D.R.
Networker
Would appreciate everyone's opinion on this. I have a hard time with recon plastics. Not much experience. Please let me know what you all think. Also, the doctor gave me an unlisted for sculpting of cartilage frame work. Would that even be billable? if so not sure what to use as comparison code for unlisted.
TIA
Pre-Op Diagnosis Codes:
* Microtia of left ear [Q17.2]
Post-Op Diagnosis Codes:
* Microtia of left ear [Q17.2]
Procedure(s):
First of 2 stage reconstruction of the external ear with rib cartilage graft entailing multiple procedures:
1. Cartilage graft harvest and transfer from left ribs. (CPT 21230-51 each for synchondrosis of ribs 6-7and 8)
2. Excision of microtic vestigial ear remnant. (CPT 14061-52)
3. Removal of old cartilage graft from the left ear
4. Detailing/sculpting and assembly of cartilaginous frame work. (CPT 69399)
5. Creation of cutaneous pocket in right ear and pedicled earlobe flap transfer and W-flap. (CPT 14061- 51)
6. Insertion of On-Q pain pump. (CPT 11981)
Description of Procedure:
The patient was brought to the preop area where a timeout was performed, and the patient was marked. The left side of his ear was marked as well as the left ribs, with planned removal of ribs 5-8. She was brought to the Operating Room, where a timeout was performed with the Anesthesia staff as well as the surgical staff. The patient was then prepped and draped in sterile fashion, both to the chest wall as well as the right ear and the entire face and scalp. This was all performed after adequate IV sedation was provided, and the patient was intubated and sedated without any complication. The patient received IV Ancef within 1 hour prior to the onset of the surgery. A 2 team approach was utilized for this procedure. The patient had sequential compression devices placed on both lower extremities.
The patient's left chest was marked and then incised in the inframammary region. Notably, the patient had a harvest incision from the right chest in the past. Subcutaneous dissection was taken overlying the rectus and external oblique fascia. This was carefully incised and dissected down to the underlying muscle. The muscle was then incised with electrocautery longitudinally along the length of the rectus muscle and dissection was taken down to the underlying ribs. In addition to that, the pectoralis major insertion site was elevated superiorly in order to expose the 5th rib. In total, ribs 5-8 were exposed. Once down to the ribs, the perichondrium was then identified and this was carefully incised with a sharp scalpel. Subperichondrial dissection was then performed separating out the soft tissues from the underlying ribs.
A block of cartilage was then taken at the region of the synchondrosis between the 6th and 7th ribs. The dissection was then taken posteriorly, leaving behind the perichondrium circumferentially around the ribs laterally. The cartilage was then incised with a scalpel and a subperichondrial dissection was then performed. Similarly, a segments of the 8th rib was also harvested for use and ear reconstruction. These ribs were then removed and the pocket was then irrigated with saline. The patient was then given 40 mm of pressure in his airway to confirm that there was no evidence of pneumothorax. There was no evidence of an air leak. The perichondrium was then approximated with 2-0 Vicryl suture.
An OnQ pain pump catheter was situated deep to the level of the rectus. The muscle layer was then reapproximated with Vicryl sutures. The catheter was exited out lateral to the chest incision and secured with 4-0 nylon stitch. The skin and subcutaneous layers were closed with deep sutures of 3-0 Monocryl and Stratafix and a running subcuticular suture of 4-0 Monocryl. Dermabond and Steri-Strips were applied. Prior to complex closure of the skin, a segment of cartilage harvested from the remaining unused rib and a block of cartilage removed from the left ear old construct was left in the subcutaneous pocket for harvest later to use during the second stage of ear reconstruction.
Concurrent to the other procedure, a template was made utilizing a clear plastic sheet. This was then utilized to trace out the shape of the normal right ear. After this was performed, the template was then copied and cut out to plan our design of the cartilage frame work for the left ear. The operative site of the left ear was identified and marked. A pocket was designed extending 1 cm past the outer margins of the planned right ear framework. This was injected with local anesthetic.
Incisions were then made overlying the preexisting ear in the shape of a W, as described by Nagata. This was placed overlying previous incisions. Dissection was then taken subcutaneously to dissect out the pocket as well as create a lobule out of the remnant earlobe. The site of the planned ear frame work was marked and the dissection was taken superiorly and circumferentially around by an additional 1cm to allow for mobilization of the soft tissues.
The remnant cartilage from the site was isolated and completely excised. In the course of dissection, a small pedicle of soft tissue was preserved along the inferior aspect of the flap, as described by Satoru Nagata. Beyond this, a block of cartilage from the previous reconstruction was identified. This measured roughly 3 by 2.5 cm in size. This cartilage block which was an amalgam of several bits of cartilage was then carefully removed. We plan to utilize this as a base for the new carved ear construct.
