Case 1: Operative Report
PREOPERATIVE DIAGNOSES: Prominent ears
POSTOPERATIVE DIAGNOSES: Prominent ears
NAME OF PROCEDURES: Otoplasty
DESCRIPTION OF OPERATION: The patient was brought to the operating room and placed in a supine position after satisfactory general anesthesia was administered. The patient’s face was prepped and draped in the standard
fashion. Preoperatively, the patient had been given 1 gm of Ancef and 8 gm of Decadron. In the preoperative holding area, the patient had been marked for an otoplasty. The patient has asymmetrical ears with her right
ear more prominent than her left. After appropriate prepping and draping, 1 percent Xylocaine with 1:100,000 units of Epinephrine were injected into the anterior and posterior aspect of both ears. A retroauricular incision was then made, measuring 4 cm in length, and a strip of skin measuring 1 cm was removed from the back of the ear. A tenotomy scissors was then used to lift the skin off the anterior aspect of the ear without creating
an incision on the anterior aspect. This was accomplished by dissecting along the tail of the helix toward the front of the ear. Rasping along the proposed antihelix was performed as well as into the triangular fossa. Nylon sutures of 4-0 clear were then placed in a mattress fashion to recreate the antihelical fold. The sutures were carried to the tail of the helix inferiorly and to the triangular fossa superiorly. After satisfactory symmetry was obtained, mattress sutures were also performed between the concha and the mastoid to draw the ear back. The wounds were irrigated with antibiotic solution. Closure was achieved utilizing a running horizontal mattress 4-0 plain suture. A small vascular drain was left in place. The same procedure was performed on each side in a similar fashion. The entire head was then wrapped to put pressure over the ears with a standard head dressing. The patient tolerated the procedure well and left the operating room in satisfactory condition. What is the ICD-10-PCS code?