} The authors concluded that breast re-reduction can be performed safely and predictably, even when the previous technique is not known; and 4 key principles were developed: Language services can be provided by calling the number on your member ID card. Plast Reconstr Surg. Transient pain that may occur as the breast enlarges and the capsule is stretched; these symptoms may be managed with analgesics. Hoyos AE, Perez ME, Dominguez-Millan R, et al. Breast reduction surgery is considered reconstructive and medically necessary in certain circumstances . background-color: #663399; To calculate body surface area (BSA) see:BMI and BSA (Mosteller) Calculator;orBSA (m2) = ([height (in) x weight (lb)]/3131)(denotes square root), BSA (m2) = ([height (cm) x weight (kg)]/3600)(denotes square root). 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. Vacuum-assisted minimally invasive surgery was carried out under general anesthesia; subjects were followed-up with physical examination and ultrasonography (US). Gynecomastia, its etiologies and its surgical management: A difference between the bilateral and unilateral cases? Data was then analyzed for surgical complications, wound complications, and medical complications within 30 days of surgery on 4545 patients. As explained below, the studies used to support the arguments for the medical necessity of breast reduction surgery are poorly controlled and therefore subject to a substantial risk of bias in the interpretation of results. In a majority of boys with pubertal gynecomastia, the condition resolves within 18 months. 1993;91(7):1270-1276. Exposure to partners using estrogen containing vaginal creams; Cancer chemotherapy (alkylating agents, methotrexate, vinca alkaloids, imatinib, combination chemotherapy), Androgen receptor blockers - bicalutamide, 5 reductase inhibitors - finasteride, dutasteride, Angiotensin converting enzyme inhibitors (captopril, enalapril), Calcium channelblockers(diltiazem, nifedipine, verapamil), Anabolic steroids(e.g., in body builders). This Clinical Policy Bulletin addresses breast reduction surgery and gynecomastia surgery. Liposuction assisted gynecomastia surgery with minimal periareolar incision: A systematic review. background-color: #cc0066; The authors reach the remarkable conclusion that a woman with normal sized breasts who has only a few ounces of breast tissue removed is as likely to receive as much benefit from breast reduction surgery as a women with large breasts who has substantially more breast tissue removed. All studies on the subject were evaluated for inclusion and 6 studies were included in the review. For additional language assistance: Chemical exfoliation for acne (eg, acne paste, acid), Mastectomy, partial (e.g., lumpectomy, tylectomy, quadrantectomy, segmentectomy), Diagnostic mammography, including computer-aided detection (CAD) when performed, Photodynamic therapy by external application of light to destroy premalignant and/or malignant lesions of the skin and adjacent mucosa (eg, lip) by activation of photosensitive drug(s), each phototherapy exposure session, Photodynamic therapy by external application of light to destroy premalignant lesions of the skin and adjacent mucosa with application and illumination/activation of photosensitizing drug(s) provided by a physician or other qualified health care professional, per day, Basic life and/or disability examination that includes: Measurement of height, weight, and blood pressure; Completion of a medical history following a life insurance pro forma; Collection of blood sample and/or urinalysis complying with "chain of custody" protocols; and Completion of necessary documentation/certificates, Weight management classes, non-physician provider, per session, Mononeuropathies of upper limb [upper extremity paresthesia], Gangrene, not elsewhere classified [tissue necrosis], Non-pressure chronic ulcer of skin of other sites, Hypertrophy of breast [symptomatic-causing significant pain, paresthesias, or ulceration], Other specified disorders of breast [soft tissue infection]. Measurement of plasma gonadotrophins, human chorionic gonadotropin (hCG), testosterone, estradiol, and dehydroepiandosterone sulphate (DHEAS). Surgical treatment of primary gynecomastia in children and adolescents. Fagerlund A, Cormio L, Palangi L, et al. 2015;10(8):e0136094. Plast Reconstr Surg. Plast Reconstr Surg. Burns JL, Blackwell SJ. A total of 211 responding surgeons were analyzed, including 80.1 % (171/211) plastic surgeons and 18.9 % (40/211) breast surgeons. and areola. Arlington Heights, IL: ASPS; May 2011. For pain interventions, evidence of effectiveness is necessary from well controlled, randomized prospective clinical trials assessing effects on pain, disability, and function. Gonzalez FG, Walton RL, Shafer B, et al. } Open surgery was performed in 56 patients, and vacuum-assisted breast biopsy was performed in 27 patients. In a systematic review, these investigators examined the role of radiotherapy in this context. 