After this pocket was carefully dissected out, the earlobe creation was performed from the remnant. The earlobe had been incised with the classic W-shaped incision and this was then elevated and transposed inferiorly via attachment anteriorly to create a new lobule. The pocket dissection and the earlobe transposition amounted to an adjacent tissue transfer measuring roughly 20-30 square centimeters.
After the pocket and the earlobe were created, the cartilage framework from the rib was then utilized to carve a new ear and the Nagata style ear frame work was carved utilizing several pieces obtained from the ribs.
The helix as well as the antihelix were then marked off and these were carefully carved utilizing a #15 blade scalpel. This was a slow meticulous process to optimize the shape of the ear and several pieces were utilized to create the ideal shape and took roughly 2-3 hours of time to do so. Several segments were used for this as well as a few smaller segments were used to create the concha posteriorly of the frame work. This framework was then positioned and anchored into the base layer, as described by Nagata. The cartilage segments were anchored to each other with clear 4-0 nylon sutures. Eventually, an appropriate ear construct was able to be created.
Upon completion of the construct, I chose not to place a 3rd layer underneath the construct as it appeared to place too much strain on the skin flap. This entailed the remaining cartilage from the old construct which was banged into the left chest. Moreover, it should be mentioned that an extensive amount of scar tissue was noted within the pocket. Despite my best attempts to thin the skin, it appeared thicker and less elastic then typical. I presume that this was related to a potential infection that mom described to me from her original ear reconstruction. I could find no documentation in the record noting that infection had occurred, however. Nevertheless the clinical findings certainly supported this assertion.
A small 10 Blake drain was placed around the frame work and the open areas were then closed with 5-0 Monocryl and a plain gut suture. In the process of insertion of the construct, the pedicle of tissue along the base of the flap had to be amputated secondary to the inability to place the construct in position. Once the drain was placed to low wall suction, the suction created a vacuum and the soft tissues draped the ear framework. Unfortunately, secondary to the thickening and immobility of the skin, the contour of the ear was less than ideal. The drain was placed posteriorly and exited through a separate stab incision, secured with a 4-0 nylon stitch. There were no bolster sutures placed but rather the Xeroform gauze was placed within the scapha. This was covered with a Glasscock splint was placed over the ear.
During the procedure, it should be noted that it became evident that there was a curvilinear scar from the previous surgery which was not visible at the time of initial incision. This could only be identified by the dermal and subcutaneous banding of scar that was identified during dissection. Because of this curvilinear incision, a segment of skin along the central portion of the flap remains slightly questionable regarding viability. It was initially violaceous. After incising this and allowing for some venous drainage, the flap itself appeared pink and healthy.
TIA
Pre-Op Diagnosis Codes:
* Microtia of left ear [Q17.2]
Post-Op Diagnosis Codes:
* Microtia of left ear [Q17.2]
Procedure(s):
First of 2 stage reconstruction of the external ear with rib cartilage graft entailing multiple procedures:
1. Cartilage graft harvest and transfer from left ribs. (CPT 21230-51 each for synchondrosis of ribs 6-7and 8)
2. Excision of microtic vestigial ear remnant. (CPT 14061-52)
3. Removal of old cartilage graft from the left ear
4. Detailing/sculpting and assembly of cartilaginous frame work. (CPT 69399)
5. Creation of cutaneous pocket in right ear and pedicled earlobe flap transfer and W-flap. (CPT 14061- 51)
6. Insertion of On-Q pain pump. (CPT 11981)
Description of Procedure:
The patient was brought to the preop area where a timeout was performed, and the patient was marked. The left side of his ear was marked as well as the left ribs, with planned removal of ribs 5-8. She was brought to the Operating Room, where a timeout was performed with the Anesthesia staff as well as the surgical staff. The patient was then prepped and draped in sterile fashion, both to the chest wall as well as the right ear and the entire face and scalp. This was all performed after adequate IV sedation was provided, and the patient was intubated and sedated without any complication. The patient received IV Ancef within 1 hour prior to the onset of the surgery. A 2 team approach was utilized for this procedure. The patient had sequential compression devices placed on both lower extremities.
The patient's left chest was marked and then incised in the inframammary region. Notably, the patient had a harvest incision from the right chest in the past. Subcutaneous dissection was taken overlying the rectus and external oblique fascia. This was carefully incised and dissected down to the underlying muscle. The muscle was then incised with electrocautery longitudinally along the length of the rectus muscle and dissection was taken down to the underlying ribs. In addition to that, the pectoralis major insertion site was elevated superiorly in order to expose the 5th rib. In total, ribs 5-8 were exposed. Once down to the ribs, the perichondrium was then identified and this was carefully incised with a sharp scalpel. Subperichondrial dissection was then performed separating out the soft tissues from the underlying ribs.
