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Incision and drainage, deep abscess or hematoma, soft tissues of neck or thorax

CPT4 code

Name of the Procedure:

Incision and Drainage of Deep Abscess or Hematoma in Soft Tissues of Neck or Thorax


Incision and drainage is a surgical procedure used to treat deep abscesses or hematomas in the soft tissues of the neck or thorax. It involves making a small incision to drain accumulated pus or blood, helping relieve pain and reduce infection risk.


This procedure addresses abscesses (pockets of pus) or hematomas (collections of blood) that form in the soft tissues of the neck or chest. The main goals are to relieve pain, prevent the spread of infection, and promote healing.


  • Swelling, redness, and tenderness in the affected area
  • Pain and discomfort
  • Presence of an abscess or hematoma confirmed by imaging tests (e.g., ultrasound)
  • Signs of infection like fever and increased white blood cell count


  • Fasting for 6-8 hours before the procedure if general anesthesia is used
  • Stopping certain medications as advised by the doctor
  • Blood tests and imaging studies for evaluation beforehand
  • Pre-procedural consultations with the surgical team

Procedure Description

  1. The patient is either given local anesthesia (numbs the area) or general anesthesia (puts the patient to sleep).
  2. A sterile field is prepared, and the surgical site is cleaned.
  3. A small incision is made over the abscess or hematoma.
  4. Pus or blood is drained out and the area is irrigated with saline.
  5. Sometimes, a drain may be placed to allow ongoing drainage.
  6. The incision is closed with sutures or left open (partially) to heal from the inside out.
  7. A sterile dressing is applied.


The procedure typically takes about 30 minutes to an hour.


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


  • Surgeon
  • Surgical nurse
  • Anesthesiologist (if general anesthesia is used)
  • Medical assistant (if required)

Risks and Complications

  • Infection at the incision site
  • Bleeding or hematoma formation
  • Damage to surrounding tissues
  • Pain at the incision site
  • Scarring


  • Relief from pain and swelling
  • Prevention of infection spread
  • Faster recovery and healing
  • Improved function and mobility


  • Keep the incision site clean and dry
  • Follow wound care instructions provided by the healthcare team
  • Pain management with prescribed medications
  • Avoid strenuous activities for a few weeks
  • Follow-up appointments to monitor healing and remove any drains or stitches


  • Antibiotic therapy for less severe infections (may be less effective without drainage)
  • Needle aspiration (less invasive but may not be sufficient for large or deep collections)
  • Watchful waiting (for small, uncomplicated hematomas that might resolve on their own)

Patient Experience

  • Patients may feel stinging from anesthesia and pressure during the procedure.
  • Mild to moderate pain is common post-procedure, managed with medications.
  • Some swelling and redness can be expected but should decrease over time.
  • Most patients can resume normal activities within a few weeks with minimal discomfort.

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