candiced
Contributor
19316(mastopexy is bundling to 19367. Per records it is being done on the same breast. I am trying to understand how or if modifier 59 on 19367 would be applicable or not?
PROCEDURES PERFORMED:
1. Right breast reconstruction with muscle-sparing free TRAM flap.
2. Right nipple-areolar reconstruction.
3. Right mastopexy flap revision.
PROCEDURE IN DETAIL: During this time, the
Plastic Surgery Service would harvest the microvascular free TRAM
flap. The Doppler signals were marked, and at this time, we felt to
have the best Doppler signals on the left side. We felt that we
would need to utilize both the medial and lateral rows in order to
increase the amount of volume harvested to create a flap with
adequate perfusion to decrease the likelihood of fat necrosis. At
this time, the patient was prepped and draped in the routine sterile
fashion. The abdominal W incision was injected with 0.5% lidocaine
with epinephrine. Once she was prepped and draped in the routine
sterile fashion, the flap harvest was then designed. A standard
incision was performed to the skin and subcutaneous tissue bevelling
superiorly to increase amount of perforators superiorly. The lateral
dissection was kept thin over the right and left flank region, in the
suprapubic region, and the right and left groin region. Attention
was taken as to not injure the lymph nodes in the right and left
groin. The flaps were then elevated from lateral to medial to
identify the lateral perforators on both right and left side. We
felt that the lateral perforators on the left side had 3 large
perforators, which maintained the circulation to the ipsilateral side
and felt that there were 2 signals medially which we felt would be
adequate for the contralateral perfusion. We chose the left side of
the flap, then elevated the right soft tissue off the rectus sheath
dividing both the medial and lateral perforators on the right side.
The umbilicus was incised with a #15 blade and dissected down to its
stalk. The medial row perforators on the left side were then
identified, and at this time, the flap harvest was then designed.
The fascial harvest was approximately 10 cm length by approximately
2.5 cm in width. The fascia was opened on both the medial and
lateral side superiorly and inferiorly and the incision of the
fascial harvest was then extended down to the pubic region. The
fascia was then elevated off the rectus laterally and medially to
identify the entire rectus muscle. The lateral border of the rectus
muscle was then elevated and the inferior epigastric vessels were
identified undersurface of the muscle. The vessels were dissected
all the way free to the origin of the external iliac artery and vein
to identify numerous intercostal branches, which were divided between
clips. Two medial muscle perforators were divided between clips.
This allowed the pedicle to the left and detached from the
undersurface of the muscle all the way up to the lowest perforators
along the lateral row. The medial perforator was identified
superiorly, and at this time, we maintained both the medial and
lateral perforators resecting a muscle of approximately 10 cm in
length by approximately 2 cm in width. The muscle was longitudinally
split leaving us with both the medial and lateral perforators. This
allowed us excellent perfusion to the flap. The muscle was
proximally and distally divided. At this time, the vessel on the
undersurface of the rectus muscle was left intact. The vessels were
now freed all the way to the origin off the external iliac artery and
vein and subsequently separated for the subsequent division. At this
time, the entire zone 4 was then removed. Significant amount of zone
2 was removed. At this time, the new areolar complex was left in the
central aspect and the remaining portion of the flap skin and dermis
was then removed. The skin paddle was left in the central aspect of
the flap to allow the subsequent placement of the flap in a vertical
position. Once Dr. Lane completed the mastectomy the size pocket was
decreased to allow improved projection. The lateral chest wall was
then secured to the chest wall region securing the subcutaneous
tissue to decrease the width of the pocket being now approximately
13.5 cm wide. This was performed from the superior aspect of the
axilla down to the inframammary fold and recreating the inframammary
fold using 2-0 Ethibond sutures. A drain was placed laterally and
secured with 3-0 Prolene suture. At this time, the internal mammary
vessels were identified opening to the pectoralis muscle over the
third costal cartilage. The muscle was longitudinally split.
