Assign the CPT procedure codes
11. PROCEDURE PERFORMED: Wide wound exploration; excision of necrotic skin and subcutaneous tissue; debridement of abscesses. Frozen section obtained intraoperatively revealed a mixed picture of granulation tissue, inflammation, and necrotic tissue. The necrosis did not extend to the edge of resection. The edge of resection was viable.
PROCEDURE: After good general endotracheal anesthesia, the patient was prepped and draped in the usual sterile fashion. The entire previous C-section incision was opened from side-to-side, and the necrotic skin edges were trimmed away. Specifically, there was a 6 by 6 cm central portion of grossly necrotic tissue that was debrided away. The subcutaneous tissue beneath this was clearly necrotic, and this was also debrided away. Skin edges on both sides were debrided away until there was bleeding, viable tissue noted. The incision was extended laterally as there was infection that had tracked laterally on both sides, and abscess cavities were uncovered here. All clearly necrotic tissue was debrided away. Hemostasis was obtained with electrocautery. The wound was irrigated and then packed with some damp Kerlix. Plans were made to look at the wound again tomorrow in the operating room and debride away any other marginal tissue.
Pathology Report Later Indicated: Granulation tissue, inflammation, and necrotic tissue.
12. PROCEDURE(S) PERFORMED: CO2 laser resurfacing of the cheeks and perioral region.
HISTORY: Erin is a 36-year-old white female who presents for evaluation and treatment of facial acne scarring. Preoperatively, we discussed the procedure in vast detail. She has undergone her preoperative skin care regimen including retin-A and hydroquinone. She is ready for facial resurfacing.
PROCEDURE: Erin was brought to the operating room and after general anesthetic was administered her face was draped with moist sterile towels and her eyes were protected with special laser eye goggles overlying moist gauze. Using the Sharplin SilkTouch laser, the skin was resurfaced with 2 passes. The first pass stayed within the cheek and perioral aesthetic. The second pass focused particularly on the perioral area and the medial cheeks with feathering into the lateral cheek regions. The skin had excellent skin response with a final shammy color and obvious skin tightening. Dressings consisting of Aquacel of the cheeks and Vaseline of the perioral region were placed. She was discharged to recovery in stable condition.
13. SURGICAL PROCEDURE: Extension of fasciotomy, lateral aspect, right thigh and dressing change. ANESTHESIA: General endotracheal. ESTIMATED BLOOD LOSS: 25 cc. SURGICAL FINDINGS: Open wound, right thigh, with compression of the vastus lateralis laterally.
DESCRIPTION: The dressings were removed. The wound was inspected, and the muscle was quite clean. However, there was some constriction of the vastus lateralis by the tensor fascia lata laterally, and this was extended in the fascia only. Dressing of Xeroform, Kerlix fluffs and a splint were then reapplied.
The patient tolerated the procedure well and left the operating room in good condition.
ADDENDUM: This patient was scheduled originally for skin graft, but we elected at this point to attempt wound vacuum suction on the thigh to see if it could be closed without a skin graft.
14. PROCEDURE PERFORMED: Excision of multiple skin tags of neck ANESTHESIA: General endotracheal, supplementing with 1% Xylocaine with 1:100,000 epinephrine, approximately 5 cc. SURGICAL FINDINGS: Fibroepithelial skin tags of the neck.
PROCEDURE: The neck was prepped with Betadine scrub and solution and draped in a routine sterile fashion. Skin tags were removed by electrocautery. The bases of the skin tags were cauterized where appropriate. Antibiotic ointment and Band-Aids were applied. The multiple skin tags were submitted for permanent sections. The patient tolerated the procedure well and left the area in good condition.
Pathology Report Later Indicated: Benign skin tags; total of 9.
15. PROCEDURE PERFORMED: Excision of lipoma, right lumbar area. ANESTHESIA: General endotracheal with 2 cc of 1% Xylocaine with 1:100,000 epinephrine. SURGICAL FINDINGS: 3.5 cm diameter subcutaneous lesion sitting on the right latissimus dorsi muscle morphologically resembling a lipoma.
