Preoperative and postoperative diagnoses: Macrmastia, Back pain, Neck pain, Shoulder pain, Shoulder grooving, Intertrigo.
Name of procedure: Right breast reduction of 1950g. Right free-nipple graft. Left breast reduction of 1915g. Left free-nipple graft.
Indications for surgery: The patient is 43 year old female with macromastia and associated back pain, neck pain, shoulder pain, shoulder grooving and intertrigo. She desired a breast reduction. Because of the extreme ptotic nature of her breasts, we felt she would need a free- nipple graft technique. In the preoperative holding are, we marked her for this free nipple graft technique of breast reduction. The patient observed these markings so she could understand the surgery and agree on the location and we proceeded. The patient also was morbidly obese with a body mass index of 54. Because of this, we felt she met the criteria for DVT prophylaxis, which included Lovenox injection. The patient understood this would increase her risk of bleeding. She also made it known she is a Jehovah's witness and refused blood products, but she did understand her risk of bleeding would significantly increase and we proceeded.
Description of Procedure: The patient was given 40mg of subcutaneous Lovenox in the Preoperative holding area. She was the taken to the operating room. Bilateral thigh-high TED hose, in addition to bilateral pneumatic compression stockings were used throughout the procedure. IV Ancef 1g was given. Anesthesia was included. Both arms were secured on padded arm boards using Kerilx rolls. A similar body bear hugger was placed. The chest and abdomen were prepped and draped in sterile fashion. I began by circumscribing around each nipple-areolar complex using a 42-mm areolar marker. On each side the free-nipple grafts were harvested. They were marked to be side specific and were stored on the back table in moistened lap sponges. Meticulous hemostasis was achieved using Bovie cautery. The tail of the apex of each breast was deepithelialized using the scalpel. I amputated the inferior portion of the breast from the right side. Again, meticulous hemostasis was achieved using the Bovie cautery. There were also large feeder vessels divided and ligated using either a medium Ligaclip or 3-0 silk tie sutures. I then moved to the left and again amputated the inferior portion of the breast. Meticulous hemostasis was achieved using the Bovie cautery.
Each of these wounds was temporarily closed using the skin stapler. The patient was the sat up. I felt we had achieved every symmetrical result. The new positions for the nipple-areolar complexes were deepithelialized using the scalpel. Meticulous hemostasis was achieved again using the Bovie cautery. The free-nipple grafts were the retrieved from the back table. They were each defatted using scissors and were placed in an only fashion on the appropriate side and each was inset using 5-0 plain sutures. Vents were made in the skin graft to allow for the egress of fluid on each side. A vertical mattress suture was used, tied over a piece of Xeroform in critical areas of each of the nipple-areolar complexes. A Xeroform bolster wrapped over a mineral oil- moistened sponge was fixed to each of the nipple-areolar complexes using 5-0 nylon suture. The vertical and transvrse incisions were closed using 3-0 Monocryl, both interrupted and running suture, and 5-0 Polene. The patient tolerated the proceudre well. Again meticulous hemostasis was achieved using the Bovie cautery. She was given another 1g of Ancef at the 2 hour mark by our anesthesiologist and was taken to the recovery room in good condition. What CPT
codes are reported?
a. 19316-50, 19355-59-50
b. 19318-50, 19350-59-50
c. 19318-50, 19355-59-50
d. 19340-50, 19350-59-50
Answer: b. 19318-50, 19350-59-50
19318 is the CPT code for breast reduction. The modifier 50 is given to indicate the bilateral procedure since, breast reduction was done to both left and right. Free nipple grafts are also done along with it . The code 19350 is given which indicates Nipple/areola reconstruction is given with modifier 59 since it is a distinct procedural service. Again this procedure is also done to both left and right nipple hence the modifier 50.
Name of procedure: Right breast reduction of 1950g. Right free-nipple graft. Left breast reduction of 1915g. Left free-nipple graft.
Indications for surgery: The patient is 43 year old female with macromastia and associated back pain, neck pain, shoulder pain, shoulder grooving and intertrigo. She desired a breast reduction. Because of the extreme ptotic nature of her breasts, we felt she would need a free- nipple graft technique. In the preoperative holding are, we marked her for this free nipple graft technique of breast reduction. The patient observed these markings so she could understand the surgery and agree on the location and we proceeded. The patient also was morbidly obese with a body mass index of 54. Because of this, we felt she met the criteria for DVT prophylaxis, which included Lovenox injection. The patient understood this would increase her risk of bleeding. She also made it known she is a Jehovah's witness and refused blood products, but she did understand her risk of bleeding would significantly increase and we proceeded.
Description of Procedure: The patient was given 40mg of subcutaneous Lovenox in the Preoperative holding area. She was the taken to the operating room. Bilateral thigh-high TED hose, in addition to bilateral pneumatic compression stockings were used throughout the procedure. IV Ancef 1g was given. Anesthesia was included. Both arms were secured on padded arm boards using Kerilx rolls. A similar body bear hugger was placed. The chest and abdomen were prepped and draped in sterile fashion. I began by circumscribing around each nipple-areolar complex using a 42-mm areolar marker. On each side the free-nipple grafts were harvested. They were marked to be side specific and were stored on the back table in moistened lap sponges. Meticulous hemostasis was achieved using Bovie cautery. The tail of the apex of each breast was deepithelialized using the scalpel. I amputated the inferior portion of the breast from the right side. Again, meticulous hemostasis was achieved using the Bovie cautery. There were also large feeder vessels divided and ligated using either a medium Ligaclip or 3-0 silk tie sutures. I then moved to the left and again amputated the inferior portion of the breast. Meticulous hemostasis was achieved using the Bovie cautery.
Each of these wounds was temporarily closed using the skin stapler. The patient was the sat up. I felt we had achieved every symmetrical result. The new positions for the nipple-areolar complexes were deepithelialized using the scalpel. Meticulous hemostasis was achieved again using the Bovie cautery. The free-nipple grafts were the retrieved from the back table. They were each defatted using scissors and were placed in an only fashion on the appropriate side and each was inset using 5-0 plain sutures. Vents were made in the skin graft to allow for the egress of fluid on each side. A vertical mattress suture was used, tied over a piece of Xeroform in critical areas of each of the nipple-areolar complexes. A Xeroform bolster wrapped over a mineral oil- moistened sponge was fixed to each of the nipple-areolar complexes using 5-0 nylon suture. The vertical and transvrse incisions were closed using 3-0 Monocryl, both interrupted and running suture, and 5-0 Polene. The patient tolerated the proceudre well. Again meticulous hemostasis was achieved using the Bovie cautery. She was given another 1g of Ancef at the 2 hour mark by our anesthesiologist and was taken to the recovery room in good condition. What CPT
codes are reported?a. 19316-50, 19355-59-50
b. 19318-50, 19350-59-50
c. 19318-50, 19355-59-50
d. 19340-50, 19350-59-50
Answer: b. 19318-50, 19350-59-50
19318 is the CPT code for breast reduction. The modifier 50 is given to indicate the bilateral procedure since, breast reduction was done to both left and right. Free nipple grafts are also done along with it . The code 19350 is given which indicates Nipple/areola reconstruction is given with modifier 59 since it is a distinct procedural service. Again this procedure is also done to both left and right nipple hence the modifier 50.