Citation Nr: 22017486 Decision Date: 03/25/22 Archive Date: 03/25/22 DOCKET NO. 19-00 105 DATE: March 25, 2022 ORDER Service connection for residuals status post bilateral breast reduction surgery for pendulous/large breasts as secondary to service-connected lumbosacral strain is granted. Service connection for painful scars under each breast from reduction surgery as secondary to service-connected lumbosacral strain is granted. FINDINGS OF FACT 1. The Veteran's September 2013 breast reduction surgery and March 2015 revision was performed secondary to complaints of breast and back pain associated with rigorous activities in service with large breasts. 2. The Veteran's residuals of breast reduction surgery, to include pain and tenderness of the breast, are proximately due to her service-connected lumbosacral strain. 3. The Veteran's painful surgical reduction scars under each breast are proximately due to her service-connected back disorder. CONCLUSIONS OF LAW 1. The criteria for service connection for residuals status post bilateral breast reduction surgery have been met. 38 U.S.C. §§ 1110, 5107; 38 C.F.R. §§ 3.102, 3.310. 2. The criteria for service connection for painful scars under each breast from breast reduction surgery for pendulous/large breasts have been met. 38 U.S.C. §§ 1110, 5107; 38 C.F.R. §§ 3.102, 3.310. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty from September 2004 to July 2013 to include in Iraq during which time she received imminent danger area pay. These matters come before the Board of Veterans' Appeals (Board) on appeal of a September 2017 rating decision by a Department of Veterans Affairs (VA) Regional Office (RO). In February 2021, the Veteran testified at a hearing before the undersigned Veterans Law Judge (VLJ). Service Connection 1. Entitlement to service connection for residuals status post bilateral breast reduction surgery for pendulous/large breasts as secondary to service-connected lumbosacral strain is granted. 2. Entitlement to service connection for painful scars under each breast from reduction surgery as secondary to service-connected lumbosacral strain is granted. The Veteran is seeking service connection for her residuals of breast reduction surgery and scarring from that surgery on her breasts. She urges that she developed pain and functional problems in her breasts related to lumbosacral strain due to rigorous activity in service which led to post service reduction surgery. Service connection is in effect for lumbosacral strain. The service treatment records reflect complaints related to the back in service. She urges that she always had problems with rigorous physical activities in service and she was told by at least one medical personnel in service that if she had breast reduction that her back would improve. She argues the surgery was not elective but instead was related to her pain in her back. See February 2021 hearing transcript, p. 3, 4. As to the scarring, she explained that the revised scars are painful and start bleeding if she wears many types of bras. Id., at 7. In general, service connection may be granted for a disability or injury incurred in or aggravated by active military service. See 38 U.S.C. § 1110; 38 C.F.R. § 3.303. To prevail on a direct service connection claim, there must be competent evidence of (1) a current disability, (2) an in-service incurrence or aggravation of a disease or injury, and (3) a nexus between the in-service disease or injury and the current disability. See Holton v. Shinseki, 557 F.3d 1362, 1366 (Fed. Cir. 2009); 38 U.S.C. § 1110; 38 C.F.R. § 3.303. Service connection may also be established by credible lay evidence and medical evidence provided by the Veteran or otherwise. 38 U.S.C. §§ 1110, 1131; 38 C.F.R. § 3.303. Service connection may be established for disability that is proximately due to or the result of a service-connected disability. 38 C.F.R. § 3.310(a). Further, a disability which is aggravated by a service-connected disability may be service-connected to the degree that the aggravation is shown. 38 C.F.R. § 3.310; El-Amin v. Shinseki, 26 Vet. App. 136 (2013); Allen v. Brown, 7 Vet. App. 439 (1995). When there is an approximate balance of positive and negative evidence regarding any issue material to the determination of a matter, VA shall resolve reasonable doubt in favor of the claimant. See 38 U.S.C. § 5107; 38 C.F.R. § 3.102. As noted above, the Veteran contends that she her large breasts impacted her ability to perform PT in service, and that she has painful residuals of the surgery she had to alleviate breast and back pain. She testified that in Iraq she noticed a lot of problems wearing her gear. She developed back issues in Iraq. The medic reportedly recommended a breast reduction to help with her back pain. Her Load Bearing Equipment (LBE) was an extra-large due to her breasts, which gave her a lot of extra weight on her back. She explained that the pain in her back is what led up to the medic recommending reduction. She noted that, during physical fitness activities, even if she wore three bras, the pain in her back and breasts when she would run was excruciating. She could not pass fitness tests and had to