Retraction was then placed. A subperiosteal dissection allowed us to
remove the rib from lateral to medial identifying the internal
mammary vessels in the anatomic position once the perichondrium had
been divided from lateral to medial. The vessels were then dissected
into the interspace superiorly and inferiorly with numerous muscular
branches being divided between Weck clips. The intercostal vessels
were divided as well and we now had a pedicle length of approximately
9 cm. The vessels were proximally separated as well as distally
separated. It was felt the vessels were adequate for the
microanastomosis with a good arterial and venous size match. At this
time, the patient was given 2000 units of intravenous heparin. The
pocket was irrigated copiously with antibiotic solution. The vessels
were proximally controlled and distally divided. The microscope was
brought onto the field and the flap was then harvested off the
abdominal region. The flap was then secured to the chest wall region
and the arterial anastomosis was then performed in end-to-end fashion
using 9-0 nylon sharp points. The venous anastomosis was performed
with 3.5 mm coupling ring in the standard fashion. Once flow was
reestablished to the flap, the overall circulation was excellent.
The perfusion of the edges of the flap showed excellent circulation,
and at this time, the flap was then placed vertically in the pocket.
Zone 2 and zone 1 were placed superiorly with a zone 3 being placed
inferiorly. This allowed the best circulatory pattern. The new
nipple was created using a modified tripod flap, which allowed us to
secure the nipple in a superior direction and placed it in the
central aspect of the nipple defect, which was in the central aspect
of the areolar complex. The nipple was then secured with 5-0 Prolene
sutures. The dermal edges were then reapproximated with 4-0 Monocryl
sutures. This allowed us to maintain projection and location of the
nipple-areolar complex, which was now placed in the central aspect of
the peri-nipple defect. The vertical limb was then trimmed,
tightening up the limb both vertically and horizontally, allowed us
to improve the projection of the breast. The excess skin was then
trimmed, de-epithelialized, and closed with a combination of 3-0
Monocryl sutures in deep dermal region and 4-0 Monocryl
intracuticular repair. The nipple was secured to the defect with 4-0
Monocryl sutures and 5-0 Prolene sutures. The overall circulatory
pattern was excellent. Once this was completed, attention was then
placed on closing the abdominal flap. The fascial defect was closed
with 0 Ethibond sutures in a figure-of-eight buried fashion. The
plication of the muscles, which was approximately external oblique,
the external oblique was then performed from xiphoid to umbilicus and
umbilicus to pubis with #1 Ethibond sutures in figure-of-eight buried
fashion. The secondary advancement and reinforcement suture with #1
Prolene suture was then placed from xiphoid to umbilicus and
umbilicus to pubis as well. The abdominal flap was then widely
undermined and advanced inferiorly. The patient was placed in the
reflex position and the abdominal flap was advanced to the lower
pubic region. This allowed us down to provisionally staple the flaps
into place. On-Q pump catheters were placed to escutcheon and
stapled into place. The intercostal block was then performed with
prilocaine, Marcaine, and Depo-Medrol with approximately 70 cc being
injected. The abdomen was irrigated copiously with antibiotic
solution and hemostasis was then performed. The wide undermining
allowed us to now inset the flap with the small amount of liposuction
laterally in order to decrease the fullness of the flank region and
to decrease the contour irregularity. Closure was then performed
with a combination of 2-0 Monocryl sutures in Scarpa's, 3 in the
subdermal, and 4-0 Monocryl intracuticular repair. The umbilicus was
inset with a standard superiorly based U-flap periumbilical defatting
and the superiorly based U-flap being secured to the 12 o'clock
position with 3-0 PDS sutures. The remaining portion the umbilical
inset was then performed with 4-0 Monocryl sutures and 5-0 fast plain
gut sutures. Overall circulation appeared to be excellent both for
the flap, the abdominal skin flap, the mastectomy skin flap, and the
umbilical skin envelope. Dermabond, Steri-Strips, Telfa, and
Tegaderm dressings were then applied. Foam tape was then utilized
and Doppler signal was then marked appropriately. The patient
tolerated the procedure well, was then extubated, and taken to
recovery room in stable condition.PROCEDURES PERFORMED:
