codedog
True Blue
AM I ON THE RIGHT TRACK ON THIS
CPT CODES
14060
15260
21235,?, dont code much plastic surgery, would these codes be a good choice ?
PREOPERATIVE DIAGNOSES: Squamous cell carcinoma of the right ala, sidewall, and tip of the nose.
POSTOPERATIVE DIAGNOSES: Squamous cell carcinoma of the right ala, sidewall, and tip of the nose, status post previous excision with negative permanent sections
PROCEDURES PERFORMED: First-stage reconstruction of the nasal tip ala and sidewall with transposition mucoperichondrial flap, cartilage graft, full-thickness skin graft, and paramedian forehead flap.
INDICATIONS: The patient a very large squamous cell carcinoma, which had involved the vestibular surface of the nares as well as the external surface. He was told that the tumor should be resected and we would need to get negative margins before consideration of any reconstruction.
The tumor was resected approximately a week ago. The permanent sections all were considered to be clear of tumor. Again, I talked to the patient and gave him the alternatives of waiting six months prior to reconstruction, which may be safer even with the negative margins, but the patient wished to proceed with reconstruction as he did not want to be deformed for period of six months.
OPERATIVE PROCEDURE: He was taken to the operating room and placed under adequate general endotracheal anesthesia. The face was prepped with Betadine and draped in a solution and draped in a customary fashion.
Attention was first turned to excising the epithelium that had grown over the wound surfaces and this was done. An additional 2 mm of tissue was resected in order to freshen the edges.
The first thing that was done was to provide a vascular lining for the sidewall of the nose and this was done by making an incision across the dorsal septum leaving behind approximately a centimeter of dorsal strut. This incision was done on the ipsilateral side of the nose and using a Cottle speculum, the cartilage was elevated away from this side of the nose.
Next, a Killian incision was made on the contralateral side and the contralateral mucosa was elevated off of the perichondrium.
A block of septal cartilage was then harvested with the use of swivel knife and scalpel blades and once this had been harvested, a proximal cranial incision was made in the contralateral perichondrium down to the floor of the nose.
Finally, the perichondrium was incised along the floor of the nose and the flap was passed through the defect and the ipsilateral perichondrium and sewn into placed to line the new sidewall of the nose. This was done without difficulty.
The cartilage was then shaved to form a sidewall strut and was sewn into place with few transfixion sutures across the mucoperichondrium.
A template was then made of the opposite side of the nose. The eventual hope was to do a heminasal reconstruction.
This patient has very glabrous skin and the scars on the tip of his nose were not proved to be favorable.
This template was then inverted and placed on the opposite side of the nose and marks were made where the feet of the ala needed to be.
This left behind approximately 7-10 mm cheek skin, which had been resected.
A cheek advancement flap was then incised along the nasolabial fold and advanced into position.
The dog-ear was removed superiorly and the cheek portion of the reconstruction was completed.
A full-thickness skin graft was then harvested from the right postauricular area and this was sewn to the mucoperichondrium, which had been transposed into the defect to form a new lining of vestibular skin. Finally, the template was rotated up onto the forehead and a forehead flap was designed using the template, which had been created. The base of the flap was placed over a fairly loud Doppler pulse, which was located in the area of the trochlea.
The flap was then elevated including the frontalis muscle down to just above the orbital rim. At this point, a subperiosteal dissection proceeded and the flap could be easily rotated down into position.
Hemostasis was achieved with electrocautery. The flap bled profusely during its transfer. The forehead was partially closed along the stalk of the flap and partially left open.
The template was then returned to the nose and measurements were made to try to find the exact spot of the base of the ala needed to be symmetrical. This was de-epithelialized and the ala was placed down there. The rest of the flap was then sewn in with multiple 5-0 Vicryl sutures. Because this patient is a smoker, no thinning of the flap was possible.
Additionally, even though a heminasal reconstruction was eventually planned, we did not excise the half of the remaining lobule until we were certain that this flap was going to be viable. The extra portions of the flap were then covered with Biobrane. The skin graft was then sewn to the edge of the flap along the vestibular margin and several transfixion sutures were placed.
The Biobrane was also placed in the forehead defect.
