CPT® Code 19307

Mastectomy, modified radical, including axillary lymph nodes, with or without pectoralis minor muscle, but excluding pectoralis major muscle

A modified radical mastectomy, as defined by CPT® Code 19307, is a surgical procedure that involves the removal of the entire breast, including the nipple and areola, along with the excision of axillary lymph nodes. This procedure may also involve the removal of the pectoralis minor muscle, although the pectoralis major muscle is preserved. The technique is characterized by an elliptical incision made around the breast, which extends into the axilla, an area known as the tail of Spence. During the surgery, the breast tissue, skin, areola, and nipple are excised en bloc, meaning they are removed as a single unit. The axillary lymph nodes are carefully dissected from their surrounding structures, including the axillary vein and adjacent nerves and muscles, and are also removed. In cases where there is insufficient skin to close the surgical site, a separately reportable skin or myocutaneous graft may be required. Additionally, a suction catheter or drainage tube is typically inserted to manage any postoperative fluid accumulation, and a prosthesis may be placed under the skin prior to closure to provide support and shape to the breast area.