How should removal of free silicone be coded?
Is 19330 appropriate for removal of retained free silicone?
Would debridement of muscle apply?
Patient Background- Patient underwent injection of free silicone in the 60's. In 2000, underwent bilateral mastectomies for this free silicone to alleviate inflammation and pain. She underwent ultrasound in July of this year which revealed
significant retained free silicone at these regions.
"A total of 23 x 6 cm of right chest wall excess skin was subsequently removed
using a mixture of sharp dissection and electrocautery. There did appear to be silicone
damaged skin just below this region. An additional 16 x 2.5 cm of skin was excised and this
was added to specimen. The right excess skin was sent to pathology for further evaluation.
Attention was turned towards the free silicone. There appeared to be extensive damage to
the skin, soft tissue, and muscle of the right chest wall due to the free silicone
injection. This damage extended into the right pectoralis major muscle. A total of 11 x 12
cm of deep dermis, subcutaneous tissue, and right pectoralis major muscle was debrided
during this process. Free silicone was also removed during this process. This dissection
was performed using a mixture of sharp dissection and electrocautery. Of note, some of the
skin flap superiorly did appear quite thin due to removal of the scar tissue and the free
silicone. This silicone damaged tissue and free silicone of the right breast was sent to
pathology for further evaluation. Adequate hemostasis was achieved using electrocautery.
What remained of the right pectoralis major muscle was tacked down to the chest wall using
horizontal mattress 2-0 Vicryl sutures. Given the size of the defect, the decision was made
to reconstruct this region with bilateral advancement flaps. The superior flap was
comprised of skin and soft tissue from the upper chest wall. The inferior flap consisted of
a reverse abdominoplasty abdominal flap of tissue which was advanced up into the defect.
This flap was elevated off of underlying muscle fascia from the upper abdomen using
electrocautery. A total of 11 x 12 cm of tissue was mobilized from the upper chest wall and
advanced over the defect. A total of 10 x 16 cm was mobilized from the upper abdomen as a
reverse abdominoplasty flap and advanced up over the defect. This did appear to adequately
reconstruct the defect. Attention was then turned towards the left chest wall. The excess
skin that had been marked with the patient sitting up preoperatively was excised using a
mixture of sharp dissection and electrocautery. Dissection proceeded in a subcutaneous
plane. A total of 22 x 4 cm of left chest wall excess skin was removed. This excess skin
was sent to pathology for further evaluation. Attention was then turned towards the free
silicone and the scar tissue at the left chest. Again, there appeared to be significant
damage to the skin, the subcutaneous tissue, and pectoralis major muscle at the left chest.
In addition, the damage did extend up into the left axillary region. A total of 9 x 16 cm
of skin, subcutaneous tissue, and left pectoralis major muscle was excised during this
debridement. Free silicone was also removed during this process. Again, the debridement
did extend up into the left axillary region. The left breast silicone damaged tissue and
free silicone was sent to pathology for further evaluation. Again, given the size of the
defect, the decision was made to proceed with bilateral advancement flap closure of the left
chest as well. A total of 9 x 16 cm of skin and soft tissue was elevated and advanced over
the defect from the upper chest wall. A reverse abdominoplasty flap was performed at the
upper left abdominal wall. The skin and soft tissue flap was raised in a suprafascial plane
using electrocautery. A total of 8 x 15 cm of tissue was mobilized and advanced over the
defect during this process. The bilateral advancement did appear to adequately cover the
defect. 15 Blake drains were then placed. One was placed at the upper left chest wall, the
second was placed at the upper abdominal wall. The third was placed at the upper right
chest wall, and a fourth was placed at the right upper abdominal wall. These drains were
affixed to the skin with nylon sutures. The entirety of the wound was irrigated copiously
with sterile saline containing bacitracin. Adequate hemostasis was achieved using
electrocautery. The deep tissue of both left and right advancement flaps were closed with
interrupted 2-0 Vicryl deep tissue sutures. The deep dermal layer of bilateral advancement
flaps were then closed with interrupted 3-0 Monocryl sutures. The skin of bilateral
advancement flaps were then closed with skin staples.
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