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CHAPTER 10  Nasal Airway Considerations in the Evaluation and Treatment of Dentofacial Deformities
• Figure 10-6  Individuals born with cleft lips and palates who have undergone primary repair and secondary reconstruction may
present with constrictions of both the internal and external nasal valves. This may be worse as a result of the surgical maneuvers
that were previously carried out. Two children with bilateral cleft lip and palate and one with unilateral cleft lip and palate are shown
to demonstrate this point. Nasal soft-tissue procedures—including “columella lengthening” in the cases of the bilateral cleft lips and
palates and the overzealous resectioning of nasal soft tissues in the case of the unilateral cleft lip and palate—were performed. In all
three cases, the nasal valves are constricted (i.e., there is airway obstruction), and the aesthetics are suboptimal.
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• Figure 10-7  A and B, A teenage girl with unilateral cleft lip and palate shows multiple
causes of nasal obstruction. These include—as shown in C and D—septal deviations,
inferior turbinate hypertrophy, nasal aperture narrowing, and nasal floor deformities, includ­
ing a residual unrepaired alveolar cleft.
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SECTION 1  Basic Principles and Concepts
• Figure 10-8  A and B, A teenager with a maxillary deficiency and a relative mandibular excess
growth pattern. C and D, The physical findings of septal deviations, inferior turbinate hypertrophy, and
a narrow (tight) nasal aperture are consistent with the patient’s history of nasal airway obstruction.
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CHAPTER 10  Nasal Airway Considerations in the Evaluation and Treatment of Dentofacial Deformities
• Figure 10-9  Illustrations and intraoperative view of a deformed nasal septum seen through a Le Fort I down-fracture. This is a demonstration
of the technique used to carry out the submucous resection of septal bone and cartilage. When indicated on the basis of the patient’s history and
clinical examination, attention is turned to the removal of the deviated portions of the septum of the nose. A, With an elevator, the submucosal
dissection of the cartilaginous (quadrangular cartilage) and bony (vomer and perpendicular plate of ethmoid) septum is carried out. B, The deviated
and thickened aspects of the cartilaginous and bony septum are resected with a rongeur. The more anterior components of the cartilaginous
septum that provide needed support to the nasal dorsum and tip are not disturbed. This includes at least 1 cm of the dorsal and caudal cartilage.
C, An intraoperative view through a Le Fort down-fracture shows a deviated septum.
A
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Deviated septum
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SECTION 1  Basic Principles and Concepts
• Figure 10-10  Illustrations and intraoperative view of inferior turbinates seen through a Le Fort I down-fracture. This is a dem­
onstration of the technique used to carry out a partial turbinate reduction. A, An incision parallel and just below each inferior
turbinates is completed through the nasal mucosa. B, The elevated nasal mucosa flaps expose the enlarged inferior turbinate.
C, The resection of the inferior aspect of the hypertrophic inferior turbinate is completed with the use of a straight (Mayo) scissors.
D, An intraoperative view of the elevated nasal flaps. The endotracheal tube is also visualized. E, After the partial resection of
each inferior turbinate, the raw surfaces are cauterized. F, The nasal mucosa flaps are then closed with interrupted resorbable
sutures.
A
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Inferior turbinates
Endotracheal tube
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CHAPTER 10  Nasal Airway Considerations in the Evaluation and Treatment of Dentofacial Deformities
turbinates (e.g., hypertrophy/enlargement), a full 20% of
their study subjects experienced a worsening of their nasal
airway function after surgery.113a
Unfortunately, in the individual with a dentofacial defor­
mity, a methodic approach to the evaluation and manage­
ment of chronic nasal airway obstruction at the time of
orthognathic surgery is often not undertaken. We suggest
that any upper airway obstructions be assessed by the
orthognathic surgeon with the same vigor as the effects of
the presenting jaw deformities on malocclusion are evalu­
ated (Figs. 10-12 and 10-13).51,83-85,87
The Effects of Respiratory Pattern and
Jaw Posture on Maxillofacial Growth
The link between an open mouth or oral breathing pattern
and maxillofacial growth has been documented in the lit­
erature.4,5,11,17,24,25,28,31,41,43,45-48,59-66,96,97,105,106,109,110 There has
been both animal experimental and human clinical research
to support a link between oral respiration, open mouth
posture, and the development of maxillomandibular dishar­
monies. With the use of rhesus monkeys as an experimental
model, Harvold and colleagues completely blocked the
nares of newborn monkeys.45-48 The researchers observed
consistent facial morphologic changes that gradually
occurred with growth in the presence of a constant open
mouth and tongue protrusive mandibular posture. The
research of this group documented that a constantly open
mouth (i.e., clockwise rotation of the mandible) in a
growing rhesus monkey was followed by the vertical length­
ening of the maxilla. The mandibular inferior border then
gradually steepens, with a resulting obtuse gonial angle.