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. Grooving where the bra straps sit on the shoulder. Can objective predictors for operative success be identified? list-style-type: lower-roman; Plast Reconstr Surg. The majority of patients had previously undergone primary breast reduction using an inferior pedicle [n = 37 (41 %)]. Sugrue CM, McInerney N, Joyce CW, et al. Yao Y, Yang Y, Liu J, et al. 2nd ed. From January 2006 to January 2010, a total of 20 men with gynecomastia were treated by an 8-G vacuum-assisted biopsy device. Thus, more than 1/3of operative subjects selected for inclusion in the study did not complete it; most of the operative subjects who did not complete the study were lost to follow-up. Evidence-based clinical practice guideline: Reduction mammaplasty. color: red!important; Furthermore, you must test negative for breast cancer on a mammogram a maximum of two years before your surgery if you are 50 or older. The majority (87.7 %) of cases presented with accompanying mastalgia. Reduction mammaplasty: The need for prospective randomized studies. 2015;75(4):370-375. 2021;147(5):1072-1083. The American Society for Plastic Surgery (2011) advises to delay surgery until breast growth ceases: Although waiting may prolong the psychological awkwardness, it is advisable to delay surgery until breast growth ceases in order to achieve the best result. This is similar tothe American College of Obstetricians and Gynaecologists'2011 Guidelines forAdolescent Health Care chapter on breast concerns in adolescents, which states regarding breast hypertrophy: Preferably, treatment should be deferred until breast growth has been completed. Saunders Co.; 1991. Reduction mammaplasty. Photographs were taken pre-operatively and 1, 3, 6, and 12 months post-operatively. You must be at least 18 years old or show completed breast growth (no change in breast size over at least a year) to qualify for Aetna breast reduction coverage. These investigators concluded that their findings do not support the use of completely autologous platelet gel to improve outcomes after reduction mammoplasty. Petty PM, Solomon M, Buchel EW, Tran NV. Annu Rev Med. Medical reduction has been achieved with agents such as dihydrotestosterone, danazol, and clomiphene. Ann Plastic Surg. Little is known about the effect of surgical treatment on the psychological aspects of the disease. 2000;44(2):125-134. Also, there was no correlation between PR expression and 2D: 4D. American Society of Plastic Surgeons (ASPS). The median complication rate was 12.4 % with no major complications, such as neoplastic, pulmonary, or adverse cardiac outcomes. Key takeaways: Health insurance does not cover cosmetic breast reduction, but it usually does cover breast reduction surgery that is considered medically necessary. 2008;121(4):1092-1100. These investigators searched the literature on the treatment of Simon's grade I and II gynecomastia in PubMed, Scopus, Science Direct, and Cochrane using keywords "gynecomastia" and "liposuction". Estrogens and estrogen like drugs,including: Drugsthat enhance estrogen formation, including: Drugs which inhibit testosterone synthesis, including, Drugs that inhibit testosterone action, including. Choban PS, Flancbaum L. The impact of obesity on surgical outcomes: A review. border-width:0; Disproportionately large breasts can cause both physical and emotional . Safran and colleagues (2021) noted that several technologies and innovative approaches continue to emerge for the optimal management of gynecomastia by plastic surgeons. Policy. list-style-image: url('https://www.aetna.com/cpb/medical/data/assets/images/purplearrow.jpg') !important; In this study the National Surgical Quality Improvement Program data set was queried for the Current Procedural Terminology code 19318 from the years 2005 to 2010, with principal outcome measurements of wound complications, surgical site infections, and reoperations. Aesthetic Plast Surg. Karamanos E, Wei B, Siddiqui A, Rubinfeld I. Devalia HL, Layer GT. ER expression did not correlate with the right (p = 0.51) and left 2D: 4D (p = 0.97). font-size: 18px; Abnormal histopathology correlated with higher age (p = 0.0053), heavier specimen (p = 0.0491), and with no previous breast surgery (p < 0.001). Each surgeon who participated in the study reported on the height, weight, and volume of reduction of their last 15 to 20 patients, and each surgeon provided their intuitive sense regarding the motivation of each patient for breast reduction surgery. 