Departmental Segregated Total Form for Plastic and Reconstructive Surgery

Departmental Segregated Total Form for Plastic and Reconstructive Surgery American Osteopathic Association and the American College of Osteopathic Surgeons Revised, COPT 11/2001 Revised, BOT 2/2006, Effective, 7/2006

AMERICAN OSTEOPATHIC ASSOCIATION PLASTIC AND RECONSTRUCTIVE SURGERY DEPARTMENTAL SEGREGATED TOTALS MAJOR PROCEDURES Base Institution: City: State: Program Director: Director of Medical Education: Training Year: Instructions: 1. This form must be completed and submitted with the required application documented by: Institutions with AOA Approved Plastic and Reconstructive Surgery residency training programs requesting an increase in the number of AOA-Approved Resident positions or, Institutions seeking approval of a new Plastic and Reconstructive Surgery residency training program. 2. Report only major procedures. (Multiple major procedures per patient may be reported.) 3. The mortality for each of the procedures listed must be reported on this form. 4. All information should reflect the procedures from July 1 to June 30 of the prior year. 5. Mail to: Residency Evaluation and Standards Committee (RESC), c/o American College of Osteopathic Surgeons, 123 North Henry Street, Alexandria, VA 22314-2903. Total Major Procedures for Training Year: Specify the number of residents for the specialty below: Plastic and Reconstructive Surgery 2

Classification I. Congenital Deformities II. III. Malignancies and Benign Tumors Head and Neck Skin Benign Soft Tissue Traumatic and Acquired Deformities Facial Trauma (non-bony) Facial Trauma (bony) Trunk Lower Extremity IV. Aesthetic Surgery V. Surgery of the Breast VI. Surgery of the Hand VII. Burns VIII. Microsurgery 3

OPERATIVE PROCEDURES I. CONGENITAL DEFORMITIES A. Cleft lip and palate 1. Primary cleft lip repair-unilaterial (27.54) 2. Primary cleft lip repair-bilateral (27.54) 3. Secondary cleft lip repair (27.59) 4. Cleft palate repair one stage (soft palate) (27.62) 5. Cleft palate repair two stage (soft plane) (27.62) 6. Pharyngeal flap or pharyngoplasty (27.63) 7. Palatal fistula repair (27.69) 8. Cleft lip nasal deformity repair-tip (27.69) 9. Other (LIST ON SEPARATE SHEET) (including release frenulum, z-plasty, lip adhesion, cross-lip flap, tongue flap, submucous cleft, columella lengthening) B. External ear (18.0) 1. Otoplasty (18.79) 2. Repositioning or revision, auricular remnant (18171) 3. Microtia staged reconstruction (18.71) C. Eyelids (08.0) 1. Ptosis repair (08.36) 2. Canthoplasty (08.59) 3. Other (LIST ON SEPARATE SHEET) D. Maxillofacial 1. Mandibular repositioning (76.64) 2. Maxillary osteotomy (76.65) 3. Major craniofacial reconstruction (76.69) E. Neck 1. Thyroglossal duct cyst or sinus (06.7) 2. Branchial cleft cyst or sinus (29.52) 3. Cystic hygroma (40.29) F. Genitourinay tract 1. Hypospadias repair (58.45) 2. Epispadias repair (58.45) 3. Vaginal reconstruction for absence (70.61 70.62) 4. Phalloplasty (64.44) 5. Other (LIST ON SEPARATE SHEET) 4

G. Hand 1. Syndactyly repair (86.85) 2. Polydactyly correction (86.85) 3. Macrodactyly correction (82.83) 4. Club hand correction (82.82) 5. Pollicization digit (82.61) 6. Other (LIST ON SEPARATE SHEET) TOTAL PROCEDURES FOR SECTION I II. MALIGNANCIES AND BENIGN TUMORS A. Head and neck neoplasms 1. Tumor of bony or dental origin (24.4) 2. V lip excision of lesion (27.43) 3. Lip excision of lesion with flap reconstruction (27.49) 4. Oro-pharyngeal lesion extirpation (29.3) 5. Oro-pharyngeal lesion extirpation with incontinuity neck dissection (29.59) 6. Antrectomy (22.39) 7. Orbital exenteration (16.5) 8. Neck dissection isolated procedure (40.40) 9. Major flap reconstruction of extirpative defect head and neck (86.70) 10. Partial nasal reconstruction (21.87) 11. Total nasal reconstruction (21.83) 12. Superficial parotidectomy (26.99) 13. Total parotidectomy (26.99) 14. Submaxillary gland or minor salivary gland excision (26.99) 15. Endoscopic procedures (29.11) 16. Other (LIST ON SEPARATE SHEET) B. Skin malignancies 1. Basal cell or squamous cell carcinoma a. Graft (86.6) b. Flap (86.7) 2. Melanoma (86.4) 3. Node dissection (40.3) C. Benign soft tissue tumor excision (86.5) (FLAP OR GRAFT) TOTAL PROCEDURES FOR SECTION II 5

