A Down Sizing

Mission San Jose in San Antonio

I see and touch an awful lot of breasts. 

Just about every “uninhanced” woman on the face of this Earth has one breast that is slightly larger than the other. I certainly do. As I age it becomes more and more obvious… the left is fuller than the right. Every time I put on a bra or look in a mirror, I am acutely aware of it and I wonder if other women notice or care about their subtle discrepancies in size. Not that I would ever bring it up in the clinic, mind you. That would be akin to your beautician asking if you want her to wax your upper lip… creates a paranoia if there was not one there to start with. 

Thankfully, I have never had a man look at my chest and run away screaming.

Every once in a while I come across a patient with a more dramatic mismatching, like the woman with one breast a cup size A and the other one a size DD. It created a serious self esteem issue. She had never had a relationship as she was terrified of anyone see her naked. She stuffed her bra with whatever she could find until someone sewed her a pillow to tuck in there instead.

Hey! Sugery can FIX that for you…

You would think this would be a no-brainer, but no…. Invariably the response from insurance companies on the request for augmentation or reduction is, “Not medically necessary.”

I always wonder who the people are making these decisions. Men? Women? If a man, would a woman make a different decision? Or vice versa?

I know the angst I have had over the years over my slightly different sizes. I cannot imagine the psychological burden carried by these women with their really noticeable differences. So what determines medical necessity? We allow breast reconstruction in breast cancer. Is is “medically” necessary? Maybe not. But it is psychologically necessary. 

So then, what determines something being psychologically necessary? What size disparity is traumatic enough to warrant coverage? One size? Two? Four? How do you measure something so subjective?

And then what else causing cosmetic angst should be covered? I had a mole removed from my face while I was still in med school. Right next to my left nostril. It wasn’t huge in real life but in my brain it covered half my face. Best thing I ever did for myself, getting that sucker whacked off. 

So, what are your thoughts? How is your breast size? What do you think about insurance covering breast augmentation or reduction? 

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136 thoughts on “A Down Sizing

  1. After my recent surgery and radiotherapy, my right breast is now slightly more misshapen and puckered to my left. Do I care? No. I still have it, and Hubby didn’t fall in love with my chest.
    As for insurance for surgery, in the case of this patient, it should be granted as it is affecting their self esteem, not their vanity. Sometimes the red tape should be used to tie up the Asses that write it.

    Liked by 9 people

  2. A tricky one to define, for sure. I’d start with psychological counceling first, sometimes it is a self-esteem issue that can be improved with love and appreciation for the imperfect self. If it is a huge size difference, I think it should be covered. When one has one leg shorter than the other, do they perform surgery and if so, is it covered?

    Liked by 2 people

    • Typically leg length discrepancies would be addressed with a shoe lift or such though I imagine leg lengthening survives would be covered under certain circumstances but I cannot say I have ever had that issue come up in my own practice.

      Liked by 1 person

      • First: You wrote this to make me go take off my shirt and check didn’t you? No really I know my left is slightly smaller than my right but it’s never bothered me. I had heard early on that it’s normal.

        If it was a bigger difference in size I honestly would think for women the surgery should be covered. It’s a big part of our womanhood and it definitely can affect people mentally/emotionally. It’s too bad Ins. companies are all about money and not people.

        Here we could get things like this covered as a medically necessary.

        Liked by 1 person

  3. Who makes these decisions, indeed! I would put this woman on the necessity side — but I wonder if they’d pay to have the large one reduced…same result, but I’m sure it would be looked at differently.

    Insurance companies? Don’t get me started…

    Liked by 3 people

    • Their goal is to deny as much as they can, regardless of the clinical and psychological impact. I just spent 30 minutes on the phone trying to get an MRI approved for a patient after my staff has spent another 30 minutes themselves. I am pretty down on the system right now.

      Liked by 3 people

      • Absolutely denial is automatic, and any β€œI” not dotted and any β€œT” not crossed is an excuse to for them to continue denial and drag the process out in the hope you will get tired of fighting. My wife, a medical coder, has to fight these despicable policies every day.

