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--- resident:david_khechoyan [2021/06/28 11:09] – [Cleft Physician Preference] stacee
+++ resident:david_khechoyan [2022/12/22 07:22] (current) – taylor
@@ Line 15: / Line 15: @@
 General Tips:\\
-\\
+Dr. Khechoyan likes to prep the patient himself. He is methodical about muscle dissection and a believer in anatomic subunits.\\
+Will place mayfield himself.\\
+Has a particular way of draping the head drape. Will likely drape himself.\\
+Pleasant days where he will do a lot of teaching and you will do a lot of first assist.\\
 ====Pediatric Plastic Surgery and Craniofacial Plastic Surgery - Post Operative Home Care Instructions====
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+====Endoscopic Strip Craniectomy (for bilateral coronal craniosynostosis)====
+<WRAP group>
+<WRAP half column>
+The patient was brought to the operating room where general anesthesia was induced in the usual fashion. She was positioned prone with her head on a horseshoe. Two incisions were marked, perpendicular to the coronal suture, above the superior temporal line, where the skull angles in medially.
+She was prepped and draped in the usual fashion. The left incision was opened with a skin knife and then bovie electrocautery, and the loose areolar tissue was cleared away with a bovie anteriorly and posteriorly. Then, parallel marks were marked with the bovie, 1.25 cm left and 1.25 cm right of the coronal suture, parallel to the suture. The coronal suture was clearly closed. The loose areolar tissue was cleared away down to the squamosal suture and medially to the midline. This was repeated on the right side. In this fashion, we could use the endoscope contralaterally for the dissection from lateral to medial, which allows for excellent visualization.
+We started bone removal on the left. We made two burr holes, one anterior and one posterior to the fused coronal suture, and connected them with a kerrison. I then cleared away the dura medially with a #1 penfield, and using the endoscope for visualization, made two parallel cuts along the suture most of the way to the fontanelle with Tessier bone scissors. I then removed that bone with large Leksell rongeurs. Once I was satisfied with bony removal, I proceeded to repeat this procedure from the burr holes inferiorly to the skull base, visualizing the middle fossa floor and the sphenoid as well.
+I then repeated the whole procedure on the right side, although I was able to remove the right medial bony strip en bloc with a combination of tessier scissors and a bovie as it dissected free more easily from the dural reflection at the fontanelle.
+Hemostasis was obtained with bone wax and surgiflo through the case.
+The wound was then thoroughly irrigated with antibiotic-impregnated saline. The incision was then closed with interrupted 3-0 Vicryl in the galea and running 4-0 monocryl in the skin. The hair was washed the wound was dressed with antibiotic ointment.
+</WRAP>
+<WRAP half column>
+{{:resident:img_5225.jpeg?200|}}
+{{:resident:img_5226.jpeg?200|}}
+{{:resident:img_5227.jpeg?200|}}
+</WRAP>
+</WRAP>
 ==== Nasolabial Flap ====
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 </WRAP>
-====Clef Lip Instructions Patient Family====
+====Bilateral Cleft Lip Repair====
+**Pending op report**\\
+{{:resident:img_5223.jpeg?400|}}\\
+{{:resident:img_5224.jpeg?400|}}
+====Unilateral Cleft Lip Repair with Nose/Septum Revision====
+The oral cavity was cleansed with Peridex mouthwash. The face was prepared and draped in a sterile fashion. The eyes were protected with Steri-Strips. A moistened throat pack was placed in the oropharynx. Fisher subunit approximation cleft lip repair was then marked out with limb dimensions as above; the key landmark points were tattooed with 25-gauge needle and methylene blue.
+The medial lip cuts were then made with a 6700 Beaver blade with marginal tissue discarded; the overlying skin and underlying labial mucosa was then minimally undermined for a distance of 1-2 mm. We confirmed that the Cupid's bow was level, and the medial triangle opened to the planned 1.5 mm.   Accordingly, the lateral lip upper buccal sulcus incision was then made, and the lateral lip element was mobilized in a supra-periosteal plane. The abnormal attachments of the facial musculature were released off the pyriform, as were abnormal attachments of the cleft-side lower lateral cartilage.