2019;8(4):431-440. Vacuum-assisted minimally invasive mastectomy was performed successfully in all cases, with no residual glands or adipose tissue observed on US. There were no statistically significant differences between the 2 vacuum-assisted breast biopsy systems according to the mean age, the mean operation time, sites, or grade. Arch Dis Child. An average of 320 specimens were excised from each side with mean blood loss of 34 ml. list-style-type: upper-roman; The authors concluded that vacuum-assisted, minimally invasive mastectomy was a feasible approach for the treatment of gynecomastia with acceptable complications. Hoyos and colleagues (2021) stated that male chest definition surgery and patients complaining of breast tissue over-growth have been increasing in recent decades. Emiroglu M, Salimoglu S, Karaali C, et al. The only criterion that the authors found supportable wasa requirementfor a pre-operative mammogram for women aged 40 years and older. Note: Chronic intertrigo, eczema, dermatitis, and/or ulceration in the infra-mammary fold in and of themselves are not considered medically necessary indications for reduction mammoplasty. The authors concluded that this study was the largest to-date examining the role of tamoxifen in idiopathic gynecomastia, and these findings showed approximately 9 in every 10 men treated with tamoxifen therapy had successful resolution of their symptoms. A total of 182 thirty-day postoperative surgical complications were documented, but stratifying patients into 2 age groups did not reveal an association between age and any surgical complication (P = .26). Resolution of idiopathic gynecomastia may take several months to years. Chadbourne EB, Zhang S, Gordon MJ, et al. Plast Reconstr Surg. These individuals cite evidence from observational studies to support this position (e.g., Chadbourne et al, 2001; Kerrigan et al, 2001). 2008;53(3):255-261. If an insufficient amount of breast tissue is removed, the surgery is less likely to be successful in relieving pain and any related symptoms from excessive breast weight (e.g., excoriations, rash). In addition, Nguyen et al (2004) ignored a wealth of published evidence of the effectiveness of physical therapy, analgesics and other conservative measures on back and neck pain generally. 1998;101(2):361-364. This population-wide analysis - the largest and most heterogeneous study to date - has demonstrated that increasing obesity class is associated with increased early postoperative complications. Plast Reconstr Surg. Compared with the open surgery group, the vacuum-assisted breast biopsy group had significantly smaller scar sizes left after the operation (5.5 1.3 cm versus 0.8 0.2 cm, p < 0.001), and shorter hospital stay time (5.5 2.4 days versus 3.1 1.6 days, p < 0.001). Ann Plast Surg. No statistically significant differences in the drainage, level of pain, size of open areas, clinical appearance, degree of scar pliability, or scar erythema were noted. Please check your insurance policy to see whether breast reduction is a covered procedure. Complications following radiotherapy were minor and self-limiting in all cases, restricted to minor skin reactions, and associated with larger radiotherapy doses delivered in fewer fractions. American Society of Plastic Surgeons (ASPS). 1998;41(3):240-245. Reduction mammoplasty specimens revealed abnormal findings in 68 (21.5 %) patients. } In addition, reduction mammoplasty needs to be compared with other established methods of relieving back, neck and shoulder pain. Reduction mammaplasty: An outcome study. They stated that no data are available for breast augmentation or breast reconstruction, and this requires investigation. list-style-type: upper-alpha; Handschin AE, Bietry D, Hsler R, et al. Fischer et al (2014a) evaluated predictors of postoperative complications following reduction mammoplasty using the NSQIP) data sets. Fischer S, Hirsch T, Hirche C, et al. 1993;17(3):211-223. The investigators found that