Through years of primate laboratory research, Harvold and
coworkers confirmed that there are significant correlations
between alterations in respiratory patterns (i.e., forced
mouth breathing), mandibular (open mouth) posture,
tongue protrusion, and characteristic maxillomandibular
dysmorphic growth (i.e., long face growth pattern).45-48
In human children who have significant nasal obstruc­
tion and a resulting open mouth posture, clinical observa­
tional studies document a similar downward and backward
rotation of the mandible with hypereruption of the
maxillary dentition.59-65 Over several years, the affected
children develop what we now recognize as a long face
growth pattern. This is documented as a vertically long
and horizontally retrusive maxillomandibular complex.
The term adenoid facies was coined to describe the child
who presents with a long, narrow, flat face; protruding
teeth; and lips that are widely separated at rest. These
features are often accompanied by an anterior open-bite
malocclusion and lip strain when attempting mouth closure.
To better understand the concept, Linder-Aronson and
Woodside completed a study in which they analyzed the
faces of children with chronic nasal obstruction who were
scheduled to undergo tonsillectomies and adenoidectomies
at a pediatric hospital in Stockholm, Sweden.63 They
• Figure 10-11  Illustration and intraoperative views of the nasal rims
and floor seen through a Le Fort I down-fracture to demonstrate the
techniques of rim, nasal floor, and anterior nasal spine recontouring
with the use of a bur on a rotary drill. A, Illustration of recontouring
with rotary drill. B and C, Intraoperative views before and after recon­
touring, respectively.
A
B
C

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SECTION 1  Basic Principles and Concepts
documented a tendency toward a long lower anterior facial
height in this group of children. Interestingly, they found
that, after the adenoids were removed and with enough
time, there was at least some improvement in the children’s
facial morphology. Unfortunately, the structure of these
long faces did not return to normal. With or without ade­
noidectomy being carried out during childhood, many of
these children reach adolescence with persistent nasal airway
obstruction in combination with significant jaw dysmor­
phology and malocclusion (i.e., the long face growth
pattern). It is our recommendation that, by adolescence, all
aspects (i.e., airway obstruction, skeletal dysmorphology,
and malocclusion) be simultaneously addressed to improve
function in the head and neck (e.g., breathing, swallowing,
speech, chewing, lip closure) and to enhance facial
aesthetics.83-85
Simultaneous Management of Chronic
Obstructed Nasal Breathing and the
Presenting Dentofacial Deformity
Posnick and colleagues conducted a clinical study with
the use of the Nasal Obstruction Symptom Evaluation
(NOSE) survey questionnaire to prospectively assess a
consecutive series of patients (N = 43) who reported
both chronic nasal obstruction and the presence of a
significant dentofacial deformity with malocclusion that
involved at least the maxilla.83 The NOSE questionnaire
is considered to be a useful marker of symptomatic
nasal airway obstruction.42,98-101 Each study subject
was documented to have septal deviation and inferior
turbinate enlargement that were consistent with airway
symptoms. Any presenting physical findings of a tight
nasal inlet or an elevated nasal floor were not specifically
studied but were clinically addressed in each patient,
when indicated. Each study patient simultaneously under­
went septoplasty, the reduction of the inferior turbinates,
and the surgical correction of the presenting jaw deformity
that included, at minimum, a Le Fort I osteotomy. Septo­
plasty and inferior turbinate reduction were performed
at the time of Le Fort I osteotomy through exposure pro­
vided by the down-fracture. The consecutive series of
patients (N = 43) who met the inclusion criteria were given
the NOSE survey questionnaire before they underwent
surgery. The NOSE questionnaire was completed in each
patient 3 months after surgery and again at least 6 months
after surgery.