perform remedial PT. She was told she was not going down far enough in sit ups, etc, due to her breasts. She could never wear the right uniform due to the breast size issue. Every day was a battle for her in the military in this regard. While STRs do not specifically cite to breast issues or breast reduction recommendations, they do reflect complaints and findings related to back pain and note weight issues consistent with the Veteran's reports. The Veteran underwent consultation for breast reduction surgery on July 23, 2013, within days of service separation. She reported that her occupation was 'military.' The consulting physician diagnosed symptomatic hypermastia. They noted that the Veteran had to perform a lot of pain running, chasing and wearing protective armor. Her military activities were very painful due to her breast size causing mid-low back pain. This was reported to have worsened over the past 5 years. The surgery was performed in September 2013. It was noted in October 2013 that she felt better, and the back pain had been absent since the surgery. She underwent excision and complex revision of heavy 12 cm scars on the medial lateral aspects of each breast in March 2015. The Veteran was afforded a VA examination for the breasts in September 2017. The diagnosis was pendulous/large breast that existed prior to service. The examiner noted that, "her enlarged breast are genetic and developmental. There would be no 'causal' relationship of back problems causing her large breast." Thus, they found the claimed condition was less likely than not proximately due to or the result of a service-connected condition. They stated the breast reduction surgery was elective and totally voluntary. They also noted scarring under the breasts resulting from the surgery. In view of the above, the Board concludes that the Veteran has satisfied the first element of service connection, a current disability as to both residuals of breast reduction surgery and scarring for the same. There is competent evidence of record in support of and against the theory that the residuals of breast reduction surgery and the surgical scarring under each breast are proximately due to or the result of his service-connected lumbosacral strain. While the aforementioned STRs are negative for any diagnosis or symptomatology related to the breasts, the Veteran has testified that the issues she has with her breasts are related to her back and the impact of the rigorous physical activities in Iraq. In further support of the claim, the non-VA physician who evaluated her and performed breast reduction shortly after service acknowledged the relationship between the breast reduction, back issues and the rigors of this particular Veteran's service. See treatment records of C.M.T, M.D., 2013-2015. Ultimately, the Veteran's assertions are competent and credible. The Veteran has presented adequate lay evidence about how the documented residuals of breast reduction surgery and surgical scarring of the breasts are related to the service-connected lumbosacral strain. The Board acknowledges the 2017 VA clinician's negative opinion. However, the Board finds that the detailed 2021 testimony from the Veteran and the assessments from the non-VA physician who performed the actual reduction and revision, collectively, competent, relevant and probative as to the issue of whether residuals of breast reduction surgery and surgical scarring of the breasts are proximately due to or the result of the lumbosacral strain as contemplated within the meaning of 38 C.F.R. § 3.310. The Board notes that the Veteran has basically stated that she got the surgery at the urging of a service medic to reduce pain in breast and back, and that there are current residuals. She cites to the relationship between the strenuous physical activities in service, her large breasts and her lumbosacral strain. The Board cannot disassociate that logical connection, under the unique facts of this case, between the current residuals of breast reduction surgery and surgical scarring of the breasts and the service-connected lumbosacral strain. The Veteran is competent to describe her pain and other problems associated with the breast issues. The Board does not find the Veteran's report of back problems due to prolonged standing to be contrary to its findings in light of the totality of the unique circumstances in this case. Based on the evidence of record, including the evidence highlighted above, the Board finds that the evidence is approximately balanced regarding whether the residuals of breast reduction surgery, to include pain and tenderness of the breast, and surgical scars of the breast, are proximately due to her service-connected lumbosacral strain. The benefit-of-the-doubt doctrine applies. 38 U.S.C. § 5107(b), Lynch v. McDonough, 21 F.4th 776 (Fed. Cir. 2021). As such, service connection is granted for the Veteran's residuals of breast reduction surgery, and surgical scars of the breast was caused by her service-connected lumbosacral strain. See 38 C.F.R. § 3.310. STEVEN D. REISS Veterans Law Judge Board of Veterans' Appeals Attorney for the Board N. Rippel, 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.