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Need Help with Breast Procedure

KBean2018

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Hello, I am coming up with 19350-50? Any thoughts are appreciated. Thank you


was identified in the preoperative holding area. The approximate site for her future nipple areolar reconstruction was marked as were areas of following in her right greater than left superior poles. She was brought to the operating room and placed on the operating table. A pillow was placed beneath her knees. SCDs placed on bilateral lower extremities and her arms placed on padded foam arm rests gently flexed at the elbow and abducted less than 90 degrees at he shoulder. She received general anesthesia. She was prepped and draped in the usual sterile fashion. I designed a modified C-V flap within a 42 mm circle on the right breast flap in the area of planned nipple reconstruction. The wings of the flaps were raised full-thickness. The base of the flap was left connected to the mastectomy skin. This was secured in layers with 4-0 Vicryl and 5-0 Chromic by stacking the wings and securing the base. The remaining skin within the 42 mm circle was depithelialized to allow for creation of a new areola. A 42 mm circular full thickness skin graft was harvested from the right lateral chest wall and defatted. A 10 cm long ellipse of redundant skin and fat along the right lateral mastectomy scar was then incised down into the subcutaneous fat. It was resected using cautery and sent to pathology for examination. The wound was irrigated with saline and hemostasis was achieved. The defect was closed in layers using 3-0 Vicryl in the dermal layer and 4-0 Monocryl stratafix in the subcuticular layer. Dermabond prineo was applied.

The same procedure was then performed on the left side. Both areaolar full-thickness grafts were placed in normal saline on the back table to be used later.

Attention was then turned to the fat grafting portion of the procedure. After making small incisions with a 15 blade scalpel in the umbilicus I infiltrated approximately 1150 cc of tumescent fluid into the anterior abdominal wall. This was from a solution of 1 L of lactated Ringer's, 1 amp of epinephrine 1:1000, 1% lidocaine plain 50 cc. After waiting several minutes to allow for vasoconstriction we harvested using 10 cc syringes approximately 360 cc of lipoaspirate first deep and then superficially with the coleman fat grafting system blunt tipped 2 mm cannulas. This lipoaspirate was then centrifuged at 3000 RPM for 3 minutes. The mesenchymal stem cell rich layer floating to the top under the intact adipocytes, and the tumescent fluid and scant red blood cells separating to the bottom. The bottom portion was discarded and we were able to then inject the purified fat graft material, from the top layer, into bilateral breasts in a radial, fanning matrix pattern. Using a variety of blunt tip injectors, I injected superiorly to fill in areas of hollowing of the right > left sueprior breast. Addition fat was injection into the anterior skin of both breasts underneath the mastectomy scars to improve her projection. 0.5-1 cc aliquots were placed using a 1 mm needle with a side port. A total of 200 cc was placed over numerous passes. Retrograde injection technique was used, injecting the microaliquots of fat as the blunt tip needle was removed.

The skin grafts were then brought from the back table and fenestrated. They were secured around the nipple flaps with 5-0 chromic sutures. Bolsters were fashioned over the graft with xeroform, cotton balls and 4-0 silk sutures.

The fat grafting incisions were all closed with 5-0 chromic simple sutures. Bandaids were placed on the breast stab incisions. Surgical bra, abdominal pad and binder was placed on the torso. The patient was awoken from anesthesia without complication and transferred to the recovery room in stable condition. At the end of the case all the needle, sponge and instrument counts were correct x 2 and I was present for the entire case.
 

kathrynw

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Administrator
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Hi, Have you looked into these codes? 19366, 19350, 15200, and 20926? Hopefully these codes can lead you in the right direction.
 
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