2025 CPT code 15738
(Active) Effective Date: N/A Surgery - Flaps (Skin and/or Deep Tissues) Feed
Muscle, myocutaneous, or fasciocutaneous flap; lower extremity.
Modifiers may be applicable, such as modifier 22 (Increased Procedural Services) for unusually complex or time-consuming procedures, or modifier 59 (Distinct Procedural Service) to distinguish this procedure from other services performed during the same session.
Medical necessity for this procedure must be clearly established. It should be used for defects or injuries where primary closure is not feasible or desirable, where significant tissue loss or damage exists, or where functional restoration or improved cosmetic outcome is the goal. The documentation should justify the need for a flap procedure over simpler wound closure techniques.
The physician prepares both the donor site on the lower extremity and the recipient site of the defect. The flap, whether muscle, myocutaneous, or fasciocutaneous, is carefully created, ensuring intact blood vessels, and transferred to the recipient site. This may involve tunneling the flap beneath the skin. Both the donor and recipient sites are closed with sutures, and dressings are applied.
- Integumentary System, Surgical Procedures on the Integumentary System, Flaps (Skin and/or Deep Tissues)
In simple words: This procedure involves creating a flap of tissue from your lower leg, which includes skin, muscle, and/or the surrounding connective tissue. This flap is then moved to another location on your lower leg to cover and repair a wound or injury. The healthy area where the tissue was taken from is also closed up.
This code describes the surgical creation of a muscle, myocutaneous (muscle and skin), or fasciocutaneous (fascia and skin) flap taken from the lower extremity. The flap is then transferred to a recipient site, which is also located on the lower extremity, to repair a defect or injury. This procedure involves meticulous dissection, ensuring the blood vessels of the flap remain intact, and may require tunneling the flap under the skin to reach the recipient site. The secondary defect created at the donor site is also closed with sutures. This code does not include extensive immobilization (e.g., large plaster casts) or donor site repair requiring skin grafts or local flaps, which are considered separate procedures.
Example 1: A patient with a large, non-healing wound on the lower leg resulting from a traumatic injury undergoes a fasciocutaneous flap transfer from a healthy area of the same leg to close and promote healing of the wound., Following the removal of a cancerous lesion on the lower extremity, a myocutaneous flap is used to reconstruct the defect, providing both tissue coverage and functional restoration., A patient with a severe burn on the lower leg requires a muscle flap transfer to cover exposed bone and facilitate skin grafting and wound healing.
Documentation should include the size and location of the primary defect, the type of flap used (muscle, myocutaneous, or fasciocutaneous), the location of the donor site on the lower extremity, the method of flap transfer, and the closure techniques for both the donor and recipient sites. Operative notes, photographs, and any complications encountered should also be documented.
- Payment Status: Active
- Specialties:Plastic Surgery, Reconstructive Surgery, Orthopedic Surgery, General Surgery
- Place of Service:Inpatient Hospital, Outpatient Hospital, Ambulatory Surgical Center