+We then turned our attention to the septoplasty portion of the operation. The caudal septum was noted to be acutely deviated to the non-cleft side. Via the medial lip incision, we were able to carefully expose the caudal septum and developed a sub-mucoperichondrial plane on the non-cleft side. The abnormal attachments of the caudal septum were then released with a Cottle elevator. The septum was then repositioned to a midline position.
+Then, the lateral lip element incisions were made with a 6700 Beaver blade, and the marginal cleft tissue was discarded. The overlying skin and underlying labial mucosa were then undermined widely in an effort to relieve all tension on the closure.
+Please note that due to the significant width of this complete cleft approximately 50% of increased procedural time and effort was required to fully mobilize the lateral lip element mucosa and skin to achieve tension-free closure, justifying the application of Modifier 22.
+The lateral nasal wall lining was released within the cleft in the coronal plane by incising intra-nasally up to the inferior turbinate, allowing for anterior transposition of the cleft-side lateral nasal vestibular lining.
+Attention was then turned to the tip rhinoplasty portion of the operation. Via the superior aspect of the lateral lip element incision, we were able to dissect carefully both superficial and deep to the cleft-side lower lateral cartilage to allow for differential re-draping of the skin envelope and the vestibular lining, respectively. Given the severity of the cleft lip nasal deformity, approximately 30% of increased procedural time and effort was required to fully mobilize the intra-nasal vestibular lining and to reposition the cleft-side lower lateral cartilage (LLC) into the proper position, justifying the application of Modifier 22.
+Once this was completed and the cleft-side lower lateral cartilage was mobilized, we placed a scroll area plication suture with 5-0 Monocryl to re-drape the cleft-side LLC into the appropriate position in relation to the upper lateral cartilage. Multiple alar transfixion sutures were then also placed in a triangular configuration to re-drape the vestibular lining with 5-0 Monocryl. Several of these alar transfixion suture were placed to define the ala-cheek crease and re-drape the vestibular lining.
+Copious irrigation with bacitracin-containing solution was then applied; hemostasis was achieved with bipolar cautery.
+The nasal floor was closed by approximation of the lateral nasal lining and the mucosa on the repositioned caudal septum with 5-0 Monocryl suture in an interrupted fashion, thereby, in effect, closing the type VII naso-labial fistula in the process and separating the nasal cavity from the labial area. Care was taken to pass at least one suture through the caudal border of the septum cartilage to secure it in the midline position.
+The labial mucosa and upper buccal sulcus incisions were closed with interrupted 5-0 Monocryl suture. The orbicularis oris muscle was then carefully approximated with a 5-0 Vicryl suture, with care taken to align the nasal, labial, and marginal components of the muscle. Finally, the dermis was approximated with 5-0 Vicryl and 5-0 Monocryl suture. The nasal sill, vermilion, cutaneous triangle, and cutaneous roll were inset and closed with interrupted 8-0 Vicryl sutures. Finally, the rest of the lip was approximated with carefully placed 7-0 Prolene sutures.
+Nasal stents (size 2) were then cut to the appropriate length, introduced to each naris, and secured with a loosely tied 3-0 Prolene suture.
+The upper lip incision was then dressed with bacitracin ointment. The throat pack was removed, and the oropharynx was suctioned.
+At the end of the operation, all sponge and needle counts were correct. The patient tolerated the operation well. The patient's care was then turned over to the Anesthesia team. The patient emerged from the anesthetic uneventfully and was transported to the recovery room in stable condition.