1. Right breast reconstruction with muscle-sparing free TRAM flap.
2. Right nipple-areolar reconstruction.
3. Right mastopexy flap revision.
PROCEDURE IN DETAIL: During this time, the
Plastic Surgery Service would harvest the microvascular free TRAM
flap. The Doppler signals were marked, and at this time, we felt to
have the best Doppler signals on the left side. We felt that we
would need to utilize both the medial and lateral rows in order to
increase the amount of volume harvested to create a flap with
adequate perfusion to decrease the likelihood of fat necrosis. At
this time, the patient was prepped and draped in the routine sterile
fashion. The abdominal W incision was injected with 0.5% lidocaine
with epinephrine. Once she was prepped and draped in the routine
sterile fashion, the flap harvest was then designed. A standard
incision was performed to the skin and subcutaneous tissue bevelling
superiorly to increase amount of perforators superiorly. The lateral
dissection was kept thin over the right and left flank region, in the
suprapubic region, and the right and left groin region. Attention
was taken as to not injure the lymph nodes in the right and left
groin. The flaps were then elevated from lateral to medial to
identify the lateral perforators on both right and left side. We
felt that the lateral perforators on the left side had 3 large
perforators, which maintained the circulation to the ipsilateral side
and felt that there were 2 signals medially which we felt would be
adequate for the contralateral perfusion. We chose the left side of
the flap, then elevated the right soft tissue off the rectus sheath
dividing both the medial and lateral perforators on the right side.
The umbilicus was incised with a #15 blade and dissected down to its
stalk. The medial row perforators on the left side were then
identified, and at this time, the flap harvest was then designed.
The fascial harvest was approximately 10 cm length by approximately
2.5 cm in width. The fascia was opened on both the medial and
lateral side superiorly and inferiorly and the incision of the
fascial harvest was then extended down to the pubic region. The
fascia was then elevated off the rectus laterally and medially to
identify the entire rectus muscle. The lateral border of the rectus
muscle was then elevated and the inferior epigastric vessels were
identified undersurface of the muscle. The vessels were dissected
all the way free to the origin of the external iliac artery and vein
to identify numerous intercostal branches, which were divided between
clips. Two medial muscle perforators were divided between clips.
This allowed the pedicle to the left and detached from the
undersurface of the muscle all the way up to the lowest perforators
along the lateral row. The medial perforator was identified
superiorly, and at this time, we maintained both the medial and
lateral perforators resecting a muscle of approximately 10 cm in
length by approximately 2 cm in width. The muscle was longitudinally
split leaving us with both the medial and lateral perforators. This
allowed us excellent perfusion to the flap. The muscle was
proximally and distally divided. At this time, the vessel on the
undersurface of the rectus muscle was left intact. The vessels were
now freed all the way to the origin off the external iliac artery and
vein and subsequently separated for the subsequent division. At this
time, the entire zone 4 was then removed. Significant amount of zone
2 was removed. At this time, the new areolar complex was left in the
central aspect and the remaining portion of the flap skin and dermis
was then removed. The skin paddle was left in the central aspect of
the flap to allow the subsequent placement of the flap in a vertical
position. Once Dr. Lane completed the mastectomy the size pocket was
decreased to allow improved projection. The lateral chest wall was
then secured to the chest wall region securing the subcutaneous
tissue to decrease the width of the pocket being now approximately
13.5 cm wide. This was performed from the superior aspect of the
axilla down to the inframammary fold and recreating the inframammary
fold using 2-0 Ethibond sutures. A drain was placed laterally and
secured with 3-0 Prolene suture. At this time, the internal mammary
vessels were identified opening to the pectoralis muscle over the
third costal cartilage. The muscle was longitudinally split.
