I have the CPT code for the ectropion repair with tarsal strip- cpt code 67917 but not sure how to code the reposition of the gold plate.Any suggestions ? Thanks
POSTOPERATIVE DIAGNOSES: 1. Left eye VII cranial nerve paralysis following gunshot injury in the past.
2. Upper lid entropion secondary to gold plate malposition.
3. Lower lid ectropion.
PROCEDURES PERFORMED: 1. Reposition of the gold plate to correct the upper lid entropion.
2. Ectropion repair using a tarsal strip procedure.
DESCRIPTION OF PROCEDURE: Informed consent was obtained from the patient. The patient was anesthetized using general anesthesia endotracheal techniques as she was very anxious and refused to have the operation under local anesthesia. Left eye was prepped and draped in the standard fashion for this procedure. Initially, the left upper lid was tackled.
Along the skin crease, a 7-mm incision was performed approximately 10 mm posterior to the lid margin. The subconjunctival tissue was dissected down towards the lid margin and posteriorly till the gold plate was isolated. The gold plate was seen capsulated by a harvest capsule and is not anchored by any suture. The fibrous capsule was cut and the gold plate was freed. It was repositioned approximately 3.5 mm posterior to the lid margin and secured with help of three 10-0 Prolene sutures to the underlying tarsal plate and muscle. Then the skin was closed in two layers using 6-0 Vicryl sutures.
Attention was directed towards performing the lower lid ectropion. A clamp was placed along the lateral canthal tendon, followed by lateral canthotomy. After making sure that the lower lid was completely free and mobilize, a 3 mm tarsal strip was fashioned. A 6-0 Prolene suture was used to anchor the tarsal strip to the lateral orbital wall periosteum. This was followed by closure of the skin with the help of interrupted 6-0 Vicryl sutures. At the end of the operation, TobraDex ointment was placed on the lid and the eye along with ice packs. The patient was successfully extubated and transferred to the recovery room without any complications.
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