DESCRIPTION OF PROCEDURE: The patient was intubated and turned to a prone position. The lesion was prepped with Betadine scrub and solution and draped in a routine sterile fashion. I injected about 2 cc of 1% Xylocaine with 1:100,000 epinephrine over the site of the lesion and around it. I excised an ellipse of skin that I left attached to the lipoma and carried dissection down to the superficial muscular fascia from which I separated the lipoma. I cauterized the bleeding and closed the wound with subcutaneous 2-0 Monocryl to close the dead space and subcuticular 3-0 Monocryl. I used Steri-Strips to oppose the skin edges, and used Kerlix fluffs and Elastoplast for the remainder of the dressing. The patient tolerated the procedure well and left the Operating Room in good condition.
Pathology Report Later Indicated: Lipoma.
16. PROCEDURES PERFORMED: 1. Facelift. 2. Derma-fat-fascia grafting to nasolabial folds and marionette lines. 3. Bilateral upper and lower lid blepharoplasties.
HISTORY: Eva is a 66-year-old white female who presents for facial rejuvenation surgery. With her in a sitting position and prior to sedation, the appropriate facial landmarks were carefully measured and marked.
PROCEDURE: The patient was brought to the operating room. After general anesthetic was administered, her face and head were prepped and draped in the usual sterile fashion. Attention was first turned to the neck and jaw line. Prior to prepping and draping, a total of 20 ml of 0.5% lidocaine with epinephrine was injected into the midline neck area as well as the jowl regions. Using a 15 blade scalpel, a small incision was made at the premarked chin-neck fold. Through this incision, liposuction was carried out using a 2-mm cannula in the central neck region as well as the jowl areas. Then, using a 15 blade scalpel, the horizontal incision at the premarked chin-neck fold was opened to a length of about 2 cm down to the subcutaneous tissue. Double hooks were used for retraction and using a headlight for visualization, facelift scissors were used to dissect the neck skin at the superficial subcutaneous plane down to approximately the thyroid cartilage region. The dissection was carried laterally to the mid jaw line under direct visualization. Under direct visualization, further subcutaneous tissue was excised with the facelift scissors to expose the platysmal bands. The platysmal bands were identified and then reapproximated in the midline with interrupted 4-0 Vicryl suture. The platysma was divided horizontally at approximately the level of the superior thyroid cartilage for about 2.5 cm bilaterally. Attention was then turned to the right side of the face. Using a 15 blade scalpel and based on the preoperative markings, facelift incisions were carried out from the temporal hairline down anterior to the ear following the ear contours. The incision was extended posterior to the tragus and then down underneath the earlobe leaving a 2 mm cuff of native cheek skin underneath the earlobe, back behind the ear and then to a stair-step incision into the posterior hairline. Under direct visualization, the facelift scissors were used to elevate the cheek flap in the superficial subcutaneous plane all the way to the lateral orbital region underneath the orbit to the nasolabial fold, onto the oral commissure and then across the midline in the neck to join the previous midline dissection and then down to the inferior neck and into the posterior hairline.
Once the flap had been elevated, the malar prominence and zygomatic arch were carefully marked. Using interrupted 4-0 Vicryl sutures, the SMAS was plicated over the malar prominence extending onto the zygomatic arch. This elevated the facial structures and jaw region approximately 2 cm. Once the appropriate contours were obtained, the skin was draped over the facial structures with only mild tension. An 11 blade scalpel was used to incise the skin at key anchor points, including the superior and posterior hairline. The skin was stapled into position at these anchor points. A marking pen was then used to carefully mark the excess skin. The excess skin was then excised with a 15 blade scalpel. In the hairline, skin staples were used to reapproximate the wound margins.