        Liked by 1 person

  4. Self-esteem is tied to our mental health, and our mental health is tied to our medical health. Issues like this should be covered by insurance. There could be diagnostic criteria developed (e.g., how much discrepancy, etc.) so that not every cosmetic breast augmentation would be covered. Simply going from a bilateral C to a triple D would not meet the criteria. Breast reduction, on the other hand, often improves posture and back pain, so that’s another condition that should be covered. If a man had a much larger scrotum on one side that was causing no other problem but self-esteem issues when he was with women, I’m betting insurance would cover it. Right alongside with his Viagra. πŸ˜„

    Liked by 4 people

  5. Mine are fine… though a reduction might outwit gravity for a while πŸ˜‰ But I do think the psychological benefits of addressing these ‘non-essential’ procedures should be looked at and covered, one way or another, on a case by case basis. What price can you put on mental and emotional health? Which is something that affects more than just the person concerned… including their relationships and children. And how much does chronic depression and its associated health issues cost?

    Liked by 3 people

  6. “Just about every β€œuninhanced” woman on the face of this Earth has one breast that is slightly larger than the other.”

    Perish the thought! No,JK, tis true,and I really believe we should spread the good news,make it public. I have lost track of all the women I have encountered visibly distressed, fearful there is something wrong with them,concerned about breast cancer…..or perhaps a brain tumor causing them to see objects in the mirror as larger or smaller than they are. Whatever crazyness we do to ourselves, it is unnecessary worry and distress.

    As to insurance companies, shoot, they are the ethical and moral judges of absolutely nothing.

    Liked by 2 people

    • I have had two “lumpectomies” after the needle aspirations failed, and while I was in the hospital with the last one, there was a young girl who had dealt with the disproportionate size issue for several years. Her surgeon removed a non-malignant tumor the size of a large grapefruit. He kept it and showed it to her (and me). She was still a very shy girl, but she remarked with a smile, “Now I won’t mind going to the beach on vacation.”

      Liked by 1 person

  7. Victo, I may be way off in my rational thought on this one, however….people pay (monthly installments) for cars, appliances, and other necessities. Why not pay like that for a breast size change! Fighting the insurance company on this is futile! 🎢 Christine

    Liked by 1 person

    • That is possible for someone who has sufficient income. Many of my patients do not. This patient was working at a fast food place, trying to make ends meet. She would have had some me portion of the bill as her responsibility but out of pocket these procedures are thousands of dollars. That would take many, many years to save for. Very few surgeons will do any procedure without cash up front.

      Liked by 1 person

  8. I had not realized that being “lopsided” was more or less universal. In all my years, I’ve only known one female acquaintance who was troubled by the size difference. All this to say, your post is enlightening.

    Should the cost of surgery to correct the difference by covered by insurance? Yes.

    “What determines something being psychologically necessary? What size disparity is traumatic enough to warrant coverage? One size? Two? Four? How do you measure something so subjective?” These are excellent questions and I don’t have the answers.

    Except, if you recall my visit to the plastic surgeon when I wanted to have my nose fixed. He sent me home to think it over, since I had just broken up after a long term relationship. I imagine, in his mind, if I went home and came back, that would be a signal that it’s important enough.

    Of course, this is Canada, and the surgery would have been covered by OHIP.

    Liked by 1 person

  9. It should be covered, but I think there should be some provision about a doctor recommending it. I think that the problem is, in most people’s head’s they think only of augmentation, and they think of it as vanity thing. In a case like the one you talked about, it should be a no-brainer, yes, insurance should pay. I know women who had reductions for health reasons. i didn’t ask, but I would assume insurance would pay for it.

    Liked by 1 person

    • Breast reductions typically have an approval process that requires demonstrating that the breast are causing back pain that does not respond to physical therapy or medications. It is easier to get that covered than it is to get breast size discrepancy addressed.

