Assign the CPT procedure codes
Assign the CPT procedure codes
28. PROCEDURE(S) PERFORMED:
1. Excision of squamous cell carcinoma of the forehead total 3.5 cm.
2. Partial layered closure 1.5 cm.
3. Full thickness skin graft total 3 cm in diameter.
PROCEDURE: Marla was brought to the operating room. After local anesthetic was administered, her face and her neck were prepped and draped in the usual sterile fashion. Using a 15-blade scalpel, the lesion was incised with a wide margin of normal-appearing tissue down to the galea. The lesion was excised at the subgaleal plane. There did not appear to be ulceration through the galea grossly. The specimen was marked with a suture at 12 o’clock superior and sent for frozen section pathology which confirmed the margins were clear. Using interrupted 4-0 Monocryl suture, the deep dermis was reapproximated medially and laterally as much as the wound margins would allow. The remaining defect then measured 3 cm in diameter. An appropriately sized full thickness skin graft was harvested from her left neck using a fresh 15-blade scalpel. The graft was defatted with sharp scissors and placed on the recipient site. It was affixed into position using interrupted 5-0 fast-absorbing suture. A tie-over dressing consisting of 5-0 nylon, Xeroform, and cotton balls was placed. The donor site was reapproximated with a running 4-0 Monocryl subcuticular suture and 5-0 fast-absorbing suture to reapproximate the epidermis, and Dermabond dressing was placed. She was discharged to the care of Dr. Almaz who is performing a total knee on the left side today.
Pathology Report Later Indicated: Squamous cell carcinoma of the skin of the forehead.
29. POSTOPERATIVE DIAGNOSIS: Multiple sinus tracts, one extending inferiorly about 7 x 3 cm in diameter, one extending to the right approximately 4 x 3 cm, and one extending to the left for about 3 cm.
SURGICAL FINDINGS: As above, plus granulation tissue present in a capsule of multiple sinus tracts. Sinus tracts measured a total of about 15 x 8 cm in their total dimensions.
SURGICAL PROCEDURE: Partial unroofing of sinus tracts through subcutaneous skin.
ANESTHESIA: General endotracheal.
DESCRIPTION OF PROCEDURE: The patient was intubated and turned in the prone position. A probe was inserted in the sinus cavity, and dissection was carried down to this. I encountered a piece of chronically infected granulation tissue coming out of a hole, in which I stuck the probe, but this continued for a distance longer than the probe and accordingly, I put my finger in this and this extended down the length of my index finger (i.e., about 7-8 cm by about 3 cm in width). I left this intact, because this would necessitate extensive dissection and we have no blood on this patient at this time. We then unroofed two other sinus cavities, and packed this open with 2-inch vaginal packing and applied a dressing and Kerlix plus an Elastoplast. Estimated blood loss: 25 cc. The patient seemed to tolerate the procedure well and left the operating room in good condition.
Pathology Report Later Indicated: Granulation tissue with inflammation.
30. SURGICAL PROCEDURES:
1. Sentinel node biopsy, left submandibular region.
2. Wide-excision (1 centimeter) of desmoplastic malignant melanoma, left side of upper lip with through-and-through excision and 1 centimeter margins on all sides.
ANESTHESIA: General endotracheal with supplementary 2 cc of 1 percent Xylocaine and 1:800,000 Epinephrine.
SURGICAL FINDINGS: The patient had a scar of the upper lip and a 5 millimeter linear, pigmented lesion near the mucosal junction. There was one submandibular lymph node identified that appeared to be benign. No occipital or posterior submandibular lymph nodes were identified despite assiduous search.
DESCRIPTION OF PROCEDURE: Following injection of radioactive dye in the Radiology Department, the patient was sent to the operating room where the face and neck were prepped with Betadine scrub and solution and draped in a routine sterile fashion. The sites that had been identified in Radiology were noted, and on the mastoid area, I detected 100 on the probe externally. I explored this, but when I got inside, I was unable to reproduce the external reading despite a vigorous exploration of the mastoid area and splitting of the sternocleidomastoid muscle over the site where most of the probe activity was evident. We made about a 3 centimeter incision in this area and explored it thoroughly in all areas indicated. I thought on occasion I palpated a lymph node, but upon deep dissection, it was noted that this was simply another fiber of the sternocleidomastoid muscle, and we abandoned this after a search of about 15 minutes. In the submandibular area, an incision was made, and activity was evident. The skin in the posterior mandibular area had a reading of 13 with an in vivo reading of 63. However, the ex vivo was only approximately 7 on the specimen itself. It may have been too small to have caused any reactivity. The background was 26 following removal of a small lymph node which was less than 1 centimeter diameter. No anterior mandibular lymph node was ever identified. Also, it should be noted that at no time did I, other than the small lymph node we removed, palpate lymphadenopathy in the mesenteric muscle region or in the region of the external maxillary artery which crossed the marginal mandibular nerve. I then marked out a margin of 1 centimeter around the previous scar, and in so doing I noted that included within this resection was a 5 millimeter linear pigmented lesion. This was excised like a wedge resection of the lower lip, and bleeding of the coronal arteries were clamped and ligated with 4-0 Vicryl. I then began closure of the mucosa, lining up the mucocutaneous junction and lining up the vermillion where it meets the white roll. After completion of the mucosal closure, the musculature was brought together. The orbicularis oculi musculature was brought together with 4-0 Vicryl suture, and interrupted 5-0 Prolene was used to reapproximate the skin. There was no evidence of residual tumor within the specimen submitted. A silk suture tagged the lip side of the specimen. Antibiotic ointment was applied, and 4 by 4 was used to cover the incision. The patient tolerated the procedure well and left the area in good condition.
Pathology Report Later Indicated: Malignant melanoma of the lip with no evidence of residual tumor within the lymph nodes.
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