The skin overlying the tragus was carefully thinned down to the dermis using small Joseph scissors. Three key interrupted 6-0 Monocryl sutures were used to reapproximate the dermal margins and to take tension off the final epidermal approximation. A 5-0 silk suture was also placed from the fascial underneath the earlobe to the deep dermis of the skin inferior to the earlobe to take tension off the lobe, itself. Then, running 6-0 nylon suture was used to reapproximate the epidermis anterior to the ear and a 5-0 nylon suture was used to reapproximate the epidermis posterior to the ear. Prior to closure, a #7 Blake drain was placed and brought out through a separate stab wound incision posteriorly and sutured into position using 3-0 silk suture. Attention was turned to the opposite side where an identical procedure was carried out. At the end of the opposite side, it was noted there was some obvious fluctuance posteriorly bilaterally despite careful hemostasis. Therefore, both sides were reopened. Small nonpulsatile bleeders were found on both sides. The wounds were irrigated and inspected carefully once again for hemostasis and then re-closed in exactly the same fashion. Attention was turned to the upper eyelids. Based on the preoperative markings, a 15 blade scalpel was used to incise the skin in a modified elliptical fashion extending into the crow’s feet region. The tissue was excised off the orbicularis muscle with small Joseph scissors. Hemostasis was obtained with electrocautery. Eva had a great deal of sub-orbicularis fat deposit. The orbicularis was carefully divided with needlepoint electrocautery superiorly and dissection was carried out down to the sub-orbicularis fat pad. Excess sub-orbicularis fat was then excised with electrocautery until the appropriate contours were obtained. Once appropriate contours were obtained, the wound margins were reapproximated with a running 6-0 fast absorbing subcuticular suture. Attention was turned to the lower eyelids. The lower eyelids had previous surgery. She did have a good deal of proptosis bilaterally. Therefore, care was taken to perform only minimal and only supportive surgery. Using a 15 blade scalpel, an incision was made from approximately the lateral third of the lower eyelid in the subciliary region out into the lateral crow’s feet region.
Through this incision, dissection was carried down to the orbicularis muscle to the sub-orbicularis plane. A small lateral fat pad was identified. Based on the preoperative markings, the septum was divided in the lateral region with small Joseph scissors. The excess fat that protruded with gentle pressure on the globe was excised with electrocautery. Two 6-0 nylon sutures were used to reapproximate the deep orbicularis layer to the periosteum at approximately the level of the canthus. These sutures were tightened until there was adequate support of the flap and to let the skin lay entirely without tension. No skin was excised. The wound margins were reapproximated with interrupted 6-0 fast absorbing suture. The identical procedure was carried out on the opposite side, once again taking care to perform minimal and only supportive lower eyelid surgery. Attention was turned to the nasolabial folds. Using a 15 blade scalpel, small stab wound incisions were made based on the preoperative markings at the superior and inferior aspects of the nasolabial folds and similarly at the superior and inferior aspects of the marionette lines. Through these incisions, a small mosquito hemostat was used to dissect deep to and medial to the nasolabial folds. Then, dermofat grafts taken from the discarded facial skin were threaded into the pockets. Once appropriate contours were obtained, the wound margins were reapproximated with interrupted 6-0 fast absorbing suture and Steri-Strips. Attention was turned to the philtrum. There was a previous scar there from excision of a nevus that caused a good deal of indentation and contraction. The scar, which was roughly elliptical, was incised with a 15 blade scalpel. It was then deepithelialized. Single skin hooks were used for retraction and a 15 blade scalpel was used to undermine the lateral philtral tissue for approximately 5 mm bilaterally. The wound margins were then reapproximated with interrupted 6-0 Monocryl deep dermal sutures and interrupted 6-0 fast absorbing suture. Upon completion of the surgery, careful inspection was once again made for any signs of hematoma and none were identified. The contours appeared symmetric and appropriate. Her eyes were dressed ‘ with Lacri-Lube in her eyes as well as cool moist 4x4s. Dressings consisting of Xeroform around the incisions, fluffs, ABDs and an elastic facial garment were placed and she was discharged to recovery in stable condition.
17. PROCEDURE PERFOMED: Insertion of a 175-ml volume tissue expander measuring approximately 6 x 5 cm at its maximal dimensions. ANESTHESIA: 5 ml 1% Xylocaine and 1:100,000 epinephrine plus general endotracheal
DESCRIPTION OF PROCEDURE: The patient’s left arm was prepped with Betadine scrubbing solution and draped in the routine sterile fashion. I injected 1% Xylocaine and 1:100,000 epinephrine distally, and made an incision adjacent to the distal portion of the giant congenital nevus in the forearm, dissecting down to the muscle fascia where I created a pocket to accommodate the expander. It was necessary to come up some on the pigmented lesion to undermine that to get the expander in, and because of the proximity of the radius in this area and the lower end of the humerus, and the necessity to make a large pocket, I did not insert the second tissue expander above this. It was felt that if it was necessary, that a flap could be created superiorly and would produce less surgical trauma in this area. The wound was closed with interrupted horizontal mattress sutures of 3-0 Prolene and Nitropaste was applied to the suture line. Xeroform, Kerlix fluffs, Kerlix roll, Kling, Sof-Rol, and a long arm fiberglass cast were then applied. Estimated blood loss was negligible. The patient tolerated the procedure well and left the operating room in good condition.
