Добавил:
Sekretar
kiopkiopkiop18@yandex.ru
t.me/Prokururor I Вовсе не секретарь, но почту проверяю
Опубликованный материал нарушает ваши авторские права? Сообщите нам.
Вуз:
Предмет:
Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_4366_Библиотеки_им_академика_М_И_Перельмана
.pdf
Chapter Coding of Reconstructive and Cosmetic Rhinoplasty Procedures 155
https://t.me/medicina_free
Commonly Used ICD-9 Codes for Nasal Surgery
470 Deviated nasal septum
478. Nasal airway obstruction
733.
Malunion nasal/septal fracture
738. Acquired nasal deformity
754. Congenital nasal/septal deformity
905. Late eect of fracture of skull or facial bones
V. Plastic surgery for unacceptable cosmetic appearance
KEY POINTS
■
No single global code describes secondary septorhinoplasty: two codes are required to report the procedure.
■
All rhinoplasty codes (primary, secondary, and cle lip rhinoplasty) include
the placement of bone and cartilage gras.
■
Rhinoplasty CPT codes do not distinguish between cosmetic and reconstructive procedures.
■
e nasal fracture codes are not used for septorhinoplasty procedures, although
one may be treating the sequelae of trauma.
REFERENCES
1. CPT: Current Procedural Terminology. Chicago: American Medical Association, .
2. Janevicius RV. CPT Corner: Rhinoplasty coding. Plastic Surgery News, July .
3. Janevicius RV. CPT Corner: Complex rhinoplasty coding. Plastic Surgery News, August .
4. Janevicius RV. CPT Corner: New codes for cle lip rhinoplasty. Plastic Surgery News, February .
5. Hart AD, Stegman MS, Ford B, eds. ICD--CM Expert Edition. Salt Lake City: Ingenix, .
6. Janevicius RV. CPT Corner: Cosmetic or reconstructive rhinoplasty? Plastic Surgery News, May
.
7. Janevicius RV. CPT Corner: Distinguishing between cosmetic and reconstructive procedures. Plastic
Surgery News, October .
8. Janevicius RV. CPT Corner: Decoding pre-authorization, pre-certication and pre-determination.
Plastic Surgery News, October .
This page intentionally left blankThis page intentionally left blank
https://t.me/medicina_free
■ ■ ■ ■ ■ ■
https://t.me/medicina_free
PART TWO
Basic Surgical
Concepts
This page intentionally left blankThis page intentionally left blank
https://t.me/medicina_free
■ ■ ■ ■ ■ ■
https://t.me/medicina_free
10
Getting Rhinoplasty Right
the First Time
Rod J. Rohrich Jamil Ahmad
P
rimary rhinoplasty oers the surgeon a unique opportunity to manipulate undisturbed tissue planes and native anatomy to produce a result that meets both
aesthetic and functional goals. Subsequent procedures are technically more dicult and less predictable because of scarring within the nasal so tissue envelope
and the potential for inadequate structural support resulting from prior alteration of the osteocartilaginous nasal framework. Accurate initial assessment and
proper execution of primary rhinoplasty based on the anatomic deformity and
using a graduated surgical approach is therefore critical.
e basic principles for successful primary rhinoplasty include the following:
1. orough clinical analysis and denition of goals preoperatively
2. Careful preoperative preparation of the patient
3. Precise operative execution
4. Adequate postoperative management
5. Expertise and experience gleaned from critical analysis of one’s own results
is chapter will focus on lessons learned from a -year experience with primary rhinoplasty. Current key concepts and strategies for success are presented.
Preoperative preparation, clinical analysis, and postoperative management are
covered in detail in Chapters , , and , respectively.
159
Part Two Basic Surgical Concepts160
https://t.me/medicina_free
Key Concepts and Strategies for Success
Over the past years, the following key concepts and strategies for success have
emerged. ese play a critical role in getting rhinoplasty right the rst time:
1. Use the open approach.
2. Incrementally reduce the dorsum.
3. Use invisible gras.
4. e best chance to get the result is during the primary rhinoplasty.