The study group included 16 males and 27 females with
a mean age of 25 years (range, 15 to 55 years). All patients
were treated with a comprehensive orthodontic and orthog­
nathic surgical approach that included a Le Fort I osteot­
omy as part of the surgical correction. The most frequent
pattern of jaw deformity identified in the study group was
a long face growth pattern (i.e., maxillary vertical excess
with Class II malocclusion), which was seen in 17 out of
43 patients (40%). Simultaneous maxillofacial procedures
completed in addition to the Le Fort I osteotomy,
septoplasty, and inferior turbinate reduction varied. Twenty-
nine of the 43 patients (67%) underwent segmentation of
the maxilla to widen the arch width or to correct the curve
of Spee. Forty-two of the patients (98%) underwent simul­
taneous sagittal split ramus osteotomies, 16 (37%) under­
went the simultaneous removal of the third molars, and 7
(16%) also underwent suction-assisted lipectomy of the
neck. Thirty-seven patients (86%) underwent oblique
osteotomy of the chin with reshaping (i.e., osseous
genioplasty).
The mean weighted NOSE score before surgery was
63.7. At the 3-month postoperative interval, the mean
NOSE score had dropped to 6.9. On the basis of the non-
parametric Wilcoxon signed-rank test, this is a significant
finding (P < .001). The mean NOSE score at 6 months after
surgery dropped even further to 6.3. This improvement in
nasal breathing remained both clinically and statistically
significant as compared with what was found before surgery.
The findings confirmed an improved nasal airway by 3
months after surgery among patients who had undergone
combined septoplasty, inferior turbinate reduction, and Le
Fort I osteotomy; these improvements continued and were
maintained at 6 months. All study patients experienced
improvements in nasal breathing as a result of the combina­
tion of procedures that were carried out.
The incidence of complications that resulted from
the intranasal procedures performed simultaneously with
the Le Fort I osteotomy as reported by Posnick and col­
leagues was minimal and not greater than those reported
in the literature for isolated procedures. Posnick and col­
leagues also reported about the incidence of Le Fort I
osteotomy–specific complications in the same cohort.
The complications were few and not greater than those
reported when a Le Fort I osteotomy was carried out as an
isolated procedure.
Approaching the Nasal
Airway Through Le Fort I
Down-Fracture (
Video 1 and 2)
A Le Fort I osteotomy provides excellent access to the nasal
septum, the inferior turbinates, the pyriform rims, the nasal
floor, the anterior nasal spine, the maxillary sinus cavities,
and the ostium, thereby allowing for the correction of any
presenting nasal airway obstruction or maxillary sinus
pathology at the time of down-fracture (see Figs. 10-9,
10-10, and 10-11).82,83 Interestingly, most otolaryngologists/
head and neck surgeons are not used to viewing these struc­
tures from this perspective (i.e., through the down-fracture),
whereas orthognathic surgeons are. There are several techni­
cal details to consider when completing septoplasty or infe­
rior turbinate reduction through the exposure provided by
the Le Fort I osteotomy. As always, care is taken to maintain
the integrity of the nasal mucosa when down-fracturing the
maxilla. Nevertheless, tears in the mucosa are common.
