sutherngyrl
Contributor
How would you suggest on coding this. 64716 and 64742
Needle point facial nerve electrodes were placed in the orbicularis oculi and auris, and were tested and found to be in good working order. These were used to actively monitor the facial nerve throughout the case. A face lift style incision around the left ear was planned and this was injected with lidocaine with epinephrine. The left face and upper neck were injected with epinephrine 1:100,000 to avoid losing nerve function from local anesthetic. She was prepped and draped in a sterile fashion. The skin was incised with a 15 blade, subcutaneous elevation was performed in the upper neck and medial cheek. The SMAS layer was then incised along the anterior and inferior border of the parotid gland and sub-SMAS dissection, then proceeded extensively throughout the mid face and upper neck for a distance of 5 x 9 sq cm. This was kept perfused on facial artery perforators. The external jugular vein and greater auricular nerve were seen and preserved. The platysma was elevated with the SMAS layer and facial nerve dissection began in the lower neck region. Using the checkpoint facial nerve stimulator, multiple branches of the facial nerve were sequentially identified and mobilized in a 360-degree fashion. These were then traced distally to observe their branching patterns. Nerve dissection proceeded into the upper neck near the midline submental region and to the orbicularis commissure location. The facial vein and artery branches were observed and kept free flowing. Additional dissection proceeded along the mid face and the parotid duct was identified along with surrounding large zygomatic nerve branch, which was stimulated and found to produce nice commissure and upper lip elevation. This was kept intact. There were 4 dominant buccal branches, which were carefully mobilized and traced distally. There were 2 branches in the marginal mandibular distribution along with 1 dominant cervical branch.
Stimulation was then meticulously performed for each branch with careful observation of the resulting facial movement. Branches that created contraction of the platysma, DAO, buccinator, orbicularis auris, and risorius were marked for transection. All branches that produced movement in the depressor labii inferioris, zygomaticus major and minor as well as some orbicularis auris branches were selected for preservation. There was 1 large main cervical branch seen with a smaller medial branch that produced depressor labii inferioris motion. The DLI branch was preserved while the 2 branches heading to the platysma were resected with clips and ligated. Next, moving superiorly, there was a branch running over the border of the mandible that when stimulated produced depressor anguli oris activity along with some mentalis activity and this was sectioned along with a subsequent distal branch. One additional very distal branch was seen in this area that also produced lower lip elevation with orbicularis activity and this was sectioned as well. Superiorly, the 4 buccal branches were then carefully mapped out. Two of them produced orbicularis squeeze along with lateralization from the risorius and buccinator, and 1 also produced commissure depression and these 2 branches were clipped and ligated while the 2 more superior branches that produced some orbicularis squeeze and slight elevation were preserved. In total, 6 facial nerve branches were ligated while 4 were preserved.
Needle point facial nerve electrodes were placed in the orbicularis oculi and auris, and were tested and found to be in good working order. These were used to actively monitor the facial nerve throughout the case. A face lift style incision around the left ear was planned and this was injected with lidocaine with epinephrine. The left face and upper neck were injected with epinephrine 1:100,000 to avoid losing nerve function from local anesthetic. She was prepped and draped in a sterile fashion. The skin was incised with a 15 blade, subcutaneous elevation was performed in the upper neck and medial cheek. The SMAS layer was then incised along the anterior and inferior border of the parotid gland and sub-SMAS dissection, then proceeded extensively throughout the mid face and upper neck for a distance of 5 x 9 sq cm. This was kept perfused on facial artery perforators. The external jugular vein and greater auricular nerve were seen and preserved. The platysma was elevated with the SMAS layer and facial nerve dissection began in the lower neck region. Using the checkpoint facial nerve stimulator, multiple branches of the facial nerve were sequentially identified and mobilized in a 360-degree fashion. These were then traced distally to observe their branching patterns. Nerve dissection proceeded into the upper neck near the midline submental region and to the orbicularis commissure location. The facial vein and artery branches were observed and kept free flowing. Additional dissection proceeded along the mid face and the parotid duct was identified along with surrounding large zygomatic nerve branch, which was stimulated and found to produce nice commissure and upper lip elevation. This was kept intact. There were 4 dominant buccal branches, which were carefully mobilized and traced distally. There were 2 branches in the marginal mandibular distribution along with 1 dominant cervical branch.
Stimulation was then meticulously performed for each branch with careful observation of the resulting facial movement. Branches that created contraction of the platysma, DAO, buccinator, orbicularis auris, and risorius were marked for transection. All branches that produced movement in the depressor labii inferioris, zygomaticus major and minor as well as some orbicularis auris branches were selected for preservation. There was 1 large main cervical branch seen with a smaller medial branch that produced depressor labii inferioris motion. The DLI branch was preserved while the 2 branches heading to the platysma were resected with clips and ligated. Next, moving superiorly, there was a branch running over the border of the mandible that when stimulated produced depressor anguli oris activity along with some mentalis activity and this was sectioned along with a subsequent distal branch. One additional very distal branch was seen in this area that also produced lower lip elevation with orbicularis activity and this was sectioned as well. Superiorly, the 4 buccal branches were then carefully mapped out. Two of them produced orbicularis squeeze along with lateralization from the risorius and buccinator, and 1 also produced commissure depression and these 2 branches were clipped and ligated while the 2 more superior branches that produced some orbicularis squeeze and slight elevation were preserved. In total, 6 facial nerve branches were ligated while 4 were preserved.