Retraction was then placed. A subperiosteal dissection allowed us to
remove the rib from lateral to medial identifying the internal
mammary vessels in the anatomic position once the perichondrium had
been divided from lateral to medial. The vessels were then dissected
into the interspace superiorly and inferiorly with numerous muscular
branches being divided between Weck clips. The intercostal vessels
were divided as well and we now had a pedicle length of approximately
9 cm. The vessels were proximally separated as well as distally
separated. It was felt the vessels were adequate for the
microanastomosis with a good arterial and venous size match. At this
time, the patient was given 2000 units of intravenous heparin. The
pocket was irrigated copiously with antibiotic solution. The vessels
were proximally controlled and distally divided. The microscope was
brought onto the field and the flap was then harvested off the
abdominal region. The flap was then secured to the chest wall region
and the arterial anastomosis was then performed in end-to-end fashion
using 9-0 nylon sharp points. The venous anastomosis was performed
with 3.5 mm coupling ring in the standard fashion. Once flow was
reestablished to the flap, the overall circulation was excellent.
The perfusion of the edges of the flap showed excellent circulation,
and at this time, the flap was then placed vertically in the pocket.
Zone 2 and zone 1 were placed superiorly with a zone 3 being placed
inferiorly. This allowed the best circulatory pattern. The new
nipple was created using a modified tripod flap, which allowed us to
secure the nipple in a superior direction and placed it in the
central aspect of the nipple defect, which was in the central aspect
of the areolar complex. The nipple was then secured with 5-0 Prolene
sutures. The dermal edges were then reapproximated with 4-0 Monocryl
sutures. This allowed us to maintain projection and location of the
nipple-areolar complex, which was now placed in the central aspect of
the peri-nipple defect. The vertical limb was then trimmed,
tightening up the limb both vertically and horizontally, allowed us
to improve the projection of the breast. The excess skin was then
trimmed, de-epithelialized, and closed with a combination of 3-0
Monocryl sutures in deep dermal region and 4-0 Monocryl
intracuticular repair. The nipple was secured to the defect with 4-0
Monocryl sutures and 5-0 Prolene sutures. The overall circulatory
pattern was excellent. Once this was completed, attention was then
placed on closing the abdominal flap. The fascial defect was closed
with 0 Ethibond sutures in a figure-of-eight buried fashion. The
plication of the muscles, which was approximately external oblique,
the external oblique was then performed from xiphoid to umbilicus and
umbilicus to pubis with #1 Ethibond sutures in figure-of-eight buried
fashion. The secondary advancement and reinforcement suture with #1
Prolene suture was then placed from xiphoid to umbilicus and
umbilicus to pubis as well. The abdominal flap was then widely
undermined and advanced inferiorly. The patient was placed in the
reflex position and the abdominal flap was advanced to the lower
pubic region. This allowed us down to provisionally staple the flaps
into place. On-Q pump catheters were placed to escutcheon and
stapled into place. The intercostal block was then performed with
prilocaine, Marcaine, and Depo-Medrol with approximately 70 cc being
injected. The abdomen was irrigated copiously with antibiotic
solution and hemostasis was then performed. The wide undermining
allowed us to now inset the flap with the small amount of liposuction
laterally in order to decrease the fullness of the flank region and
to decrease the contour irregularity. Closure was then performed
with a combination of 2-0 Monocryl sutures in Scarpa's, 3 in the
subdermal, and 4-0 Monocryl intracuticular repair. The umbilicus was
inset with a standard superiorly based U-flap periumbilical defatting
and the superiorly based U-flap being secured to the 12 o'clock
position with 3-0 PDS sutures. The remaining portion the umbilical
inset was then performed with 4-0 Monocryl sutures and 5-0 fast plain
gut sutures. Overall circulation appeared to be excellent both for
the flap, the abdominal skin flap, the mastectomy skin flap, and the
umbilical skin envelope. Dermabond, Steri-Strips, Telfa, and
Tegaderm dressings were then applied. Foam tape was then utilized
and Doppler signal was then marked appropriately. The patient
tolerated the procedure well, was then extubated, and taken to