Reference no: EM133170382

Operation: Left transaxillary subpectoral mammoplasty with saline-filled implant.

Preoperative diagnosis: Left hypomastia.

Postoperative diagnosis: Left hypomastia.

Anesthesia: General.

Procedure: After first obtaining a suitable level of general anesthesia with the patient in the supine position, the breasts were prepped with Betadine scrub and solution. Sterile towels, sheets, and drapes were placed in the usual fashion for surgery of the breasts. Following prepping and draping, the anterior axillary folds and the inframammary folds were infiltrated with a total of 20 cc of 0.5 percent Xylocaine with 1:200,000 units of epinephrine.

After a suitable hemostatic waiting period, transaxillary incisions were made, and dissection was carried down to the edge of the pectoralis fascia. Blunt dissection was then used to form a bilateral subpectoral pocket. Through the subpectoral pocket a sterile suction tip was introduced, and copious irrigation with sterile saline solution was used until the irrigant was clear.

Following completion of irrigation, 250-cc saline-filled implants were introduced. They were first filled with 60 cc of saline and checked for gross leakage; none was evident. They were overfilled to 300 cc of saline each. The patient was then placed in the seated position, and the left breast needed 10 cc of additional fluid for symmetry.

Following completion of the filling of the implants and checking the breasts for symmetry, the patient's wounds were closed with interrupted vertical mattress sutures of 4-0 Prolene. Flexan dressings were applied, followed by the patient's bra. She seemed to tolerate the procedure well.

Choose the appropriate CPT and ICD-10-CM codes:

Multiple Choice

• 19316-LT, N64.82
• 19324-LT, N64.82
• 19325-LT, N64.82
• 19328-LT, N64.82