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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
- Anesthesia: Administered general anesthesia.
- Incision: A horizontal or diagonal incision is made across the breast.
- Removal: Entire breast tissue, including the nipple, areola, and part of the skin, are removed.
- Drain Placement: Temporary drains may be placed to remove fluids.
- Closure: Incision is closed with sutures or surgical staples.
- 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.