PatMacc
Contributor
The patient had commissuroplasty and tissue rearrangement for repair of congenital hemifacial microstomia. I am considering the unlisted code 40799 for the procedure. However, I am undecided whether repair of the lip would be a better choice - 40650 - 40652 or adjacent tissue rearrangement, 14060. Any thoughts? Op Note Below:
HISTORY: The patient is a 6 yr old born with congenital hemifacial microsomia involving left microstomia. He has sialorrhea during mastication.
PROCEDURE: The patient is brought to the OR, placed in supine position. After general endotracheal anesthesia was established, we marked out the key antatomic landmarks of the left oral commissure. We then infiltrated with 0.5% lidocaine with epinephrine. After adequate time elapsed for epinephrine effect, we then incised the margins of the cleft in a wedge-shaped fashion. We then dissected out the muscle from the cheek, subcutaneous tissue. And then at the vermilion margin, we dissected out as well using Bovie electrocautery to release the margin muscles to we can get muscle closure and contiennce of the commissure. Inside, we saved theatretic vermilion as that is near the defect and rolled it into the oral cavity. We left this in place, and then we dissected back to identify the best possible muscle for the repair.
We extended out in the cheek about 1.5 cm - 2 cm then identified all muscle margins and then closed with it 5-0 PDS in interrupted fashion. We then had to play with skin elements. We lined up the white roll with 7-0 nylon, and we had to play with the skin element wit a little bit, resecting some of the dog ear, and then cheating some of the superior part anteriorly to get rid of extra redundancy. This was closed with 5-0 PDS in the deep layer and then 7-0 nylon. We then closed the white roll with 7-0 nylon and then at the we-dry junction, which happens really close at the commissure, we converted over to chromic. We used a combination of simple and horizontal mattress sutures to get good submucosal approximation. We trimmed the excess tissue that represented teh vermilion inside the mouth. we were actually in the ____ and the resection turned out to be essentially a wedge of the lip. We then repaired the intraoral mucosa by trimming it up. We trimmed it in a little bit of Z-plasty fashion to prevent shortening of that lip, then closed it with 5-0 chromic. At the end of procedure, bacitracin was applied. The patient was extubated in the operating room and transferred to the PACU in stable condition without complication.
HISTORY: The patient is a 6 yr old born with congenital hemifacial microsomia involving left microstomia. He has sialorrhea during mastication.
PROCEDURE: The patient is brought to the OR, placed in supine position. After general endotracheal anesthesia was established, we marked out the key antatomic landmarks of the left oral commissure. We then infiltrated with 0.5% lidocaine with epinephrine. After adequate time elapsed for epinephrine effect, we then incised the margins of the cleft in a wedge-shaped fashion. We then dissected out the muscle from the cheek, subcutaneous tissue. And then at the vermilion margin, we dissected out as well using Bovie electrocautery to release the margin muscles to we can get muscle closure and contiennce of the commissure. Inside, we saved theatretic vermilion as that is near the defect and rolled it into the oral cavity. We left this in place, and then we dissected back to identify the best possible muscle for the repair.
We extended out in the cheek about 1.5 cm - 2 cm then identified all muscle margins and then closed with it 5-0 PDS in interrupted fashion. We then had to play with skin elements. We lined up the white roll with 7-0 nylon, and we had to play with the skin element wit a little bit, resecting some of the dog ear, and then cheating some of the superior part anteriorly to get rid of extra redundancy. This was closed with 5-0 PDS in the deep layer and then 7-0 nylon. We then closed the white roll with 7-0 nylon and then at the we-dry junction, which happens really close at the commissure, we converted over to chromic. We used a combination of simple and horizontal mattress sutures to get good submucosal approximation. We trimmed the excess tissue that represented teh vermilion inside the mouth. we were actually in the ____ and the resection turned out to be essentially a wedge of the lip. We then repaired the intraoral mucosa by trimming it up. We trimmed it in a little bit of Z-plasty fashion to prevent shortening of that lip, then closed it with 5-0 chromic. At the end of procedure, bacitracin was applied. The patient was extubated in the operating room and transferred to the PACU in stable condition without complication.