Question about closure with adjacent tissue transfer of a flap

tholcomb

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Hello Fellow Coders,

I have a question about the operative note below I was looking at cpt 15734.


PROCEDURE: *
Excision of pilonidal cyst. *
Closure with adjacent tissue transfer of myofascial gluteus flaps, 110 square cms x 2 sides (220 sq cms total


The patient was brought to the operating room, and after the induction of *
general anesthesia, was placed in the prone jack-knife position upon the *
operating table. Each of the sinus openings was probed with a blunt malleable *
probe. The cyst openings were then injected with 50% dilute methylene blue dye *
to help identify the cyst wall intraoperatively. The skin was infiltrated with 0.5% Marcaine with epinephrine to aid in post-operative analgesia. *
A longitudinal elliptical incision was made in the midline encompassing all of *
the sinus openings. Bovie electrocautery was used to carry the incision *
full-thickness through the skin and subcutaneous tissues, excising the cyst in *
its entirety. The dissection was carried down to the presacral fascia where the *
cyst was is seen to extend. The cyst was excised in its entirety en bloc with its overlying ellipse of skin. It was passed off the table as specimen. Hemostasis was obtained using Bovie electrocautery. The wound was irrigated with sterile saline and then dried. *
At this time, we detached both the right and left gluteus muscles from their *
insertion on the sacrum using Bovie electrocautery. The myofascial flaps were *
raised approximately 5 cm laterally for each flap. This included development of the flaps by dividing tissue deep to and superficial to the muscle. The midline defect, which *
consisted of only presacral fascia and the midline sacrum in the middle was *
approximately 11 x 10 cms. We used these muscle flap to cover this area by *
suturing the 2 advanced myofascial flaps to one another using a running 0 *
Vicryl suture in the midline. Once these were sutured *
together, the presacral fascia and sacral bone were completely covered with the *
myofascial flaps in the midline, allowing for better blood supply for healing of *
the large wound and decreased depth of the gluteal cleft. *
The wound was again irrigated with sterile saline and then dried. Hemostasis *
was excellent. A 10 flat JP drain was placed in the subcutaneous space and run out through a separate stab incision in the left buttock.
The drain was sutured to the skin with a 3-0 Nylon stitch. The subcutaneous tissue was reapproximated using 2-0 Vicryl in a *
running stitch. The skin was closed using 4-0 Monocryl in a running *
subcuticular stitch. Mastisol, Steri-Strips, and then a sterile dressing were *
applied. All sponge, needle, and instrument counts were correct at the end the *
case. The patient tolerated the procedure well, was extubated, and brought to *
the recovery room, awake and in stable condition.


Thank you,
TH
 
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