Maxillary and mandibular osteotomy - Revision history

Tony.Wang at 17:24, 7 January 2025

2025-01-07T17:24:22Z

← Older revision		Revision as of 10:24, 7 January 2025
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	* Standard IV induction: lidocaine (1.5 mg/kg), propofol (1-3 mg/kg), ± short acting opiate of choice (Fentanyl, Sufentanil, Alfentanil) and rocuronium (0.6mg/kg)		* Standard IV induction: lidocaine (1.5 mg/kg), propofol (1-3 mg/kg), ± short acting opiate of choice (Fentanyl, Sufentanil, Alfentanil) and rocuronium (0.6mg/kg)
			**Can consider methadone IV 0.15-0.2 mg/kg on induction for postoperative pain management

	* Nasal Intubation		* Nasal Intubation

Christopher.Deeble: added some details to introduction, patient evaluation, potential complications

2022-11-12T04:53:39Z

added some details to introduction, patient evaluation, potential complications

← Older revision		Revision as of 21:53, 11 November 2022
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	{{Infobox surgical procedure		{{Infobox surgical procedure
	\| anesthesia_type = General		\| anesthesia_type = General
	\| airway = Nasal ETT		\| airway = Nasal ETT (RAE or MLT)
	\| lines_access = PIV x2 (Large bore IV x1-2)		\| lines_access = PIV x2 (Large bore IV x1-2)
	± Arterial line		± Arterial line
Line 7:		Line 7:
	5-lead ECG		5-lead ECG
	Temperature		Temperature
	\| considerations_preoperative = Possible airway difficulty given the patient's midface and mandibular abnormalities		\| considerations_preoperative = Possible airway difficulty given the patient's midface and mandibular abnormalities (comorbidities such as OSA)
	\| considerations_intraoperative = Highly stimulating, painful surgery		\| considerations_intraoperative = Highly stimulating, painful surgery, bed 90-180, consider TIVA to help with PONV, controlled hypotension (to help minimize bleeding), minimize nausea and coughing during extubation
	~~Bed~~ 90-180
	\| considerations_postoperative = PONV		\| considerations_postoperative = PONV
	Pain		Monitor airway patency
	Surgical mouth closure with heavy elastic vs wires		Pain -- multimodal pain control, minimize IV opioids
			Surgical mouth closure with heavy elastic vs wires (consider having cutting device nearby if needing to urgently open mouth)
	}}		}}

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	=== Surgical Procedure ===		=== Surgical Procedure ===
	Both mandible and maxilla may be ‘advanced’, ‘set back,’ or rotated before being fixed into new positions according to the particular skeletal problem. Sagittal split of the mandible and horizontal Le Fort I osteotomy of the maxilla are the most frequently performed procedures. These may be combined with genioplasty, an osteotomy of the mandibular symphysis to improve the profile of the chin. The combination of mandibular and maxillary (‘bi-maxillary’) surgery, though more complex, allows the greatest possible degree of correction.<ref>{{Cite journal\|last=Mercuri\|first=L.G.\|date=2006\|title=Re: Dimitroulis, G. The role of surgery in the management of disorders of the temporomandibular joint: a critical review of the literature. Part 2. Int J Oral Maxillofac Surg 2005: 34: 231–237\|url=http://dx.doi.org/10.1016/j.ijom.2005.07.018\|journal=International Journal of Oral and Maxillofacial Surgery\|volume=35\|issue=3\|pages=284–286\|doi=10.1016/j.ijom.2005.07.018\|issn=0901-5027}}</ref><ref>{{Cite journal\|last=Beck\|first=James I.\|last2=Johnston\|first2=Kevin D.\|date=2014-02-01\|title=Anaesthesia for cosmetic and functional maxillofacial surgery\|url=https://www.sciencedirect.com/science/article/pii/S174318161730121X\|journal=Continuing Education in Anaesthesia Critical Care & Pain\|language=en\|volume=14\|issue=1\|pages=38–42\|doi=10.1093/bjaceaccp/mkt027\|issn=1743-1816}}</ref>		Both mandible and maxilla may be ‘advanced’, ‘set back,’ or rotated before being fixed into new positions according to the particular skeletal problem. Sagittal split of the mandible and horizontal Le Fort I osteotomy of the maxilla are the most frequently performed procedures. These may be combined with genioplasty, an osteotomy of the mandibular symphysis to improve the profile of the chin. The combination of mandibular and maxillary (‘bi-maxillary’) surgery, though more complex, allows the greatest possible degree of correction.<ref>{{Cite journal\|last=Mercuri\|first=L.G.\|date=2006\|title=Re: Dimitroulis, G. The role of surgery in the management of disorders of the temporomandibular joint: a critical review of the literature. Part 2. Int J Oral Maxillofac Surg 2005: 34: 231–237\|url=http://dx.doi.org/10.1016/j.ijom.2005.07.018\|journal=International Journal of Oral and Maxillofacial Surgery\|volume=35\|issue=3\|pages=284–286\|doi=10.1016/j.ijom.2005.07.018\|issn=0901-5027}}</ref><ref>{{Cite journal\|last=Beck\|first=James I.\|last2=Johnston\|first2=Kevin D.\|date=2014-02-01\|title=Anaesthesia for cosmetic and functional maxillofacial surgery\|url=https://www.sciencedirect.com/science/article/pii/S174318161730121X\|journal=Continuing Education in Anaesthesia Critical Care & Pain\|language=en\|volume=14\|issue=1\|pages=38–42\|doi=10.1093/bjaceaccp/mkt027\|issn=1743-1816}}</ref>

