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Removal of tissue expander without insertion of implant

CPT4 code

Name of the Procedure:

Removal of Tissue Expander without Insertion of Implant

Summary

This procedure involves surgically removing a tissue expander, which is a device used to stretch skin and tissue to prepare for a permanent implant. No new implant is placed during this surgery.

Purpose

The primary purpose of this procedure is to remove the tissue expander after it has served its purpose of creating sufficient space in the tissue. This may be necessary if the patient is not immediately ready to receive a permanent implant or decides against further reconstruction.

Indications

  • Completion of the tissue expansion process.
  • Patient's decision against further immediate reconstructive surgery.
  • Complications such as infection or discomfort related to the tissue expander.
  • Delaying or canceling the insertion of a permanent implant for medical or personal reasons.

Preparation

  • Patients may be advised to fast for at least 8 hours before the procedure.
  • Medication adjustments, especially blood thinners, may be necessary.
  • Preoperative assessment and diagnostic tests, such as blood work or imaging studies, may be conducted.

Procedure Description

  1. The patient is given local or general anesthesia, depending on the extent of the surgery and individual needs.
  2. An incision is made over the area where the tissue expander is located.
  3. The surgeon carefully removes the tissue expander.
  4. The surgical area is examined for any signs of infection or complications.
  5. Once confirmed to be in order, the incision is closed with sutures.
  6. A sterile dressing is applied over the surgical site.

Duration

The procedure typically takes about 30 to 60 minutes.

Setting

The surgery is usually performed in a hospital or an outpatient surgical center.

Personnel

  • Surgeon
  • Surgical nurse
  • Anesthesiologist or nurse anesthetist
  • Operating room technician

Risks and Complications

  • Infection at the incision site.
  • Bleeding or hematoma formation.
  • Scarring or dissatisfaction with cosmetic results.
  • Pain or discomfort post-procedure.
  • Rarely, allergic reactions to anesthesia.

Benefits

  • Removal of the expander can relieve any associated discomfort.
  • Prevention of potential complications linked to long-term expander use.
  • Allows the patient time to consider further reconstructive options.

Recovery

  • Post-procedure care includes managing pain with prescribed medication and keeping the surgical site clean and dry.
  • Patients are usually advised to avoid strenuous activities for several days.
  • Follow-up appointments are necessary to monitor healing and discuss further reconstruction plans if desired.
  • Most patients recover within 1 to 2 weeks.

Alternatives

  • Keeping the tissue expander in place longer, if medically advisable.
  • Proceeding with the insertion of a permanent implant immediately.
  • Choosing non-surgical methods for dealing with the underlying condition.

Patient Experience

During the procedure, patients under general anesthesia will be unconscious and feel no pain. Those with local anesthesia will be awake but numb at the surgical site. After the procedure, some discomfort or mild pain is expected, which is manageable with medication. Patients may also experience mild swelling or bruising around the surgical area.

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