      Liked by 1 person

  10. If it is psychologically important to have some symmetry then a criteria can be established for coverage. Doctors need to establish the criteria, and doctors and patients must push for coverage. I have never noticed a difference, but I would support it.

    Liked by 1 person

  11. Ultimately – what pissed me off about any surgical procedure that isn’t ‘covered’ by medical – is he/she with the most money wins. Years ago I was referred by my gp to a surgeon to have some moles removed from my face. He thought it was necessary, the surgeon did not – spent all of fifteen seconds looking at them, declared them ‘non cancerous ‘ and gave me a quote for 800.00 to remove them. He might as well have said eight million. Same thing in my wallet. I don’t have a self esteem issue, but as I’m blindingly fair skinned and as a farmer am out in the sun- I guess I’m to wait until they are cancerous. Or scrape up 800 bucks.
    With the size discrepancy you mention – I think it should be covered by insurance.

    Liked by 1 person

  12. Hey Victo,

    Thank you for an thoughtful read.

    Curious to ask if you are suggesting that insurance offer blanket coverage for addressing all breast size discrepancies or just those where there is excessive deviation in size? If the latter, how then would that point of deviation be measured and agreed upon as a standard?

    Also, how would one set about measuring self-esteem and relate it directly and unequivocally to breast size discrepancy if/when presenting a case requesting an insurance company pay for surgery? One imagines low self-esteem is a complex issue with many contributing factors. How might just one of those factors be singled out?

    Namaste πŸ™‚

    DN

    Liked by 1 person

    • There would have to be an agreed standard for size deviation. Greater than a cup size difference? That would be fair. I think if a patient is bringing it up as an issue that is significant enough to be called causing emotional distress. That being said, my small discrepancy should not warrant surgery, even though it may cause me distress. The discrepancy is not enough. The fix itself may create a variation equal to what I already have.

      Liked by 1 person

      • Thank you Victo. I find myself generally in agreement with you.

        I have one last question, do you mind? How do you think the cost of carrying out treatments might be reduced to enable more patients to come forward for this type of surgery? Why is the surgery so expensive to perform in the first place?

        Thank you.

        DN

        Liked by 1 person

      • Healthcare costs in the US are out of control for a multitude of reasons, not the least of which being the administrative costs of dealing with multiple insurance companies with constantly changing rules. For instance, an MRI of the back. Some plans, I can order it and there is no problem. Some I can order and I have to supply proof that they have failed conservative management. Another I have been wrestling with for two weeks trying to get it approved, sucking up hours of staff time and my time for one single patient. Billing is a joke. I pay over $100,000/yr to a company to manage submitting of charges. My staff has to take care of problems and collections. Then some hospitals inflate prices for elective surgery to make up for budget shortfalls elsewhere. It is a mess. Now, India…. I was reading an article about how cost had been dramatically reduced for pediatric heart patients. The cost was tons cheaper and outcomes were better. Without insurance, lower cost was critical to saving more lives so they kept working at it until they got it as low as possible. That is what we need here in the US, that kind of drive and innovation.

        Liked by 2 people

  13. Now that you mention it, my boobs are different sizes. So are my feet, which is probably true for most people too. I believe breast reductions for ‘sanity reasons’ are covered by insurance (and even those who are uninsured) in Australia. A friend had her breasts (yes both) reduced years ago. The surgery was either covered by insurance or done as an elective process for which an uninsured person go on a waiting list until their turn comes up (could be months). Emergency cases are dealt with promptly whether the patient is insured or not.

    I am uninsured in Australia. Recently I had my first cataract done at no extra charge to me (other than what I pay in taxes). I waited just under 10 months from seeing the specialist for the first time and having the surgery. The second eye will be done in two or three months. Follow-up visits to the specialist cost $110 each and there will be four visits in all.

    Liked by 2 people

    • Thank you so much for sharing how things are in Australia. I am always curious how this is handled elsewhere! There are many things about our bodies that are not perfectly symmetrical. If you look closely in the mirror, one ear is often higher or one shoulder.

      Liked by 1 person

  14. Mine’s okie it’s a D cup and both are about the same size . Guess I’m one of the lucky ones. Hubby jokes that they only look that way because he fondles them both equally 😩 as for insurance I think it’s should be up to the practitioner to decide if it’s medical or not. Not the insurer .

    Liked by 2 people

  15. I think a psych evaluation should be a prerequisite, unless you have a case like your A vs DD. Covering elective surgery where it’s a minor thing could really raise insurance rates, and we would all be paying for it. I really dislike the part of Obamacare that had everyone paying for the same type of insurance – I don’t need coverage for pregnancy and pediatric care anymore, for example. Neither does my husband, although I fully understand why we need to pay for it so it gets covered.

    Liked by 1 person

  16. I think a significant mismatch should be covered. I would think that could also affect the person’s posture and activities, perhaps in subtle ways. I think that woman with a size A and DD is similar to the case of a woman who wants implants after breast removal due to cancer. Both would suffer with some kind of psychological trauma, for different reasons but still would affect their state of mind.

    Liked by 1 person

  17. I know of a young lad who was suffering from gynecomastia and it was not covered by our system here in Canada. He felt so strongly about this he dug up the money himself to have it resolved. I do think it should be covered.
    Leslie

    Liked by 1 person

  18. I miss my lil breasts. They were nice. These DDs are still foreign to me. They told me I would nurse them away, but they lied. I don’t want surgery, I just miss the ease of movement and the unburdened feeling. And um, clothes I didn’t look slutty in. SOCIETY, Bah.
    I think that fixing a noticeable discrepancy should be covered by insurance — whether it’s one breast up or another down. Surely that throws off posture and wounds the psyche? Reductions should always be covered, in my opinion. I dunno about enhancements being covered overall, but it seems to me that psychologically, a lot of women benefit from them. *shrugs* It’s hard to draw a line somewhere, about other people’s bodies. I wouldn’t want that kinda power.

    Liked by 1 person

    • I wish nursing had made my breasts permanently larger. It is fascinating how pregnancy and nursing affects everyone so differently! But yeah, making decisions about other’s bodies and psyche’s is terribly intimidating.

      Liked by 1 person

      • I feel they need to cover this stuff, with some criterion, of course.

        I know, right? At least they’re not as big as they were when I was pregnant. I’ll be grateful. Mmhm.

        Liked by 1 person

      • I approved everything. The adjusters hated me – I ruined their numbers all the time. Now, if someone with asymmetry called / forwarded a request for coverage for surgical correction, this is what I’d do. I’d call them on the sly, tell them to get 6 couples counseling sessions documented, and then I’d have something to clip onto the APPROVED paperwork I’d be forwarding.
        I didn’t last long in the insurance world, it was a true David vs Goliath constant battle for me.

        Liked by 1 person

    • Thank you. I guess when you think about things that can go wrong with our bodies, there are worse things maybe but our society is so breast centric… it is hard not to let it affect you. I am sorry to hear that your dear one has had to wrestle with it herself!

      Liked by 1 person

      • You are right about our breast-centric view. I always thought it was a guy thing, an obsession, breasts have always seemed like eye magnets, topics of jokes to cover up an awkward sexual urge, almost as awkward as involuntary erections, as you discussed in a previous post, but also our jokes and comments hide an awarenes of the mystery that men are not able to comprehend — the mystery of reproduction, yes, but also the wonder of motherhood. So this issue that you discuss now never occurred to me in the past. Seeing through others’ eyes is so important. The post+ comments helps me more than you probably anticipated. But so many of your reflections do.

        Liked by 1 person

  19. All health care decisions should be in the hands of the patient in conjunction with the advice of their physician. I just can not wrap my head around the US health care system, I find it astonishing. I can not think of a better way to disempower the people of a nation than for the government to put the health of its citizens into the hands of a greedy corporate entity. The sole purpose of the insurer is to profit from the misery of others. How can any of their decisions be in the best interests of the patient?