			=== Other Associated Pathologies ===
			20% of adult population affected by sleep-disordered breathing, with 7-8% with moderate-to-severe OSA. OSA correlated with obesity, metabolic syndrome, systemic and pulmonary hypertension, congestive heart failure, arrhythmias, heart attacks, stroke. STOP-BANG to screen for OSA.

			Other ENT pathology may be present in OSA patients (eg septal deviation, laryngotracheomalacia, tonsil and adenoid hypertrophy). OSA patient may show increased sensitivity to opioids and benzodiazepines.

			===== STOP-BANG: =====
			'''S'''nore loudly?

			'''T'''ired during the day?

			'''O'''bserved cessation of breathing during sleep?

			'''P'''ressure (high blood pressure)?

			'''B'''MI > 35 kg/m^2?

			'''A'''ge > 50 years?

			'''N'''eck circumference > 40 cm?

			'''G'''ender male?

			(yes to 0-2 low risk, yes to 3-4 intermediate risk, yes to 5-8 high risk)

	== Preoperative management ==		== Preoperative management ==
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	\|Airway		\|Airway
	\|Patients often have asymmetric/underdeveloped facies (midface, nasal patency, retrognathic jaw) and may also exhibit a small mouth opening and an inability to prognath their jaw		\|Patients often have asymmetric/underdeveloped facies (midface, nasal patency, retrognathic jaw) and may also exhibit a small mouth opening and an inability to prognath their jaw
			Check for predicators of difficult mask ventilation
	\|-		\|-
	\|Neurologic		\|Neurologic
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	\|-		\|-
	\|Cardiovascular		\|Cardiovascular
	\|		\|Check for cardiovascular comorbidities, such as systemic and pulmonary hypertension, CHF, cardiac arrhythmias, MI, stroke
	\|-		\|-
	\|Pulmonary		\|Pulmonary
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	\|-		\|-
	\|Gastrointestinal		\|Gastrointestinal
	\|		\|Higher incidence of GERD
	\|-		\|-
	\|Hematologic		\|Hematologic
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	* ± PT/PTT		* ± PT/PTT
	* ± T&C (depending on patient factors or greater than average expected blood loss from surgical team)		* ± T&C (depending on patient factors or greater than average expected blood loss from surgical team)
			*Further studies as indicated from H&P and comorbidities
			**If pulmonary issues, may need CXR, ABG, PFTs
			**If cardiac issues, may need ECG or ECHO

