Implant-Based Breast Reconstruction

CPT 19340
Approach Open
Add-on / Variant CPTs
  • 19342 — Delayed insertion of breast prosthesis
  • 19325 — Mammaplasty, augmentation with implant
  • 19357 — Breast reconstruction with tissue expander
Preoperative Diagnosis:

Status post mastectomy for [breast cancer / BRCA prophylaxis]

Postoperative Diagnosis:

Same

Procedure Performed:

[Immediate / delayed] implant-based breast reconstruction [with / without] acellular dermal matrix (ADM), [right / left / bilateral]

Attending Surgeon:

[Attending name], MD

First Assistant:

[Resident/Fellow/PA name]

Anesthesia:

General endotracheal
Patient supine with arms out on arm boards. Intraoperative positioning assessment in upright position.

Indications:

Patient with [breast cancer / BRCA mutation] status post [skin-sparing / nipple-sparing] mastectomy by the breast surgery team. Patient desires [implant-based / direct-to-implant / tissue expander] reconstruction. Body habitus and skin envelope [adequate / limited]. Prior radiation [history / none]. Implant type, size, and position discussed. Risks including infection, implant failure, capsular contracture, rippling, and asymmetry discussed. Consent obtained.

Findings:

Skin flap perfusion [adequate / limited]. [Nipple-areolar complex perfusion confirmed with SPY/ICG angiography.] Mastectomy pocket dimensions [X x Y] cm. Selected implant: [Allergan / Mentor / Sientra] [round / shaped] [X] cc [smooth / textured] silicone gel implant.

Description of Procedure:

The patient was positioned supine and the breast was prepped and draped in sterile fashion in coordination with the breast surgery team following mastectomy. [Pocket irrigation with triple antibiotic solution (bacitracin, cefazolin, gentamicin) performed.]
The pectoralis major muscle was elevated off the chest wall from its inferior and lateral border using electrocautery. [An acellular dermal matrix (ADM) [Alloderm / Flex HD], sized [X x Y] cm, was sutured to the inferior border of the pectoralis using 2-0 Vicryl, creating a complete implant pocket.] The implant pocket was irrigated again with antibiotic solution.
A [X]-cc [manufacturer] silicone gel implant was inserted into the pocket in a no-touch technique using a Keller funnel. The implant was positioned [centrally / appropriately]. The pectoralis and ADM were closed over the implant with [running 2-0 Vicryl]. The patient was raised to 60 degrees for intraoperative assessment. Implant position [symmetric / satisfactory]. Skin closed in layers with 3-0 Monocryl deep dermis and 4-0 Monocryl subcuticular. Steri-strips applied.
[For tissue expander:] A [X]-cc expander was placed. Filled intraoperatively to [X] cc [or to patient tolerance]. Plan for serial expansion in clinic.
Patient tolerated the procedure well.

Complications:

None

Specimens:

None

Estimated Blood Loss:

Minimal

Drains:

[One / two] [10-Fr] JP drains placed in the implant pocket

Disposition:

Patient taken to PACU in stable condition.

Epic SmartPhrase Version 
PREOPERATIVE DIAGNOSIS: Status post mastectomy for [breast cancer / BRCA prophylaxis]
POSTOPERATIVE DIAGNOSIS: Same
PROCEDURE PERFORMED: [Immediate / delayed] implant-based breast reconstruction [with ADM], [right / left / bilateral]
ATTENDING SURGEON: ***, MD/DO
FIRST ASSISTANT: ***
ANESTHESIA: General endotracheal

INDICATIONS: The patient is a .PTAGE-year-old .PTSEX with [breast cancer / BRCA mutation], status post [skin-sparing / nipple-sparing] mastectomy. Patient desires [direct-to-implant / tissue expander] reconstruction. [No prior radiation.] Implant type, size, and position discussed. Risks including infection, implant failure, capsular contracture, and asymmetry were discussed. Informed consent obtained.

FINDINGS: Skin flap perfusion adequate [confirmed with SPY/ICG angiography]. Mastectomy pocket dimensions *** × *** cm. Selected implant: [Allergan / Mentor / Sientra] *** cc [round / shaped] smooth silicone gel, lot #***.

DESCRIPTION OF PROCEDURE:
Patient positioned supine. Breast prepped in sterile fashion in coordination with breast surgery team following mastectomy. Pocket irrigated with triple antibiotic solution (bacitracin, cefazolin, gentamicin). Pectoralis major elevated off the chest wall from its inferior and lateral border with electrocautery. [ADM (Alloderm / Flex HD), *** × *** cm, sutured to inferior pectoralis border with 2-0 Vicryl, completing the pocket.] Pocket re-irrigated. A ***-cc [manufacturer] silicone gel implant (lot #***) inserted in no-touch technique via Keller funnel. Pectoralis [and ADM] closed over implant with running 2-0 Vicryl. Patient raised to 60 degrees. Implant position symmetric and satisfactory. Skin closed with 3-0 Monocryl deep dermis and 4-0 Monocryl subcuticular. Steri-strips applied. JP drains placed. Patient tolerated the procedure well.

ESTIMATED BLOOD LOSS: Minimal
SPECIMENS: None
COMPLICATIONS: None
DRAINS: [One / two] 10-Fr JP drains in implant pocket
DISPOSITION: Patient taken to PACU in stable condition.

Signed: .ME, .MYDEGREE
.TODAY
Variants

Tissue expander (two-stage)

Stage 1: expander placement (CPT 19357). Stage 2: exchange to permanent implant (CPT 19342). Document expander size and initial fill volume.

Pre-pectoral reconstruction

Implant above pectoralis muscle with complete ADM wrap. Document muscle preservation, ADM dimensions, and complete pocket coverage.

With nipple reconstruction

CPT 19350. Document technique (CV flap, skate flap, star flap), areolar tattooing plan.

Charting Tips
  • Document implant manufacturer, model, lot number, and size (required for breast implant registry)
  • State ADM brand, size, and fixation technique
  • Note ICG/SPY perfusion assessment of skin flaps if performed
  • No-touch implant technique and antibiotic irrigation protocol
  • Intraoperative position check and symmetry assessment
  • Prior radiation significantly increases complication risk. Document it explicitly.
Billing Tips
  • 19340 (immediate implant same day as mastectomy, 10.22 wRVU) vs 19342 (delayed-immediate or separate-day placement, 10.22 wRVU): timing determines the code, not implant type.
  • 19357 (tissue expander placement, 14.47 wRVU) is used for staged reconstruction. The subsequent expander-to-implant exchange is 19342.
  • Global period is 90 days for all breast reconstruction codes. Coordinate post-op billing with the mastectomy surgeon.
  • Bilateral reconstruction: append modifier -50 or bill each side separately with -RT/-LT. Reimbursement is 150% of the bilateral rate.
  • Document whether reconstruction is immediate (same operative session as mastectomy) or delayed. This is critical for code selection and payer authorization.
  • Oncoplastic or reduction-mammaplasty codes may apply when contralateral symmetry procedures are performed. Document symmetry work separately.
  • Surgeon-owned tissue expander supplies: bill prosthesis separately (HCPCS L8600). The implant is not bundled into the surgical fee.