DELINEATION OF PRIVILEGES - GENERAL SURGERY DIVISION OF PLASTIC SURGERY Adults and Pediatrics Unless Specified

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1 KALEIDA HEALTH Name Date DELINEATION OF PRIVILEGES - GENERAL SURGERY DIVISION OF PLASTIC SURGERY Adults and Pediatrics Unless Specified PLEASE NOTE: Please check the box for each privilege requested. Do not use an arrow or line to make selections. We will return applications that ignore this directive. GENERAL STATEMENTS Privileges in Surgery are separated into the following divisions: General Surgery and Plastic Surgery. Applicants desiring procedure privileges in more than one division must complete separate forms for each division requested. Procedures are grouped by anatomic region. Procedures are also separated into levels of complexity (Level I, Level II, and Level III), which require increasing levels of education and experience. In general, procedures learned during residency are grouped in Level I and are granted upon evidence of successful completion of residency training. Level II procedures may or may not require evidence of additional training beyond residency. Documentation of additional training and/or experience is required for all Level III procedures. LEVEL I (CORE) PRIVILEGES Level 1 (core) privileges are those able to be performed after successful completion of an accredited residency program in that core specialty. The removal or restriction of these privileges would require further investigation as to the individual s overall ability to practice, but there is no need to delineate these privileges individually. Admission and Follow-Up History and Physical for diagnosis and treatment INJECTION PROCEDURES Injection Steroid I & D / DEBRIDEMENT Debridement Debridement, Dressing Change Re-Exploration Breast Evacuation Hematoma Incision and Drainage BIOPSY AND EXCISIONS Biopsy (finger, hand, muscle, sural nerve) Excision Basal Cell Carcinoma Excision Breast Mass, Bilateral Excision Cyst Sebaceous Excision Hemangioma Upper Extremity Excision Hidradenitis, Axillary/Buttocks Excision Lesion and Reconstruction Excision Lesion Eyelid, Benign/Malignant Excision Lesion Hand Excision Lesion Nose w/ Local Cutaneous Skin Flap Excision Skin Lesion Excision Lipoma Excision Lymph Nodes Excision Mass Excision Melanoma Excision Neuroma Hand/Finger(s) Excision Nevi Removal Foreign Body (Foot/Hand) LEVEL I (CORE) PRIVILEGES (CON T) Excision (lunate, pisiform, scaphoid, exostosis finger) Salivary Gland Biopsy/Excision SOFT TISSUE REPAIRS / RECONSTRUCTIONS Repair Laceration Earlobe Revision Amputation Stump Scar Revision (Burns, Keloids, Trauma) Z-Plasty Hand Soft Tissue Deficiencies Pressure Sores Lacerations FLAPS AND GENERAL RECONSTRUCTION Flap Debridement, Defatting, Delay, Cutaneous, Division-Inset of Distant Pedicle Upper Extremity to Abdomen Flap Island Pedicle Myocutaneous Forearm to hand (PIA) Reconstruction Facial Defect with Flap (MOHS) Reconstruction Lumbar Spine with Myocutaneous Flap Scalp Reduction Re-Exploration Flap Reconstruction (breast, sternum, upper and lower extremity) Excision Melanoma with Cutaneous Skin Flap Release Frenulum (tongue tied) Repair Ectropin Local and Regional Flaps GRAFTS (skin, fat, bone, fascia, cartilage, prosthetic) Excision Basal Cell Carcinoma with STSG Excision Lesion Skim with STSG Excision Melanoma with STSG REDUCTION FACIAL FRACTURE Closed Reduction Nasal Fracture ORIF (malar, orbital floor fracture, maxilla, mandible, zygoma)

