Citation Nr: 21006782 Decision Date: 02/05/21 Archive Date: 02/05/21 DOCKET NO. 14-26 749 DATE: February 5, 2021 ORDER Service connection for residuals of bilateral breast reduction surgery, to include pain and numbness, is granted. Service connection for residual scars from breast reduction surgery is granted. FINDINGS OF FACT 1. The Veteran underwent bilateral breast reduction surgery in service. She has current symptoms of breast pain, numbness, and axillae tenderness associated with her in-service surgery. 2. The Veteran underwent bilateral breast reduction surgery in service. She has resultant scars around the areola, under the breast, and from the areola to the bottom of the breast. CONCLUSIONS OF LAW 1. The criteria for entitlement to service connection for residuals of bilateral breast reduction surgery, to include pain and numbness, have been met. 38 U.S.C. §§ 1110, 1131, 5107 (2014); 38 C.F.R. §§ 3.102, 3.303 (2020). 2. The criteria for entitlement to service connection for residual scars from breast reduction surgery have been met. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. §§ 3.102, 3.303. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty in the U.S. Army from September 1999 to September 2003. These matters come before the Board of Veterans’ Appeals (Board) on appeal from a December 2011 rating decision by a Department of Veterans Affairs (VA) Regional Office (RO). The December 2011 rating decision denied entitlement to service connection for breast pain and numbness. The Veteran’s March 2011 claim requested service connection for residuals of her bilateral breast reduction surgery. The record reveals that the Veteran has complaints of breast pain and numbness, as well as tenderness of the axillae with arm movement as a result of her reduction surgery. The record additionally reveals that she has several scars as a result of her reduction surgery. The Board considers both her subjective symptoms of breast pain and numbness, and tenderness to the axillae and her scars to be residuals of her breast reduction surgery, and is separating the issue into two claims based on how the rating criteria would address these symptoms. The Veteran is currently in receipt of a noncompensable ratings for surgical scars related to her feet and her c-section. These noncompensable ratings do not address her breast surgery scars. The Veteran’s claim of entitlement to service connection for residuals of breast reduction surgery was previously before the Board in July 2018 and January 2020. The Board remanded the issue twice due to inadequate examinations/opinions. The January 2020 remand requested an addendum medical opinion based on a review of the record. Direct and aggravation opinions were provided in March and June 2020, respectively. 1. Entitlement to service connection for residuals of bilateral breast reduction surgery, to include pain and numbness, is granted. 2. Entitlement to service connection for residual scars from breast reduction surgery is granted. The Veteran is seeking entitlement to service connection for residuals of her in-service bilateral breast reduction surgery. Service connection will be granted if the evidence demonstrates that a current disability resulted from an injury or disease incurred in or aggravated by active military service. 38 U.S.C. § 1131; 38 C.F.R. § 3.303 (a). Establishing service connection generally requires competent evidence of three things: (1) a current disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) a causal relationship, i.e., a nexus, between the claimed in-service disease or injury and the current disability. Holton v. Shinseki, 557 F.3d 1362, 1366 (Fed. Cir. 2009). Service connection may also be granted for a disease first diagnosed after discharge when all of the evidence, including that pertinent to service, establishes that the disease was incurred in service. 38 C.F.R. § 3.303 (d). The Board must determine the value of all evidence submitted, including lay and medical evidence. See Buchanan v. Nicholson, 451 F.3d 1331 (Fed. Cir. 2006). When there is an approximate balance of positive and negative evidence regarding any issue material to the determination of a matter, the Secretary shall give the benefit of the doubt to the claimant. 