# Wide Local Exc Retromolar Trigone/Lateral tongue lesion



## Joyce Burchett (Jun 5, 2014)

Need help coding this procedure--looked at 41116 & 41120 but it sounds like this was 1 big excision.  I couldn't locate a CPT that really fits this procedure.  Any help would be appreciated. 
 History squamous cell carcinoma of RT tonsillar fossa treated w/chemo in past. Recently developed nonhealing ulcer in this region & biopsy revealed marked cytologic atypia. It was thought that possible squamous cell carcinoma could be noted. It was decided to proceed with a wide local excision in this area. Pt. taken to OR & exam of oral cavity revealed ulcerated region at the junction of RT posterolateral tongue & floor of mouth. Appeared to be evidence of significant hyperkeratosis and/or carcinoma also extending up on to the lateral aspect of soft palate. Mouth was opened with a side biter & the tongue was then at this time retracted. Using a headlight & a needle-tip Bovie, the edges of all these irregular areas were demarcated & the Bovie was used to carefully outline approx. a 5-7 mm margin outside of all these areas. After this, making small dots around the entire area, these were carefully connected & the flap of this tissue was carefully elevated. Superficially where there appeared to mostly hyperkeratosis, the amount of resection was superficial through the epithelium into the soft tissue. Dissection was also carried over the alveolus, taking care to avoid exposure of significant bone of the alveolar bone. Where the ulcer, however, appeared to be present there appeared to be a firm area of about a centimeter. Wide excision of this area with about a centimeter margin was then taken down into the tongue & dissection carried gradually in a circumferential way around this entire lesion until a small portion of tongue as well as the entire buccal area having mucosal irregularites was removed. Hemostasis maintained with use of the needle tip Bovie as well as with bipolar cautery. At this time after resecting this entire region, this was then oriented & sent to pathology. Pt awakened from anesthesia & taken to postop recovery.  Path report of RT retromolar trigon/lateral tongue lesion--invasive moderately differentieated suamous cell carcionoma.


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