Insertion or replacement of breast implant on separate day from mastectomy

CPT4 code

Name of the Procedure:

Insertion or Replacement of Breast Implant (Delayed Breast Reconstruction)

Summary

This procedure involves placing or replacing a breast implant after a previous mastectomy, which is the surgical removal of one or both breasts to treat or prevent breast cancer. The implant helps restore the shape and appearance of the breast.

Purpose

This procedure aims to reconstruct the breast mound for cosmetic and psychological benefits following breast cancer treatment. It helps improve body image, self-esteem, and overall quality of life.

Indications

Previous mastectomy for breast cancer.
Patient desire for breast reconstruction.
Adequate healthy tissue at the surgical site.
No active infection or cancer recurrence at the surgical site.
Physical and emotional readiness for the procedure.

Preparation

Pre-operative consultation with a plastic surgeon to discuss goals and expectations.
Medical evaluation and clearance, including blood tests and imaging studies.
Possible adjustments to current medications as directed by the healthcare provider.
Fasting for a specified period before the procedure, usually from midnight the night before surgery.

Procedure Description

Anesthesia: The patient is placed under general anesthesia for the duration of the procedure.
Incision: An incision is made at the mastectomy scar or a new site, depending on the specific case.
Implant Placement: A breast implant is inserted into a pocket either underneath the pectoral muscle or on top, depending on the patient's anatomy and previous surgeries.
Closure: The incision is carefully sutured, and dressings or a surgical bra is applied to support healing.

Duration

The procedure typically takes 1 to 2 hours.

Setting

The procedure is performed in a hospital operating room or an outpatient surgical center.

Personnel

Plastic Surgeon
Surgical Nurses
Anesthesiologist
Surgical Technicians

Risks and Complications

Infection
Bleeding or hematoma
Capsular contracture (scar tissue around the implant)
Implant rupture or leakage
Asymmetry or unsatisfactory aesthetic result
Anesthesia-related risks
Pain and/or changes in nipple sensation

Benefits

Restoration of breast appearance and body symmetry.
Improved psychological well-being and self-confidence.
Most patients report long-term satisfaction with the results.

Recovery

Post-operative instructions include rest, limited physical activity, and wound care.
Pain management with prescribed medications.
Wearing a surgical bra or compression garment.
Follow-up appointments to monitor healing and address any concerns.
Most patients return to normal activities within 4 to 6 weeks.

Alternatives

Autologous tissue reconstruction (using the patient's own tissue instead of an implant).
External breast prosthesis (non-surgical option for breast appearance).
Decision to remain flat without reconstruction.

Patient Experience

During the procedure, patients are asleep under general anesthesia and will not feel anything.
Post-operative discomfort and swelling are common and managed with pain medications.
Mild to moderate pain can be expected, which usually subsides over days to weeks.
Support from medical staff and loved ones is crucial for emotional and physical recovery.