38 U.S.C. § 5107(b); see also Gilbert v. Derwinski, 1 Vet. App. 49 (1990). The Veteran’s enlistment medical evaluation from July 1999 did not note any findings related to her breasts. In April 2002, the Veteran complained of burning on the inside of her breasts for two weeks, with a rash under each breast. She had discontinued breast feeding two months prior. On January 15, 2003, the Veteran underwent bilateral breast reduction surgery. Two days later she complained of mild (or possibly moderate, the handwriting is difficult) pain. Her sensation was intact. By January 28, 2003, she had mild swelling in the left breast. She was doing well and treating her pain with Motrin. A June 2003 service treatment record noted that the Veteran was seen for complaints of scar formation following breast reduction surgery. The record appeared to note keloids of superior margin of junctions. A drawing indicates that she had scars on the interior sides of both breasts. She was given Hydrocortisone cream. Post-service VA records included an October 2004 treatment note wherein her in-service breast reduction surgery was described. She had scars, no discreet masses, a thickening in the lower quadrant of the left breast. She had a normal mammogram and normal ultrasound. The mammogram showed a small amount of glandular tissue in both breasts. It was noted her mother had breast cancer. A June 6, 2011 VA treatment record included the Veteran’s report of in-service low self-esteem due to her weight and breast reduction, which she felt left her “scarred.” A June 9, 2011 record included her report of acute pain in the bilateral breasts described as a burning or “catching” in the right axilla region. A January 24, 2012 VA treatment record included the Veteran’s repeated complaint of pain under the axillae since her breast reduction, worse if she raised her arm quickly. She described the pain as a cramp or muscle spasm, which occurred bilaterally. She described a history of breast reduction in 2001 with initial shoulder symptoms that started within two weeks post reduction. She reported that in the past two years, pain and locking have been more often. She would rub the painful area for 5 minutes to get relief. On evaluation, she had scars from breast reduction bilaterally, axillae negative bilaterally without discrete mass or nodule. She had some fibroglandular changes. There were no nodules in the lateral breast areas where she felt cramps. The Veteran was seen again on June 20, 2014; she had a prior ultrasound of her breasts in 2012 which was negative. She reported a lesion on her right breast that would sting with a burning sensation around the areola area. She stated that she had a breast reduction in 2001 and with “raising [right] arm the lateral aspect of the [right] breast hurts and is tender.” Her medical history included fibroadenosis of breast, status post breast reduction in 2001 in Korea. On evaluation she had no breast discharge, 2 cm x 1 cm nodule area at the base of right breast midline, and similar nodularity base of left breast midline. An ultrasound was ordered. She was asses with status post breast reduction with muscle cramps and spasming in adjacent area to axillae with raising of arms. In November 2016, the Veteran participated in a VA scar examination related to her breast surgery residuals claim. The examiner noted the June 2003 in-service record of two small areas of keloid scars. On examination, she had nontender scars with no skin breakdown. She reported numbness of her breasts, but she was noted to be able to feel the examination tape that was used to measure her scars. “Breast exam noted no tenderness. There is no evidence of numbness.” She was diagnosed with in-service breast reduction with residual scars but no evidence of other residuals. She had a left breast scar under the breast measuring 25 cm, bottom of nipple 7 cm, periareolar around nipple 9 cm, and bottom of breast to nipple 7 cm. She had the same measurement of scars on the right breast, except the under-breast scar was 26 cm. The November 2016 examination was found partially inadequate. On remand, the Veteran participated in breast and scar examinations in May 2019. The May 2019 scar examination noted the Veteran had two painful scars (sharp pain, stinging) of the scars under both breasts. Her under breast scars measured 20 cm x 1 cm under both. The May 2019 breast examination diagnosed “status post breast reduction.” She reported complications of tenderness, pain, and muscle spasm while healing from surgery. She stated her condition had stayed the same, with continued pressure and stinging pain in the bilateral breasts. She also reported that her scars get irritated and itch, had muscle spasm in both left and right side under arms, tenderness to the touch, areolas are extremely sensitive and also numb. The examiner provided a negative nexus opinion with the rationale that that the Veteran had one complaint of breast pain in April 2002, and a rash, and there were no other service treatment records reflecting chronic pain or tenderness in either breast after surgery. She had normal mammogram and ultrasound in 2004, and there were no medical records of a chronic disability. “Therefore, the veteran did have an in-service breast reduction with residual scar, but does not have any other [service treatment record] to reflect a chronic condition.” A January 2020 Board remand noted that the 2019 medical examinations and opinion was inadequate and remanded for additional opinions based on record review. In March 2020, a medical examiner provided a positive opinion noting that the Veteran entered service in July 1999 without a breast condition noted, underwent a bilateral breast reduction on January 15, 2003, and complained of