AKEISTER
Networker
Could someone help? This is the operative report, the doctor is insisting i use 68705 67950, I don't think that is correct.
PROCEDURES: 1. Left lower lid Z-plasty.
2. Left lower lid spindle procedure.
INDICATIONS FOR PROCEDURE: A 82-year-old male with basal cell cancer on his left lower lid, had it removed, had cicatricial ectropion, had a skin graft initially, but still had medial ectropion and tearing, so I consented him to the risks, benefits, and alternatives of a canthoplasty by way of a Z-plasty and a spindle procedure. He agreed to proceed.
DESCRIPTION OF PROCEDURE: After informed consent was obtained, the patient was met in the preoperative holding area, and the lower lid was examined, and the vector of cicatrix was identified, and then a Z-plasty incision line was drawn to change the vector to a horizontal cicatrix, therefore eliminating the downward pull on the lid. He was then taken to the operating room suite and placed supine on the operating room table. A member of the Anesthesia Department placed an IV and delivered monitored anesthesia care. Next, 2 mL of a 1/1 mixture of 2% lidocaine with epinephrine and 0.75% Marcaine were injected into the left medial canthal region underneath the Z-plasty. The patient was then given Tetracaine drops in each eye. He was then prepped and draped in the usual sterile ophthalmic fashion. Corneal protective shields were placed over both eyes.
A #15 Bard-Parker blade was used to make an incision through the Z-plasty lines. The flaps were then cut with Wescott scissors, and some udermining at the base of each triangle was made. There was scar tissue underneath this that was also adding to the cicatricial effects, so this was cut free with Wescott scissors. Once the lid was more lose, the Z flaps were transposed, and the deep margins were secured with interrupted 4-0 Vicryl suture, and then the flaps were secured at the skin using 6-0 Prolene sutures. Approximately 14 sutures were used to reapproximate all the edges. Once I was satisfied with the contour and the closure of the Z-plasty, I placed a 6-0 Vicryl suture in the medial lid margin to rotate it and then formed an 8 mm long by 4 mm high spindle cut with a Bovie on the conjunctival margin just centered underneath the inferior punctum. The conjunctiva was removed with Wescott scissors. Retractor bend was then repaired back to tarsal plate closing the spindle with 3 interrupted 6-0 Vicryl sutures burying the knots. This resulted in good approximation of the lower lid punctum. There was still some billowing of conjunctival tissue from swelling, and I was concerned this would cause a thickening of the lid and not allow healing close to the globe, so I place a 6-0 plain gut suture through the fornix and brought it out through the cheek and tied it snugly which helped deeped the fornix a bit and flatten the lid more.
I then took the coreal protective shield out and the traction stitch and placed erythromycin ointment copiously on all the incision lines. I then placed a pressure patch over the eye to leave in place for 24 hours to supply pressure to the Z-plasty and increase the rate of survival. I removed the corneal protective shield from the other eye.
PROCEDURES: 1. Left lower lid Z-plasty.
2. Left lower lid spindle procedure.
INDICATIONS FOR PROCEDURE: A 82-year-old male with basal cell cancer on his left lower lid, had it removed, had cicatricial ectropion, had a skin graft initially, but still had medial ectropion and tearing, so I consented him to the risks, benefits, and alternatives of a canthoplasty by way of a Z-plasty and a spindle procedure. He agreed to proceed.
DESCRIPTION OF PROCEDURE: After informed consent was obtained, the patient was met in the preoperative holding area, and the lower lid was examined, and the vector of cicatrix was identified, and then a Z-plasty incision line was drawn to change the vector to a horizontal cicatrix, therefore eliminating the downward pull on the lid. He was then taken to the operating room suite and placed supine on the operating room table. A member of the Anesthesia Department placed an IV and delivered monitored anesthesia care. Next, 2 mL of a 1/1 mixture of 2% lidocaine with epinephrine and 0.75% Marcaine were injected into the left medial canthal region underneath the Z-plasty. The patient was then given Tetracaine drops in each eye. He was then prepped and draped in the usual sterile ophthalmic fashion. Corneal protective shields were placed over both eyes.
A #15 Bard-Parker blade was used to make an incision through the Z-plasty lines. The flaps were then cut with Wescott scissors, and some udermining at the base of each triangle was made. There was scar tissue underneath this that was also adding to the cicatricial effects, so this was cut free with Wescott scissors. Once the lid was more lose, the Z flaps were transposed, and the deep margins were secured with interrupted 4-0 Vicryl suture, and then the flaps were secured at the skin using 6-0 Prolene sutures. Approximately 14 sutures were used to reapproximate all the edges. Once I was satisfied with the contour and the closure of the Z-plasty, I placed a 6-0 Vicryl suture in the medial lid margin to rotate it and then formed an 8 mm long by 4 mm high spindle cut with a Bovie on the conjunctival margin just centered underneath the inferior punctum. The conjunctiva was removed with Wescott scissors. Retractor bend was then repaired back to tarsal plate closing the spindle with 3 interrupted 6-0 Vicryl sutures burying the knots. This resulted in good approximation of the lower lid punctum. There was still some billowing of conjunctival tissue from swelling, and I was concerned this would cause a thickening of the lid and not allow healing close to the globe, so I place a 6-0 plain gut suture through the fornix and brought it out through the cheek and tied it snugly which helped deeped the fornix a bit and flatten the lid more.
I then took the coreal protective shield out and the traction stitch and placed erythromycin ointment copiously on all the incision lines. I then placed a pressure patch over the eye to leave in place for 24 hours to supply pressure to the Z-plasty and increase the rate of survival. I removed the corneal protective shield from the other eye.