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Mastotomy with exploration or drainage of abscess, deep

CPT4 code

Name of the Procedure:

Mastotomy with Exploration or Drainage of Abscess, Deep

Summary:

A mastotomy with exploration or drainage of an abscess is a surgical procedure where an incision is made in the breast tissue to locate and either explore or drain a deep abscess. This helps to relieve pain, treat the infection, and prevent further complications.

Purpose:

  • Medical Condition: Addresses deep breast abscesses, which are pockets of infection.
  • Goals: To alleviate pain, remove infected material, and promote healing.

Indications:

  • Persistent or recurrent breast pain.
  • Swelling or redness in the breast.
  • Fever or other signs of infection.
  • Failure of less invasive treatments (e.g., antibiotics) to resolve the abscess.

Preparation:

  • Fasting: Usually required for a few hours before the procedure.
  • Medications: Adjustments may be needed as per doctor’s advice.
  • Diagnostics: Ultrasound or mammogram to locate the abscess.

Procedure Description:

  1. Incision: A small cut is made in the breast over the abscess.
  2. Exploration: Surgical tools are used to locate the abscess.
  3. Drainage: The abscess is drained of pus and other infected material.
  4. Cleaning: The area is cleaned and sometimes irrigated with saline.
  5. Closure: The incision may be left open to drain or closed with sutures, depending on the situation.
  • Tools: Scalpels, forceps, suction devices.
  • Anesthesia: Local anesthesia to numb the area, possibly sedation.

Duration:

The procedure usually takes between 30 minutes to 1 hour.

Setting:

Performed in a hospital or outpatient surgical center.

Personnel:

  • Surgeon
  • Surgical nurse
  • Anesthesiologist or nurse anesthetist

Risks and Complications:

  • Common: Pain, bleeding, infection, and scarring.
  • Rare: Damage to surrounding tissue, recurrence of the abscess, adverse reactions to anesthesia.

Benefits:

  • Immediate relief from pain and symptoms of infection.
  • Successful drainage usually leads to a rapid decline in infection symptoms.

Recovery:

  • Post-Procedure Care: Wound care instructions, possible drainage tube care, antibiotics.
  • Recovery Time: Typically a few days to a week for initial recovery. Full healing in a few weeks.
  • Restrictions: Limited physical activity, follow-up appointments for wound inspection and suture removal.

Alternatives:

  • Antibiotics: May be tried initially if the abscess is not too severe.
  • Needle Aspiration: Less invasive but might not be suitable for deep abscesses.
  • Pros and Cons: Antibiotics alone may not be effective; needle aspiration might not completely resolve deeper infections.

Patient Experience:

  • During: Minimal discomfort due to anesthesia.
  • After: Some pain and soreness, manageable with over-the-counter or prescribed pain relievers.
  • Pain Management: Analgesics and antibiotics to control pain and infection.

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