2 Plastic Surgery Name: Page 2 LEVEL I (CORE) PRIVILEGES (CON T) HAND SURGERY/WRIST, GENERAL AND RECONSTRUCTIVE Manipulation Extremity Ganglion Excision Upper & Lower Extremity Release Contracture Finger(s) Release Dorsal compartment Wrist Excision Ganglion Cyst Tenovaginectomy Finger(s) Release Syndactyly Fingers and Toes Fasciectomy Palmar & Digital (Dupuytren s) NERVE REPAIR / NEUROLYSIS / DECOMPRESSION / TRANSPOSITION / GRAFT Decompression Median Nerve Bilateral and Unilateral (Carpal Tunnel) Decompression Ulnar Nerve (Cubital Tunnel) Neurolysis (digital, median, radial and ulnar nerve) Repair Nerve (digital, median, radial and ulnar nerve REMOVAL OF HARDWARE Removal of Pin(s) Finger/Hand Removal Plates & Screws Wrist BODY CONTOURING Liposuction (Adults) Lipectomy Lipolysis RHYTIDECTOMY (Facial, Coronal, Neck) Platysmoplasty Rhytidectomy PLASTY Blepharoplasty Correction Ptosis Eyelid, Single/Bilateral Septorhinoplasty Septoplasty PLASTY (CON T) Rhinoplasty Abdominoplasty (Adults) Otoplasty, Unilateral/Bilateral Labiaplasty (Adults) MAMMOPLASTY Augmentation Mammoplasty, Single/Bilateral Capsulectomy/Capsulotomy Breast(s) Mastectomy Immediate Reconstruction (Latissimus Flap Free/Pedicle, Tissue Expander, TRAM Flap Free/Pedicle) Reconstruction Areola/Nipple, Unilateral/Bilateral Reconstruction Breast Bilateral (with Latissimus Pedicle Flap, with Tissue Expander) Reconstruction Breast Bilateral with TRAM Pedicle Flap Reconstruction Breast Single (with Latissimus Pedicle Flap, with Tissue Expander, with TRAM Pedicle Flap) Mastopexy, Single/Bilateral Reduction Mammoplasty, Single/Bilateral Reduction Mammoplasty with Free Nipple Graft, Bilateral/Unilateral Removal Mammary Implant, Single/Bilateral Removal Tissue Expander with Insertion Mammary Implant, Single/Bilateral Replace Mammary Implant, Unilateral/Bilateral Excision Gynecomastia, Bilateral TISSUE EXPANDER Insertion, Removal, Replace Tissue Expander LASER SURGERY Excision Lesion Skin CO2, KTP, Nevi CO2 (Chest/Abdomen, Back/Hips, Face/Head, Neck, Upper and Lower Extremity) GENERAL COSMETIC Chemical Peel and Dermabrasion, Facial/ Dermabrasion, Forehead Hair Transplant, Flaps, Reduction Tattoo Removal Augmentation Chin (Implant)

3 Plastic Surgery Name: Page 3 LEVEL II PRIVILEGES Those procedures listed below, including those not listed in Level I, which may require documentation of additional experience or training. * FLAPS AND GENERAL RECONSTRUCTION Reconstruction abdominal/ventral hernia repair Reconstruction Cervical Spine with Myocutaneous Flap Reconstruction Chest Wall with Latissimus Dorsi Pedicle Flap, with Rectus Muscle Pedicle Flap, with TRAM Pedicle Flap Reconstruction Lower Extremity with Myocutaneous Flap Reconstruction Sternum Bilateral Cutaneous and Bilateral Pectoral Flaps/Omentum, Rectus Muscle Flaps, TRAM Flaps Reconstruction Sternum Bilateral Cutaneous and Unilateral Pectoral Flaps, Rectus Muscle Flaps, TRAM Flaps Reconstruction Upper Extremity with Latissimus Free Flap Genital Reconstruction including vaginal (Hypospadius) Hemartoma Surgery (Vascular malformations) HAND JOINT / LIGAMENT SURGERY AND RECONSTRUCTION Amputation Reconstruction Ligamentous Hand/Wrist Synovectomy Carpal Bones, Interphalangeal Joint Finger(s) IPJ, Wrist REPAIR OR RELEASE TENDON / TENOLYSIS / TENDON GRAFT AND TRANSFER Repair Tendon Extensor Hand, Flexor Arm and Hand Repair Tendons and Nerves Forearm, Finger(s), Hand, Wrist Tendon Graft Upper Extremity Tendon Transfer Hand/Wrist Tenolysis Hand, Wrist (Dorsal Compartments), Wrist/Forearm NERVE REPAIR Decompression Median Nerve with Abductorplasty Myelomeningocele repair (with Neurosurgery) REDUCTION OF FRACTURE, DISLOCATIONS, HAND AND WRIST Closed Reduction Percutaneous Pinning Carpal(s), Metacarpal(s), Wrist ORIF Finger(s) TREATMENT OF FACIAL DISEASES AND INJURIES INCLUDING MAXILLOFACIAL STRUCTURES Cleft Lip & Palate Surgery (Cleft lip, Cleft palate, Pharyngeal Flap) Nose Reconstruction (Cleft lip nasal deformity) Ear Reconstruction (Microtia) Eyelid Reconstruction Head and Neck Surgery Facial Fractures, including mandible BONE CARTILAGE REMOVAL AND/OR GRAFTING, AUTOLOGOUS & PROSTHETIC Excision Tumor Hand Fusion Scaphoid with Bone Graft Distal Radius, with Bone Graft Iliac Crest Graft Composite (Ear/Nose) Harvest Bone Graft Iliac Crest ORIF Scaphoid with Bone Graft Iliac Crest ORIF Scapula