    Liked by 1 person

    • A national healthcare system will limit access to care similarly. It must, I am afraid. But then the government is better interested in controlling costs, too. Surgeries and meds and everything would cost less. It would have to. Currently we are the most expensive in the world and have some of the worst outcomes. It is a shameful profit driven mess.

      Like

  20. I would think that such a big deviation in size would cause not only posture, but spine problems with the body having to compensate and all. Though I tend to bulge over more on the left, my deviation is not too bad, but I’ve wanted breast reduction on both since I was 11 years old. Time and gravity seemed to stretch the skin and add Ds to my cup size. I didn’t know until a couple years ago that you could go to the next letter, and the next….. It’s not fun.

    Liked by 1 person

  21. You deal with everything, don’t you?!

    The discrepancy between an A and a DD is huge. This isn’t even just emotional distress. There has to be physical discomfort as well – which will only get worse as she ages. I’m guessing her shoulders are going to be affected first.

    After reading this, I will no longer fret about the discrepancy in mine. Following the surgery on my collarbone, I had a lot of swelling on my left side – enough that I appeared to have 3 boobs. THAT alarmed me. Glad I’m back down to only 2 … even if one is slightly more perky than the other πŸ™‚

    Liked by 1 person

  22. As a woman who has no problem displaying her breasts publically- member “Free The Nipple”, in that I see no difference in women’s chests and men’s chests other than the presence of larger mammary glands, surgical correction of a mismatch in breast size is medically important to this patient. If one arm was noticeably larger than the other arm, one leg shorter than the other, one would make medically necessary corrections surgical or not. Psychological pain like any other pain is quite subjective and should be treated on an individual basis. Why do we as a society tend to believe that this woman’s psychological pain not important? The same society that places sexual objectification on a woman’s breasts but not a man’s breasts.

    Liked by 2 people

  23. I feel it should be covered. Plus, why is it an insurance company can determine what is medically necessary in the first place? What medical degree do they hold that would warrant their opinion in the first place? They simply want to continue to collect premiums with as little outgoing as possible to keep shareholders happy. They have little to no concern for people! Also, my eyes and teeth are in my body, why do I require separate coverage for them. Goes back yet again to the collection of premiums. I hate insurance companies.

    Liked by 1 person

  24. Best opening line ever.

    OF COURSE these decisions are made my men! Are you kidding? You do know that Viagra is covered, right? That pretty much says it all. I’ve seen different-sized breasts. Didn’t bother me. Saw breasts once that had hairy nipples. That was a bit of a shock. Got over it really quick.

    Liked by 1 person

  25. I think as much as we all pay for insurance, it should cover whatever the hell I want. I can feel myself getting worked up here, but I really do think insurance, itself is a scam and this is just another example. The fact that we have to prove anything to insurance companies, or that there’s some list to approve what is medically necessary is just ridiculous to me.

    Liked by 1 person

  26. Wonderful post. Yes, one of my breasts is slightly smaller than the other but not enough to notice when I was young and now at 73 it really doesn’t matter. I also noticed that the right side of my face droops noticeably more than the left side. That bothered me a bit so I asked the doctor about it. After checking me he told me it wasn’t anything medical, I was not symmetrical and as you age it just gets more pronounced. A facelift would take care of it if I wanted but I am not interested in going under the knife again. I’ll live with it and smile more.
    I do think that the poor woman with the breast size with A and DD should be covered under insurance. I hope it works out for her. If I had enough money I’d send enough to her to be able to get the surgery.

    Liked by 1 person

  27. Great post….and like most the woman in the world I have one larger than the other….I was what some say blessed with more….I have never thought that…I wished for the small breast when I was younger….the ones that you didn’t have to worry wearing a bra or not….I have considered having them removed however I don’t think that the insurance would agree with me….I believe that the insurances should cover needed breast augmentation…xx.

