igrigoras@iowaclinic.com
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Suggestions please CPT codes on the below procedure:
PROCEDURES: Revision of bilateral breast reconstruction with excision of contour deformity and complete capsulectomy bilaterally with implant removal on the right.
INDICATIONS: This is a 66-year-old woman, who has undergone bilateral mastectomy for cancer. She had a persistent fluid collection around the left implant. This was revised over a drain and despite the drain removal after the drain had diminished, she once again had accumulated some fluid. This eventually became infected and required removal of the implant. We initially tried to leave the AlloDerm layer in the left chest in hopes of reinserting the implant after the infection cleared, but she continued to collect fluid which required serial aspiration. At that point, she decided that she would forego the reconstruction altogether and would like to have everything removed.
PROCEDURE IN DETAIL: She was brought to the operating room and the anesthetic introduced without complication. We began on the right side first. The transverse incision of the inverted T incision was marked for excision. We planned the incision just below the previous incision across the bottom portion of the breast. The skin and subcutaneous tissue were divided and deepened with electrocautery unit. We then encountered the ADM AlloDerm layer. This was removed en bloc from the right chest with complete removal of the implant and the complete capsulectomy. After the capsulectomy was finished, we opened the capsule and the implant was completely intact without evidence of any defect or leakage. We then pulled the tissue down and tacked this together at the nipple line first, at the top of the vertical incision. This was found to be adequate, and we released the suture and then infiltrated the dissected field with 0.25% Marcaine. It was irrigated with saline. Hemostasis secured and then we closed over a 15-French round fluted drain. The incision was brought down in the nipple line first and tacked together with 3-0 Monocryl. The right and left halves of the excessive skin were then marked at the appropriate level, trimmed, and removed with scalpel blade and electrocautery unit. There was some minor fat sculpting done at the corners to prevent a dog-ear deformity. The remainder of the incision was closed with interrupted 3-0, followed by running subcuticular 3-0 Monocryl, and the drain was secured with a separate nylon suture. We then turned our attention to the left side. Here, we performed a similar procedure, except that the implant had already been removed. We made the incision below the transverse incision similar to the right side and then shelled out the remaining AlloDerm completely and excised this and the scar tissue over the underlying pectoral muscle was also excised, performing a complete capsulectomy. We inspected the cavity to ensure that there were no remnants of the AlloDerm ADM layer left behind. We then irrigated with saline, infiltrated with the anesthetic solution, and closed similar to the right side over a 15-French drain. She had a nice flat contour on both chests at the completion of the procedure. She tolerated the procedure well and then was taken to the recovery area in good condition. There were no complications.
PROCEDURES: Revision of bilateral breast reconstruction with excision of contour deformity and complete capsulectomy bilaterally with implant removal on the right.
INDICATIONS: This is a 66-year-old woman, who has undergone bilateral mastectomy for cancer. She had a persistent fluid collection around the left implant. This was revised over a drain and despite the drain removal after the drain had diminished, she once again had accumulated some fluid. This eventually became infected and required removal of the implant. We initially tried to leave the AlloDerm layer in the left chest in hopes of reinserting the implant after the infection cleared, but she continued to collect fluid which required serial aspiration. At that point, she decided that she would forego the reconstruction altogether and would like to have everything removed.
PROCEDURE IN DETAIL: She was brought to the operating room and the anesthetic introduced without complication. We began on the right side first. The transverse incision of the inverted T incision was marked for excision. We planned the incision just below the previous incision across the bottom portion of the breast. The skin and subcutaneous tissue were divided and deepened with electrocautery unit. We then encountered the ADM AlloDerm layer. This was removed en bloc from the right chest with complete removal of the implant and the complete capsulectomy. After the capsulectomy was finished, we opened the capsule and the implant was completely intact without evidence of any defect or leakage. We then pulled the tissue down and tacked this together at the nipple line first, at the top of the vertical incision. This was found to be adequate, and we released the suture and then infiltrated the dissected field with 0.25% Marcaine. It was irrigated with saline. Hemostasis secured and then we closed over a 15-French round fluted drain. The incision was brought down in the nipple line first and tacked together with 3-0 Monocryl. The right and left halves of the excessive skin were then marked at the appropriate level, trimmed, and removed with scalpel blade and electrocautery unit. There was some minor fat sculpting done at the corners to prevent a dog-ear deformity. The remainder of the incision was closed with interrupted 3-0, followed by running subcuticular 3-0 Monocryl, and the drain was secured with a separate nylon suture. We then turned our attention to the left side. Here, we performed a similar procedure, except that the implant had already been removed. We made the incision below the transverse incision similar to the right side and then shelled out the remaining AlloDerm completely and excised this and the scar tissue over the underlying pectoral muscle was also excised, performing a complete capsulectomy. We inspected the cavity to ensure that there were no remnants of the AlloDerm ADM layer left behind. We then irrigated with saline, infiltrated with the anesthetic solution, and closed similar to the right side over a 15-French drain. She had a nice flat contour on both chests at the completion of the procedure. She tolerated the procedure well and then was taken to the recovery area in good condition. There were no complications.