	=== Operating room setup<!-- Describe any unique aspects of operating room preparation. Avoid excessively granular information. Use drug classes instead of specific drugs when appropriate. If none, this section may be removed. --> ===		=== Operating room setup<!-- Describe any unique aspects of operating room preparation. Avoid excessively granular information. Use drug classes instead of specific drugs when appropriate. If none, this section may be removed. --> ===
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	* Tylenol PO 15mg/kg (Max: 1g)		* Tylenol PO 15mg/kg (Max: 1g)
	* ± Anxiolysis with midazolam (PO or IV) after considering patient preferences and factors		* ± Anxiolysis with midazolam (PO or IV) after considering patient preferences and factors
	* ~~Scopolamine~~ patch as needed		* Aprepitant or scopolamine patch as needed
	* Consider antisialagogue dose of glycopyrrolate prior to induction		* Consider antisialagogue dose of glycopyrrolate prior to induction
	** Adult		** Adult
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	=== Maintenance and surgical considerations<!-- Describe the important considerations and general approach to the maintenance of anesthesia, including potential complications. Be sure to include any steps to the surgical procedure that have anesthetic implications. --> ===		=== Maintenance and surgical considerations<!-- Describe the important considerations and general approach to the maintenance of anesthesia, including potential complications. Be sure to include any steps to the surgical procedure that have anesthetic implications. --> ===

	* Maintain anesthetic depth with volatile anesthetic ± IV infusions		* Check ETT to make sure no pressure on nasal ala
			*Maintain anesthetic depth with volatile anesthetic ± IV infusions
	** Example setup:		** Example setup:
	*** Sevoflurane (MAC of ~ 0.5)		*** Sevoflurane (MAC of ~ 0.5)
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	* Airway difficulties/emergencies due to swelling or inability to handle secretions/bleeding		* Airway difficulties/emergencies due to swelling or inability to handle secretions/bleeding
	** Have closure removal devices at bedside at all time		** Have closure removal devices at bedside at all time
			*Hypertension, and risk of associated bleeding
			*Damage to ETT during surgery

	== Procedure variants<!-- This section should only be used for cases with multiple approaches (e.g. Laparoscopic vs. open appendectomy). Otherwise, remove this section. Use this table to very briefly compare and contrast various aspects between approaches. Add or remove rows as needed to maximize relevance. Consider using symbols rather than words when possible (e.g. +, –, additional symbols such as ↑ and ↓ are available using the "Ω" tool in the editor). --> ==		== Procedure variants<!-- This section should only be used for cases with multiple approaches (e.g. Laparoscopic vs. open appendectomy). Otherwise, remove this section. Use this table to very briefly compare and contrast various aspects between approaches. Add or remove rows as needed to maximize relevance. Consider using symbols rather than words when possible (e.g. +, –, additional symbols such as ↑ and ↓ are available using the "Ω" tool in the editor). --> ==

CFitzgerald: additional hypotensive strategies

2022-07-28T21:35:01Z

additional hypotensive strategies

← Older revision		Revision as of 14:35, 28 July 2022
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	** Pediatric		** Pediatric
	*** PO Dose: 2+ yo: 0.04-0.1 mg/kg PO; Parenteral Dose, 2+ yo: 0.0004-0.01 mg/kg SC/IM/IV (Max: 0.1-0.2 mg/dose, 0.8 mg/day)		*** PO Dose: 2+ yo: 0.04-0.1 mg/kg PO; Parenteral Dose, 2+ yo: 0.0004-0.01 mg/kg SC/IM/IV (Max: 0.1-0.2 mg/dose, 0.8 mg/day)



	=== Regional and neuraxial techniques<!-- Describe any potential regional and/or neuraxial techniques which may be used for this case. If none, this section may be removed. --> ===		=== Regional and neuraxial techniques<!-- Describe any potential regional and/or neuraxial techniques which may be used for this case. If none, this section may be removed. --> ===

