Nipple-Sparing Mastectomy
[Invasive ductal carcinoma / DCIS / BRCA mutation], [right / left] breast
Same
[Nipple-sparing / skin-sparing] mastectomy, [right / left], with sentinel lymph node biopsy [and immediate tissue expander placement]
[***, MD/DO]
[Resident name]
General endotracheal
Patient presents with [invasive ductal carcinoma / DCIS / BRCA1/2 mutation] of the [right / left] breast. [Tumor [X] cm, [X] cm from nipple / multicentric disease / patient preference for mastectomy.] [Neoadjuvant chemotherapy completed / not given.] Oncoplastic and reconstructive planning completed with plastic surgery. Sentinel lymph node biopsy planned. Risks including wound complications, flap necrosis, nipple-areola complex (NAC) ischemia, and reconstruction complications discussed. Consent obtained.
Mastectomy flaps developed to [pectoralis fascia / pectoralis muscle] in all quadrants. NAC perfusion [intact / had mild ischemia at end of case, assessed as [viable].] Retro-areolar biopsy: [negative on frozen section / deferred to permanent]. Axilla explored; sentinel node mapping below.
SENTINEL LYMPH NODE BIOPSY: Radiocolloid [Technetium-99m sulfur colloid] injected [preoperatively in nuclear medicine / in OR around areola]. [Isosulfan blue / methylene blue] injected peritumorally. Gamma probe used to identify sentinel node basin in [right / left] axilla. [X] hot and/or blue nodes identified through a separate axillary incision [/ through the mastectomy incision]. Nodes sent for [frozen section: negative / permanent pathology].
MASTECTOMY: A [lateral / inferior / periareolar / inframammary fold] incision was made. [The nipple-areola complex was preserved.] Skin flaps were developed in the plane between the superficial fascia (Camper's fascia) and the breast parenchyma, preserving the subdermal plexus, using [electrocautery / scalpel]. Flap thickness was assessed throughout; adequate thickness maintained to preserve vascularity while avoiding residual breast tissue. The breast was dissected from the pectoralis major fascia [/ pectoralis muscle] from medial to lateral in all quadrants. The axillary tail of the breast was included in the specimen. The specimen was removed and sent to pathology.
Retro-areolar tissue was sent for frozen section: [negative / positive; NAC excised].
[Plastic surgery performed immediate reconstruction with tissue expander; see separate note.]
Hemostasis confirmed. [Closed-suction drain placed through separate stab incision.] Skin closed with [3-0 Monocryl / 4-0 Monocryl / Steri-Strips]. Patient tolerated the procedure well.
None
Mastectomy specimen to pathology with orientation [/ Sentinel lymph nodes individually labeled to pathology]
Minimal
[Closed-suction drain / None]
Patient to PACU. [Discharged same day / Admitted overnight for reconstruction].
Epic SmartPhrase Version
PREOPERATIVE DIAGNOSIS: [Invasive ductal carcinoma / DCIS / BRCA mutation], [right / left] breast
POSTOPERATIVE DIAGNOSIS: Same
PROCEDURE PERFORMED: [Nipple-sparing / skin-sparing] mastectomy, [right / left], with SLNB [and immediate tissue expander]
ATTENDING SURGEON: ***, MD/DO
FIRST ASSISTANT: ***
ANESTHESIA: General endotracheal
INDICATIONS: The patient is a .PTAGE-year-old .PTSEX with [IDC / DCIS / BRCA mutation], [right / left] breast. [Tumor *** cm / multicentric / patient preference.] [Neoadjuvant chemo complete.] Reconstructive planning done with plastic surgery. Risks including flap necrosis and NAC ischemia discussed. Informed consent obtained.
FINDINGS: Mastectomy flaps to pectoralis fascia in all quadrants. NAC perfusion intact. Retro-areolar biopsy [negative on frozen]. [SLNB: *** hot/blue nodes from axilla, sent to pathology.]
DESCRIPTION OF PROCEDURE:
SLNB: Radiocolloid injected preoperatively. [Blue dye injected peritumorally.] Gamma probe mapped [right / left] axilla. *** sentinel nodes retrieved via [separate axillary incision / mastectomy incision]; sent to [permanent pathology / frozen: negative]. MASTECTOMY: [Lateral / inframammary fold] incision; NAC preserved. Flaps developed in plane between superficial fascia and breast parenchyma, preserving subdermal plexus, with electrocautery. Adequate flap thickness throughout. Breast dissected from pectoralis fascia medial to lateral in all quadrants; axillary tail included. Specimen removed and sent to pathology. Retro-areolar tissue: [negative on frozen / sent to permanent pathology.] [Plastic surgery performed tissue expander; see separate note.] Hemostasis. [Drain placed.] Skin with 4-0 Monocryl. Patient tolerated procedure well.
ESTIMATED BLOOD LOSS: Minimal
SPECIMENS: Mastectomy specimen (oriented) to pathology. [Sentinel nodes individually labeled to pathology.]
COMPLICATIONS: None
DRAINS: [Closed-suction drain / None]
DISPOSITION: Patient to PACU. [Discharged / Admitted for reconstruction.]
Signed: .ME, .MYDEGREE
.TODAYVariants
Skin-sparing mastectomy
Nipple-areola complex excised; breast skin preserved for reconstruction. Document NAC removal and reason. Retro-areolar biopsy not required since NAC is removed.
Prophylactic mastectomy (BRCA)
Document genetic indication, counseling completed, and no known cancer in specimen. No SLNB required for prophylactic mastectomy (no invasive cancer).
Bilateral mastectomy
Perform SLNB on both sides if bilateral invasive disease. Document each side separately with individual findings, flap thickness, and drain placement.
Charting Tips
- Document NAC perfusion assessment at end of case, as delayed ischemia can occur
- State retro-areolar biopsy result (frozen section or deferred); if positive, NAC must be excised
- Note skin flap thickness (too thin = ischemia, too thick = residual breast tissue)
- Document each sentinel node: hot, blue, or both; counts; size
- Orient mastectomy specimen for pathology; at minimum mark superior and lateral
Documentation & Reimbursement Considerations
- Report Nipple-Sparing Mastectomy as the primary service when it is the definitive operation performed.
- Nipple-sparing mastectomy uses the same reporting as skin-sparing and simple mastectomy. Skin/nipple preservation does not change the reporting. Document technique in the operative note for clinical record purposes.
- SLNB is standard for invasive breast cancer and for clinically node-negative DCIS undergoing mastectomy (SLNB cannot be performed after the breast is removed if occult invasion is later found). All three codes are unbundled from the primary service.
- If the reconstructing surgeon is different from the ablative surgeon, each bills their own codes. Document which surgeon performed what portion.
- Medicare pays at 150% (100% for first side, 50% for second). Do not submit two separate claims with LT/RT modifiers under Medicare — this is incorrect for Medicare and can result in denial. Some commercial payers accept LT/RT on separate lines; verify payer rules. Document findings, flap thickness, drain placement, and NAC status for each side separately.
- Document the indication (prophylactic vs. therapeutic), as it affects DRG and quality metrics but not reporting selection.