4 Plastic Surgery Name: Page 4 LEVEL II PRIVILEGES (CON T) * Ostomy Wrist Osteotomy Wrist with Bone Graft and Fixation ARTHROPLASTY, ARTHRODESIS, ARTHROTOMY / HAND AND WRIST Arthrodesis Intercarpal Joint(s), Interphalangeal Joint(s) Finger, Metacarpaophalangeal Joint(s) MCPJ Arthroplasty Carpometacarpal Joint(s), Metacarpal Joint(s), Wrist, Metatarsophalangeal Joint First Bilateral/Unilateral, Metatarsophalangeal Joint First with Implant Bilateral/Unilateral Arthroscopic Debridement Wrist, Removal Loose Bodies Wrist, Repair Triangular Fibrocartilage Complex Tear Wrist, Synovectomy Wrist Arthroscopy Wrist Arthrotomy Wrist Drainage Abscess Capsulodesis Metacarpaophalangeal Joint(s), Wrist Capsulotomy Carpal Bones, Interphalangeal Joints Finger(s) IPJ, Metacarpaophalangeal Joint(s) MCPJ, Metatarsophalangeal Joint(s) MTPJ, Wrist Fusion Multiple Joint Hand RECONSTRUCTION BONE OR JOINT DEFORMITY, FACE, HANDS, WRISTS Excision Bone Spur Hand LASER SURGERY Resurfacing Skin Facial Laser CO2 Vaporization Lesion Skin,/ Vascular Laser CO2/TD (Back/Hip(s), Chest/Abdomen, Face/Head, Neck, Upper/Lower Extremity) ENDOSCOPIC Decompression Median Nerve, Bilateral/Unilateral Endoscopic (Carpal Tunnel), Endoscopic with Abductorplasty Endoscopic Plastic Surgery Forehead, with Blepharoplasty Upper/Lower Bilateral

5 Plastic Surgery Name: Page 5 MODERATE/CONSCIOUS SEDATION 1. Providers seeking privileges in moderate/conscious sedation must complete either the ASA sedation course cost $ ( or Medsimulation course cost $75.00 ( receiving a score of 85% or above. * e: Providers completing the on-line training course provided by Medsimulation from other institutions receiving a score of 85% or higher will be accepted as an equivalent measure of acceptable knowledge for sedation privileges. * 2. Once the provider has successfully passed the course, he/she must send the certificate of course completion to the medical staff office via (medicalstaffoffice@kaleidahealth.org) or fax ( or ). 3. In addition to demonstrating medical knowledge through completion of this course, providers must also maintain airway management skills through current completed training and certification in ACLS, ATLS or PALS. (ACLS is offered through Kaleida Health Corporate Clinical Education. Please call for information. You can also take either course online if you prefer. The following are just a few suggestions. You may be able to obtain this training somewhere else: $179.00, $ or $ ) 4. After a four year period of privileging the provider must repeat either the ASA sedation course or Medsimulation course and receive a score of 85% or greater or a comparable course reviewed and accepted by the Chief of Anesthesiology. They must also maintain airway management skills through completed and current training and certification in ACLS, ATLS or PALS.

6 Plastic Surgery Name: Page 6 LEVEL III PRIVILEGES These procedures require documentation of a completed Fellowship * FLAPS AND GENERAL RECONSTRUCTION Reconstruction Chest Wall with Latissimus Dorsi Free Flap, with Rectus Muscle Free Flap, with TRAM Free Flap Reconstruction Cranium with Latissimus Free Flap and Rib Graft Reconstruction Lower Extremity with Fascial Cutaneous Dorsal Foot Free Flap, Upper Arm Free Flap, Forearm Free Flap Reconstruction Lower Extremity with Latissimus Muscle Free Flap, with Rectus Muscle Free Flap Reconstruction Upper Extremity with Latissimus Free Flap, with Rectus Muscle Free Flap, With Serratus Anterior Free Flap Craniofacial Surgery/Orthognathic Surgery Congenital Hand Reconstruction Microvascular Surgery (DIEP flap breast reconstruction) HAND SURGERY / WRIST, GENERAL AND RECONSTRUCTIVE Reimplantation, revascularization amputated hand/digit MAMMOPLASTY Reconstruction Breast Single/Bilateral with Latissimus Free Flap, With TRAM Free Flap

7 Plastic Surgery Name: Page 7 KEY *NOT GRANTED DUE TO: Provide Details Below **WITH FOLLOWING REQUIREMENTS Provide Details Below 1) Lack of Documentation 1) With Consultation 2) Lack of Required Training/Experience 2) With Assistance 3) Lack of Current Competence (Databank Reportable) 3) With Proctoring 4) Other (Please Define) (i.e., Exclusive Contract) 4) Other (Please Define) DETAILS: National Practitioner Databank Disclaimer Statement Kaleida Health must report to the National Practitioner Data Bank when any clinical privileges are not granted for reasons related to professional competence or conduct. (Pursuant to the Health Care Quality Improvement Act of 1986 (42 U.S.C et seq.) / Signature of Applicant Date I approve of the procedures requested by the applicant: (a) as requested (b) as amended I, the Chief of Service, have consulted with the Chief of the Division of Pediatric Surgical Services (or designee) concerning any requests of this applicant for Level II/III privileges on patients below the age of 18. / Signature of Chief of Service Date APPLICANT: PLEASE RETAIN A COPY OF THIS SIGNED DELINEATION FOR YOUR RECORDS