CPT® Code 19368

Breast reconstruction; with single-pedicled transverse rectus abdominis myocutaneous (TRAM) flap, requiring separate microvascular anastomosis (supercharging)

The procedure described by CPT® Code 19368 involves breast reconstruction utilizing a single-pedicled transverse rectus abdominis myocutaneous (TRAM) flap, which necessitates a separate microvascular anastomosis, commonly referred to as supercharging. This surgical technique is typically performed to restore the breast's shape and appearance following a mastectomy, either immediately after the removal of breast tissue or at a later date after the completion of other treatments. The TRAM flap is composed of skin, fat, and muscle that are harvested from the abdominal area and then transplanted to the chest to create a new breast mound. Prior to the procedure, the abdomen is marked while the patient is in a standing position to ensure optimal flap design and vascular supply. An incision is made along these markings, extending down to the aponeurotic plane of the abdominal muscles. The surgical approach is designed to preserve the superior epigastric artery, which is crucial for maintaining blood flow to the flap. During the flap harvesting process, careful dissection is performed to minimize damage to the nerves and arteries, thereby preserving muscle function post-surgery. The dissection continues upward towards the xiphoid process and laterally to the oblique muscles, creating a tunnel that allows for the flap to be transferred to the chest area. A circular incision is made around the umbilicus to detach the umbilical pedicle from the flap, and further dissection is carried out along the pubic region. Depending on the reconstruction needs, either one or both rectus muscles may be harvested, ensuring that only the necessary tissue is taken to maintain adequate blood supply. Once the flap is prepared, it is rotated into position on the chest, where it can be shaped to achieve a natural breast contour. The procedure may involve microvascular anastomosis to enhance blood flow, particularly by connecting the inferior epigastric artery to nearby blood vessels. After ensuring proper blood circulation to the flap, the surgical team secures the flap in place, closes the chest incisions, and places drains to manage fluid accumulation. The abdominal incision is also closed, often with reinforcement of the abdominal muscles using mesh if both rectus muscles were utilized. Finally, the umbilicus is repositioned and secured, and the skin incisions are closed to complete the reconstruction process.