5. Follow patients long term.
USE THE OPEN APPROACH
Although the closed approach does provide access to the nasal structures for rhinoplasty, it is our opinion that the open approach provides far greater exposure
and opportunity to more accurately assess and manipulate the structural ele
ments of the nose.
isolated deformities and straightforward manipulations of the nasal tip. Patients
requiring extensive tip work, component dorsal hump reduction, and any case
requiring precise control are completed through the open approach.
,
e closed approach is therefore reserved for correction of
-
Rationale for the Open Rhinoplasty Approach
Distinct Advantages
Binocular visualization
Evaluation of complete deformity without distortion
Precise diagnosis and correction of deformities
Allows use of both hands
More options with original tissues and cartilage gras
Direct control of bleeding with electrocautery
Suture stabilization of gras (invisible and visible)
Potential Disadvantages
Transcolumellar scar
Prolonged operative time
Protracted nasal tip edema
Columellar incision separation
Delayed wound healing
Chapter Getting Rhinoplasty Right the First Time 161
https://t.me/medicina_free
Characteristics of the open approach that have led to our preference include the
following:
1. It provides clear anatomic exposure of the nasal deformity, allowing a
more accurate diagnosis of the cause of the external deformity.
2. It facilitates the performance of technical maneuvers allowing preservation and/or restoration of specic structures using incremental control.
3. It provides the surgeon with more options in altering the osteocartilaginous framework and improved accuracy in suture and gra placement,
which is crucial to a well-executed operation.
e open rhinoplasty technique provides unparalleled exposure for accurate anatomic diagnosis and systematic technical execution.
INCREMENTALLY REDUCE THE DORSUM
One of the most common reasons that patients seek rhinoplasty is the presence
of a dorsal hump. In the past, signicant emphasis was placed on achieving an
aesthetically pleasing lateral prole, yet little attention was given to the consequences of dorsal hump reduction on the frontal view. As a result, deformities
such as the inverted-V deformity were commonplace. Other problems that become evident on the frontal view include issues with the dorsal aesthetic lines,
such as poor denition, asymmetries, too narrow, or too wide, and residual deformities of the bony vault.
e nasal dorsum should have two symmetrical, smooth dorsal aesthetic lines.
ey should be slightly curved divergent lines extending from the medial su-
Part Two Basic Surgical Concepts162
https://t.me/medicina_free
perciliary ridges to the tip-dening points. e width of the bony vault should
be about % to % of the normal alar base width. e base of the bony vault
serves as the nose-cheek junction.
Nasal bone
Upper lateral
cartilage
Dorsal aesthetic lines
A closer look at the dorsal aesthetic lines reveals the complexity of the underlying anatomy. Superiorly, the dorsal aesthetic lines are formed by the so tissue
contours and the underlying nasal bones while inferiorly, the dorsal septum and
upper lateral cartilages underlie the so tissue of the midvault. e dorsal aesthetic lines span the keystone area—the junction of the upper lateral cartilages
with the overlying nasal bones.
In the past, the approach to the dorsum—using a composite dorsal hump reduction technique—was likely the source of many postoperative problems at
the midvault.
Chapter Getting Rhinoplasty Right the First Time 163
https://t.me/medicina_free
Excess cartilage removal at the midvault leads to poorly dened dorsal aesthetic
lines and can also cause problems with the internal nasal valves.
We have evolved a component approach to the dorsum to prevent these undesirable problems.
,
It involves the following:
1. Release of the upper lateral cartilages from the dorsal septum
Part Two Basic Surgical Concepts164
https://t.me/medicina_free
2. Resection of the dorsal septum incrementally
3. Rasping of the bony dorsum
Соседние файлы в папке Библиотека им академика М.И. Перельмана