College of Physicians and Surgeons of British Columbia300–669 Howe Street Vancouver BC V6C 0B4 www.cpsbc.ca

Telephone: 604-733-7758 Toll Free: 1-800-461-3008 (in BC) Fax: 604-733-3503

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NON-HOSPITAL MEDICAL AND SURGICAL FACILITIES ACCREDITATION PROGRAM

Appropriate Procedures ListPLASTIC SURGERY

Physician name: CPSID:

Facility applying to:

Please indicate only the procedures you wish to perform at the above-mentioned facility.

Skin grafts – split thickness or full thickness

FaceBiopsyBlephroplasty – upper and/or lowerBrowliftChin augmentationCleft lip – bilateral completeDebridement – jointDrainage/aspirationExcision – scarExcision – tumour, cyst, soft tissue massFaceliftIrrigation and debridementMalar augmentationMandibular osteotomy – internal fixation – bilateralMaxillary fracture zygomatic – arch – open reduction and wiringMaxillary fracture zygomatic – reductionNasal fracture – wire plate fixation – open reductionNeck liftOrbital floor open reductionOsteotomies, mandibular maxillofacial – bilateralOtoplastyPtosis repairRemoval forehead wrinklesRepair lacerationsRhinoplastyScalp liftScar revisionSuction lipectomy*

AbdomenAbdominal panniculectomyAbdominoplastyBiopsyDrainage/aspirationExcision – tumour, cyst, soft tissue massIrrigation and debridementLipectomyScar revisionSuction lipectomy*

Upper extremitiesBiopsyBrachioplastyDrainage/aspirationExcision – tumour, cyst, soft tissue massIrrigation and debridementSuction lipectomy*Tenolysis

BreastBreast augmentationCapsulectomy/capsulotomyDrainage/aspirationExcision – tumour, cyst, soft tissue massExcision gynecomastiaInsertion tissue expandersIrrigation and debridementMastopexyNipple areolar reconstruction and/or tattooingReduction mammoplastyScar revisionSuction lipectomy*

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College of Physicians and Surgeons of British ColumbiaAppropriate Procedures List – Plastic Surgery

Physician name: CPSID: Facility applying to:

Please indicate only the procedures you wish to perform at the above-mentioned facility.

Gender affirmation surgeryChest construction — removal of breast tissue with or without contouringBreast construction — breast augmentation

Groin, buttock and lower extremitiesBiopsyButtock liftDrainage/aspirationExcision – tumour, cyst, soft tissue massHymenoplastyIrrigation and debridementLabiaplastyLaser vaginal resurfacingScar revisionSuction lipectomy*Thigh lift

Hand and wristAmputation – finger(s), transmetacarpalArthrodesisArthroplasty – finger jointArthroscopyArthrotomy – MP/PIP/DIP jointsBiopsyBone grafting – metacarpal/phalanxClosed reductionDebridement – jointExcision – tumour, cyst, soft tissue massExternal fixationGanglia excisionHand and wrist – internal fixation device – removalImplant arthroplasty – metatarsal phalangeal jointIrrigation and debridementLigament reconstructionManipulation

Median nerve release (endoscopic or open)Needle aponeurotomy – hand deformityNerve blockNerve repairNeurolysisORIF – carpal bone, scaphoid, carpus, phalangeal fractureOsteotomyPalmar fasciectomyRemoval loose bodyScapholunate reconstructionTendon releaseTendon repairTendon transferTenolysisTenoplastyTenosynovectomyTriangular fibrocartilage complex (TFDD) repair

SkinBiopsyDermabrasionDrainage/aspirationExcision – tumour, cyst, soft tissue massIrrigation and debridementScar revision

TendonOpen tendon lengtheningRepair and reconstructionSoft tissue release – muscle or tendonTendon repairTendon transfer/transplant

*Total aspirate should not exceed 5000 ml.

I hereby certify that the procedures selected in this application are within the scope of my current practice.

Physician signature: Date: