Bobby A
Networker
could someone please help with this procedure note, i have came up with CPT codes; 21365, 21390, and 14060
Pre-op Diagnosis: Displaced left tripod fractures of the face.
Post-op Diagnosis: same
Procedure Performed: Open reduction internal fixation for fractures on the left face. Reconstruction of the left orbital floor with supra foil implant.
Indications for the procedure: The patient is a 39-year-old male who had sustained facial trauma with grossly displaced tripod fractures on the left side of the face being. The cheek was significantly depressed, consistent with the pattern of the fractures.
During the surgery, a sterile corneal shield was applied for protection of both eyes. There were removed at the end of the surgery.
Description of the procedure: Patient was in supine position and received general anesthesia. The patient's face as well as the oral cavity were prepped and draped in a sterile manner. For this case, all the respective sites for incision were infiltrated with 0.25% Marcaine with epinephrine prior to the incisions. We proceeded with removal of some old external sutures on the face and the forehead.
We started with incision at the lateral left eyebrow area using a 15. Blade. We dissected down to the bone. Hemostasis was achieved with electrocautery. Periosteal elevator was used to expose the surface of the bone. The zygomatical frontal fracture site was identified. We could also easily palpate the deformity on the left cheek and zygomatic area. A blunt instrument was introduced behind the zygoma. Force was applied so as to readvance the zygoma forward and also we elevating it upward. This immediately produced a correction of the deformity on the left side of the cheek. We then proceeded with exploration the other fracture sites to confirm appropriate alignment.
A sub ciliary incision at the left lower eyelid was made. He initially we dissected as a skin flap which was then converted to skin-muscle flap as we dissected down to the inferior orbital rim. Hemostasis was achieved with electrocautery. An incision was made on the edge of the inferior orbital rim and the periosteal was elevated and extended posteriorly to examine the floor. There was a fracture of the floor but without the significant gap. Nonetheless, we subsequently placed a supra foil implant after examining the other fractures. Another incision was made at the left upper buccal sulcus using a 15. Blade. Hemostasis was achieved with electrocautery. We dissected down to the bone and exposed fractures at the zygomatical maxillary area. This fracture was noted to be displaced with an overlap. Blood instrument was inserted in between the gap and the fracture site was reduced. We again re-examined the zygoma and the zygomatical frontal area to verify that the alignments were adequate. The previous reduction and correction for the cheek was still maintained.
Then we proceeded with plating the left zygomatical frontal fracture site using a 0.8 mm, 6-hole straight plate which was bent accordingly to fit the contour (5 screws were accommodated for this plate). The fracture site at the zygomatical maxillary area was fixated using an X-plate, 0.7 mm (3 screws were accommodated for this plate). For the fracture site at the orbital floor, a supra foil implant, 0.35 mm, was inserted along the floor and secured anteriorly with 5 0 Prolene sutures x2. Forced duction test was performed which revealed no restriction to passive range of motion of the left eye globe.
The wound at the left lateral brow was approximated with interrupted 3-0 Vicryl sutures for the muscular layers and then 3-0 Vicryl interrupted sutures for the dermis followed by continuous subcuticular suturing using 4-0 Vicryl material. Skin affix glue is applied on the outer surface. The lower eyelid skin was redraped in anatomical position. The inner layers was approximated with interrupted 5 0 Vicryl sutures. Then a 5 0 Vicryl continuous subcuticular suturing was applied for the wound edges. Subsequently, ophthalmic antibiotic ointment was applied. For the wound at the left upper buccal
Pre-op Diagnosis: Displaced left tripod fractures of the face.
Post-op Diagnosis: same
Procedure Performed: Open reduction internal fixation for fractures on the left face. Reconstruction of the left orbital floor with supra foil implant.
Indications for the procedure: The patient is a 39-year-old male who had sustained facial trauma with grossly displaced tripod fractures on the left side of the face being. The cheek was significantly depressed, consistent with the pattern of the fractures.
During the surgery, a sterile corneal shield was applied for protection of both eyes. There were removed at the end of the surgery.
Description of the procedure: Patient was in supine position and received general anesthesia. The patient's face as well as the oral cavity were prepped and draped in a sterile manner. For this case, all the respective sites for incision were infiltrated with 0.25% Marcaine with epinephrine prior to the incisions. We proceeded with removal of some old external sutures on the face and the forehead.
We started with incision at the lateral left eyebrow area using a 15. Blade. We dissected down to the bone. Hemostasis was achieved with electrocautery. Periosteal elevator was used to expose the surface of the bone. The zygomatical frontal fracture site was identified. We could also easily palpate the deformity on the left cheek and zygomatic area. A blunt instrument was introduced behind the zygoma. Force was applied so as to readvance the zygoma forward and also we elevating it upward. This immediately produced a correction of the deformity on the left side of the cheek. We then proceeded with exploration the other fracture sites to confirm appropriate alignment.
A sub ciliary incision at the left lower eyelid was made. He initially we dissected as a skin flap which was then converted to skin-muscle flap as we dissected down to the inferior orbital rim. Hemostasis was achieved with electrocautery. An incision was made on the edge of the inferior orbital rim and the periosteal was elevated and extended posteriorly to examine the floor. There was a fracture of the floor but without the significant gap. Nonetheless, we subsequently placed a supra foil implant after examining the other fractures. Another incision was made at the left upper buccal sulcus using a 15. Blade. Hemostasis was achieved with electrocautery. We dissected down to the bone and exposed fractures at the zygomatical maxillary area. This fracture was noted to be displaced with an overlap. Blood instrument was inserted in between the gap and the fracture site was reduced. We again re-examined the zygoma and the zygomatical frontal area to verify that the alignments were adequate. The previous reduction and correction for the cheek was still maintained.
Then we proceeded with plating the left zygomatical frontal fracture site using a 0.8 mm, 6-hole straight plate which was bent accordingly to fit the contour (5 screws were accommodated for this plate). The fracture site at the zygomatical maxillary area was fixated using an X-plate, 0.7 mm (3 screws were accommodated for this plate). For the fracture site at the orbital floor, a supra foil implant, 0.35 mm, was inserted along the floor and secured anteriorly with 5 0 Prolene sutures x2. Forced duction test was performed which revealed no restriction to passive range of motion of the left eye globe.
The wound at the left lateral brow was approximated with interrupted 3-0 Vicryl sutures for the muscular layers and then 3-0 Vicryl interrupted sutures for the dermis followed by continuous subcuticular suturing using 4-0 Vicryl material. Skin affix glue is applied on the outer surface. The lower eyelid skin was redraped in anatomical position. The inner layers was approximated with interrupted 5 0 Vicryl sutures. Then a 5 0 Vicryl continuous subcuticular suturing was applied for the wound edges. Subsequently, ophthalmic antibiotic ointment was applied. For the wound at the left upper buccal