A block of cartilage was then taken at the region of the synchondrosis between the 6th and 7th ribs. The dissection was then taken posteriorly, leaving behind the perichondrium circumferentially around the ribs laterally. The cartilage was then incised with a scalpel and a subperichondrial dissection was then performed. Similarly, a segments of the 8th rib was also harvested for use and ear reconstruction. These ribs were then removed and the pocket was then irrigated with saline. The patient was then given 40 mm of pressure in his airway to confirm that there was no evidence of pneumothorax. There was no evidence of an air leak. The perichondrium was then approximated with 2-0 Vicryl suture.
An OnQ pain pump catheter was situated deep to the level of the rectus. The muscle layer was then reapproximated with Vicryl sutures. The catheter was exited out lateral to the chest incision and secured with 4-0 nylon stitch. The skin and subcutaneous layers were closed with deep sutures of 3-0 Monocryl and Stratafix and a running subcuticular suture of 4-0 Monocryl. Dermabond and Steri-Strips were applied. Prior to complex closure of the skin, a segment of cartilage harvested from the remaining unused rib and a block of cartilage removed from the left ear old construct was left in the subcutaneous pocket for harvest later to use during the second stage of ear reconstruction.
Concurrent to the other procedure, a template was made utilizing a clear plastic sheet. This was then utilized to trace out the shape of the normal right ear. After this was performed, the template was then copied and cut out to plan our design of the cartilage frame work for the left ear. The operative site of the left ear was identified and marked. A pocket was designed extending 1 cm past the outer margins of the planned right ear framework. This was injected with local anesthetic.
Incisions were then made overlying the preexisting ear in the shape of a W, as described by Nagata. This was placed overlying previous incisions. Dissection was then taken subcutaneously to dissect out the pocket as well as create a lobule out of the remnant earlobe. The site of the planned ear frame work was marked and the dissection was taken superiorly and circumferentially around by an additional 1cm to allow for mobilization of the soft tissues.
The remnant cartilage from the site was isolated and completely excised. In the course of dissection, a small pedicle of soft tissue was preserved along the inferior aspect of the flap, as described by Satoru Nagata. Beyond this, a block of cartilage from the previous reconstruction was identified. This measured roughly 3 by 2.5 cm in size. This cartilage block which was an amalgam of several bits of cartilage was then carefully removed. We plan to utilize this as a base for the new carved ear construct.
After this pocket was carefully dissected out, the earlobe creation was performed from the remnant. The earlobe had been incised with the classic W-shaped incision and this was then elevated and transposed inferiorly via attachment anteriorly to create a new lobule. The pocket dissection and the earlobe transposition amounted to an adjacent tissue transfer measuring roughly 20-30 square centimeters.
After the pocket and the earlobe were created, the cartilage framework from the rib was then utilized to carve a new ear and the Nagata style ear frame work was carved utilizing several pieces obtained from the ribs.
The helix as well as the antihelix were then marked off and these were carefully carved utilizing a #15 blade scalpel. This was a slow meticulous process to optimize the shape of the ear and several pieces were utilized to create the ideal shape and took roughly 2-3 hours of time to do so. Several segments were used for this as well as a few smaller segments were used to create the concha posteriorly of the frame work. This framework was then positioned and anchored into the base layer, as described by Nagata. The cartilage segments were anchored to each other with clear 4-0 nylon sutures. Eventually, an appropriate ear construct was able to be created.
Upon completion of the construct, I chose not to place a 3rd layer underneath the construct as it appeared to place too much strain on the skin flap. This entailed the remaining cartilage from the old construct which was banged into the left chest. Moreover, it should be mentioned that an extensive amount of scar tissue was noted within the pocket. Despite my best attempts to thin the skin, it appeared thicker and less elastic then typical. I presume that this was related to a potential infection that mom described to me from her original ear reconstruction. I could find no documentation in the record noting that infection had occurred, however. Nevertheless the clinical findings certainly supported this assertion.
A small 10 Blake drain was placed around the frame work and the open areas were then closed with 5-0 Monocryl and a plain gut suture. In the process of insertion of the construct, the pedicle of tissue along the base of the flap had to be amputated secondary to the inability to place the construct in position. Once the drain was placed to low wall suction, the suction created a vacuum and the soft tissues draped the ear framework. Unfortunately, secondary to the thickening and immobility of the skin, the contour of the ear was less than ideal. The drain was placed posteriorly and exited through a separate stab incision, secured with a 4-0 nylon stitch. There were no bolster sutures placed but rather the Xeroform gauze was placed within the scapha. This was covered with a Glasscock splint was placed over the ear.
During the procedure, it should be noted that it became evident that there was a curvilinear scar from the previous surgery which was not visible at the time of initial incision. This could only be identified by the dermal and subcutaneous banding of scar that was identified during dissection. Because of this curvilinear incision, a segment of skin along the central portion of the flap remains slightly questionable regarding viability. It was initially violaceous. After incising this and allowing for some venous drainage, the flap itself appeared pink and healthy.