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	* Consider higher volume hydration (if tolerated) to prevent PONV		* Consider higher volume hydration (if tolerated) to prevent PONV
	* Discuss with surgical team need for and timing of deliberate hypotension for otherwise healthy young adults to minimize surgical blood loss and need for transfusion<ref>{{Cite journal\|last=Shepherd\|first=Jonathan\|date=2004\|title=Hypotensive anaesthesia and blood loss in orthognathic surgery\|url=http://dx.doi.org/10.1038/sj.ebd.6400238\|journal=Evidence-Based Dentistry\|volume=5\|issue=1\|pages=16–16\|doi=10.1038/sj.ebd.6400238\|issn=1462-0049}}</ref>		* Discuss with surgical team need for and timing of deliberate hypotension for otherwise healthy young adults to minimize surgical blood loss and need for transfusion<ref>{{Cite journal\|last=Shepherd\|first=Jonathan\|date=2004\|title=Hypotensive anaesthesia and blood loss in orthognathic surgery\|url=http://dx.doi.org/10.1038/sj.ebd.6400238\|journal=Evidence-Based Dentistry\|volume=5\|issue=1\|pages=16–16\|doi=10.1038/sj.ebd.6400238\|issn=1462-0049}}</ref>
			**if not controlled with a similar IV anesthetic plan as above you may consider other hypotensive agents for as needed example agent listed below:
			***Sodium Nitroprusside or SNP (Infusion), Glyceryl trinitrate or GTN (Infusion), Clonidine (Infusion or bolus), β-blockers (Infusion or bolus), Magnesium (Bolus)
	* Redose Acetaminophen as able		* Redose Acetaminophen as able
	* Be vigilant for bradycardia (mediated through the trigeminovagal reflex) throughout the procedure, especially when making the maxillary osteotomies and during the use of mandibular retractors subperiosteally during a mandibular osteotomy as some cases of severe bradycardia and asystole have been documented.<ref>{{Cite journal\|last=Lang\|first=Scott\|last2=Lanigan\|first2=Dennis T.\|last3=van der Wal\|first3=Mike\|date=1991-09-01\|title=Trigeminocardiac reflexes: maxillary and mandibular variants of the oculocardiac reflex\|url=https://doi.org/10.1007/BF03008454\|journal=Canadian Journal of Anaesthesia\|language=en\|volume=38\|issue=6\|pages=757\|doi=10.1007/BF03008454\|issn=1496-8975}}</ref><ref>{{Cite journal\|last=Campbell\|first=R.\|last2=Rodrigo\|first2=D.\|last3=Cheung\|first3=L.\|date=1994\|title=Asystole and bradycardia during maxillofacial surgery.\|url=https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2148710/\|journal=Anesthesia Progress\|volume=41\|issue=1\|pages=13–16\|issn=0003-3006\|pmc=2148710\|pmid=8629742}}</ref>		* Be vigilant for bradycardia (mediated through the trigeminovagal reflex) throughout the procedure, especially when making the maxillary osteotomies and during the use of mandibular retractors subperiosteally during a mandibular osteotomy as some cases of severe bradycardia and asystole have been documented.<ref>{{Cite journal\|last=Lang\|first=Scott\|last2=Lanigan\|first2=Dennis T.\|last3=van der Wal\|first3=Mike\|date=1991-09-01\|title=Trigeminocardiac reflexes: maxillary and mandibular variants of the oculocardiac reflex\|url=https://doi.org/10.1007/BF03008454\|journal=Canadian Journal of Anaesthesia\|language=en\|volume=38\|issue=6\|pages=757\|doi=10.1007/BF03008454\|issn=1496-8975}}</ref><ref>{{Cite journal\|last=Campbell\|first=R.\|last2=Rodrigo\|first2=D.\|last3=Cheung\|first3=L.\|date=1994\|title=Asystole and bradycardia during maxillofacial surgery.\|url=https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2148710/\|journal=Anesthesia Progress\|volume=41\|issue=1\|pages=13–16\|issn=0003-3006\|pmc=2148710\|pmid=8629742}}</ref>

CFitzgerald: consistency in max dose labeling

2022-07-28T21:28:34Z

consistency in max dose labeling

← Older revision		Revision as of 14:28, 28 July 2022
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	* Pretreatment of both nares with Oxymetazoline (Afrin)		* Pretreatment of both nares with Oxymetazoline (Afrin)
	* Tylenol PO 15mg/kg (Max of 1g)		* Tylenol PO 15mg/kg (Max: 1g)
	* ± Anxiolysis with midazolam (PO or IV) after considering patient preferences and factors		* ± Anxiolysis with midazolam (PO or IV) after considering patient preferences and factors
	* Scopolamine patch as needed		* Scopolamine patch as needed
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	=== Emergence<!-- List and/or describe any important considerations related to the emergence from anesthesia for this case. --> ===		=== Emergence<!-- List and/or describe any important considerations related to the emergence from anesthesia for this case. --> ===

	* Toradol 0.5 mg/kg, ~~max~~ 30 mg		* Toradol 0.5 mg/kg, Max: 30 mg
	* Zofran		* Zofran
	* Reversal with sugammadex		* Reversal with sugammadex

CFitzgerald: inital page draft

2022-07-28T21:27:04Z

inital page draft

New page

{{Infobox surgical procedure
| anesthesia_type = General
| airway = Nasal ETT
| lines_access = PIV x2 (Large bore IV x1-2)
± Arterial line
| monitors = Standard
5-lead ECG
Temperature
| considerations_preoperative = Possible airway difficulty given the patient's midface and mandibular abnormalities
| considerations_intraoperative = Highly stimulating, painful surgery
Bed 90-180
| considerations_postoperative = PONV
Pain
Surgical mouth closure with heavy elastic vs wires
}}

== Overview ==

=== Indications ===
Class II-III malocclusion is one of the most common reasons for performing a maxillary and mandibular osteotomies. Severe malocclusion is typically caused by maxillary hypoplasia and is commonly found in patients with orofacial clefts, obstructive sleep apnea (OSA), and maxillary atrophy. Maxillary surgery is required in up to 25% of cleft lip and palate patients.<ref>{{Cite journal|last=Buchanan|first=Edward P.|last2=Hyman|first2=Charles H.|date=2013|title=LeFort I Osteotomy|url=https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3805729/|journal=Seminars in Plastic Surgery|volume=27|issue=3|pages=149–154|doi=10.1055/s-0033-1357112|issn=1535-2188|pmc=3805729|pmid=24872761}}</ref><ref>{{Cite journal|last=Scolozzi|first=Paolo|date=2008|title=Distraction Osteogenesis in the Management of Severe Maxillary Hypoplasia in Cleft Lip and Palate Patients|url=http://dx.doi.org/10.1097/scs.0b013e318184365d|journal=Journal of Craniofacial Surgery|volume=19|issue=5|pages=1199–1214|doi=10.1097/scs.0b013e318184365d|issn=1049-2275}}</ref>

=== Surgical Procedure ===
Both mandible and maxilla may be ‘advanced’, ‘set back,’ or rotated before being fixed into new positions according to the particular skeletal problem. Sagittal split of the mandible and horizontal Le Fort I osteotomy of the maxilla are the most frequently performed procedures. These may be combined with genioplasty, an osteotomy of the mandibular symphysis to improve the profile of the chin. The combination of mandibular and maxillary (‘bi-maxillary’) surgery, though more complex, allows the greatest possible degree of correction.<ref>{{Cite journal|last=Mercuri|first=L.G.|date=2006|title=Re: Dimitroulis, G. The role of surgery in the management of disorders of the temporomandibular joint: a critical review of the literature. Part 2. Int J Oral Maxillofac Surg 2005: 34: 231–237|url=http://dx.doi.org/10.1016/j.ijom.2005.07.018|journal=International Journal of Oral and Maxillofacial Surgery|volume=35|issue=3|pages=284–286|doi=10.1016/j.ijom.2005.07.018|issn=0901-5027}}</ref><ref>{{Cite journal|last=Beck|first=James I.|last2=Johnston|first2=Kevin D.|date=2014-02-01|title=Anaesthesia for cosmetic and functional maxillofacial surgery|url=https://www.sciencedirect.com/science/article/pii/S174318161730121X|journal=Continuing Education in Anaesthesia Critical Care & Pain|language=en|volume=14|issue=1|pages=38–42|doi=10.1093/bjaceaccp/mkt027|issn=1743-1816}}</ref>

== Preoperative management ==

=== Patient evaluation ===
{| class="wikitable"
|+
!System
!Considerations
|-
|Airway
|Patients often have asymmetric/underdeveloped facies (midface, nasal patency, retrognathic jaw) and may also exhibit a small mouth opening and an inability to prognath their jaw
|-
|Neurologic
|
|-
|Cardiovascular
|
|-
|Pulmonary
|
|-
|Gastrointestinal
|
|-
|Hematologic
|
|-
|Renal
|
|-
|Endocrine
|
|-
|Other
|
|}

=== Labs and studies ===

* CBC, T&S with blood type verification
* ± PT/PTT
* ± T&C (depending on patient factors or greater than average expected blood loss from surgical team)

