# Oral defect



## jwschroeterjr@gmail.com (Dec 14, 2010)

What is the code for a Oral defect?


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## msrd_081002 (Dec 14, 2010)

Need additional information from the case scenario. It's insufficient for code selection.

Thanks


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## jwschroeterjr@gmail.com (Dec 15, 2010)

I just need the diagnosis code for this condition. Here is the report
PREOPERATIVE DIAGNOSIS:
1. Oral cavity cancer.
2. Oral defect.
3. Mandibular defect.
4. External chin and lip defect.

POSTOPERATIVE DIAGNOSIS:
1. Oral cavity cancer.
2. Oral defect.
3. Mandibular defect.
4. External chin and lip defect.

INDICATIONS:
The patient with oral cavity cancer, status post resection with a large mandibular defect, intraoral and external chin and lip defect.

OPERATION:
1. Left osteocutaneous fibular free-flap.
2. Adjacent tissue transfer to close 4.5 x 16 cm lower leg defect.
3. Reconstruction of the jaw with multiple osteotomies using fibular bone graft.
4. Reconstruction of the oral cavity vestibule with fibular skin paddle.
5. Adjacent tissue transfer of the patient's native skin to close 2 x 6 cm chin and lip defects.

ANESTHESIA:
General endotracheal. Please see procedure for total blood loss and fluids.

FINDINGS:
A 28 cm of fibular bone altogether with a 4.5 x 6 cm skin paddle was harvested. Total tourniquet time was 2 hours. Donor site was closed primarily by adjacent tissue transfer. Fibula was osteotomized to reshape the mandible to reconstruct symphysis, bilateral parasymphysis. and left mandibular body. Stryker plating system was used. Anastomosis was performed to left facial artery and to the left confluence of Raney veins. Total ischemic time was 2 hours and 54 minutes.

PROCEDURE:
After Dr. was finished with his portion of procedure, the room was turned over to me. Tourniquet was inflated to 350 mm of pressure after low leg was exsanguinated with Esmarch wrap, and a 4.5 x 16 cm skin paddle was centered over the posterior musculocutaneous septum. A 15 blade was used to make an anterior portion of the incision which was extended out to the subfascial layers, and we proceeded with subfascial dissection laterally and posteriorly over the lateral compartment musculature until the septum was identified. Two main perforators were identified and at this point, dissection proceeded over the fibula dividing the attachments of the peroneus longus and peroneus brevis muscles. Intermuscular septum was identified and divided. Anterior tibial artery and vein were identified and preserved, and we proceeded with dividing the muscles of extensor pollicis longus until the interosseous membrane was identified. It was incised sharply and at this point a posterior skin incision was made with a 15 blade and extended down through the fascia. Proximal and distal osteotomy were made over the fibular bone using oscillating saw leaving 6 cm of bone distally and 5 cm of bone
proximally. Following this, the tibialis posterior muscle was divided placing out the pedicle only proximal to takeoff from the tibioperoneal trunk. The distal pedicle was ligated, and a portion of the soleus muscle was harvested with a fibular osteocutaneous flap. Once the entire flap was isolated on the pedicle, tourniquet was let down. Total tourniquet time was 2 hours, and flap was allowed to reperfuse for 40 minutes. Once this was done, proximal pedicle was divided and flap was brought to the head and neck site. Lower leg was thoroughly irrigated. A 19-French drain was placed into the wound, and we proceeded with undermining anteriorly and posteriorly. After adequate undermining, the patient had enough skin laxity to have the defect closed primarily. A 3-0 and 2-0 Vicryl sutures were used for subcutaneous closure, and staples were used for the skin closure. Once flap was transferred to the head and neck site, we proceeded stripping the periosteum from the proximal bone to lengthen the pedicle, we stripped the periosteum until the 11.5 cm of bone was isolated, and osteotomy was made to remove this proximal portion of the fibular bone. We proceeded with wedge osteotomies laterally as well as another wedge osteotomy centrally after elevating the periosteum from the fibula to be able to reshape the fibula and accommodate the current defect. A 2.0 mm mini plate was used to fixate the bone graft on the right side, and we used a longer but yet a thin 2.0 mm plate to span all the way from the left native mandibular ramus and to fix osteotomized bone graft pieces in place. Monocortical and bicortical locking screws were used for this fixation. Following this, binocular operating microscope was brought into field. The pedicle vessels were turned out as well as the recipient vessels. Left facial artery was used to perform end-to-end anastomosis to the peroneal artery using 9-0 nylon suture. Following this, a 3.0 mm coupler was used to perform end-to-end anastomosis of the largest of the peroneal venae comitantes to the confluence of the Raney veins on the left side as well. Once both anastomoses were performed, good inflow was confirmed by the arterial Doppler, and outflow was confirmed by clinical examination. Total ischemia time was 2 hours and 54 minutes. Once the microvascular portion was performed, we proceeded for advancing the skin paddle to the ventral tongue and laterally to reconstruct anterolateral floor of mouth, to reconstruct the alveolus and also to advance the skin paddle to reconstruct the gingival labial sulcus as far as the labial mucosa. We proceeded with advancement of the right lip, and we excised another smaller portion of the denervated epiglottis muscle to tighten and preserve functionality of the oral orifice sling. The right innervated portion of the lip was advanced laterally towards the commissure, and 3-0 Vicryl sutures were used for epiglottis muscle anastomosis, and additional 3-0 Vicryls were used to secure the advanced chin and lip skin as well as 3-0 Vicryls were used for mucosal closure. Following this, neck was thoroughly irrigated, and two 15-French Blake drains were placed into the neck, and neck was closed in multiple layers using 3-0 Vicryl for platysmal and subcutaneous closure and staples for the neck skin closure and 5-0 fast-absorbing gut suture for the chin and lip skin closure. Following this, the endotracheal tube was removed from tracheotomy and a number 6 cuff Shiley tracheostomy tube was placed and secured using 2-0 silk suture. Good ventilation was confirmed by anesthesia circuit. Following this, general anesthetic was continued, and the patient was transferred directly to Intensive Care Unit in satisfactory condition.

I was present and participated in the entire portion of the procedure.


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## msrd_081002 (Dec 15, 2010)

It implies *oromandibular surgical defects *that occured following oral cancer resection.

Going through the report, physician specified the following oralsurgical defects(reconstructed)
RE:ORAL DEFECT Specified anatomical areas:
-ventral tongue
-floor of mouth
-oral mucosal
-alveolus
-gingival labial sulcus as far as the labial mucosa.
-preserved "functionality of the oral orifice/ sling"
----------------------------------------------------
(other-added mandible;neck skin;external chin+lip)
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I'd assign 998.89+528.79+disturbance of oral epithelium including tongue +997.4- reflecting "functionality" oral orifice/sling+ 145.9 NOS CA Oral cavity+ E878.8

Pls look up complications/surgical procedures/specfied-*998.89*

( for aquired surgical defects- *Mandible=+738.8* ; external chin= 738.19; lip=528.5)+*oral cavity ca icd*+E878.8


I've just replied to ORAL defect ICD query only out of 4 dx'es mentioned in Post/op DX'es.

Thanks


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