Do I code the excision or just the debriedement and flap closure???
PREOPERATIVE DIAGNOSIS: Giant 15 x 10 cm nonhealing open wound from
trauma to scalp and forehead.
POSTOPERATIVE DIAGNOSIS: Giant 15 x 10 cm nonhealing open wound from
trauma to scalp and forehead.
PROCEDURE PERFORMED: Excision of skin and subcutaneous tissue and
underlying muscle for debridement of wound and fasciocutaneous flap
closure.
DESCRIPTION OF PROCEDURE: Under general anesthesia with the patient
prepped and draped in the usual sterile fashion. Scalpel was used
and Bovie cauterization was used to completely excise the very large
defect. This is the first stage of reconstruction to try and get the
wound closed. The wound was cultured and the specimen was sent to
pathology. There were no foreign bodies noted within the area.
Following complete excision this left a very large defect that had to
be closed by Washio fasciocutaneous flap base branch at the
superficial temporal artery. Flaps were elevated all the way down to
the cranial base on both sides and then elevated and interdigitated
in a Washio pattern, closing with multiple horizontal mattress
sutures and staples because of the infection that had been present.
The patient tolerated the procedure well. There were no known
complications. The patient was sent to recovery room in good
condition.
PREOPERATIVE DIAGNOSIS: Giant 15 x 10 cm nonhealing open wound from
trauma to scalp and forehead.
POSTOPERATIVE DIAGNOSIS: Giant 15 x 10 cm nonhealing open wound from
trauma to scalp and forehead.
PROCEDURE PERFORMED: Excision of skin and subcutaneous tissue and
underlying muscle for debridement of wound and fasciocutaneous flap
closure.
DESCRIPTION OF PROCEDURE: Under general anesthesia with the patient
prepped and draped in the usual sterile fashion. Scalpel was used
and Bovie cauterization was used to completely excise the very large
defect. This is the first stage of reconstruction to try and get the
wound closed. The wound was cultured and the specimen was sent to
pathology. There were no foreign bodies noted within the area.
Following complete excision this left a very large defect that had to
be closed by Washio fasciocutaneous flap base branch at the
superficial temporal artery. Flaps were elevated all the way down to
the cranial base on both sides and then elevated and interdigitated
in a Washio pattern, closing with multiple horizontal mattress
sutures and staples because of the infection that had been present.
The patient tolerated the procedure well. There were no known
complications. The patient was sent to recovery room in good
condition.