=== Operating room setup ===

* Airway
** Nasal ETT
** Accordion and/or straight connector
** ± Nasal trumpet
** ± Fiberscope or VL device
* Bolus line ± fluid warmer connected to largest PIV
* Lower body forced-air warmer
* 2 infusion channels and 2 syringe pumps on a manifold
* Maintenance/Carrier line with flushed octopus connecter

=== Patient preparation and premedication ===

* Pretreatment of both nares with Oxymetazoline (Afrin)
* Tylenol PO 15mg/kg (Max of 1g)
* ± Anxiolysis with midazolam (PO or IV) after considering patient preferences and factors
* Scopolamine patch as needed
* Consider antisialagogue dose of glycopyrrolate prior to induction
** Adult
*** PO Dose: 1-2 mg PO; Parenteral Dose: 0.1-0.2 mg SC/IM/IV (Max: 1-2 mg/dose, 8mg/day)
** Pediatric
*** PO Dose: 2+ yo: 0.04-0.1 mg/kg PO; Parenteral Dose, 2+ yo: 0.0004-0.01 mg/kg SC/IM/IV (Max: 0.1-0.2 mg/dose, 0.8 mg/day)

=== Regional and neuraxial techniques ===

* Mandibular and maxillary nerve blocks performed by the surgeons can be utilized to aid postoperative pain relief

== Intraoperative management ==

=== Monitoring and access ===

* Standard ASA monitors
** Core temperature monitoring likely only available via bladder or rectal given oral or nasal probes are likely to interfere with surgical exposure
* PIV x2 , at least 1 large-bore PIV for resuscitation
* ± Arterial line as needed based on patient-specific factors
* ± BIS, PSI, or raw EEG monitoring

=== Induction and airway management ===

* Standard IV induction: lidocaine (1.5 mg/kg), propofol (1-3 mg/kg), ± short acting opiate of choice (Fentanyl, Sufentanil, Alfentanil) and rocuronium (0.6mg/kg)

* Nasal Intubation
** Consider fiberscopic placement vs DL or VL ± oral manipulation with MaGill forceps
** Consider dilation with lubricated nasal trumpet (one-size greater than the desired ETT) - this will additionally aid in confirming which nare is most likely to easily accommodate the ETT and allow for change in ETT sizing prior to intubation attempt if there is difficulty
** Airway typically secured by surgical team with suture before wrapping the patient's head

* Dexamethasone 4-10mg, typically at least (0.1mg/kg with Max: 10mg for post operative pain/swelling)
* ± Tranexamic Acid (TXA) bolus, typically 1 gram or 30mg/kg over 10-15 minutes
* Ancef, weight-based dosing

=== Positioning ===

* Supine with neck extended, on foam donut
* Careful eye protection and padding
* One or two arms tucked
* Table is usually turned 90-180 degrees

=== Maintenance and surgical considerations ===

* Maintain anesthetic depth with volatile anesthetic ± IV infusions
** Example setup:
*** Sevoflurane (MAC of ~ 0.5)
*** Dexmedetomidine (0.2-0.4 mcg/kg/min)
*** Short-acting opiate (eg. Sufentanil/Alfentanil) or Ultra-short-acting opiate (Remifentanil)
*** ± Tranexamic Acid (TXA)
*** ± Phenylephrine
*** ± Background propofol for PONV

* Consider higher volume hydration (if tolerated) to prevent PONV
* Discuss with surgical team need for and timing of deliberate hypotension for otherwise healthy young adults to minimize surgical blood loss and need for transfusion<ref>{{Cite journal|last=Shepherd|first=Jonathan|date=2004|title=Hypotensive anaesthesia and blood loss in orthognathic surgery|url=http://dx.doi.org/10.1038/sj.ebd.6400238|journal=Evidence-Based Dentistry|volume=5|issue=1|pages=16–16|doi=10.1038/sj.ebd.6400238|issn=1462-0049}}</ref>
* Redose Acetaminophen as able
* Be vigilant for bradycardia (mediated through the trigeminovagal reflex) throughout the procedure, especially when making the maxillary osteotomies and during the use of mandibular retractors subperiosteally during a mandibular osteotomy as some cases of severe bradycardia and asystole have been documented.<ref>{{Cite journal|last=Lang|first=Scott|last2=Lanigan|first2=Dennis T.|last3=van der Wal|first3=Mike|date=1991-09-01|title=Trigeminocardiac reflexes: maxillary and mandibular variants of the oculocardiac reflex|url=https://doi.org/10.1007/BF03008454|journal=Canadian Journal of Anaesthesia|language=en|volume=38|issue=6|pages=757|doi=10.1007/BF03008454|issn=1496-8975}}</ref><ref>{{Cite journal|last=Campbell|first=R.|last2=Rodrigo|first2=D.|last3=Cheung|first3=L.|date=1994|title=Asystole and bradycardia during maxillofacial surgery.|url=https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2148710/|journal=Anesthesia Progress|volume=41|issue=1|pages=13–16|issn=0003-3006|pmc=2148710|pmid=8629742}}</ref>