+Resident:\\
+Marking instructions: Fisher repair. Marks alar rim stopping at the mid alar point. Next marks nasal-cheek junction and stops at subalare. These two points make a line and allow placement of the nasal sill mark. This is an intersection with a bowtie semicircular line with the columellar midline and side points. Transposes these marks to the lateral side. Draws cupid bow points. Now you can measure the total lip height (TLH usually around 8), and greater lip height (GLH usually around 6). Subtract these and rose thompson effect to get the lesser lip height (LLH). Note that this is the base of the triangle. Make the backcut perpindecular to the GLH line.\\
+====Cleft Lip Instructions Patient Family====
 Post Operative Home Care Instructions for Dr. David Khechoyan \\
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 If you have concerns about your child after discharge home, you may call De Khechoyan's office at 720-777-6409 to schedule a clinic appointment or to speak to Do Khechoyan, one of the nurses, or the on call provider. \\
+====Rhinoplasty (for cleft lip revision) with Rib Graft====
+<WRAP group>
+<WRAP half column>
+The proposed excision was marked out as a lenticular excision with a fine marking pen. Local anesthetic, 0.25% bupivacaine with 1:200,000 epinephrine was infiltrated into the proposed surgical site(s), with appropriate weight-based dosing. The surgical site was prepared and draped in a sterile fashion. The eyes were protected with eyelids taped down with Steri-Strips.
+The operation began with the rib cartilage graft harvest from the right chest. An approximately 4-cm in incision was made in the right infra-mammary fold with a 15-blade, and dissection proceeded down through the subcutaneous tissue, superficial fascia with monopolar cautery down to the deep fascia, which was in turn incised. The rectus abdominis muscle was split along its fibers, and the perichondrium of the 7th rib was incised and dissected circumferentially around the rib cartilage. The rib cartilage graft was then harvested from costochondral junction to sternochondral junction. The deep perichondrium was intact. Irrigation was instilled, and a Valsalva maneuver confirmed absence of a pleural injury, with no air leak or bubbling. The cartilage graft was stored in saline-soaked gauze. The surgical site was irrigated and closed in layers, in a standard fashion. A sterile dressing was applied.
+Attention was then turned to the nose. The nasal cavity was packed with Afrin-soaked cottonoids. The nasal tip and columellar incision were infiltrated with 1% lidocaine with 1:100,000 epinephrine, with weight-based dosing. A stair-step columellar incision was made with a 6700 Beaver blade and continued bilaterally as infra-cartilaginous incisions. The nasal envelope was dissected off the underlying cartilaginous network. Please note that this was the patient's third rhinoplasty, with the most recent one performed by me with rib cartilage graft; there was excess scar tissue, which rendered the elevation of the nasal skin envelope more challenging and time consuming. The nasal envelope was successfully lifted up with no perforations of the skin and intact, preserved perfusion. The dorsum cartilaginous and bony hump was reduced with rasps and smoothed out. The lower lateral cartilages (LLCs) and upper lateral cartilages (ULCs) were split in midline and reflected off the septum. The previously placed bilateral spreader grafts, columellar, and septal extension grafts were removed. The mucosa was reflected off the septum. The caudal portion of the septum was shortened to allow repositioning to the midline, and better midline position of septum was noted. New bilateral spreader grafts were carved from the newly harvested cartilage graft and sutured in place with 5-0 PDS suture, with improved width of the mid-vault and improved straightening of the septum in this region. A new columellar graft was carved and sutured in place with 5-0 PDS suture, incorporating and equalizing the medical crura of the bilateral LLCs. Dome defining and dome equalization sutures were placed with 5-0 PDS suture. Finally, stacked transverse (rectangular) tip grafts were carved and sutured in place to improve nasal tip projection. Transfixion suture was placed with 4-0 Chromic suture to hold the caudal septum and medial crura in midline position. The skin envelope was reflected, and we noted a more straight nasal tip and mid-vault, as well as improved nasal tip projection and definition. Copious irrigation was applied; hemostasis was achieved. The columellar incision was closed with 5-0 Monocryl in the deep dermal layer, followed by interrupted 6-0 Prolene sutures. The intra-nasal portions of the incision were closed with interrupted 5-0 Chromic sutures. No nasal osteotomies were performed. No Doyle splints were placed. The nasal incisions were dressed with topical bacitracin ointment. Steri-strips and Aquaplast splint was then applied to the dorsum and tip for edema control. Please note that Modifier 22 applies to this operation given the fact that this operation is the third reconstructive operation to correct cleft lip nasal deformity for this patient. Approximately 75-100% of increased procedural time and technical effort was required to achieve a safe, reliable reconstruction.
