Olympic Plastic Surgery



Olympic Plastic Surgery Center

9927 Mickelberry Rd. NW, Suite 121

Silverdale, Washington 98383

Phone (360)286-2456 Fax (855) 792-1166

Date

Insurance provider

Patient name

Member ID #

Dear Provider,

This letter is in reference to (Pt name) who is a (age) year-old female. The patient was seen in consultation regarding breast reduction surgery. The medical problems related to her condition include breast hypertrophy (611.1), neck pain (723.1), upper back pain (724.1), lower back pain (724.2), shoulder pain (723.9, 719.41), bra strap grooving (738.3), headaches (784.0), intertrigo (695.89), congenital breast deformity (757.6), breast pain (611.71), thoracic kyphosis (737.1), chafing (709.8), poor posture, breast asymmetry, cephalgia, pendulousness, exercise intolerance, problems with clothes fitting properly, and nipple-areola distortion.

We would like to perform bilateral breast reduction surgery (19318-50) as an outpatient procedure in hopes of alleviating her symptoms. Symptoms are more important than breast volume in determining which women have the greater health burden. Her current bra size is ____. Her height is ____ inches and her weight is ____ pounds which gives her a BMI of ____. As you know, it is very difficult to estimate the amount of weight to be removed preoperatively, but in her case, I would estimate glandular resection to be ____ grams on the right and ____ grams on the left side. I believe this would give a reasonable prognosis of symptomatic relief.

I sincerely hope that you will see this as a fit and covered service to improve the overall quality of health and life for the patient. I look forward to your timely reply. If you have further questions regarding this patient, please do not hesitate to contact me.

Sincerely,

Thomas J. Meeks D.O., FACOS, FACS

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