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Plastic & Reconstructive Surgery

Breast Ptosis

ICD-10 Code
N64.81

Plastic & Reconstructive Criteria for Breast Ptosis.

Clinical Presentation & Protocol

Patient Usually Complains Of

Patient presents for evaluation of breast ptosis, reporting concerns regarding breast shape, volume loss, and inferior nipple-areolar complex (NAC) displacement. Onset is associated with [post-pregnancy/weight loss/aging]. Patient denies associated breast pain, nipple discharge, or palpable masses. Goals include [mastopexy/augmentation-mastopexy] to improve breast contour and symmetry.

Clinical Examination Findings

Breast examination reveals Grade [I/II/III/Pseudoptosis] ptosis. Nipple-areolar complex is positioned [at/below] the inframammary fold (IMF). Skin envelope demonstrates [mild/moderate/severe] laxity with [good/poor] elasticity. Glandular tissue distribution is [superior/inferior] deficient. No palpable masses, lymphadenopathy, or skin dimpling noted. Chest wall symmetry is [symmetrical/asymmetrical].

Treatment Protocol

Discussed surgical options including mastopexy with [periareolar/vertical/inverted-T] incision pattern. Addressed potential for concomitant breast augmentation if volume restoration is required. Informed patient of risks including scarring, sensory changes, asymmetry, and potential impact on breastfeeding. Patient consents to proceed with [surgical plan].

Detailed clinical guide coming soon.