The nose was then lightly packed with Surgicel.
CPT CODES
14060
15260
21235,?, dont code much plastic surgery, would these codes be a good choice ?
PREOPERATIVE DIAGNOSES: Squamous cell carcinoma of the right ala, sidewall, and tip of the nose.
POSTOPERATIVE DIAGNOSES: Squamous cell carcinoma of the right ala, sidewall, and tip of the nose, status post previous excision with negative permanent sections
PROCEDURES PERFORMED: First-stage reconstruction of the nasal tip ala and sidewall with transposition mucoperichondrial flap, cartilage graft, full-thickness skin graft, and paramedian forehead flap.
INDICATIONS: The patient a very large squamous cell carcinoma, which had involved the vestibular surface of the nares as well as the external surface. He was told that the tumor should be resected and we would need to get negative margins before consideration of any reconstruction.
The tumor was resected approximately a week ago. The permanent sections all were considered to be clear of tumor. Again, I talked to the patient and gave him the alternatives of waiting six months prior to reconstruction, which may be safer even with the negative margins, but the patient wished to proceed with reconstruction as he did not want to be deformed for period of six months.
OPERATIVE PROCEDURE: He was taken to the operating room and placed under adequate general endotracheal anesthesia. The face was prepped with Betadine and draped in a solution and draped in a customary fashion.
Attention was first turned to excising the epithelium that had grown over the wound surfaces and this was done. An additional 2 mm of tissue was resected in order to freshen the edges.
The first thing that was done was to provide a vascular lining for the sidewall of the nose and this was done by making an incision across the dorsal septum leaving behind approximately a centimeter of dorsal strut. This incision was done on the ipsilateral side of the nose and using a Cottle speculum, the cartilage was elevated away from this side of the nose.
Next, a Killian incision was made on the contralateral side and the contralateral mucosa was elevated off of the perichondrium.
A block of septal cartilage was then harvested with the use of swivel knife and scalpel blades and once this had been harvested, a proximal cranial incision was made in the contralateral perichondrium down to the floor of the nose.
Finally, the perichondrium was incised along the floor of the nose and the flap was passed through the defect and the ipsilateral perichondrium and sewn into placed to line the new sidewall of the nose. This was done without difficulty.
The cartilage was then shaved to form a sidewall strut and was sewn into place with few transfixion sutures across the mucoperichondrium.
A template was then made of the opposite side of the nose. The eventual hope was to do a heminasal reconstruction.
This patient has very glabrous skin and the scars on the tip of his nose were not proved to be favorable.
This template was then inverted and placed on the opposite side of the nose and marks were made where the feet of the ala needed to be.
This left behind approximately 7-10 mm cheek skin, which had been resected.
A cheek advancement flap was then incised along the nasolabial fold and advanced into position.
The dog-ear was removed superiorly and the cheek portion of the reconstruction was completed.
A full-thickness skin graft was then harvested from the right postauricular area and this was sewn to the mucoperichondrium, which had been transposed into the defect to form a new lining of vestibular skin. Finally, the template was rotated up onto the forehead and a forehead flap was designed using the template, which had been created. The base of the flap was placed over a fairly loud Doppler pulse, which was located in the area of the trochlea.
The flap was then elevated including the frontalis muscle down to just above the orbital rim. At this point, a subperiosteal dissection proceeded and the flap could be easily rotated down into position.
Hemostasis was achieved with electrocautery. The flap bled profusely during its transfer. The forehead was partially closed along the stalk of the flap and partially left open.
The template was then returned to the nose and measurements were made to try to find the exact spot of the base of the ala needed to be symmetrical. This was de-epithelialized and the ala was placed down there. The rest of the flap was then sewn in with multiple 5-0 Vicryl sutures. Because this patient is a smoker, no thinning of the flap was possible.
Additionally, even though a heminasal reconstruction was eventually planned, we did not excise the half of the remaining lobule until we were certain that this flap was going to be viable. The extra portions of the flap were then covered with Biobrane. The skin graft was then sewn to the edge of the flap along the vestibular margin and several transfixion sutures were placed.
The Biobrane was also placed in the forehead defect.
The nose was then lightly packed with Surgicel.