comorbid conditions increased across obesity classifications (p < 0.001), with significant differences noted in all cohort comparisons except when comparing class I to class II (p = 0.12). Plast Reconstr Surg. 0017 - Breast Reduction Surgery and Gynecomastia Surgery, are met. margin-top: 38px; Grade IV: Marked breast enlargement with skin redundancy and feminization of the breast. Orthopedic or spine surgeon evaluation of spinal pain; Radiotherapy (for the prevention or management of gynecomastia recurrence); Vacuum-assisted breast biopsy system for treament of gynecomastia. The effectiveness of surgical and nonsurgical interventions in relieving the symptoms of macromastia. A detailed physical examination, including testicular examination. 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. No author listed. Breast cancer found at the time of breast reduction. The goals of the surgery are to relieve symptoms caused by heavy breasts, to create a natural, balanced appearance with normal location of the nipple and areola, to maintain the capacity for lactation and allow for future breast exams/mammograms with minimal scarring or decreased sensation. 2003;111(2):688-694. World J Surg. Sixty to 70% of males develop a transient subareolar breast tissue during their adolescence (Tanner Stages II and III). 2021 Aug 11 [Online ahead of print]. Marshall WA, Tanner JM. Variations in pattern of pubertal changes in girls. Gynecomastia resection plus high-definition liposculpture was successfully performed in 436 consecutive men (open inverted-omega incision resection, n = 132; liposuction, n = 304). Socioeconomic Committee Position Paper. Bruhlmann Y, Tschopp H. Breast reduction improves symptoms of macromastia and has a long-lasting effect. Breast reduction surgery (also called reduction mammaplasty) is a type of invasive procedure that involves incisions (cuts) in your skin to decrease the size and weight of your breasts . Links to various non-Aetna sites are provided for your convenience only. @media print { Anzarut A, Guenther CR, Edwards DC, Tsuyuki RT. J Plast Surg Hand Surg. 1999;103(6):1687-1690. Aetna plans exclude coverage of cosmetic surgery that is not medically necessary, . Sollie M. Management of gynecomastia-changes in psychological aspects after surgery-a systematic review. Nor is it intuitively obvious that removal of smaller amounts of breast tissue would offer significant relief of back, shoulder or neck pain. Reduction mammoplasty for macromastia. Med Decis Making. Seitchik MW. top: 0px; The authors also noted that patients with BMI greater than 40 kg/m were significantly more likely to develop postoperative wound complications (p = 0.02). However, if liposuction is used as an adjunctive technique, the decision to use drains should be left to the surgeon's discretion. Breast Concerns of Adolescents. N Engl J Med. Examining any complication, a significant increase was noted with increasing obesity class (p < 0.001). American College of Obstetricians and Gynecologists (ACOG), Committee on Adolescent Health Care. American Society of Plastic Surgeons (ASPS). In total there were 306 women in the 3 trials, and 505 breasts were studied (254 drained, and 251 who were not drained). Clinical outcomes in reduction mammaplasty: A systemic review and meta-analysis of published studies. The member has gigantomastia of pregnancy accompanied byany of the following complications, and delivery is not imminent: For medical necessity criteria for surgery to correct breast asymmetry, seeCPB 0185 - Breast Reconstructive Surgery. 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. This may lead to additional scarring and additional operating time. I have recently met with my primary doctor after speaking to my insurance company (aetna) for months about getting a breast reduction. 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. Liposuction was also used adjunctively in all cases (average of 455 cc; range, 50 to 1,750 cc). 2010;45(3):650-654. He Q, Zheng L, Zhuang D, et al. padding: 10px; Priorities Forum Policy Statement. Gynaecomastia. The authors concluded that the limited evidence available showed no significant benefit of using post-operative wound drains in reduction mammoplasty, although LOS may be shorter when drains are not used. 2009;19(3):e85-e90. list-style-type : square !important; 2016;20(3):256-260. 