18. PROCEDURES PERFORMED: Dermabrasion and scar revision ANESTHESIA: General endotracheal with approximately 7 cc of 1% Xylocaine and 1:100,000 Epinephrine ESTIMATED BLOOD LOSS: Less than 25 cc COMPLICATIONS: None SPONGE AND NEEDLE COUNT: Correct
INDICATION: This patient has a widened scar with large suture marks as a result of resection of a dermatofibrosarcoma protuberans about 1 year ago.
SURGICAL FINDINGS: A 22.5-cm-long unsightly scar of the neck with suture marks and widening of the scar.
DESCRIPTION OF PROCEDURE: The patient’s neck was prepped with Betadine scrub and solution and draped in a routine sterile fashion. The scar was injected with 7 cc of 1% Xylocaine and 1:100,000 epinephrine and dermabraded. It was excised to include parts of the suture marks. This was excised down to fat, but some residual scarring remained. This was left in to help provide support and blood supply. I closed the wound with subcuticular 3-0 Monocryl and interrupted twists of 5-0 Prolene. The dressing consisted of thymol iodide powder and 4x4s. The patient tolerated the procedure well and left the area in good condition.
Pathology Report Later Indicated: Benign scar tissue.
19. PROCEDURE PERFOMED: Bilateral breast reduction using inferior pedicle technique.
1. 800 grams resected from the right side.
2. 900 grams from the left side.
ANESTHESIA: General endotracheal
SURGICAL FINDINGS: The breasts were predominantly glandular, being about 75% very firm fibrous glandular tissue interspersed with 25% fat.
INDICATIONS: The patient has interscapular back pain and neck pain, which she has had for several years. This has become progressively severe and is not relieved by the usual measures. It is felt that the back pain is caused by her large and pendulous breasts with regard to her body habitus.
DESCRIPTION OF PROCEDURE: In accordance with the preoperatively marked new nipple site, we marked out an inferior pedicle breast pattern, and instilled about 75 cc of tumescent solution into the right side of the breast. Tumescent solution was prepared with 25 cc of 2% Xylocaine and 1 cc of 1:1,000 epinephrine plus 3 cc of 8.4% sodium bicarbonate added to 1,000 cc Ringer’s lactate. After installation of solution at the junctional points and along the suture lines, the vertical stalk was de-epithelialized leaving about 1.5 cm of de-epithelialized stalk above the areola. The new areolar site and the areolar size were planned using the 45 mm cookie cutter marker as a guide. The 3, 6, 9, and 12 o’clock positions were marked on the new areolar window and on the areola itself. The vertical stalk having been de-epithelialized, deep dissection was started at the 12 o’clock position and came towards the 3 o’clock between the upper end of the vertical limb and the medial flap. At the caudal edge of the medial flap we began to bevel away from the vertical limb, and connected this with an incision in the inframammary area at the level of the pectoralis major fascia. The incision on the caudal edge of the medial flap was beveled in such a way as to leave about 2 cm of thickness on the flap, and the incision between the upper part of the vertical limb and the medial flap was not carried down deeply into the tissue, leaving some glandular tissue connected with the central stalk. After resection of the medial triangle, deep dissection then started at the 12 o’clock position and came towards the 9 o’clock position coming between the upper end of the vertical limb and the lateral flap, but not going deeply in to the space between the lateral flap and the vertical limb. In other words, we left some glandular tissue attached to the central stalk. We then connected this with an incision at the inframammary level down to the pectoralis major fascia, and began our dissection on the caudal edge of the lateral flap leaving about 1.5 cm of thickness of the lateral flap. The superior triangle was then resected, but we attempted to leave this area also with much of the vertical stalk, which carried the nipple areola, and after resection of approximately 800 grams of tissue on the right side, we detached the dermis inferiorly at the vertical stalk, and inset the lateral and medial flaps with a subcuticular 3-0 Monocryl suture. We then used subcuticular 3-0 Monocryl for key points on the areolar window the vertical limb, and the inframammary limb. We used skin staples to better appose the skin edge. Final weight on the right was about 800 grams.
