D.R.
Networker
Would appreciate anyone's help. Provider has submitted 14060 / 15839 / 30420. I am not sure of 15839 for debulking and I do not think there is a code for a cadaver rib graft. Thanks in advance for your help!!
Post-Op Diagnosis Codes:
* Cancer of lateral nasal wall (CMS/HCC) [C11.2]
* Maxillary sinus cancer (CMS/HCC) [C31.0]
* Fistula of skin [L98.8]
Procedure(s):
Debulking of right nasal flap; Reconstruction of right nose with cadaver rib graft; Mucosal advancement flap 3.5 x 3 cm (Right)
Indications for Operative Procedure:
68 y.o. male with a history of cancer of the maxillary sinus. He had mult failed reconstruction attempts in Boston. The patient now presents today for 2nd stage nasal reconstruction rib graft.
Debulking of right nasal flap.
As a first step towards the reconstruction, we proceeded with evaluating the right-sided forehead flap. Notably, it had retracted significantly leading to decreased height of the nose on the right side. There was also an extensive amount of bulk associated with the flap as typical of what is seen following for stage from a 3 stage forehead flap reconstruction.
I initially incised the forehead flap edges and carefully dissected the flap off in the subcutaneous plane in order to keep the flap as thin as possible. Once this was accomplished, there was a large bulk of soft tissue still present overlying the nose. Radical debulking of this tissue was then performed overlying the previous skin graft and reconstructing the nasal mucosa. An extensive amount of subcutaneous tissue and fascia was resected as part of this debulking. This measured 3.5 x 3 cm in area.
Mucosal advancement flap 3.5 x 3 cm
After thinning of the forehead flap and debulking of the remainder of the nose, examination of the residual nasal mucosa revealed significant contracture leading to loss of nasal height. This layer similarly had to be carefully released in order to allow for recreation of the height of the nose. As result, a mucosal flap measuring 3.5 x 3 cm was elevated and then carefully advanced inferiorly in order to get as much length as possible. Once this mucosa was advanced as much as possible, we then proceeded with performing the reconstruction of the underlying cartilaginous framework of the nose.
Reconstruction of right nose with cadaver rib graft
Given the patient's older age of 68, rather than harvesting rib autogenously, I chose to proceed with use of cadaveric rib graft. This cartilage was carefully cut into thin strips measuring roughly a millimeter 1.25 mm in thickness. The rib cartilage was not thick enough to provide the full 3.5 cm of height in a single layer. Therefore, 2 strips of rib cartilage were utilized to reconstruct the nasal framework. The strips were placed horizontally and anchored laterally to the periosteum. Medially, the cartilage grafts were buried on the undersurface of the upper lateral and lower lateral nasal cartilage remnants. These were sutured into position with 4-0 PDS sutures.
After the framework was put in place, the mucosal advancement flaps were stretched out overlying the cartilage and sutured to the cartilage utilizing 4-0 chromic sutures.
Once the cartilage grafts were anchored into position, I then proceeded to suture the forehead flap back into position. After the debulking, the length of the flap was improved and was able to be brought to the edge of the nasal mucosa. This was brought together along the nasal margin utilizing 5-0 chromic sutures. Anteriorly, the margins of the flap were carefully trimmed to optimize nasal contour. 5-0 Monocryl sutures were utilized to close the dermis both anteriorly and posteriorly along the nasal cheek junction. Anteriorly, the skin was sutured together with running sutures of 6-0 nylon. Laterally, the skin along the nasal cheek junction was brought together with interrupted and running sutures of 5-0 plain gut.
Examination of the nasal airways
Finally, some comment should be made about the patient's nasal airways. Preoperatively, the patient had stated that he felt like he was unable to breathe through his nose. Examination of the right side of his nose revealed that the nasal passages were completely patent. However, examination on the left side revealed deviation of the remnant of the septum into the left nasal airway, presumably made worse from some of the retraction of the flap which deviated the nasal tip slightly to the right. Because of this, the septum appeared to be obstructing the patient's left nasal airway passage.
Based on this examination, I suspect that the patient has empty nose syndrome on the right side due to his cancer resection. As result, although he is able to breathe through his right nose, lack of sensation regarding this gives him the feeling that he is choking. This is made worse by the fact that his left nasal airway has been worsened due to some of the skewing of the septum into the left side. To help with this, Doyle splints were placed bilaterally to try to create more of a patent nasal airway.