After the down-fracture and disimpaction of the maxilla, an
elevator is used to achieve the submucosal exposure of all

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CHAPTER 10  Nasal Airway Considerations in the Evaluation and Treatment of Dentofacial Deformities
buckled and deviated portions of the cartilaginous and bony
septum. With the use of a rongeur, the buckled or deviated
portions of the cartilaginous and bony septum are removed
(i.e., submucosal resection); however, adequate dorsal and
caudal components of the cartilaginous septum are pre­
served for structural support. If a cosmetic rhinoplasty is a
future consideration, then the preservation of as much
useful septal cartilage as possible for later tip grafting is
important. Next, an incision that is parallel and just below
each inferior turbinate is completed through the nasal
mucosa. If the nasal mucosa was torn during the down-
fracture, then the exposure provided is used and extended
as needed for the additional visualization of each inferior
turbinate. With the use of a scissors (e.g., Mayo scissors),
the inferior aspect of each enlarged inferior turbinate can
be excised via partial resection. Other surgical techniques to
reduce enlarged inferior turbinates are described, such as
intramural ablation. The direct visualization of the more
cephalic positioned nasotracheal tube within the surgical
field limits the chance of injury during the turbinate reduc­
tion procedure. There is sufficient room for the surgeon to
work around the endotracheal tube. With no oxygen leaks
in the ventilation system, the cauterization of the exposed
raw surface of each inferior turbinate is completed. Suture
repair of the nasal floor mucosa is then accomplished. No
nasal packs or splints are required for postoperative manage­
ment. With this approach, the author has not experienced
significant intraoperative bleeding or postoperative airway
compromise.
Management of Residual Postoperative
Nasal Obstruction
When the baseline presurgical nasal airway obstruction is
clarified and then managed simultaneously through the Le
Fort I down-fracture, residual nasal obstruction is uncom­
mon. When a degree of postsurgical nasal obstruction per­
sists, it is generally the result of an incomplete presurgical
diagnosis or the inadequate operative correction of all of the
aspects that are causing the blockage (e.g., constricted aper­
ture, elevated floor, enlarged inferior turbinates, septal
deviations). After septoplasty and inferior turbinate proce­
dures and after routine postoperative intranasal swelling
subsides, continued nasal obstruction may also occur as a
result of scar formation.67,79,83 Should a degree of nasal
obstruction persist, it is important to confirm that residual
septal deviation, turbinate hypertrophy, and nasal valve
(internal and external) stenosis are not factors. If these
causes are ruled out and if postsurgical obstruction remains,
scar bands of varied thickness are likely to be the cause. If
so, the intranasal synechiae can extend from the operated
septum to the inferior turbinates or to the healing areas
along the nasal mucosal floor. The resulting scar bands are
usually small to moderate in size, and they can often be
corrected in the surgeon’s office with the use of local spray
anesthesia and scissors transaction under endoscopic visual­
ization. Occasionally, dense, thick synechiae occur; these
may contract a straightened septum into a lateralized posi­
tion. For more extensive scar bands and when further sep­
toplasty or turbinate reduction is required, management in
the operating room via an intranasal approach (with the
placement of a separating splint between the septum and
the lateral nose to prevent the adjacent fresh mucosal edges
from re-creating the scar contracture) is preferred.
Effects of Maxillary Arch Expansion and
Nasal Floor Recontouring on the Airway
Nasal Floor Recontouring: Effects on
the Airway (
Video 3 and 4)
The presence of excess vertical alveolar height of the anterior
maxilla above the roots of the teeth results in a high nasal
floor that constricts the nasal passageways, thereby causing
increased nasal airway resistance.24,113 This is a frequent
occurrence in patients with a long face growth pattern (see
Chapter 21). The need for vertical intrusion (i.e., superior
repositioning) of the anterior maxilla to reduce the gummy
smile, to improve lip closure, and to reduce mentalis strain
is generally required as part of the long face correction (see
Figs. 10-5, 10-11, and 10-13). As a result of maxillary intru­
sion, any baseline nasal obstruction caused by a high nasal
floor will worsen unless it is simultaneously addressed. The
need to recontour the nasal floor, the pyriform rims, and the
anterior nasal spine region is also frequent in patients with
cleft lips and palates (e.g., unilateral or bilateral cleft lip and
palate) that present with a maxillary deformity. Recontouring
to lower and level the nasal floor, to widen the pyriform rims,
and to reduce and reshape the anterior nasal spine can simul­
taneously be performed through the Le Fort I down-
fracture. This will both enhance upper lip and nose aesthetics
and reduce nasal airway resistance. The recontouring pro­
cedure is carried out with a watermelon-shaped bur on a
low-speed rotary drill and a rongeur under direct visualiza­
tion either before or after the maxilla is secured (i.e., fixed
with plates and screws) in its new location (see Chapter 15
and Fig. 10-11).
