csorensen21@yahoo.com
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Very new to plastics and craniofacial surgery. Not sure what modifiers or procedures to use? 15824? But from a reimbursement standpoint this is viewed as cosmetic? Any help would be much appreciated!!! Thank you!
Preoperative diagnosis:
1. Acromegaly.
2. Craniofacial deformity secondary to acromegaly status post multiple craniofacial procedures to correct this.
3. Persistent hyperplasia and deformity of bilateral zygomas.
4. Facial soft tissue sagging bilaterally secondary to acromegaly.
Post operative Diagnosis:
1. Acromegaly.
2. Craniofacial deformity secondary to acromegaly status post multiple craniofacial procedures to correct this.
3. Persistent hyperplasia and deformity of bilateral zygomas.
4. Facial soft tissue sagging bilaterally secondary to acromegaly.
Procedures:
1. Coronal approach, sublabial approach and subciliary approaches to bilateral osteotomies of the zygomas and orbits with reconstruction. This was performed by Dr. ____ as the primary surgeon and Dr. ____ as the TSA.
2. Lower oral vestibuloplasty, with was performed by Dr. ___ as the primary surgeon and Dr. ____ as the TSA.
3. Removal of retained craniofacial hardware.
4. Bilateral subperiosteal rhytidectomy. Dr. ____as the primary surgery for that and Dr. ___ as the TSA. (our portion that we are billing for other procedures we were the TSA)
Indications:
The patient is a 46-year-old female with history of acromegaly and secondary craniofacial deformity. She has undergone multiple reconstructive procedures and presents with residual deformities of the zygomas related to the acromegaly. She is a candidate for further reconstruction. We discussed indications, risks and potential complications. She also had significant sagging of the facial soft tissues bilaterally secondary to her condition. She also had drooping of the lower lip with lip incompetence. the above procedures were recommended and again the indications, risks, potential complications as well as alternatives to surgery were discussed and informed consent was obtained. Risks discussed included but were not limited to risks of bleeding, potential need for transfusion, hematoma, infections, scarring, residual cosmetic deformity, potential for nerve injury including injury to the supraorbital and supratrochlear nerves with resultant hypestheia or anesthesia in the distribution of the forehead and scalp. Injury to the infraorbital nerves with potential hypestheia or anesthesia and the region of the cheek, nose, upper lip and upper dentition and potential for injury to the mental nerve with potential for hypestheia or anesthesia of the chin, lower lip. It was discussed the possible potential for facial nerve injury with resultant weakness, particularly in the frontal branch of the facial nerve during the elevation of the coronal flap. This could be temporary or permanent. Of note, she did have a preoperative weakness of the right brow with decreased elevation compared to the left and asymmetry. We did discuss the potential for facial nerve injury, which could be permanent, partial or complete.
Procedures:
The patient was identified in the preop area, taken to the operating room, placed supine on the operating table and general nasotracheal anesthesia was induced. The tube was secured in a manner such that there was no pressure placed on the nasal ala. The entire head, face and neck were exposed. The prior coronal incision was used. The hair was braided anterior to the incision as well as posterior to it to facilitate exposure. A small strip of hair was shaved at the incision site. She did receive preoperative IV antibiotics. Sequential compression devices were placed for induction of anesthesia Lacri-lube and corneal shields were placed to protect the globes. The patients head, face and neck were prepped and draped in sterile fashion. The first portion of the procedure, including the bicoronal flap and the sublabial approach and bilateral subciliary approaches is dictated elsewhere by Dr. ___. After the osteotomies were made at the zygomas and orbits bilaterally, the zygomas were repositioned and rigidly fixated. The subperiosteal facelift was performed. The facial soft tissues were elevated subperiosteal from the coronal approach and intraoral approach. Two suspension sutures were placed on each side. This was a purse string suture that consisted of a long lasting absorbable suture. The first suture was secured to the inferolateral orbital rim by a drill hole. The orbital contents were protected during performance of the drill hole just inside of the inferolateral orbital rim. The suture was passed through the drill hole and subperiosteal bites of the medial facial soft tissues were then performed in a purse string manner. Tightening of this suture elevated the medial soft tissues from the nasolabial fold area including the malar fat pad up to the lateral orbital region. Next, the soft tissues of the face more laterally was suspended again, using a purse string suture of the periosteum region of the temporal area to the lateral facial soft tissue to the oral commissure. This suture resulted in suspension of the lateral soft tissues of the mid face. Two such sutures were placed on each side similarly. It was felt that adequate suspension as well as adequate and symmetric suspension was obtained. Sutures were then tightened and on inspections, there was adequate elevation of the soft tissues, which was symmetrical. She did have elevation of the upper lip to the mid aspect of the incisor after the suspension. This was significant improvement from her preoperative condition.
The vestibuloplasty was performed by Dr. ____ and I was the TSA for that. The remainder of the wound was copiously irrigated. Closure was performed per Dr. ___ dictation. the dressing was applied per Dr. ___ dictation. The patient tolerated the procedure well.
