The effect of template-based sequential (TBS) coding on an NHS plastic surgical practice.

INTRODUCTION: Clinical coding is often a mystery to us surgeons, but in actuality, it has a huge bearing on the financial sustainability of our services. Given the rapid innovations in plastic surgical procedures, clinical coders often struggle to decipher the extent of surgery. Meeting midway is the way forward here. METHODS: In a prospective audit over a six-month period, we analysed data from 2586 patients in our practice: a combination of general plastic surgery and specialist facial reanimation services. This involved comparing data from the first three months where coding was performed by clinical coders based on operating notes per se (phase I) and the subsequent three months when the operating surgeon filled in the OPCS 4.7 (version 2014) codes at the time of completing the operating notes; the clinical coders then vetted this information (phase II) as part of a sequential TBS coding system. RESULTS: In terms of outpatient income, there was a 3% increase in facial palsy income and 6% increase in general plastic services, but the most significant improvement was in terms of procedural income per case. General plastic surgery cases saw an increase of 49%, while facial palsy income increased by 58% over the same period. Greater insight into OPCS and HRG codes also allowed for the calculation of the actual tariffs for specific procedures. CONCLUSIONS: Having the operating surgeon as the primary coder, using a template, with subsequent vetting by the clinical coders, improves data capture, and this in turn increases income. Future recommendations include the use of proforma-based operating notes for workhorse procedures.

Paradoxical Frontalis Activation: An Underrecognized Consequence of Facial Palsy.

BACKGROUND: Aberrant reinnervation and synkinesis are common and debilitating after facial palsy. Paradoxical frontalis activation can antagonize eye closure and increase the risk of corneal damage. If recognized, judicious botulinum toxin injection to the affected side may reduce this risk. METHODS: One hundred consecutive patients with synkinesis were identified from a prospective database. Routine facial view photographs were converted to a standardized scale using iris diameter. The vertical distance from the midpoint of the midcanthal line to the inferior border of the eyebrow was measured bilaterally. A value of p < 0.05 was considered significant. RESULTS: Eighty-two patients were included, with a median age of 44 years (interquartile range, 33 to 59 years); 59 of the patients were women. The commonest cause was idiopathic (n = 55). The median time since onset of palsy was 13 months (interquartile range, 6.5 to 27 months). There was less midpoint of the midcanthal line to the inferior border of the eyebrow excursion on the synkinetic side of the face (p < 0.001). Twenty-two patients (27 percent) displayed paradoxical frontalis movement on the affected side of their face, with increased midpoint of the midcanthal line to the inferior border of the eyebrow distance (eyebrow raise) when attempting eye closure compared with eyebrow raise (n = 19), and tight eye closure compared with gentle eye closure (n = 3). CONCLUSIONS: This study highlights the phenomenon of paradoxical frontalis activation during eye closure. This is often underrecognized and may contribute to lagophthalmos. The authors found it to be present in 27 percent of patients with moderate or severe synkinesis. Further dynamic studies are required to understand the relationship among frontalis activity, eye closure, and the effects of its inhibition.

An objective assessment of botulinum toxin type A injection in the treatment of post-facial palsy synkinesis and hyperkinesis using the synkinesis assessment questionnaire.

This study aimed to provide reliable and valid evidence that botulinum toxin type A (BTX-A) is a successful treatment for facial synkinesis in facial palsy by using the synkinesis assessment questionnaire (SAQ) tool. Fifty-one patients completed questionnaires pre- and post-BTX-A treatment over 103 cycles of treatment. Each patient was individually assessed and then treated according to their presenting symptoms with a dosage in each injection site of between 0.5 and 5 U of BTX-A. A two-tailed paired samples t-test was used to compare the scores for each question before and after treatment. A significant difference was found between all scores before and after treatment at the level of p < 0.05. There was not only an improvement in the mean score in the post-treatment group but also a smaller spread of scores in the post-treatment group than in the pre-treatment group. The study showed that SAQ scores decreased significantly for every question on the SAQ after treatment. This indicates that BTX-A is an effective treatment for synkinesis, adding further weight to current evidence. The study also indicated that BTX-A continues to be effective even after three rounds of treatment, with a significant decrease in overall scores after each treatment cycle.