post-surgery residuals in January 2012, described as a cramp or muscle spasm. She also had evidence of scars from breast reduction surgery. The examiner noted that a June 2014 treatment record diagnosed post-breast reduction surgery with muscle cramps and spasm in adjacent area to axilla with raising her arms. The medical examiner also reviewed the November 2016 scar examination, and the opinion that because the Veteran was able to feel the exam tape it, that she did not have numbness. The medical examiner also reviewed the Veteran’s statements and appellate brief, including a December 2019 argument which noted she had complications of tenderness, pain, and muscle spasm while healing from surgery, and she continued to have pressure and stinging pain in both breasts. She also stated her scars got irritated and itched, she had spasms in both arms, and she had tenderness to touch in the area was extremely sensitive and numb. The medical examiner provided a positive medical opinion, noting it was at least as likely as not that the Veteran’s breast reduction surgery residuals of pain, tenderness, and numbness caused by breast reduction surgery during service. She had large pendulous breasts on entrance, inhibiting her ability to pass a physical training test. She underwent breast reduction surgery in service, and she reported that she developed symptoms in both breasts consisting of pain, numbness, and a cramping sensation after surgery. “She appeared to have an uneventful recovery initially, but as time went on, she developed symptoms as noted above.” There had been no intervening trauma. “Numbness was denied by previous examiners because it was felt that she could identify the sensation of the tape measure…the perception of touch, however, is not exactly equal to the lack of numbness. One can have a numb feeling, but yet still have the ability to sense touch.” The 2020 medical examiner found that it was at least as likely as not that the symptoms of cramping and pain in the axilla with sudden movements or overhead movements was a manifestation of adhesions secondary to the surgical incisions, even though they did not manifest initially. “It is not uncommon for adhesions, post surgically, to manifest symptomatically years and sometimes decades after the surgery.” Notably, in June 2020 additional opinion was provided based on whether the Veteran entered service with a clear and unmistakable pre-existing condition that was clearly and unmistakably not aggravated by service. The Board finds that this opinion is unnecessary given the positive opinion provided in March 2020. The Board notes that the record contains conflicting medical opinions. In weighing the probative value of these opinions, the Board is cognizant that CAVC has stressed that “[i]t is the factually accurate, fully articulated, sound reasoning for the conclusion, not the mere fact that the claims file was reviewed, that contributes probative value to a medical opinion.” See generally Nieves-Rodriguez v. Peake, 22 Vet. App. 295 (2008). The Board has previously found the 2016 and 2019 examinations and opinions to be inadequate. The Board finds the March 2020 medical examiner’s opinion is more probative than the negative opinions of record as it includes a thorough review of the record, opinion with rationale, and addresses the prior negative findings of numbness. The Board finds that entitlement to service connection for residuals of breast reduction surgery, including pain and numbness, and entitlement to service connection for post-surgical scars are warranted. The Veteran entered service with a normal evaluation of her breasts. She underwent breast reduction surgery in service, which resulted in several post-surgical scars. Indeed, in-service treatment records included a complaint of keloid scar formation. It is unclear why her scars would not have been easily service-connected as they are obviously the result of in-service surgery and were not present prior to surgery. The March 2020 examiner has also noted that her subjective complaints of pain, numbness, and tenderness/catching with arm movement are due to her in-service surgery. The March 2020 examiner has indicated that it can take years for adhesions or post-surgical symptoms to develop and has found that her complaints are a result of her in-service breast surgery. Additionally, the Board finds the Veteran’s subjective complaints of pain, tenderness, and numbness to be credible as they have been repeated from 2011 onward. As such, entitlement to service connection for residuals of breast reduction surgery and entitlement to service connection for post-surgical scars (breast reduction) are warranted. Romina A. Casadei Acting Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board M. H. Stubbs, Counsel The Board’s decision in this case is binding only with respect to the instant matter decided. This decision is not precedential and does not establish VA policies or interpretations of general applicability. 38 C.F.R. § 20.1303.