Flap Graft Repair Help


Norristown, PA
Best answers
I have copied in part the operative report. Since this is my weak area can someone help me with the coding of this report?

PREOPERATIVE DIAGNOSIS: Nasal reconstruction.

POSTOPERATIVE DIAGNOSIS: Nasal reconstruction.

ANESTHESIA: Local with intravenous sedation.

PROCEDURE: The patient was brought into the operating room, and after a satisfactory state of intravenous sedation was achieved, his face was prepped with Betadine and draped. Lidocaine 1% plain was injected as a field block surrounding the nose and at the base of the pedicle at the right nasal brow. Transection was then made at the base of the pedicle at the medial brow, and then a small triangular flap was fashioned from the residual skin of the pedicle flap so that it could be inset into the defect created by excision of the pedicle base. This triangular flap reconstruction was altogether approximately 2.5 square cm and was situated at the right medial brow repaired with 5-0 chromic in the deeper dermis and 6-0 nylon for the skin. Then, the major part of the pedicle was defatted as much as felt to be safe down to the super tip area. Some of this defatting had already been performed 3 weeks earlier, but there is still a moderate amount of dissection and defatting performed, especially where I was unable to do it 3 weeks ago higher up or superiorly up the pedicle. Additionally, the full aesthetic unit up to the nasal bridge was then excised of skin and underlying muscle with even a small amount of cartilaginous hump removed to allow for a nicer aesthetic appearance.

The flap was then advanced into the new aesthetic unit all the way to the nasal bridge, and the total area of undermining and advancement all together, primary and secondary defects, were measured approximately 4 cm in vertical height x 3 cm in width for a total area of approximately 10 to 12 square cm. The flap was inset with multiple sutures of 6-0 nylon. The color of the flap appeared to be pale pink and was judged to be acceptable. The site was covered with Adaptic and sterile gauze but not over the flap itself so that it could be observed by the patient's wife overnight. Gauze was simply placed on each side.

There were three independent procedures performed. The first was a division of the forehead flap. The second was that of a flap closure of the pedicle base at the right medial brow over an area of 2.5 square cm, and the third was a dissection or undermining of the nasal flap with advancement with a total area of flap reconstruction of 10 to 12 square cm.

I appreciate any response/help with this report.:)