Post-Op Diagnosis Codes:
* Cancer of lateral nasal wall (CMS/HCC) [C11.2]
* Maxillary sinus cancer (CMS/HCC) [C31.0]
* Fistula of skin [L98.8]
Procedure(s):
Debulking of right nasal flap; Reconstruction of right nose with cadaver rib graft; Mucosal advancement flap 3.5 x 3 cm (Right)
Indications for Operative Procedure:
68 y.o. male with a history of cancer of the maxillary sinus. He had mult failed reconstruction attempts in Boston. The patient now presents today for 2nd stage nasal reconstruction rib graft.
Debulking of right nasal flap.
As a first step towards the reconstruction, we proceeded with evaluating the right-sided forehead flap. Notably, it had retracted significantly leading to decreased height of the nose on the right side. There was also an extensive amount of bulk associated with the flap as typical of what is seen following for stage from a 3 stage forehead flap reconstruction.
I initially incised the forehead flap edges and carefully dissected the flap off in the subcutaneous plane in order to keep the flap as thin as possible. Once this was accomplished, there was a large bulk of soft tissue still present overlying the nose. Radical debulking of this tissue was then performed overlying the previous skin graft and reconstructing the nasal mucosa. An extensive amount of subcutaneous tissue and fascia was resected as part of this debulking. This measured 3.5 x 3 cm in area.
Mucosal advancement flap 3.5 x 3 cm
After thinning of the forehead flap and debulking of the remainder of the nose, examination of the residual nasal mucosa revealed significant contracture leading to loss of nasal height. This layer similarly had to be carefully released in order to allow for recreation of the height of the nose. As result, a mucosal flap measuring 3.5 x 3 cm was elevated and then carefully advanced inferiorly in order to get as much length as possible. Once this mucosa was advanced as much as possible, we then proceeded with performing the reconstruction of the underlying cartilaginous framework of the nose.
Reconstruction of right nose with cadaver rib graft
Given the patient's older age of 68, rather than harvesting rib autogenously, I chose to proceed with use of cadaveric rib graft. This cartilage was carefully cut into thin strips measuring roughly a millimeter 1.25 mm in thickness. The rib cartilage was not thick enough to provide the full 3.5 cm of height in a single layer. Therefore, 2 strips of rib cartilage were utilized to reconstruct the nasal framework. The strips were placed horizontally and anchored laterally to the periosteum. Medially, the cartilage grafts were buried on the undersurface of the upper lateral and lower lateral nasal cartilage remnants. These were sutured into position with 4-0 PDS sutures.
After the framework was put in place, the mucosal advancement flaps were stretched out overlying the cartilage and sutured to the cartilage utilizing 4-0 chromic sutures.
Once the cartilage grafts were anchored into position, I then proceeded to suture the forehead flap back into position. After the debulking, the length of the flap was improved and was able to be brought to the edge of the nasal mucosa. This was brought together along the nasal margin utilizing 5-0 chromic sutures. Anteriorly, the margins of the flap were carefully trimmed to optimize nasal contour. 5-0 Monocryl sutures were utilized to close the dermis both anteriorly and posteriorly along the nasal cheek junction. Anteriorly, the skin was sutured together with running sutures of 6-0 nylon. Laterally, the skin along the nasal cheek junction was brought together with interrupted and running sutures of 5-0 plain gut.
Examination of the nasal airways
Finally, some comment should be made about the patient's nasal airways. Preoperatively, the patient had stated that he felt like he was unable to breathe through his nose. Examination of the right side of his nose revealed that the nasal passages were completely patent. However, examination on the left side revealed deviation of the remnant of the septum into the left nasal airway, presumably made worse from some of the retraction of the flap which deviated the nasal tip slightly to the right. Because of this, the septum appeared to be obstructing the patient's left nasal airway passage.
Based on this examination, I suspect that the patient has empty nose syndrome on the right side due to his cancer resection. As result, although he is able to breathe through his right nose, lack of sensation regarding this gives him the feeling that he is choking. This is made worse by the fact that his left nasal airway has been worsened due to some of the skewing of the septum into the left side. To help with this, Doyle splints were placed bilaterally to try to create more of a patent nasal airway.