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Pre-op Diagnosis: Breast mass in female [N63.0]
Post-op Diagnosis: SAME
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CPT Code: Procedure: DIAGNOSTIC EXCISION LEFT BREAST MASS
*PR EXCISE BREAST CYST
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ICD-10 : Post-Op Diagnosis Codes:
* Breast mass in female [N63.0]
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Specimens:
ID Type Source Tests Collected by Time
A : palpable mass left breast Breast Breast, Left SURGICAL PATHOLOGY TISSUE EXAM
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Findings: dense inframammary ridge bilaterally, more pronounced left lower inner parasternal breast margin with ill-defined mass effect. A curved incision was made more centrally with a thick flap created to the area of interest which is generously excised using Harmonic Focus to avoid cautery with her pacemaker in place. At conclusion there is a deliberate flattening of the area without marked contour loss and incision is closed in layers. I did not place a clip.
Indications: She has a prominent inframammary ridge, more so on the left with a slight swelling in the left lower inner quadrant adjacent to the sternum. Imaging discloses no pathology. I performed a needle biopsy and that was nondescript tissue and I would have expected fat necrosis. As an alternative to continued monitoring, she and I decided to pursue a diagnostic excision both to remove the mass but also to assure absence of a proliferative disorder.
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Description of Procedure: In the supine position with appropriate monitoring she received general anesthesia with IV antibiotic. The left breast is prepped with chlorhexidine and draped after 3 minutes. A curved incision is made about 3 fingerbreadths from the lower inner quadrant breast margin, scalpel enters the subcutaneous adipose tissue and I now used Harmonic Focus with a thick 6 mm flap dissected to the medial most margin, and then circumferentially until amputated. I take a small volume more inferiorly to result in a smooth transition and deliberate flattening (the mound has been removed). I used 4-0 Vicryl suture and create a lateral subcutaneous flap and attached superficial aspect of this carried medially to the underside of the medialmost flap. A few more simple interrupted subcutaneous sutures were placed and then the skin closed with subcuticular technique. A Steri-Strip was used as a dressing, she tolerated a Steri-Strip before but otherwise is intolerant of other adhesives. She is now awakened and extubated, transported to PACU.
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