+The eyes were irrigated with BSS.
+</WRAP>
+<WRAP half column>
+**Setup:**
+  * Has nurses place 3x Mepilex on patient in pre-op area (sacrum and bilateral shoulders)
+  * Headrest
+  * Patient shoulders to the edge of the table
+  * In females, mark the IMF on side of rib graft donor site. Then mark 1-2mm below the IMF to mark where incision will be.
+  * Place tegaderm over the ETT after it is taped in place
+  * Place silk tape over eyes
+  * Throat pack goes in before prepping
+  * Preps nasal cavity with qtips and betadine
+  * Prep oral cavity with Peridex and brush teeth
+  * Prep patient face with betadine, rib graft site with CHG - prep in the ears/neck and have a continuous sterile field between face and rib graft site
+{{:resident:ribgraftmarking.jpeg?400|}}
+</WRAP>
+</WRAP>
 ====Khechoyan’s Orthognathic Pathway====
 (this is preliminary and may change, but at least gives you an overview)
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 Updated: 1/17/19  MSA
-==== Operative Report (Cleft Palate Repair) ====
+====Cleft Palate Repair====
 <WRAP group>
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 Please note that Modifier 22 applies to the cleft palate portion of operation as increased procedural effort and time was required to achieve tension free cleft palate repair in this patient with complete, wide cleft palate. Also, complete, radical intra-velar veloplasty was performed bilaterally with microscope-assisted dissection utilizing microsurgical technique with preservation of the blood supply to the levator veli palati muscle bundles bilaterally. This required approximately 75-100% of increased procedural time and effort to achieve safe and complete dissection.
-At the end of the operation, all sponge and needle counts were correct. The patient tolerated the operation well. The patient's care was then turned over to the Anesthesia team. The patient emerged from the anesthetic, was extubated nd was transported to the recovery room in stable condition.
+At the end of the operation, all sponge and needle counts were correct. The patient tolerated the operation well. The patient's care was then turned over to the Anesthesia team. The patient emerged from the anaesthetic, was extubated and was transported to the recovery room in stable condition.
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 <WRAP half column>
-Photos\\
+Anatomy:(Reported from Amboss)
-Anatomy: Anatomy (Reported from Amboss):
 Hard Palate: Receives blood from greater palatine artery (branch of descending palatine artery which comes from maxillary artery).
 Innervated by greater palatine and nasopalatine nerves (branches of maxillary N)
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 Lesser palatine nerve does secretomotor, sensory and taste. Vagus N does motor\\
-Post-operative care: Include restrictions, splints, etc...\\
+Attending Pearls:
+Cleft Lip
-Attending Pearls: Cleft Lip
+Failure of medial nasal process and maxillary prominence to close at 4-6 weeks of gestation
-failure of medial nasal process and maxillary prominence to close at 4-6 weeks of gestation
+anterior to incisive foramen (IF)
-anterior to incisive foramen
 problems: Can’t form fluid air seal which causes issues with speaking and eating, cosmetic and malocclusion of teeth
 Van der Wounde’s syndrome
-Repaired at 2-3 morphs, Millard Rotation-advancement
+Repaired at 2-3 months, Millard Rotation-advancement
 Cleft Palate
 Primary: anterior to IF, failure of medial and lateral palatine processes to fuse
 Secondary: posterior to IF: failure of lateral fusion at 7-12 weeks
 Problems: can’t suck properly for feedings, middle ear infections, velopharyngeal insufficiency (air escapes during speech)
 DiGeorge and Stickler Syndrome
-Repaired at 9-15 months of hard and soft palate, then nasal and CL revisions at around 3 y/o, alveolar cleft bone grafting at around 7, around 16 orthognathnic surgery to fix malocclusion of teeth and around same time can do formal rhinoplasty:\\
+Repaired at 9-15 months of hard and soft palate, then nasal and CL revisions at around 3 y/o, alveolar cleft bone grafting at around 7, around 16 orthognathic surgery to fix malocclusion of teeth and around same time can do formal rhinoplasty:\\
 </WRAP>
 </WRAP>
+====Sagittal strip craniectomy with biparietal morcellation====
+<WRAP group>
+<WRAP half column>
+The patient and the patient's family were met in the pre-operative area.