On the left side, we once again made our junctional incisions and instilled about 125 cc of tumescent solution at these sites along the suture line. De-epithelialization of the vertical stalk was carried out. We then began our initial dissection at the 12 o’clock position and came towards the 9 o’clock position coming between the upper end of the vertical stalk and the medial flap. We began to bevel away from the vertical limb at the caudal edge of the medial flap, and connected this with an incision at the inframammary area at the level of the pectoralis major fascia. We also beveled underneath the medial flap in such a manner as to leave about 2 cm of thickness on the leading edge, but attempted to maintain continuity between the deep tissue of the medial flap and the central vertical limb. On the lateral side deep dissection started at the 12 o’clock position and came towards the 3 o’clock position between the upper end of the vertical limb and the lateral flap, once again trying to maintain continuity of the deep tissue of the lateral flap with the vertical limb, and beveling away from the vertical limb starting at the caudal edge and to the lateral flap. After connecting this with an incision on the caudal edge of the lateral flap, we also included the Tail of Spence in the dissection. On the right side we had also included the Tail of Spence in our lateral dissection. After resection of the lateral triangle, the dermis was detached at the vertical limb inferiorly, and we in-set the lateral and medial flaps at the midpoint, the vertical limb with a horizontal half mattress suture of 0 Prolene, in-setting the new areolar size at the new window with subcuticular 3-0 Monocryl, and using 3-0 Monocryl for the vertical limb. Subcuticular 3-0 Monocryl was also used for the inframammary limb, and skin staples were used to better appose the skin edges. Dressings consisted of Xeroform, Kerlix fluffs, a support bra, and an external Ace bandage. There were no complications. Estimated blood loss was 125 cc and sponge and needle count were correct. The patient tolerated the procedure well and left the area in good condition.
Pathology Report Later Indicated: Normal breast tissue.
20. PROCEDURE PERFORMED: 1. Excision of basal cell carcinoma of skin of the left lower lip, 3.25 cm. 2. Suprahyoid neck mass dissection. 3. Bilateral advancement flap closure of surgical defect, lip, 16 square cm. ANESTHESIA: Local with IV sedation ESTIMATED BLOOD LOSS: Less than 25 CC.
DESCRIPTION OF PROCEDURE: After consent was obtained, the patient was taken to the operating room and placed on the operating room table in the supine position. After an adequate level of IV sedation was obtained, the patient’s lower face and neck were prepped with Betadine prep and then draped in a sterile manner. The incision was outlined in the lower lip area down to the mental crease area. An incision was also marked on the upper neck in the medial aspect just above the hyoid bone. The incision was extended also to the left submandibular area. The area was then infiltrated with l% Xylocaine with 1:100,000 units of epinephrine. Attention was first focused on the lip. Utilizing sharp dissection full thickness excision was accomplished to include mucosa and skin. 3 mm margins on each side were utilized. Frozen section reported basal cell carcinoma completely excised with negative margins. At the time that frozen section was being done the neck was addressed. Sharp dissection was carried down to the skin and subcutaneous tissue. Superior and inferior subplatysmal flaps were elevated. The lymphoid tissue in the suprahyoid area extending from the submental area to the left proximal submandibular area was then dissected and removed along with the masses. Dissection was carried down to the digastric muscle fascia. Hemostasis was achieved with silk ties and bipolar cautery. That area was sprayed with Hemaseal and then the wound closed with the deeper tissue approximated with interrupted 4-0 Vicryl suture and the skin approximated with skin staples. Bacitracin ointment and a dressing were applied. Attention was then refocused on the lip. Bilateral advancement flaps were developed again by extending the incision along the mental crease line. The mucosa was left intact. The flaps were approximated with interrupted 4-0 Vicryl suture. 4-0 Vicryl suture was then utilized in interrupted mattress closure fashion to close the mucocutaneous area of the lower lip, as well as the mucosa. The skin was approximated with interrupted closure of 6-0 nylon. Bacitracin ointment was then applied. The patient tolerated the procedure well, there was no break in technique, and the patient was awakened and taken to the Postanesthesia Care Unit in good condition.
Pathology Report Later Indicated: Basal cell carcinoma of the external lip and metastatic carcinoma to the neck.