Preoperative diagnosis:
1. Acromegaly.
2. Craniofacial deformity secondary to acromegaly status post multiple craniofacial procedures to correct this.
3. Persistent hyperplasia and deformity of bilateral zygomas.
4. Facial soft tissue sagging bilaterally secondary to acromegaly.
Post operative Diagnosis:
1. Acromegaly.
2. Craniofacial deformity secondary to acromegaly status post multiple craniofacial procedures to correct this.
3. Persistent hyperplasia and deformity of bilateral zygomas.
4. Facial soft tissue sagging bilaterally secondary to acromegaly.
Procedures:
1. Coronal approach, sublabial approach and subciliary approaches to bilateral osteotomies of the zygomas and orbits with reconstruction. This was performed by Dr. ____ as the primary surgeon and Dr. ____ as the TSA.
2. Lower oral vestibuloplasty, with was performed by Dr. ___ as the primary surgeon and Dr. ____ as the TSA.
3. Removal of retained craniofacial hardware.
4. Bilateral subperiosteal rhytidectomy. Dr. ____as the primary surgery for that and Dr. ___ as the TSA. (our portion that we are billing for other procedures we were the TSA)
Indications:
The patient is a 46-year-old female with history of acromegaly and secondary craniofacial deformity. She has undergone multiple reconstructive procedures and presents with residual deformities of the zygomas related to the acromegaly. She is a candidate for further reconstruction. We discussed indications, risks and potential complications. She also had significant sagging of the facial soft tissues bilaterally secondary to her condition. She also had drooping of the lower lip with lip incompetence. the above procedures were recommended and again the indications, risks, potential complications as well as alternatives to surgery were discussed and informed consent was obtained. Risks discussed included but were not limited to risks of bleeding, potential need for transfusion, hematoma, infections, scarring, residual cosmetic deformity, potential for nerve injury including injury to the supraorbital and supratrochlear nerves with resultant hypestheia or anesthesia in the distribution of the forehead and scalp. Injury to the infraorbital nerves with potential hypestheia or anesthesia and the region of the cheek, nose, upper lip and upper dentition and potential for injury to the mental nerve with potential for hypestheia or anesthesia of the chin, lower lip. It was discussed the possible potential for facial nerve injury with resultant weakness, particularly in the frontal branch of the facial nerve during the elevation of the coronal flap. This could be temporary or permanent. Of note, she did have a preoperative weakness of the right brow with decreased elevation compared to the left and asymmetry. We did discuss the potential for facial nerve injury, which could be permanent, partial or complete.
Procedures:
The patient was identified in the preop area, taken to the operating room, placed supine on the operating table and general nasotracheal anesthesia was induced. The tube was secured in a manner such that there was no pressure placed on the nasal ala. The entire head, face and neck were exposed. The prior coronal incision was used. The hair was braided anterior to the incision as well as posterior to it to facilitate exposure. A small strip of hair was shaved at the incision site. She did receive preoperative IV antibiotics. Sequential compression devices were placed for induction of anesthesia Lacri-lube and corneal shields were placed to protect the globes. The patients head, face and neck were prepped and draped in sterile fashion. The first portion of the procedure, including the bicoronal flap and the sublabial approach and bilateral subciliary approaches is dictated elsewhere by Dr. ___. After the osteotomies were made at the zygomas and orbits bilaterally, the zygomas were repositioned and rigidly fixated. The subperiosteal facelift was performed. The facial soft tissues were elevated subperiosteal from the coronal approach and intraoral approach. Two suspension sutures were placed on each side. This was a purse string suture that consisted of a long lasting absorbable suture. The first suture was secured to the inferolateral orbital rim by a drill hole. The orbital contents were protected during performance of the drill hole just inside of the inferolateral orbital rim. The suture was passed through the drill hole and subperiosteal bites of the medial facial soft tissues were then performed in a purse string manner. Tightening of this suture elevated the medial soft tissues from the nasolabial fold area including the malar fat pad up to the lateral orbital region. Next, the soft tissues of the face more laterally was suspended again, using a purse string suture of the periosteum region of the temporal area to the lateral facial soft tissue to the oral commissure. This suture resulted in suspension of the lateral soft tissues of the mid face. Two such sutures were placed on each side similarly. It was felt that adequate suspension as well as adequate and symmetric suspension was obtained. Sutures were then tightened and on inspections, there was adequate elevation of the soft tissues, which was symmetrical. She did have elevation of the upper lip to the mid aspect of the incisor after the suspension. This was significant improvement from her preoperative condition.
The vestibuloplasty was performed by Dr. ____ and I was the TSA for that. The remainder of the wound was copiously irrigated. Closure was performed per Dr. ___ dictation. the dressing was applied per Dr. ___ dictation. The patient tolerated the procedure well.