III. TRAUMATIC AND ACQUIRED DEFORMITIES A. Soft tissue 1. Major facial laceration repair (acute) (86.59) 2. MAJOR Scar revision (86.84) 3. Local rotation flaps (86.74) 4. Delays or transfers of distant flaps (86.74) 5. Dermabrasion for scars (86.25) 6. Tissue expansion (86.8) 7. Other (LIST ON SEPARATE SHEET) B. Eyelids (08.0) 1. Major eyelid reconstruction (08.7) 2. Tear duct repair (09.7) 3. Dacryocystorhinostomy (09.81) 4. Ectropion repair (08.4) 5. Entropian repair (08.4) 6. Tarsorrhaphy or canthhoplasty (08.52) 7. Other (LIST ON SEPARATE SHEET) C. Facial nerve palsy 1. Nerve repair or graft (86.81) 2. Fascia or tendon sling (86.81) 3. Muscle transfer or graft (86.81) D. Facial Fractures 1. Nasal fracture a. Closed reduction (21.71) b. Open reduction (21.72) 2. Mandibular fracture a. Closed reduction (76.65) b. Open reduction (76.76) 3. Zygomatic-maxillary complex fracture a. Closed reduction (76.71) b. Open reduction (76.72) 4. Orbital floor or rim fracture a. Closed reduction (76.78) b. Open reduction (76.79) 5. Combination of two or more of above (complex) (76.99) 6. Other (LIST ON SEPARATE SHEET) E. Trunk 1. Pressure ulcer repair a. Sacral (86.89) b. Ischial (86.89) c. Trochanteric (86.89) d. Other (LIST ON SEPARATE SHEET) 6

2. Genitourinaty a. Major trauma repair (86.89) b. Dermis graft for Peyronie s Disease (86.89) c. Insertion of prosthesis (62.7) d. Phalloplasty (64.44) e. Other (LIST ON SEPARATE SHEET) F. Lower extremity 1. Excision or debridement, ulcer and skin graft (86.6) 2. Free flap repair (86.7) 3. Muscle flap (86.7) 4. Cross leg flap (86.7) 5. Musculocutaneous flap (86.7) 6. Other (LIST ON SEPARATE SHEET) TOTAL PROCEDURES FOR SECTION III IV. AESTHETIC SURGERY A. Face 1. Facelift (86.82) 2. Browlift (08.36) 3. Blepharoplasty (08.89) 4. Chemical peel or dermabrasion (86.24) 5. Rhinoplasty (21.85) 6. Septoplasty (21.88) 7. Otoplasty (18.5) 8. Chin augmentation (76.68) 9. Hair transplants (86.64) 10. Suction assisted lipectomy (86.83) 11. Other (LIST ON SEPARATE SHEET) 12. Laser Resurfacing 13. Facial augmentation - autologues - synthetic 14. Laser ablation of vascular lesions B. Trunk (body contouring) 1. Abdominal dermolipectomy (86.83) 2. Buttock dermolipectomy (86.83) 3. Suction lipectomy (AT LEAST 1000 CC PRESENT) (86.83) 7

C. Extremity 1. Arm dermolipectomy (86.83) 2. Thigh dermolipectomy (86.83) 3. Suction lipectomy (86.83) TOTAL PROCEDURES FOR SECTION IV V. SURGERY OF THE BREAST A. Reduction mammoplasty (85.30) B. Augmentation mammoplasty (85.50) C. Mastopexy (85.6) D. Subcutaneous mastectomy simple (85.33) E. Gynecomastia (85.32) F. Reconstruction (85.7) 1. Microvascular myocutoneous flap (85.85) 2. With musculocutaneous flap (85.89) 3. Tissue expansion (85.89) G. Nipple/areolar complex reconstruction (85.87) H. Release of capsular contraction after augmentation mammoplasty (85.99) I. Other (LIST ON SEPARATE SHEET) TOTAL PROCEDURES FOR SECTION V VI. SURGERY OF THE HAND (82.0) A. Major skin coverage (excluding burns) (86.89) B. Primary or secondary tendor repair (82.45) C. Primary or secondary nerve repair (04.3) D. Tendon graft (82.72) E. Implantation of silastic rod (82.79) F. Tendon transfer (82.56) G. Nerve graft (04.5) H. Tenolysis (82.91) I. Neurolysis (04.49) J. Palmer or digital fasciectomy (82.35 congenital) (82.61) K. Pollicization or digital transposition (not congenital) (82.61) L. Arthrodesis (81.20) M. Tenodesis (82.85) N. Arthroplasty 1. Implant (81.71 2. Other (81.79) 8

O. Fractures (79.0) P. Local flaps or grafts (86.73) Q. Dislocations (79.7) R. Carpal tunnel (04.43) S. Other (LIST ON SEPARATE SHEET) TOTAL PROCEDURES FOR SECTION VI VII. BURN MANAGEMENT, ACUTE AND RECONSTRUCTION A. Early treatment (86.99) 1. Major burns requiring fluid and electrolyte therapy B. Escharotomy or major debridement (86.22) C. Skin grafting (acute) (86.6) D. Late reconstruction (86.89) E. Other (LIST ON SEPARATE SHEET) TOTAL PROCEDURES FOR SECTION VII VIII. MICROSURGERY A. Free flap transfers (other than lower extremity) (86.7) B. Replantation of digit (84.22) C. Replantation of extremity (84.29) D. Revascularization (84.29) E. Other (LIST ON SEPARATE SHEET) TOTAL PROCEDURES FOR SECTION VIII 9