Preoperative and postoperative diagnosis: Laxity of skin and muscle of the abdomen

Procedure: Abdominoplasty

The 46-year-old female patient desired to have an abdominoplasty because of the lax skin, subcutaneous tissue, and muscle of her abdomen. The risks of the procedure were explained to the patient, and she signed the consent to have the procedure.

When the patient presented to the operatory area, the midline of the abdomen was marked for the planned incisions. The abdomen was prepped, and 45 cc of a local infiltration of 1% Lidocaine with 1:1000000 dilution of epinephrine was administered along the planned incisional lines.

A skin incision was made along the marking, which was carried through the skin and subcutaneous tissue with Bovie electrocautery. Dissection of the tissue was completed down to the fascial musculature of the abdomen. A periumbical incison was made, and the umbilical stalk was freely dissected. Additional dissection occurred, and a moderate amount of redundant skin was assessed. Using a #15 blade and Bovie electrocautery, a superior incision was made. The tissue along the upper incision was thinned, and, with hemostatis achieved, the site was irrigated with saline. Above and below the umbilicus, a plication of the rectus muscle was performed. With the patient in the semiflexed position, several tacking 2-0 Vicryl sutures were placed. An incision was then made at the iliac crest bilaterally using a #15 blade. Using Bovie electrocautery, the periumbilical area was defatted. 3-0 Vicryl sutures were used to close. On both sides, drains were placed and sutured in place. Closure was completed with additional 3-0 Vicryl sutures and subcuticuar 4-0 Vicryl sutures. 3-0 and 4-0 Vicryl sutures, followed by 5-0 nylon sutures, were used to close the periumbical area. The wound was dressed. There was approximately 55 cc of blood loss. After extubating the patient, she was transferred to the recovery area in stable condition.

CPT code(s):

Preoperative and postoperative diagnosis: Bilateral breast hypoplasia and symmetry

Operation performed: Bilateral augmentation mammoplasty

The patient was prepped and draped in the usual sterile fashion, and then general anesthesia was achieved. Local infiltration with 1% Lidocaine with 1:100,00 dilution of epinephrine was performed. On the right breast, using a #15 blade, an inframammary incision was made and carried through the skin and subcutaneous issue. A Bovie electrocautery dissection was completed down to the pectoralis muscle, and a submuscular pocket was created. Saline was used to irrigate the site. Hemostasis was achieved.

The same procedure then was completed on the left breast, with dissection performed in a symmetric fashion to recreate a submuscular pocket. Two implants were inspected, and they were placed in the submuscular pockets. Additional dissection was performed on the left side to achieve symmetry. 3-0 Vicryl sutures were used to close the muscle layer. The subcutaneous deep dermal layer was then closed with 3-0 Vicryl sutures and the subcuticular with 4-0 Vicryl sutures. The wounds were dressed, and a Velcro breast band was placed on the superior aspect of the breast. After extubating the patient, she was sent to recovery in stable condition.

CPT code(s):

Preoperative diagnosis: Cyst

Postoperative diagnosis: Pending review of pathology findings

Procedure: Fine-needle aspiration cyst

This 59-year-old male patient was prepped and draped in the usual fashion for a fine-needle aspiration. The cyst on his right shoulder was identified, and the area was cleansed. A 25-gauge needle was guided, by palpation, into the cyst, and the fluid was removed from the cyst. The fluid was sent for pathology. The needle was withdrawn, and a bandage was placed over the wound site. There were no complications.

CPT code(s):

Podiatry Note

This 67-year-old diabetic patient is seen today for debridement of all nails on his right and left feet. He states that he is having a problem walking, and his feet are painful. The nails on both feet were debrided. There were no signs of infection or open wounds. He was instructed to continue to follow up with me on a regular basis to monitor any possible podiatric conditions due to his diabetes.

CPT code(s):