+The surgical site was marked with the surgeon's initials.
+The risks, benefits, details, and alternatives of the operation were discussed in detail. All questions were answered. The informed consent for surgery was signed by parent/guardian.
+The patient was brought into the operating room and laid supine on the operating room table. General anesthesia was induced by the Anesthesiology provider. A pre-operative intravenous dose of antibiotics was administered.
+A time-out was performed during which we identified the operation and the operative site. All team members introduced themselves. All issues and concerns were discussed and resolved before proceeding with the operation.
+The eyes were protected with Tegaderm tapes.
+A bicoronal sinusoidal incision was designed from ear to ear and infiltrated with local anesthetic; local anesthetic, 0.25% bupivacaine with 1:200,000 epinephrine, was infiltrated into the proposed surgical site(s), with appropriate weight-based dosing. The hair around the incision was minimally shaved.
+The surgical site was prepared and draped in a sterile fashion.
+The incision was made with a 15-blade and monopolar cautery down through the galea; wide, bidirectional sub-galeal undermining and scalp mobilization was performed to expose the cranium from frontal to occipital bones. The sagittal suture was noted to be fused; the metopic, bilateral coronal and lamboid sutures were noted to be open.
+Three pairs of parasagittal burr holes were made along the planned parasagittal cuts from the anterior fontanelle to the lambda.
+A 3-cm strip craniectomy centered over the fused sagittal suture was then performed from anterior fontanelle to the lambda, after burr holes were made and the dissection proceeded across the midline and bone was removed across the midline with Kerrison rongeurs; there were no dural tears, and the patient remained hemodynamically stable.
+As bilateral frontal cranioplasty and remodeling, a caudally-based barrel stave (approximately 2 cm in width) straddling the open RIGHT coronal suture was cut with a craniotome, dissected off the dura, out-fractured as a green-stick fracture with a Tonsil clamp, and contoured into the appropriate more rounded shape with a Tessier elevator.
+Then, a caudally-based barrel stave (approximately 2 cm in width) straddling the open LEFT coronal suture was cut with a craniotome, dissected off the dura, out-fractured as a green-stick fracture with a Tonsil clamp, and contoured into the appropriate more rounded shape with a Tessier elevator.
+Then, bilateral, extensive parietal morcellation cuts were designed and then cut with a craniotome in a brick-type pattern, spanning an expanse of 6.5 to 7.0 cm from parasagittal edge of the sagittal craniectomy to the superior temporal crest, with two bone graft (flaps) caudally and three bone graft (flaps) toward the midline. These extensive bone grafts were retained with their attachment to dura and secured in placed with a Surgicel. This was done on the right side first, and then the left side.
+A 7-French flat Jackson-Pratt drain was placed through the RIGHT occiput.
+Copious irrigation was applied with at least 1 liter of normal saline; hemostasis was noted. The scalp was then closed in layers, with 3-0 Vicryl for the galea layer, followed by a running 4-0 Monocryl suture on the surface; bacitracin was applied to the incision.
+Please note that Modifier 22 applies to all components of this operation as significantly increased operative time and technical effort were required to safely achieve all steps of this operation. This was primarily because of thicker bone in the bilateral parietal and frontal regions, which rendered every part of the operation more challenging, including, but not limited to, making burr holes, craniotomy cuts, and reshaping of the barrel staves, among other steps. These circumstances and findings justifies the application of Modifier 22.
+At the end of the operation, all sponge and needle counts were confirmed to be correct.
+The patient tolerated the operation well.
+The patient's care was then turned over to the Anesthesia team.
+The patient emerged from the anesthetic uneventfully and was transported to the recovery room in stable condition.
+</WRAP>
+<WRAP half column>
+***
+</WRAP>
+</WRAP>