=== Emergence ===

* Toradol 0.5 mg/kg, max 30 mg
* Zofran
* Reversal with sugammadex
* Ensure removal of all throat packing
* OGT for gastric decompression/removal of surgical bleeding
* Extubate awake and following commands (swallowing in particular)
* Head up or reverse trendelenburg positioning
* Do not suction in the mouth after OGT has been removed
** Consider instead using a soft suction catheter through contralateral nare

* Expect significant postoperative facial swelling
* Removal of the nasal ETT after Le Fort I osteotomy should be done gently because the sectioned nasal septum may easily be displaced

== Postoperative management ==

=== Disposition ===

* PACU -> observation/overnight admission

=== Pain management ===

* Tylenol q6h (liquid PO), NSAID (liquid PO), and IV narcotics all used in perioperative setting, continued after discharge
** Some patients may be excellent candidates for PCAs post-PACU discharge as nursing ratios change and may be recommended for if their pain is particularly difficult to control

* Maxillofacial surgeons typically advise patients to prepare for a prolonged, painful recovery (~six-weeks off) with additional jaw-healing takings up to 2-3 months

=== Potential complications ===

* The reported incidence of PONV after orthognathic surgery varies from 7<ref>{{Cite journal|last=Ichinohe|first=Tatsuya|last2=Kaneko|first2=Yuzuru|date=2007|title=Nitrous Oxide Does Not Aggravate Postoperative Emesis After Orthognathic Surgery in Female and Nonsmoking Patients|url=http://dx.doi.org/10.1016/j.joms.2006.06.283|journal=Journal of Oral and Maxillofacial Surgery|volume=65|issue=5|pages=936–939|doi=10.1016/j.joms.2006.06.283|issn=0278-2391}}</ref> to 40%<ref>{{Cite journal|last=Silva|first=Alessandro C.|last2=O’Ryan|first2=Felice|last3=Poor|first3=David B.|date=2006|title=Postoperative Nausea and Vomiting (PONV) After Orthognathic Surgery: A Retrospective Study and Literature Review|url=http://dx.doi.org/10.1016/j.joms.2006.05.024|journal=Journal of Oral and Maxillofacial Surgery|volume=64|issue=9|pages=1385–1397|doi=10.1016/j.joms.2006.05.024|issn=0278-2391}}</ref>, with steroid prophylaxis and up to 83%<ref>{{Cite journal|last=Piper|first=Swen N.|last2=Röhm|first2=Kerstin|last3=Boldt|first3=Joachim|last4=Kranke|first4=Peter|last5=Maleck|first5=Wolfgang|last6=Seifert|first6=Rudolf|last7=Suttner|first7=Stefan|date=2008|title=Postoperative nausea and vomiting after surgery for prognathism: Not only a question of patients' comfort. A placebo-controlled comparison of dolasetron and droperidol|url=http://dx.doi.org/10.1016/j.jcms.2007.07.011|journal=Journal of Cranio-Maxillofacial Surgery|volume=36|issue=3|pages=173–179|doi=10.1016/j.jcms.2007.07.011|issn=1010-5182}}</ref> with no antiemetic prophylaxis
* Airway difficulties/emergencies due to swelling or inability to handle secretions/bleeding
** Have closure removal devices at bedside at all time

== Procedure variants ==

{| class="wikitable wikitable-horizontal-scroll"
|+
!
!Variant 1
!Variant 2
|-
|Unique considerations
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|Position
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|Surgical time
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|EBL
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|Postoperative disposition
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|Pain management
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|Potential complications
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|}

== References ==

[[Category:Surgical procedures]]
[[Category:Orthognathic surgery]]
[[Category:Maxillofacial surgery]]