    Liked by 1 person

      • I wish there was a way to get help more from insurance companies for a lot of what they consider unnecessary. I’ve lost a lot of weight but the flabbiness remains and I just wish I could get that taken care of but it has to be a subject of argument to the insurance companies. I mean, I suppose there are worse things, but having your self-esteem take a shot because of imperfections is just devastating sometimes.

        Liked by 1 person

  28. I’m actually pretty even so I’ve never given it much thought. It seems like such a discrepancy in size would have physical effects as well as psychological. Wouldn’t it throw off the posture or strain the shoulders in one direction?

    Liked by 1 person

  29. Pingback: Writing Links 3/27/17 – Where Genres Collide

  30. I always said I’d NEVER get a boob job. Now, after nursing 2 kids, I have to wear a bra all the time – even at night. Otherwise, I roll over on myself in my sleep. It’s disoncerting. And as I age, I’m getting the crease in between them, making me look older. I wish I could go back to my flat-chested days when I was younger and skinnier. I hated that then, but now….

    Liked by 1 person

  31. (I wish I had time to read all of the comments.) Repeat after me: Insurance companies are evil. At this point they are necessary evils, but evil all of the same.

    As you know, I could write a few thousand words on insurance companies and mental health issues.

    Isn’t it nice they, and only they, can accurately determine “medical” from “psychological” as if there is some kind of thick, black line that divides the two and never do they meet?

    Yes, there probably does need to be some kind of guideline, some judgement call, by somebody, so that every bimbo’s boob job doesn’t get paid for by everyone else. But it isn’t the MD’s in the front lines making that call. It isn’t the PCP, the surgeon, the psychologists. It very well could be a computer scanning CPT codes. Or some pencil pusher with a policy manual. Peer to peer? Still is the insurance company’s lackey.

    That’s me being tactful. πŸ™‚

    Liked by 1 person

  32. There are all sorts of reasons for augmentation. I apologize to the men in advance, because this may come off as sexist; but by men, who often times are in positions to decide was is medically necessary or not, do not understand that psychology associated with breast size in women. For them, they are eye candy, visually pleasing, and from time to time, manually or orally pleasing, but after that, they’re done. We have to live with their weight or lack of weight. Are they high or low? Are they sweating beneath this shirt and bra, where no one can see? Are they causing me back and shoulder pain? Will they produce when I want to reproduce? Will they lead to ultimate death? So, yes, augmentation should be covered, if not to save a life, then to make that life fuller.

    Liked by 1 person

  33. Oh dear, I guess mine are unequally small. They never really got beyond training bra stage πŸ˜† but if I had such a marked difference as in your patient, I know I wouldn’t be able to focus on anything else. It seems ridiculous that something of this magnitude wouldn’t be covered under insurance.

    Liked by 2 people

  34. If you are paying for medical insurance then every doctor approved treatment or surgery should be paid by your insurance company!
    I have always felt that way about all insurance companies. If an insurance company claims to cover the expenses you incur, for your health care, home, car, etc. then it should be bound to pay for every event regardless of what it is unless fraudently caused by you.
    Insurance companies have so many exclusions and loopholes that you really never know what your exact coverage is until an event happens.

    Liked by 1 person

  35. Mine are small and surprisingly similar, to the point that I’d never given this issue any thought before. I think that your patient’s issue is similar to that of a cancer survivor who would, understandably, want reconstruction to make both sides match and look “normal,” whatever that means to the patient. I would support its being covered by insurance.

    Liked by 1 person

  36. It seems every thing on my right side (dominant) is slightly bigger than my left. I never thought it was noticeable until a friend commented on my arm being bigger than my lef onet and when I had some surgery last year, the nurse putting those inflatable leg things on me mentioned my right leg was bigger than the left….and she could tell that just by looking. Is that normal? That our dominant side is slightly larger? Or am I just a freak of nature? LOL

    Liked by 1 person

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