2021;74(11):3128-3140. #closethis { Study subjects included 3538 patients with an average age of 43 years and body mass index of 31.6 kg/m(2) and most patients underwent outpatient surgery (80.5%) with an average operative time of 180 minutes.The incidence of overall surgical complications was 5.1% and the incidence of major surgical complications was 2.1%. The authors of the BRAVO study reached several conclusions about reduction mammoplasty, most notably that breast size or the amount of breast tissue removed does not have any relationship to the outcome of breast reduction surgery (Kerrigan et al, 2002; Collins et al, 2002). Am J Infect Control. Gynecomastia Treatment through Open Resection and Pectoral High-Definition Liposculpture. Breast reconstruction/breast enlargement Breast reduction/mammoplasty Excision of excessive skin due to weight loss Gastroplasty/gastric bypass This was further isolated when comparing morbidly obese patients to non-obese (p < 0.001), class I (p < 0.001), and class II (p = 0.01) patients. They stated that in the light of these findings, contralateral reduction mammoplasty with histopathological evaluation in breast cancer patients offered a sophisticated tool to catch those patients whose contralateral breast needs increased attention. 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. Tobacco use and body mass index as predictors of outcomes in patients undergoing breast reduction mammoplasty. Level of Evidence = IV. Kasielska-Trojan A, Danilewicz M, Antoszewski B. The end-point was the complete resolution of gynecomastia. 2007;356(5):479-485. A total of 2779 patients were identified with a mean age of 42.7 (14.1) years and BMI of 31.6 (7.0) kg/m. The author identified the psychological domains affected by the disease and the effect of surgical treatment on these. Effects of reduction mammaplasty on pulmonary function and symptoms of macromastia. The average age of the studied individuals was 25.7 years (SD = 7.8); ER and PR expression was detected in breasts, and digit ratios were calculated in patients with idiopathic gynecomastia. outline: none; Sabistons Textbook of Surgery (Burns & Blackwell, 2008)states that breast size should be stable for one year: There is no set lower age limit but, for the adolescent with breast hypertrophy, reduction is deferred until the breasts have stopped growing and are stable in size for at least 12 months before surgery.. The average age was 24.7 years (range of 18 to 47 years). Well-designed clinical trials provide reliable information about the effectiveness of an intervention, and provide valid information about the characteristics of patients who would benefit from that intervention. } 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. Breast Reduction Surgery and Gynecomastia Surgery - Medical Clinical Policy Bulletins | Aetna Page . Aetna does not provide health care services and, therefore, cannot guarantee any results or outcomes. .strikeThrough { Level of Evidence = IV. 2017;35:157-161. } The traditional method of breast reduction requires an open incision around the areola extending downward to the crease beneath the breast. Oxfordshire NHS Trust. Sollie (2018) noted that gynecomastia affects up to 2/3 of the male population. Aetna considers breast reconstructive surgery to correct Conversely, many patients believe if a procedure is considered cosmetic, it is not a medically indicated and covered procedure. Abnormal histopathological findings were more frequent in patients with reduction mammoplasty performed prior to oncological treatment (p < 0.001), and in patients with immediate reconstruction (p = 0.0064). Pain/discomfort/ulceration from bra straps cutting into shoulders; Skin breakdown (severe soft tissue infection, tissue necrosis, ulceration hemorrhage) from overlying breast tissue; There is a reasonable likelihood that the member's symptoms are primarily due to macromastia; Reduction mammoplasty (also spelled as 'mammaplasty') is likely to result in improvement of the chronic pain; Pain symptoms persist as documented by the physician despite at least a 3-month trial of therapeutic measures such as: Analgesic/non-steroidal anti-inflammatory drugs (NSAIDs) interventions and/or muscle relaxants, Dermatologic therapy of ulcers, necrosis and refractory infection, Physical therapy/exercises/posturing maneuvers, Supportive devices (e.g., proper bra support, wide bra straps), Chiropractic care or osteopathic manipulative treatment. Although the BRAVO study nominally included a "control group", there was no comparison group of subjects selected from the same cohort, who were randomized or otherwise appropriately assigned to reduce bias, and treated with conservative management according to a protocol to ensure optimal conservative care. Major complications (1.6 %) included unilateral hematoma and localized infection. 