Name of the Condition

• Capsular Contracture of Breast Implant, Initial Encounter
• Medical term: T85.44XA

Summary

Capsular contracture is a condition that occurs when the scar tissue, which naturally forms around a breast implant, tightens and squeezes the implant. This can result in pain, changes in breast appearance, and implant distortion.

Causes

• The precise cause is not well understood but may include inflammation around the implant, bacterial contamination, hematoma (blood accumulation), or rupture of the implant.

Risk Factors

• History of breast surgery or trauma.
• Immunologic responses.
• Certain bacterial infections.
• Tobacco use.
• Radiation therapy to the breast area.

Symptoms

• Tightness or hardness of the breast.
• Pain or discomfort, especially when lying down.
• Distortion or misshaped appearance of the breast.
• Changes in breast position or symmetry.

Diagnosis

• Physical examination by a healthcare provider.
• Imaging tests such as ultrasound or MRI to assess the condition and exclude other issues like rupture.

Treatment Options

• Non-surgical options include massage and medications to reduce inflammation and pain.
• Surgical intervention can involve capsulotomy (opening the capsule) or capsulectomy (removal of the capsule and possibly replacing the implant).

Prognosis and Follow-Up

• Follow-up includes regular monitoring by healthcare providers to assess any progression or recurrence.
• Prognosis is generally good with appropriate treatment, although recurrence can happen.

Complications

• Persistent pain and discomfort.
• Further distortion of breast shape.
• Implant rupture or a need for implant removal or replacement.

Lifestyle & Prevention

• Regular follow-ups and screenings post-surgery.
• Adherence to post-operative care instructions to minimize infection.
• Smoking cessation may reduce risk.

When to Seek Professional Help

• Unusual pain or severe discomfort.
• Noticeable changes in the shape or appearance of the breast.
• Signs of infection like redness, swelling, or fever.

Additional Resources

• American Society of Plastic Surgeons: https://www.plasticsurgery.org/
• Breastcancer.org: https://www.breastcancer.org/

Tips for Medical Coders

• Ensure the documentation specifies "initial encounter" to use the correct code.
• Verify any underlying issues like implant rupture, as these might require additional coding.
• Avoid confusing capsular contracture with other breast implant complications.