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Excision, tumor, soft tissue of face or scalp, subcutaneous; 2 cm or greater
CPT4 code
Name of the Procedure:
Excision of Tumor, Soft Tissue of Face or Scalp, Subcutaneous; 2 cm or Greater Common Name(s): Soft Tissue Tumor Removal, Subcutaneous Tumor Excision Medical Term: Excision, Tumor, Subcutaneous, Face/Scalp
Summary
This procedure involves the surgical removal of a tumor located in the soft tissue just under the skin on the face or scalp. It is performed when the tumor measures 2 centimeters or larger.
Purpose
Medical Condition or Problem:
The procedure addresses the presence of abnormal or potentially harmful growths in the soft tissue under the skin of the face or scalp.
Goals or Expected Outcomes:
- Remove the entire tumor to prevent growth, spread, or discomfort.
- Obtain tissue for pathology to diagnose the nature of the tumor (benign or malignant).
- Improve physical appearance and function if the tumor is causing disfigurement or functional impairment.
Indications
Symptoms or Conditions:
- Visible lump or mass on the face or scalp.
- Pain, discomfort, or tenderness at the site of the tumor.
- Rapid growth or change in size/shape of the tumor.
- Functional impairment or cosmetic concerns related to the tumor.
Patient Criteria:
- Tumor 2 cm or larger.
- Tumors suspected to be malignant based on clinical assessment or previous biopsy.
- Patient in overall good health and suitable for minor surgical procedures.
Preparation
Pre-Procedure Instructions:
- Fasting may be required for a few hours before the surgery if general anesthesia is used.
- Adjustments to medications, such as blood thinners, may be necessary.
- Preoperative blood tests or imaging studies (e.g., MRI, CT scan) may be conducted.
Diagnostic Tests:
- Biopsy to determine the nature of the tumor.
- Imaging tests for tumor assessment and surgical planning.
Procedure Description
- The patient is positioned comfortably, and the surgical site is cleaned and sterilized.
- Local anesthesia or sedation is administered to ensure the patient is pain-free.
- The surgeon makes a precise incision over the tumor site.
- The tumor is carefully excised, along with a margin of surrounding healthy tissue to ensure complete removal.
- The surgical wound is closed with sutures or staples, and a sterile dressing is applied.
Tools and Equipment:
- Scalpels and surgical scissors.
- Sutures or staples for wound closure.
- Surgical drapes, sterilization equipment, and anesthesia equipment.
Anesthesia/Sedation:
- Local anesthesia for small, controlled excisions.
- General anesthesia or sedation if the procedure is extensive or patient preference.
Duration
The procedure typically takes around 30 minutes to 1 hour, depending on the size and complexity of the tumor.
Setting
The procedure is usually performed in an outpatient clinic, surgical center, or hospital operating room.
Personnel
- Surgeon (typically a plastic surgeon or dermatologist).
- Surgical nurse or assistant.
- Anesthesiologist or nurse anesthetist (if sedation or general anesthesia is used).
Risks and Complications
Common Risks:
- Bleeding and infection at the surgical site.
- Scarring or changes in skin sensation around the surgical area.
Rare Risks:
- Adverse reactions to anesthesia.
- Incomplete removal of the tumor, requiring additional surgery.
- Damage to underlying structures (e.g., nerves).
Management:
- Prompt treatment of infections with antibiotics.
- Monitoring and follow-up care to manage any complications.
Benefits
Expected Benefits:
- Complete removal of the tumor, reducing the risk of recurrence.
- Relief from symptoms such as pain or discomfort.
- Improved cosmetic appearance.
Realization Timeline:
- Immediate improvement in appearance post-surgery.
- Symptom relief shortly after the procedure.
Recovery
Post-Procedure Care:
- Keep the surgical site clean and dry.
- Follow wound care instructions provided by the healthcare team.
- Take prescribed pain relievers and antibiotics if necessary.
Recovery Time:
- Initial recovery within a few days.
- Full healing may take several weeks.
Restrictions and Follow-Up:
- Avoid strenuous activities that may affect the surgical site.
- Attend follow-up appointments for wound assessment and suture removal (if non-dissolvable).
Alternatives
Other Treatment Options:
- Observation and monitoring of smaller, asymptomatic tumors.
- Non-surgical treatments such as radiation or chemotherapy (for malignant tumors).
Pros and Cons:
- Surgery provides immediate removal but involves risks and recovery time.
- Non-surgical options may be less invasive but could require longer treatment periods and may not be as definitive.
Patient Experience
During the Procedure:
- Patient will feel minimal to no pain due to anesthesia.
- Mild pressure or tugging sensations may be noticed.
After the Procedure:
- Some soreness, swelling, and bruising around the surgical site.
- Over-the-counter or prescribed pain relief can be used to manage discomfort.
- The healthcare team will provide detailed post-operative care instructions to ensure a smooth recovery.