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Excision, lesion of palate, uvula; with local flap closure

CPT4 code

Name of the Procedure:

Excision, lesion of palate, uvula; with local flap closure

Summary

This procedure involves the surgical removal of a lesion (abnormal tissue growth) on the palate or uvula. The area is then closed using a flap of nearby healthy tissue, ensuring proper healing.

Purpose

This procedure addresses growths or lesions on the palate or uvula that may be benign or malignant. The goal is to remove the abnormal tissue, prevent its recurrence, and promote healing with minimal scarring.

Indications

  • Presence of benign or malignant lesions on the palate or uvula.
  • Symptoms such as obstruction to breathing or swallowing.
  • Persistent sores, discomfort, or bleeding from the affected area.
  • Biopsy-confirmed abnormal tissues warranting excision.

Preparation

  • Patients may be advised to fast for 6-8 hours prior to the procedure.
  • Adjustments to medications, especially blood thinners, may be necessary.
  • Pre-operative evaluations might include blood tests and imaging studies (e.g., MRI or CT scans).
  • A pre-surgical consultation to discuss the procedure, risks, and post-operative care.

Procedure Description

  1. The patient is placed under local anesthesia to numb the area.
  2. The surgeon excises the lesion from the palate or uvula using surgical instruments.
  3. The excised area is closed with a local flap, which involves repositioning nearby healthy tissue to cover the defect.
  4. Sutures or other closure techniques may be used to secure the flap.
  5. The patient is monitored until the effects of anesthesia diminish.

Duration

The procedure typically takes 30 to 60 minutes, depending on the size and complexity of the lesion.

Setting

The procedure is usually performed in a hospital or outpatient surgical center.

Personnel

  • Otolaryngologist or oral and maxillofacial surgeon
  • Surgical nurse or assistant
  • Anesthesiologist (if general anesthesia is required)

Risks and Complications

  • Infection at the surgical site
  • Bleeding or hematoma formation
  • Scarring or difficulty with healing
  • Sensation changes in the palate or uvula
  • Difficulty speaking or swallowing temporarily
  • Rarely, recurrence of the lesion

Benefits

  • Removal of abnormal and potentially harmful tissue.
  • Alleviation of symptoms such as discomfort, bleeding, or obstruction.
  • Promotes healthy tissue regeneration with minimal scarring.

Recovery

  • Post-operative instructions may include dietary restrictions (soft foods) and guidelines for oral hygiene.
  • Pain management with prescribed medications or over-the-counter pain relievers.
  • Avoid strenuous activity for a few days post-procedure.
  • Follow-up appointments to monitor healing and ensure no complications arise.
  • Normal activities can typically resume within a week, with full recovery in a few weeks.

Alternatives

  • Monitoring: For smaller, non-troublesome lesions, observation may be an option.
  • Laser ablation: Uses laser energy to remove the lesion with minimal invasion.
  • Cryotherapy: Involves freezing the lesion to remove it.
  • Each alternative comes with its own set of pros and cons regarding effectiveness, recovery time, and potential risks.

Patient Experience

During the procedure, the patient will feel minimal to no pain due to local anesthesia. Post-procedure, mild discomfort and swelling are common, manageable with pain medications. Patients may experience temporary difficulty in speaking or swallowing, which typically subsides as the area heals.

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