Surgeon wants to move what she thinks would be the right amount, I asked her to remove what insurance says is necessary (Photo)

Question

Insurance says I need to remove approx 500g based on my weight And height. I am wearing a 36G. I measure 35 inches underbust and 44in around when wearing non padded bra. I asked the surgeon to remove the minimum to be covered by insurance. She said she would not go by what the insurance dictates but rather reduce me to a C/D cup. I'd like to maintain a least a D cup. She wants to be sure I'm relieved of pain but I don't want to wake up unhappy that I'm too small. Should I find another surgeon?

Ramiro Morales, Jr., MD · Answer

Thank you for your question and concerns.  With all breast surgery, it is impossible to assure and predict exact post op bra size before surgery.  As with any type of clothing, depending on the manufacturer, the letter or Cup size of the bra can vary greatly with any given patient from brand to brand.  Thus, as PS we rarely promise and exact post op bra size, rather instead a range, while still keeping to the insurance requirements for tissue removal.  Also, each woman's breast tissue volume to weight ratio can vary greatly based on the density of the breast tissue.  That said if you do not trust the opinion of your PS, you can certainly seek a second opinion.  But be sure to see a Board-Certified PS for your second opinion that does a lot of breast surgery.  Also, just be aware that if you were approved for surgery by one PS, and you chose another, the entire process of obtaining authorization usually has to start again from the beginning.

James N. Romanelli, MD, FACS · Answer

Dear Diligent 651426

Thank you for your question.

It sounds like there are 3 different perspectives that are not necessarily aligned:

1) Your insurance requires 500 gram removal
2) You want to be at least a D cup
3)  The surgeon wants to reduce you to a C/D

It would be a good idea to have a consultation with another Board Certified Plastic Surgeon.

Before I operate on a patient I must be certain that we have the same goals.

Best of Luck
Dr. Romanelli

Matthew S. Kilgo, MD · Answer

Hello,Insurance companies often require a minimum amount of breast tissue to be removed during a breast reduction for it to qualify as medically necessary. Many insurers use a patient’s body surface area, calculated based on height and weight, to determine a proportional amount of tissue that should be removed. The “Schnur Sliding Scale” is a common reference chart that estimates required tissue removal based on BSA.Insurance companies also look for documented symptoms associated with macromastia (excessively large breasts), such as chronic neck, shoulder, or back pain, skin irritation, shoulder grooves from bra straps, and posture issues. Documentation of non-surgical interventions (e.g., physical therapy, weight loss) is often required to show that other treatments haven’t relieved these symptoms.Despite having symptoms, it is not always possible to remove the minimum requirement established by the insurance company safely. When I see patients for a breast reduction evaluation, I provide an estimate that in my opinion will likely provide the best aesthetic outcome while minimizing potential complications. If my estimate does not meet the minimum threshold provided by the insurance company, I advise the patient to proceed with the surgery cosmetically. I hope this helps.

Ellen Ozolins, MD · Answer

Thank you for your question. It’s important to have an open and clear conversation with your surgeon about your preference to maintain a D cup. Let her know that while pain relief is a priority, you’re also concerned about ending up too small. While breast size isn’t guaranteed after reduction, your surgeon should work to find a balance between achieving pain relief and keeping you within the range of your desired cup size. If your surgeon is unwilling to consider your input and insists on reducing your breasts to a size that you’re not comfortable with, you may want to consider consulting with another surgeon.

Gary M. Horndeski, MD · Answer

Many plastic surgeons feel the same way I do in the sense that we will not accept insurance payments. They have criteria, which sometimes are not in the best interest of the patient. If your desire is to be reduced to a size 36 D then that would require approximately 600 gram removal. At size 36, each 200 grams removed corresponds to 1 cup size change. However, weight removal alone may not cure neck, back, or shoulder pain. The technique I recommend is The Bellesoma Method. This will reduce and reshape your breast tissue creating upper pole fullness without implants, elevate them higher on the chest wall and more medial to increase your cleavage. The weight of the breast is transferred to the underlying pectoralis major muscle resulting in pain relief without excessive reduction. Vertical scars are avoided, nipple sensation (in 95%) and the ability to breast feed are maintained. This technique is not covered by insurance.

Best Wishes,

Gary Horndeski, M.D.

Best Wishes,

Gary Horndeski, M.D.

Irena Karanetz, MD · Answer

Hi,

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. 
 
It is easiest to think of breast reduction as including the breast lift.

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 1-3 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.  It is reasonable to to expect full C/small D cup breast size after the breast reduction surgery.
 
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 Karanetz
Breast Fellowship-Trained
Board Certified Plastic Surgeon
Queens, New York
(516) 833 0309

Sarah Mess, MD · Answer

Insurance companies have a list of requirements that have to be met for a "medically necessary" breast reduction. They can, and do, deny claims even when the minimum grams are met. While the minimum gram reduction is typically 500, some plans require resections of 1000 grams or more to meet the minimum requirements. We moved to cosmetic only breast reduction years ago, so we could provide functional and aesthetic results. I've attached a link to a blog post I wrote years ago on the subject including the patient photos showing a 500ish reduction. While 500 or 600 is absolutely the right number for many breast reduction patients, it's going to deliver smaller than optimal breasts for others. Your doctor may not be able to satisfy both your requests. Do you have enough breast tissue to take off 500 or more grams and still be a D cup? Many patients, like the one in the blog post, do not. Wishing you the best results regardless of your decision.

Connie Hiers, MD, FACS · Answer

Although I agree with your surgeon, go talk to another and see what he/she says.  Your tissue will only support just so much weight. You did not show your breasts so I cannot be specific. However, stretched-  out skin will not support heavy breasts.

Scott C. Lindsay, DO · Answer

Thanks for your question! I do think it is important to be on the same page as your surgeon. That's how you end up happy - by expectations being set and then met. I would suggest another opinion. Good luck!

Eric Chang, MD · Answer

Hi Diligent651426
When looking for a plastic surgeon, it's important that the patient and surgeon are on the same page about the patient's aesthetic goals. In my practice, I have patients print out breast reduction before and after photos of what their ideal breast size is because a "D" cup bra varies from store to store.
 If your desire is a fuller look postop, find a plastic surgeon who understands this and thinks it is possible to do for you. best of luck to you

Surgeon wants to move what she thinks would be the right amount, I asked her to remove what insurance says is necessary (Photo)

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