
Thank you for the question. 
Based on what you are describing, it does sound that you have large/heavy breasts causing physical symptoms, and breast reduction may be an option for you. However, it is difficult to tell without seeing the photos and/or in person consultation. 
Schnur Sliding Scale is a scale used by many insurance companies as a guideline for how much breast tissue should be removed in order to improve your physical symptoms. In addition, most insurances in order to approve the surgery, will require for 2-3 letters of medical necessity (from your chiropractor, primary doctor, OBGYN, Dermatologist, etc) demonstrating that your physical symptoms due to large breasts are not improving with conservative management. 
The goal of breast reduction surgery it to make the breasts smaller and lifted, but also proportionate with the rest of your body. 
I suggest that you seek an in person consultation with a Board-Certified Plastic Surgeon specializing in Breast Reduction surgeries to further discuss your options, specific techniques, concerns and expectations. Make sure you specifically look at before and after pictures of real patients who have had this surgery performed by your surgeon and evaluate their results. 
I hope this helps.Best regards, Dr. Karanetz
Dr. Irena KaranetzBreast Fellowship-TrainedBoard Certified Plastic Surgeon

Christopher Pannucci, MD, MS · Answer

Hi Jaylynn21,
This is an excellent question. For cosmetic breast reduction, meaning a reduction that you pay out of pocket for, there are no guidelines other than an understanding between you and your surgeon about your goals.
Insurance based breast reduction is quite different. most insurance companies will not even consider approving a surgical breast reduction unless the patient has been through one year or more of multiple primary care doctor visits to document symptom severity, chiropractor appointments, massage therapy, and/or physical therapy. Many plastic surgeons will inquire about these prior to your initial visit, as we know that without these things, most breast reduction will not be approved.
Your surgeon will document your symptoms, which often include back and neck and shoulder pain, bra strap grooving, trouble finding clothes that fit, and awkwardness in social situations. In addition, the physical exam will document your measurements as well as photos, and allow your surgeon to make an estimate of the amount of tissue that would be removed.
You asked about the Schnur scale, which is a way to correlate your body surface area (the surface area of your entire body ruled out flat) with the expected removal weight to meet criteria for insurance. For example, a woman who is 5 foot 5 and weighs 180 pounds has a body surface area of 1.80. The Schnur scale would suggest that 441 g of breast tissue should be removed per side. While the Schnur scale is not the end all be all, many insurance programs use it as a guide to expected removal weight. This is specifically to avoid cosmetic mastopexy being passed off as medically necessary breast reduction.
There are many factors that go into insurance paying for reduction, as noted above. Ultimately, getting your documentation in line as it pertains to her primary care doctor visits as well as other services, prior to making a point with a plastic surgeon would be in her best interest.
Hope this helps.
Best,Christopher Pannucci MDBoard Certified Plastic SurgeonPlastic Surgery NorthwestSpokane, Washington

Aftab Siddiqui, FRCS(Plast) · Answer

Thanks for a very good question. a discussion on breast reduction begins with a  detailed history, examination and discussion on patient expectation. then surgeon can use computer software to determine current breast tissue volume. Then there are discussion of surgical techniques suitable of the case, where the nipple position is going to be, how to preserve blood supple to the nipple, i.e., pedicle, and how much breast and skin tissue to be excised. this operation is not not done by cup size but generally final results is achieved which should be suitable on the patients frame and desired volume is achieved. Generally the procedure is combined with liposuction to get good results. Looking at before and after of previous patients can give you good idea what to expect and 3D simulation of the produce can be helpful. Generally this is a very satisfying procedure for the patients.

Gary M. Horndeski, MD · Answer

The Schnur scale is based on body surface area. This allows insurance carriers to authorize the amount required to be removed to meet insurance criteria. I do not use this or recommend it as it is not proven. The guidelines I use are basically I scan the breasts with a computer to determine your current breast volume, measure the width of your chest wall and use an equation to compute how large of breasts you can handle.

Best Wishes,

Gary Horndeski, M.D.

Best Wishes,

Gary Horndeski, M.D.

Connie Hiers, MD, FACS · Answer

If your insurance company is covering the reduction, they will require a certain amount of breast tissue to be excised based on your height and weight. The more overweight you are, the more tissue must be removed to be covered.  The guide insurance companies use is called the Schnur scale. If you are paying the costs yourself, you can request a certain size. However, your surgeon will want to leave some breast tissue behind to keep nipple function and sensation. Very large women with very large breasts may safely go down to D to DD cup size, where smaller ladies may safely go down to a C. Going down to A or B cups may require losing nipple sensation and function for enough blood flow is not present.

Scott C. Lindsay, DO · Answer

Hello and thank you for your question.
It depends on the desired result you are looking for and what will look best on your frame. If you are going through Insurance it will depend how many grams they require. Schedule a consultation with a board certified plastic surgeon to discuss your options. Best wishes!

Camille Cash, MD · Answer

The amount of breast tissue to remove is determined when you speak with your surgeon about your goals for surgery.  It may be that you are hoping for a general cup size or to improve asymmetry.  If you are having a breast reduction paid for through insurance the insurance company will determine the minimum amount of tissue that needs to be removed in order for coverage to be provided.

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