Pre-op Diagnosis: Excess skin [L98.7]
Post-op Diagnosis: excess skin of upper arms ( bat wing deformity) bilateral
Excess skin of chest wall right and left lateral chest35x10 cm,
38×12 cm right chest
Painful scar abdomen 21 cm horizontal scar and 19 cm vertical component
Procedure(s): Bilateral – BRACHIOPLASTY
excision bilateral excess soft tissue lateral chest
Right 38×12 cm
Left 35×10 cm
Painful scar abdomen excision and closure
21 cm horizontal component and 19 cm vertical component or 40 cm total length
Anesthesia: General
Findings:excess skin with poor skin elasticity secondary to massive weight loss
Technique: as follows
Indication for procedure:
50-year-old female status post bariatric surgery presented to my office with chief complaint of redundant skin secondary to massive weight loss. The areas of involvement included her upper arms where she had a bat wing deformity from this, her lateral chest area lateral to the breast extending into the back with redundant skin folds which caused irritation from her bra and difficulty wearing clothes and activities. Patient also had a previous panniculectomy of the floridly type and she complained of a painful scar involving the lower vertical component and the mid horizontal component. Patient was brought to surgery today for correction of the batwing deformity of the arms, excision of the skin of the lateral chest area bilaterally and also excision of the painful scar involving the lower midline vertical incision as well as the midportion of the horizontal incision of the abdomen.
Surgical procedure:
Patient was seen preoperatively in the holding area. At this time the procedure was reviewed with her this included description of the procedure location of the scars and also physical marking of the patient marking the areas of excess skin to be resected. Questions were addressed. We also discussed home care. The patient had requested overnight stay however the hospital was not allowing overnight stays due to the fact that there was a staffing issue with not enough beds so in order to proceed with the surgery the patient had to be treated as a outpatient to go home. She was in agreement with this after explaining this to her.
Surgical procedure:
Patient was taken to the operating room and placed on table in supine position. After induction of general anesthesia she was intubated with an oral endotracheal tube. We began the procedure in the supine position. The arms and abdomen were prepped with Hibiclens prep to 1st perform the brachioplasty to be followed by the scar excision of the abdomen. She was draped in sterile fashion and time-out performed. Following time-out attention was turned to the right arm. The horizontal incision along the inner aspect of the arm was created from the axilla to the area of the elbow. A skin flap was then developed inferiorly to elevate the tissue in the posterior aspect of the arm from the axilla to the area of the elbow on the ulnar aspect. The flap was elevated along the plane of the superficial fascia so as not to injure cutaneous nerves or larger blood vessels. Hemostasis was obtained easily with electrocautery once the flap was elevated for resection a tailor tacking technique was used to excise the excess skin in the batwing deformity along the entire length of the incision.
There was a very short vertical component extending into the right axilla to eliminate the dog ear. After doing this and excising the excess skin there was noted to be a good reduction in the dog-ear deformity without the closure being too tight and good skin approximation. This was stapled in place temporarily and attention was directed to the left arm. Similarly on the left arm the incision was made from the axilla to the area of the ulnar aspect of the elbow. We followed the line along the entire bat wing deformity. Next the inferior skin flap was developed along the plane of the superficial fascia to elevate the redundant skin for resection. Hemostasis was obtained easily with electrocautery. Again using a sequential tailor tacking technique the excess skin was excised and the skin flaps stapled in place temporarily after obtaining hemostasis.
Next closure of each of the arm resection was then performed in layers initially a 15 French Blake drain was placed in the base of the wound and brought out through a stab incision on the upper lateral chest wall and sutured to the skin with 2-0 silk suture. Wound closure was then performed by 1st closing the superficial fascial layer with 3-0 Vicryl suture. The dermis was reapproximated with inverted interrupted 3-0 Vicryl suture and final skin closure performed with a running subcuticular 3-0 Stratafix the closure was the same on both arms. After closing the skin incision the Blake drains were activated in a Prineo dressing placed over the incisions. Attention was then directed to the abdominal region.
