Implant-Based Breast Reconstruction
Status post mastectomy for [breast cancer / BRCA prophylaxis]
Same
[Immediate / delayed] implant-based breast reconstruction [with / without] acellular dermal matrix (ADM), [right / left / bilateral]
[***, MD/DO]
[Resident/Fellow/PA name]
General endotracheal
Patient with [breast cancer / BRCA mutation] status post [skin-sparing / nipple-sparing] mastectomy by the breast surgery team. Patient desires [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. Patient Decision Checklist reviewed and completed. Consent obtained.
Skin flap perfusion [adequate / limited]. [Nipple-areolar complex perfusion confirmed with SPY/ICG angiography.] Mastectomy pocket dimensions [X x Y] cm. Selected implant: [Mentor / Motiva / Allergan Natrelle smooth] [round / shaped] [X] cc smooth silicone gel implant, lot #[XXX].
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 (vancomycin, cefazolin, gentamicin) performed.]
The pectoralis major muscle was elevated off the chest wall from its inferior and medial 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 dual-plane pocket with ADM forming the inferior sling.] The implant pocket was irrigated again with antibiotic solution.
A [X]-cc [manufacturer] silicone gel implant (lot #[XXX]) 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 75–90 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.
None
None
Minimal
[One / two] [10-Fr] JP drains placed in the implant pocket
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. Patient Decision Checklist reviewed. 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: [Mentor / Motiva / Allergan Natrelle] *** 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 (vancomycin, cefazolin, gentamicin). Pectoralis major elevated off the chest wall from its inferior and medial border with electrocautery. [ADM (Alloderm / Flex HD), *** × *** cm, sutured to inferior pectoralis border with 2-0 Vicryl, creating dual-plane pocket with ADM inferior sling.] 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 75–90 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
.TODAYVariants
Tissue expander (two-stage)
Document expander size, initial fill volume, and tissue quality at exchange.
Pre-pectoral reconstruction
Implant above pectoralis muscle with complete ADM wrap. Document muscle preservation, ADM dimensions, and complete anterior (and posterior if used) pocket coverage.
With nipple reconstruction
Document technique (C-V flap, skate flap, star flap), areolar tattooing plan. Areolar tattooing performed within the 90-day global period is bundled and cannot be billed separately.
Charting Tips
- Document implant manufacturer, model, lot number, and size for National Breast Implant Registry (NBIR) tracking
- Per FDA 2021 requirement, confirm completion of the Patient Decision Checklist (PDC) before implant placement and document this in the preoperative note
- Note ICG/SPY perfusion assessment of skin flaps if performed
- No-touch implant technique and antibiotic irrigation protocol
- Intraoperative position check (75–90 degrees) and symmetry assessment
- Prior radiation significantly increases capsular contracture and implant loss risk. Document radiation history explicitly.
Documentation & Reimbursement Considerations
- Report Implant-Based Breast Reconstruction as the primary service when it is the definitive operation performed.
- Immediate implant placement at mastectomy and delayed implant insertion or replacement each carry 10.22 wRVU and a 90-day Medicare global period. Timing determines the reporting pathway, not implant type.
- Tissue expander placement for staged reconstruction carries 14.47 wRVU and a 90-day Medicare global period. A standard stage-2 expander-to-implant exchange carries 7.30 wRVU and a 90-day global period. More extensive capsular work may support a different service when a formal capsulectomy or multiple radial capsulotomies are performed and documented; a straightforward exchange should not be reported as that more extensive service.
- Global period is 90 days for all breast reconstruction codes. Coordinate post-op billing with the mastectomy surgeon.
- Bilateral reconstruction: for Medicare, append bilateral-procedure reporting to a single line item (1 unit); reimbursement is 150% of the unilateral fee schedule amount. Some commercial payers accept right- or left-side reporting on two separate lines — verify payer policy before submitting.
- Document whether reconstruction is immediate (same operative session as mastectomy) or delayed. This is critical for reporting selection and payer authorization.
- Document the symmetry work separately.
- Implant device charges are facility-billed, not surgeon-billed, and should not be included on the professional claim.