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Incision and drainage of soft tissue abscess, subfascial (ie, involves the soft tissue below the deep fascia)

CPT4 code

Name of the Procedure:

Incision and drainage of soft tissue abscess, subfascial
Common Name: Subfascial Abscess Drainage

Summary

Incision and drainage of a subfascial soft tissue abscess is a surgical procedure used to treat infections that are located beneath the deep fascia. The procedure involves making an incision in the skin and fascia to allow the infected material to drain out.

Purpose

This procedure is used to treat abscesses that occur under the deep fascia, a layer of fibrous tissue. The goals are to relieve pain, reduce infection, and prevent the spread of infection.

Indications

  • Persistent or severe localized pain and swelling
  • Signs of infection such as redness, warmth, and tenderness
  • Fever or other systemic signs of infection
  • Failure of more conservative treatments like antibiotics

Preparation

  • Patients may be advised to fast for several hours before the procedure.
  • Blood tests to check for infection and blood clotting status.
  • Imaging studies, such as an ultrasound or MRI, to locate the abscess.

Procedure Description

  1. The patient will be anesthetized, which may involve local, regional, or general anesthesia depending on the size and location of the abscess.
  2. The area over the abscess will be cleaned and prepared in a sterile manner.
  3. The surgeon will make an incision over the abscess site and through the fascia to reach the abscess cavity.
  4. The pus and infected material will be drained out.
  5. The cavity may be washed with saline solution to ensure all infected material is removed.
  6. A drain might be placed to allow any residual infection to continue draining.
  7. The incision will be closed or left partially open to allow continued drainage, depending on the case.

Duration

The procedure typically takes 30 minutes to an hour.

Setting

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

Personnel

  • Surgeon
  • Surgical nurse
  • Anesthesiologist or nurse anesthetist
  • Possibly a surgical assistant

Risks and Complications

  • Infection at the incision site
  • Bleeding
  • Damage to nearby tissues or organs
  • Recurrence of the abscess
  • Scarring and delayed wound healing

Benefits

  • Relief from pain and pressure caused by the abscess
  • Reduction in infection and prevention of its spread
  • Quick return to normal activities and health

Recovery

  • Patients may need to take antibiotics post-procedure.
  • Pain management with prescribed medications.
  • Keep the wound clean and dry; follow specific wound care instructions.
  • Follow-up appointments to monitor healing and check for recurrence.
  • Generally, full recovery can be expected within a few weeks.

Alternatives

  • Antibiotic therapy alone, although it is often not sufficient for subfascial abscesses.
  • Image-guided needle aspiration, which might be less invasive but also less effective.
  • Observation and symptomatic treatment for small abscesses that might resolve on their own.

Patient Experience

  • Patients may experience mild to moderate discomfort during healing.
  • Pain can be managed with prescribed medications.
  • Numbness or tingling in the area may occur temporarily.
  • Encouragement to contact healthcare providers if experiencing fever, increased pain, or any signs of recurrent infection.

Feel free to reach out with any additional questions or for more specific details related to your health condition.

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