2006;118(4):840-848. Preoperative patient factors and comorbidities, as well as intraoperative variables, were assessed. 18th ed. This Clinical Policy Bulletin may be updated and therefore is subject to change. Schnur subsequently refuted the validity of the Schnursliding scaleand stated that thescale should no longer be used as a criterion for the determination of insurance coverage for breast reduction surgery (Nguyen et al, 1999). background-position: right 65%; And if you are in Canada the surgeon decides. Laituri CA, Garey CL, Ostlie DJ, et al. Prostate Cancer Prostatic Dis. 2020 Sep 4 [Online ahead of print]. The NSQIP recorded two complication types: major complications (deep infection and return to operating room) and any complication (all surgical complications). } Healing balms, scented soaps, skin lotions, shampoos and styling gels containing lavender oilor tea tree oil. Role of tamoxifen in idiopathic gynecomastia: A 10-year prospective cohort study. A study reporting on a survey of health insurer policies on breast reduction surgery (Nguyen et al, 2004) found that no insurer medical policies could be supported by the medical literature. 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. Reduction mammaplasty: A review of managed care medical policy coverage criteria. This trial included all male patients who presented to the authors breast clinic who were diagnosed with primary gynecomastia, and were treated with a trial of tamoxifen 10 mg daily therapy, over a 10-year period from October 2004 to October 2015. Aesthet Surg J. Surgical treatment of gynecomastia: Complications and outcomes. } For example, at a body surface area of 1.5m, Aetna requires a minimum weight of 385 grams removed from each breast, whereas the Schnur scale would only require 260g. Raispis T, Zehring RD, Downey DL. Breast reduction for symptomatic macromastia. The authors concluded that even with the high level of evidence demonstrating the safety of BBR without drains, they are still routinely utilized. Apart from a significantly shorter LOS for those participants who did not have drains (MD 0.77; 95 % CI: 0.40 to 1.14), there was no statistically significant impact of the use of drains on outcomes. They reviewed their records on pectoral high-definition liposculpture between January of 2005 and October of 2019 in 4 surgical centers in Colombia. Treatment of adolescent gynecomastia. A systematic search of the published literature was performed. 2005;55(3):227-231. Removing the adipose tissue in pseudogynecomastia usually has no long term effect as adipose tissue reaccumulates unless the individual loses weight. The author average amount of breast tissue removed for women in 5 kg weight bands, ranging from 45-49 kg to 90+ kg. Klinefelters syndrome, testicular, adrenal, or pituitary tumors, and thyroid or hepatic dysfunction are also associated with gynecomastia. Lonie S, Sachs R, Shen A, et al. Howrigan P. Reduction and augmentation mammoplasty. Anesthesia may be injected along with saline solution until the tissue is firm, and a suction cannula is used to extract fat from the breast. The risks included infection, wound breakdown, scarring, and the need for re-operating. Dancey A, Khan M, Dawson J, Peart F. Gigantomastia--a classification and review of the literature. Radiotherapy for prevention or management of gynecomastia recurrence: Future role for general gynecomastia patients in plastic surgery given current role in management of high-risk prostate cancer patients on anti-androgenic therapy. PLoS One. Prepubertal gynecomastia linked to lavender and tea tree oils. Quality of life after breast reduction. Often times, insurance company will dictate how much breast tissue to be removed. A total of 3 RCTs were identified and included in the review out of 190 studies that were initially screened; all evaluated wound drainage after breast reduction surgery. Surgeon. 2014b;30(6):641-647. Behmand RA, Tang DH, Smith DJ Jr. Outcomes in breast reduction surgery. 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. Asian J Surg. A total of 81 patients were included in this study. Washington, DC: ACOG; 2011:121-122. Bertin ML, Crowe J, Gordon SM. Drains were used significantly less by surgeons performing greater than or equal to 20 BBRs (p = 0.02).