PATIENT NAME: _________________________________________________ DOB: _________________ DOS: _________________
INCISION& APPROACH
□INTER□ INTRA □ INFRA □ Trans - Columellar
□ Transfixion – Unilateral □Transfixion – Bilateral □ Killian
Approach: □Closed □ Open □ Closed/Open
□Retrograde □Trans – Cartilaginous □ Delivery
NASAL TIP
□ UNTOUCHED
Incision:
Cephalic Resection:
□ Retrograde □ Trans – Cartilage □ Delivery □ Open
Delivery:
□ Cephalic Resection □Incision □Lateral Seg. Excision □Domal Excision
Sutures:□Intradomal□Transdomal□Creation □ Other:______________
Tip Graft: □Peck □Juri□Other:__________________________________
Sheen Graft:
□Type I – Crushed □Type II – Bruised □Type III- Solid □Type IV – Backstop
Open Structure:
□Suture □Graft □Domal Excision □Other: _______________________
Comment:
□ UNTOUCHED
Dorsum: □Untouched □Lowered □Augmented □ Smoothed Other:
Redix: □Reduction – Rasp □Reduction – Osteotome□ Augmented – Single Graft
□Augmented – Multiple Graft □Other: ______________________
Bone: □ Rasp□Osteotome□Other:______________________
Cartilage: □ Lowered□Augmented □Shortened □Spreader
□Other: ________________________________________
OSTEOTOMIES □ UNTOUCHED
DORSUM
Lateral :
None
Low-High
Low-Low
Double Level
Transverse
None
Digital
Osteotome
Medial
None
Medial
Medial Oblique
Continuous
Movement
Greenstick
Complete
Right Left
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Dr. Kevin Sadati · 359 San Miguel Drive, Suite 110 Newport Beach, CA 92660 · (949) 706-7776 · Fax (949) 200-3810
□ UNTOUCHED
Nostril Sill: □Right □Left
Alar Wedge Right: □Type I □Type II □Type III □Combined
Alar Wedge Left: □Type I □Type II □Type III □ Combined
Caudal Septum/ANS: □Untouched □Rotation □Shorten □Augment
□Upper ½ □Lower ½ □ ANS Resected □ ANS Contoured □ Footplates
ALAR BASE
Comments:
□NONE
Source: □Septum □Conchai□ Excision □Rib □Alloplast
Tip Graft: □None Peck □Sheen □Open Structure
Alar Graft: □None □Onlay□Spreader □Extender
Spreader Graft: □None □Bilateral □Uni Right □Uni Left □Asymmetric
Dorsal Graft: □None□ Inlay□Onlay□Single Layer □Double Layer
Columellar Graft: □None □Crural Strut □ O-M Graft □Structural Support □Col-labial Contour Pomp
Radix Graft: □None □Single □Multiple □Other:__________________
Other Grafts: □None □A/V/U Graft □Lateral Wall □Other:____________
GRAFT
Comment:
□NONE
INTRA NASAL SURGERY
Septoplasty: ______________________________________________________
□Mucosa □Bone
Turbinate Left: □Mucosa □Bone
Turbinate Right:
Comment:
OTHER SURGERY:
□NONE
Chin: _____________________________________________________
Eyelids: ___________________________________________________
Face: _____________________________________________________
Malar: ____________________________________________________
Comment:
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Dr. Kevin Sadati · 359 San Miguel Drive, Suite 110 Newport Beach, CA 92660 · (949) 706-7776 · Fax (949) 200-3810