Victoria Posted Mon 21st of August, 2017 12:32:53 PM
What CPT codes should be used for the following surgical procedure?
Attention was turned first to the tissue expander exchanges. 0.25% bupivacaine with epinephrine was used to anesthetize the patient's existing inframammary crease incisions. The right breast mound was addressed initially. A 15 blade knife was use to excise the patient's existing scar. Dissection was carried down to the underlying capsule at an oblique angle. The capsule was entered and an intact textured tissue expander was encountered. This was well incorporated with the surrounding capsule. Blunt dissection was used to separate the capsule from the device. The tissue expander was delivered from the pocket intact. A small amount of serous fluid in the capsule was cultured. The breast pocket was irrigated copiously with bacitracin irrigation solution and inspected with the aid of a lighted retractor. no abnormalities was noted. The full coverage Alloderm was well incorporated.
With the aid of the lighted retractor, extensive capsulotomy was preformed medially to release and enhance the cleavage area. Linear capsulotomies were also performed along the full length of the lateral extent of the capsule and the fully incorporated Alloderm graft excised. This was set aside in sterile saline. After again irrigating the wound, a lateral capsulorrhaphy was performed using interrupted and running 2-0 pds suture. Various sizers were brought onto the field. A 580 ml srx sizer was felt to be optimal.
Attention was then turned to the left breast mound. An identical procedure was performed and an intact tissue expander removed. A small quantity of serous fluid was cultured. Inspection of the left capsule also revealed excellent incorporation of the allograft. No abnormalities were noted. Medial capsule release and lateral capsulorrhaphies were performed and the intervening alloderm set aside in saline. Insured natural position of the sizers, which were significantly smaller than the total fill volume of her tissue expanders.
Permanent implants were brought onto the field. The patient was reprepped. Each implant was rinsed with concentrated triple antibiotic irrigation (gentamicin, bacitracin, ancef) and carefully placed in the breast pockets using a sterile keller funnel. A 580 ml style srx allergan implant was placed on the right, and a 615 ml style srx allergan implant was placed on the left. A #15 French round jp drain was placed in each breast pocket and brought out through a separate stab incision. The drains were secured with 2-0 nylon. The capsule on each side was approximated with interrupted 2-0 pds sutures.
At this point the 2 alloderm grafts (8x3 cm, 8x2cm) were brought back onton the filed. Each graft was carefully defatted. Using a combination of sharp and blunt dissection, 2 pockets were formed in the subcutaneous tissue of the lower outer quadrant of the left breast and the lateral thorax. These pockets were planned under redundant tissue of the patient's previous reduction mammoplasty flaps that will be excised at the time of her next surgery. 4-0 chromic was sutured at each corner of the flaps. After irrigating the pockets with antibiotic irrigation solution, the alloderm grafts were carefully positioned and the chromic sutures brought to the skin as parachute sutures, securing the grafts in place.
Attention was then turned to the right ryan flap. 0.25% bupivacaine, with epinephrine was used to anesthetize the upper abdominal flap. A 15 blade knife was used to incise the skin. A combination of blunt and sharp dissection was then used to mobilize the inferiorly based skin, subcutaneous tissue and fascia flap. Care was taken to preserve a broad-based well vascularized pedicle. The wound was irrigated with antibiotic irrigation solution and meticulous hemostasis insured. The leading edge of the flap was de-epithelialized and contoured appropriately.
At the proper predetermined level of the ideal crease position, dissection was carried down to the underlying rib periosteum. The de-epithelialized flap was then advanced and inset the buried interrupted sutures of 2-0 pds. Additional 2-0 and 3-0 peds was used to inset the ryan flap and reapproximate the inferior mastectomy flap. Final closure was achieved with a subcuticular 5-0 monocryl. An identical procedure was performed on the left breast inframammary crease. (4cm x 8cm on each side).
SuperCoder Answered Tue 22nd of August, 2017 14:19:12 PM