1. History of breast cancer.
2. Status post bilateral mastectomy and reconstruction with deep inferior epigastric perforator flaps.
3. Asymmetry of the breasts.
4. Contour deformity of the upper breasts with the left side being smaller.
1. Revision of reconstructed right and the left breast by removal of the skin paddle and performing local tissue rearrangement in the form of mastopexy.
2. Correction of the contour deformity and the volume asymmetry of the right and the left breast by fat grafting.
3. Harvesting of the fat from the upper abdomen, lower abdomen, and flanks and hips.
INDICATIONS FOR THE OPERATION: This is a patient who basically has had previous operation for breast cancer. She has mastectomy and reconstruction with a DIEP flap. She has now asymmetry of the breasts with the breasts being more ptotic. The skin island was much below the nipple-areolar complex area. It appeared to be on measurements that she has lost some weight and suffers from ptotic breasts, and she has contour deformity of the upper breasts with volume asymmetry with the left side being smaller.
DESCRIPTION OF PROCEDURE: With that in mind, she was marked in the preoperative holding area; the Wise pattern and then after that the area where the fat to be harvested, and then the patient was taken to the operating room and placed in the supine position. Anesthesia was induced. The area was prepped and draped in the usual sterile fashion. Starting with the tumescent solution, multiple stab incisions at the previous incision inferiorly were made, and then tumescent solution was injected in the right and left flanks, upper abdomen, and lower abdomen. The total amount that was injected was almost 1800 mL. Then, while waiting for the vasoconstriction effect, using the Wise pattern, breast revision in the form of mastopexy with a local tissue rearrangement was done. The skin was deepithelialized. The skin pedicle was removed and then elevated superiorly. The mastectomy flaps on either side were advanced and closed in basically an inverted-T incision. The same was done on the left side. The patient was placed in the upright position, and looked very good after doing the local tissue rearrangement and the excision of the skin paddle on both sides. There was definitely a contour deformity medially and superiorly on the left and also on the right and volume difference. So, with that in mind, we elected to harvest the fat. First, pretunneling was done. The fat was harvested with the size 3 cannula under low machine suction. Multiple pretunneling was done passing in both flanks. The amount of the fat that was harvested from the flanks was in symmetrical fashion, upper abdomen and the lower abdomen. The fat that was harvested, total aspirate was about 2 liters. That was taken to be washed. It was in a closed suction system called red ball. Then after that, using a small cannula, 2.5 mm, feathering to smoothen the area of the upper abdomen, lower abdomen, and the flanks was done, and total amount that was suctioned with the feathering was about 2000 mL. Meanwhile, after the fat was purified and washed, it was injected in multiple planes in small quantity about 5 to 10 mL used with a small cannula. It was mainly to correct the contour deformity, so most of the injection was deep dermal and subcutaneous tissue. There was no intramuscular injection. Then, the same was done on the left side. The total amount that was injected on the right was 200 mL and on the left was 320 mL because of the volume difference. The patient was placed in the upright position to look for the symmetry that was improved. Then after that, the incisions were closed with interrupted 5-0 Prolene. Compression garment was placed onto the abdomen. On the breasts, a non-pressure dressing was applied. The patient was transferred to the recovery room with stable vital signs and in stable condition.
I would code this with CPT 19380 - Revision of reconstructed breast. This code includes repositioning the breast; making adjustments to the inframammary crease; making capsular adjustments; and performing scar revisions, fat grafting, liposuction, and so on.
See CPT® Assistant December 2017 / Volume 27 Issue 12
CPT Assistant, December 2017 Page: 13 Category: Frequently Asked Questions
Surgery: Integumentary System
Does the procedure described by code 19380 include making a separate incision from the previous breast construction area to achieve symmetry if the elliptical incision measures 10 cm on the lateral chest, for example, not inclusive of the mammary fold?
CPT code 19380, Revision of reconstructed breast, is a global service that includes all maneuvers involved in revising an already reconstructed breast, even when multiple maneuvers are performed. This includes repositioning the breast; making adjustments to the inframammary crease; making capsular adjustments; and performing scar revisions, fat grafting, liposuction, and so on. Therefore, it is not appropriate to report additional codes.