Breast Reduction/Revision/Reconstruction

[nsteinhauser]

I would appreciate any help on this plastics case. I'm thinking 19318-50 and I want to also code for a reconstruction (19366 or 19380?) but I don't know if I can code that on top of the reduction. Or - do you only code for revision of reconstructed breast? The patient had already went through bilateral mastectomies for breast CA with implant reconstruction in 1991. Then last year had removal of bilateral ruptured implants with bilateral free TRAM flap reconstructions with internal mammary artery and vein anastomosis. During that procedure they had difficulty with the anastomosis of the left breast and had a resultant asymmetry of the breasts. She desired to have both breasts reduced in size due to significant back pain and lateral chest pain and also to attempt to achieve symmetry. The body of the op note reads as follows:
"Attention was first directed to the left breast which was significantly larger than the right. A #10 blade scalpel was used to incise the skin. Bovie electrocautery was used to create an inferior flap of tissue that would be removed in an attempt to regain symmetry and decrease breast size. The old previous abdominal skin was removed and the underlying flap was sculptered to obtain the best symmetry with reduced size as possible. Next, attention was directed to the right breast in which an inferior incision was also created. Flaps of proper thickness were also created inferior and superior as performed on the left breast. Careful attention was placed not to be too medial where the anastomosis is. The breast tissue was sculpted to reduce volume and achieve a symmetric result. The patient was placed in an upright position to properly assess symmetry. A #15 Blake drain was placed in each breast. Copious amounts of antibiotic irrigation was performed on each breast and hemostasis was confirmed. 3-0 Monocryl was placed in the deep dermal layer of the incision. 4-0 Monocryl was placed in a running fashion to reapproximate the skin. There were 564 grams of tissue removed from the left side and 302 grams removed from the right side."

[terridiaz]

I would just use the 19318-50 because he did a reduction, there was no revision.

[nsteinhauser]

Thank you for your time and help.