Plastic repair of cleft lip/nasal deformity; primary bilateral, 1 of 2 stages
CPT4 code
Name of the Procedure:
Plastic Repair of Cleft Lip/Nasal Deformity; Primary Bilateral, 1 of 2 Stages Common Names: Bilateral Cleft Lip Repair, Lip and Nose Surgery for Cleft Lip
Summary
This surgical procedure fixes the split in the upper lip and deformities in the nose that come with a bilateral cleft lip. It is the first of two stages that aim to restore normal appearance and function.
Purpose
Medical Condition Addressed: Bilateral cleft lip, a congenital deformity characterized by splits on both sides of the upper lip. Goals: To close the cleft, improve lip and nose appearance, enable better functionality for eating and speaking, and enhance overall facial symmetry.
Indications
Symptoms/Conditions:
- Visible gaps on both sides of the upper lip.
- Nasal deformities associated with bilateral cleft lip. Patient Criteria: Newborns or infants diagnosed with bilateral cleft lip, typically between 3 to 6 months of age, when they are strong enough for surgery.
Preparation
Pre-Procedure Instructions:
- Fasting for at least 6 hours before the procedure.
- Necessary adjustments to medication intake as advised by a healthcare provider. Diagnostic Tests/Assessments:
- Physical examination.
- Preoperative blood tests.
Procedure Description
Step-by-Step Explanation:
- The patient is given general anesthesia to ensure they are asleep and pain-free.
- Surgeons make incisions along the cleft edges.
- Tissue flaps are created and meticulously stitched together to close the cleft.
- Any nasal deformities are addressed concurrently by reshaping the nostrils and nasal cartilage. Tools/Equipment Used: Scalpel, sutures, specialized surgical instruments for delicate tissue handling. Anesthesia Details: General anesthesia is administered by an anesthesiologist.
Duration
The procedure typically takes around 2 to 3 hours.
Setting
The surgery is performed in a hospital or specialized surgical center.
Personnel
Healthcare Professionals Involved:
- Plastic or craniofacial surgeon
- Surgical nurses
- Anesthesiologist
- Pediatrician for postoperative care
Risks and Complications
Common Risks:
- Bleeding
- Infection
- Scarring Rare Complications:
- Anesthesia-related risks
- Poor wound healing
- Need for additional surgeries Management: Monitoring and intervention protocols in place to manage any complications.
Benefits
Expected Benefits:
- Improved facial appearance.
- Enhanced ability to eat, speak, and breathe normally. Timeline for Realization: Benefits are typically seen immediately post-surgery with continued improvements as healing progresses.
Recovery
Post-Procedure Care:
- Wound care instructions.
- Pain management with prescribed medications. Expected Recovery Time:
- Initial recovery in a few weeks, with complete healing around 6 to 12 months. Restrictions/Follow-Up:
- Avoid strenuous activities for a few weeks.
- Scheduled follow-up appointments for monitoring healing and planning the next stage of surgery.
Alternatives
Other Treatment Options:
- Nasoalveolar Molding (NAM) prior to surgery to improve outcomes. Pros and Cons:
NAM can reduce the severity of the cleft preoperatively but requires patient compliance and multiple fittings.
Patient Experience
During the Procedure: The patient will be asleep under general anesthesia and will not experience pain during the surgery. After the Procedure:
- Mild to moderate discomfort managed with pain medication.
- Swelling and bruising around the lip and nose. Pain Management: Prescribed analgesics and comfort measures to ensure minimal discomfort.
This markdown provides a comprehensive overview of the plastic repair of cleft lip/nasal deformity procedure, helping patients and caregivers understand what to expect.