CPT® Code 19369

1. Indications

The procedure described by CPT® Code 19369 is indicated for patients requiring breast reconstruction following mastectomy. The specific indications include:

• Breast Cancer Treatment: Patients who have undergone mastectomy due to breast cancer may seek reconstruction to restore breast shape and volume.
• Immediate Reconstruction: This procedure can be performed immediately following mastectomy, allowing for simultaneous reconstruction and reducing the number of surgeries required.
• Delayed Reconstruction: Patients may also opt for this procedure at a later date after completing other treatments, such as chemotherapy or radiation therapy.
• Bilateral Mastectomy: The bipedicled TRAM flap technique is particularly suitable for patients undergoing bilateral mastectomy, as it allows for the use of both rectus abdominis muscles to create two separate flaps for reconstruction.

2. Procedure

The procedure for breast reconstruction using a bipedicled TRAM flap involves several detailed steps:

• Preoperative Marking: Prior to anesthesia, the abdomen is marked while the patient is standing to outline the area from which the flap will be harvested. This ensures optimal positioning and vascular supply.
• Incision and Dissection: An incision is made along the marked lines, extending down to the aponeurotic plane of the abdominal muscles. The upper area of the incision is beveled to include as much supraumbilical vasculature as possible, which is critical for maintaining blood supply to the flap.
• Preservation of Blood Vessels: The superior epigastric artery is preserved during the dissection to ensure adequate blood flow to the flap. The inferior epigastric artery may also be harvested for potential microvascular anastomosis.
• Flap Harvesting: Dissection continues up to the xiphoid and costal arches, extending laterally to the oblique muscles. The flap is then tunneled to the recipient bed area in the chest, ensuring it is large enough for placement.
• Umbilical Pedicle Freeing: A circular incision is made around the umbilicus to detach the umbilical pedicle from the cutaneous flap, allowing for its relocation during reconstruction.
• Muscle Harvesting: For a bipedicle procedure, both rectus muscles are harvested by transecting them at the pubic insertion. Only the tissue directly over or adjacent to the muscles is harvested to maintain vascular integrity.
• Flap Transfer: The harvested flap(s) are rotated superiorly through the tunnel to the chest area. The tissue can be manipulated to achieve a cosmetically acceptable breast shape.
• Microvascular Anastomosis: If necessary, microvascular anastomosis is performed to ensure adequate blood flow to the transplanted flap, which may involve connecting the inferior epigastric artery to blood vessels under the arm or sternum.
• Closure and Drains: Once blood flow is established, drains are placed, and the flap is secured. The chest incisions are then closed, and drains are placed before closing the abdomen.
• Reinforcement and Final Closure: If both rectus abdominis muscles were harvested, abdominal muscles may be reinforced with mesh. The umbilicus is relocated to the center of the abdomen and secured, followed by closure of the final skin incision with sutures or skin clips in a low transverse line above the pubis.

3. Post-Procedure

Post-procedure care following a bipedicled TRAM flap breast reconstruction includes monitoring for complications, managing pain, and ensuring proper healing of both the breast and abdominal sites. Patients may require drains to be in place for a period to prevent fluid accumulation. Recovery time can vary, but patients are typically advised to avoid strenuous activities for several weeks. Follow-up appointments are essential to assess the viability of the flap and the overall healing process. Additional cosmetic procedures, such as liposuction or skin tailoring, may be considered to enhance the aesthetic outcome. The relocated umbilicus will also be monitored for proper healing and positioning.