An elliptical incision was made around the horizontal scar at the base of the abdomen following the old scar from the panniculectomy. Heavy scar tissue was noted was excised in this area. The vertical component of the scar was then excised in an elliptical fashion necessitating incision around the umbilicus as well. Redundant skin was removed from this area and hemostasis obtained. Following excision of the painful scar area the skin was undermined slightly to allow for closure and a single 19 French Blake drain was placed along the horizontal component of the wound and brought out through a stab incision on the right lateral aspect of the lower abdomen and sutured to the skin with 2-0 silk suture.
Once we are satisfied with hemostasis wound closure was performed in 3 layers Scarpa’s fascia was closed with inverted interrupted 2-0 Vicryl suture. The dermis was reapproximated with inverted interrupted 3-0 Vicryl suture and final skin closure performed with a running subcuticular Stratafix 3-0. The length of these areas that were closed was 21 cm along the inferior aspect of the scar and the horizontal component and 19 cm in length for the vertical aspect of the scar. Following closure the skin was cleansed and dried and a Prineo dressing placed over all of these areas. The umbilicus was also sutured in its original position as well.
Following this the drapes removed and the patient was repositioned on the operating table in a right lateral decubitus position. A axillary roll was placed the patient was also placed on a beanbag for positioning. With the patient positioned properly in the right lateral decubitus position attention was directed to the defect on the lateral chest. The area of the lateral chest was then prepped with Hibiclens prep and draped in sterile fashion. We again performed time-out confirming the area and then the markings were created once more with a marking pen for excision of this redundant skin. The size of the resection of the right chest was 38 x 12 cm. The exit incision extended just lateral to the breast and extended along the lateral chest onto the back area.
The inferior incision was then created with a 10 blade and dissection proceeded with electrocautery down to the superficial fascia. The skin was elevated superiorly along the plane of the superficial fascia to undermine the redundant skin to be resected. This resection was carried approximately 12 cm. Once this was done again using a tailor tacking type closure the redundant skin was excised along the entire length of the incision. The total area to be resected was 38 x 12 cm. After the redundant skin was excised hemostasis was obtained with electrocautery. Final skin closure was performed in layers closing the superficial fascia with interrupted 2-0 Vicryl sutures. The dermis was reapproximated with inverted interrupted 3-0 Vicryl suture. Final skin closure performed with a running subcuticular 3-0 Stratafix. Correction of small dog ears at the anterior and posterior end of the incision was done by excising a small amount of extra tissue to eliminate redundant tissue. The skin was then cleansed and dried and a Prineo dressing placed over the incision.
The drapes removed patient was repositioned on the operating table placed in a left lateral decubitus position. Again care was taken to pad the extremities, an axillary roll was placed, and pillows were placed between the knees to eliminate pressure points. The right chest was then prepped with Hibiclens prep along the areas to be excised and draped in sterile fashion. The preoperative markings which were placed were redone at this time using the marking pen. Next using a 10 blade the inferior incision was created along the entire length. The size of the area to be resected on the left chest was 35 x 10 cm. The redundant skin of the lateral chest and this area was then performed along the superficial fascia extending from the incision superiorly under the redundant skin flap. Once again a tailor tacking method was then performed to eliminate the excess skin superiorly which made up the redundant skin of the lateral chest. This allowed us to close the wound without undue tension. After hemostasis was obtained final skin closure was performed with inverted interrupted 2-0 Vicryl in the fascia followed by inverted interrupted 3-0 Vicryl in the dermis and a running subcuticular 3-0 Stratafix for final skin closure. A Prineo dressing was then placed over the incision after cleansed cleansing the skin with saline
The drapes were then removed the patient was repositioned temporarily on the table in a supine position. Subsequent to this she was transferred to the recovery stretcher where she was placed in compression sleeves and also a surgical girdle. She was then awakened extubated and taken to the recovery area in good condition no surgical or anesthetic complications.
CPT and ICD 10 codes:
11406 EXC B9 LESION MRGN XCP SK TG T/A/L >4.0 CM
12037 REPAIR INTERMEDIATE S/A/T/E >30.0 CM; (-XU Unusual Non-Overlap Svc)
15836 EXCISION EXCESSIVE SKIN T SUBQ TISSUE ARM
L98.7 – Excessive and redundant skin and subcutaneous tissue
L90.5 – Scar conditions and fibrosis of skin
Question: Would code 15836 need a modifier (50)?
Question: For code 15878. Can I have clarification of where this procedure was done?