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Mastectomy, simple, complete

CPT4 code

Name of the Procedure:

Mastectomy, Simple, Complete

  • Common Name: Simple Mastectomy
  • Medical Terms: Total Mastectomy

Summary

A simple mastectomy is a surgical procedure involving the removal of an entire breast, including the nipple, areola, and most of the overlying skin. It is primarily used to treat or prevent breast cancer.

Purpose

  • Medical Condition: Treatment of breast cancer or as a preventive measure for those at high risk.
  • Goals: To remove cancerous tissues and reduce the risk of cancer spreading or recurring.

Indications

  • Diagnosed breast cancer.
  • Genetic mutations (e.g., BRCA1 or BRCA2).
  • Large or multifocal tumors.
  • Recurrence of cancer in the breast.

Preparation

  • Pre-procedure Instructions:
    • Fasting may be required if general anesthesia is used.
    • Medication adjustments, especially blood thinners.
    • Arrange for post-surgery transportation and support.
  • Diagnostic Tests:
    • Blood tests.
    • Imaging studies like mammograms or MRIs.
    • Biopsy results.

Procedure Description

  1. Anesthesia: Administered general anesthesia.
  2. Incision: A horizontal or diagonal incision is made across the breast.
  3. Removal: Entire breast tissue, including the nipple, areola, and part of the skin, are removed.
  4. Drain Placement: Temporary drains may be placed to remove fluids.
  5. Closure: Incision is closed with sutures or surgical staples.
  6. Dressings: Sterile dressings are applied to the wound.

Duration

Approximately 1-3 hours, depending on the complexity and whether simultaneous reconstruction is performed.

Setting

Performed in a hospital or surgical center.

Personnel

  • Lead Surgeon (performing the mastectomy).
  • Surgical nurses.
  • Anesthesiologist (administering anesthesia).
  • Technicians and possibly a plastic surgeon (if reconstruction is planned).

Risks and Complications

  • Common Risks: Infection, bruising, swelling.
  • Rare Risks: Bleeding, complications from anesthesia, blood clots, seroma (fluid buildup), nerve damage.
  • Management: Antibiotics to prevent infection, pain management, and monitoring for complications.

Benefits

  • Effective removal of cancerous tissues.
  • Decreased risk of cancer recurrence.
  • Potential peace of mind for high-risk patients.

Recovery

  • Post-procedure Care: Wound care instructions, drainage management, medications for pain and preventing infection.
  • Recovery Time: Typically 4-8 weeks.
  • Restrictions: Avoid heavy lifting and strenuous activities. Follow-up appointments for wound check and drain removal.

Alternatives

  • Lumpectomy: Only the tumor and a small margin of tissue are removed.
    • Pros: Conserves most of the breast.
    • Cons: Often requires radiation therapy.
  • Double Mastectomy: Removal of both breasts.
    • Pros: Reduces risk of cancer in the second breast.
    • Cons: More extensive surgery and longer recovery.

Patient Experience

During the procedure, the patient will be under general anesthesia and will not feel pain. Post-operative pain and discomfort are managed with medications. Patients may experience emotional and physical changes, and support from healthcare professionals, counselors, or support groups is encouraged.

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