Maxillary Arch Expansion: Effects on
the Airway
Studies predominantly show that maxillary arch expansion
will improve a tight nasal inlet and thereby decrease nasal
airway resistance.15,22,68 The documented improved nasal
breathing is believed to result from a widened airway space,
primarily at the level of the internal nasal valve brought
about by maxillary arch expansion.* Seeberger and col­
leagues92 and Wreidt and colleagues114 examined patients via
acoustic rhinometry before and after surgically assisted
rapid maxillary expansion and recorded profound increases
in total nasal volumes. They also reported that their patients
experience better nasal airflow with a distinct subjective
*References 6, 9, 16, 22, 26, 34, 39, 40, 44, 49, 62, 68, 69, 102, 108,
111

Orth
r ognathic Surg
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A
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• Figure 10-12  A 20-year-old man with a combined long face growth pattern (environmental) and a right side hemimandibular elongation (heredi­
tary). There is an asymmetrical Class III negative overjet malocclusion. The patient had a lifelong history of obstructed nasal breathing with docu­
mented septal deviation, hypertrophic inferior turbinates, and an elevated nasal floor. He was referred to this surgeon for evaluation, and he agreed
to a comprehensive orthodontic and orthognathic approach. With the relief of dental compensation, the patient’s surgery included a maxillary Le
Fort I osteotomy (horizontal advancement and vertical shortening); bilateral sagittal split ramus osteotomies (mandibular straightening and asym­
metrical correction); osseous genioplasty (vertical shortening); and septoplasty, inferior turbinate reduction, and nasal floor recontouring. A, Frontal
views in repose before and after reconstruction. B, Frontal views with smile before and after reconstruction.

299
CHAPTER 10  Nasal Airway Considerations in the Evaluation and Treatment of Dentofacial Deformities
Orth
r ognathic Surg
r ery; J.C. Posnick
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r ery; J.C. Posnick
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C
D
C, Oblique facial views before and after reconstruction. D, Profile views before and after reconstruction.
• Figure 10-12, cont’d 
Continued

300
SECTION 1  Basic Principles and Concepts
Prior to treatment
After treatment
Pre surgery
E
F
G
E, Occlusal views before
retreatment, after orthodontic decompensation, and
after treatment. F, Articulated dental casts that indicate
analytic model planning. G, Lateral cephalometric radio­
graphs before and after reconstruction.
• Figure 10-12, cont’d

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CHAPTER 10  Nasal Airway Considerations in the Evaluation and Treatment of Dentofacial Deformities
improvement in nasal breathing. Maxillary widening may
be accomplished with a number of techniques (e.g., rapid
palatal expansion, surgically assisted rapid palatal expan­
sion, segmental Le Fort I osteotomy). The method selected
is dependent on the age of the patient and the combination
of airway, occlusal, and facial aesthetic needs. The frequent
need for arch expansion in the individual with a long face
growth pattern is well recognized (see Fig. 10-4), and it is
also common with other dentofacial deformities (e.g., max­
illary deficiency with relative mandibular excess, primary
mandibular deficiency, bimaxillary dental protrusion, and
cleft maxillary deformities). Expiratory pressure, expiratory
flow values, and inspiratory flow values have all been docu­
mented to improve immediately after lateral nasal wall wid­
ening. These benefits should remain long term unless lateral
wall relapse occurs.
Comprehensive Approach to Chronic
Nasal Airway Obstruction
The fact that Posnick and colleagues showed a more signifi­
cant symptomatic improvement in nasal breathing in their
study patients as compared with that found by Stewart
and colleagues when septoplasty only was carried out is not
surprising.100 This likely resulted from the strict patient
selection process and the other procedures that were simul­
taneously carried out (e.g., inferior turbinate reduction,
transverse widening of the maxilla, horizontal maxillary
advancement, lowering the nasal floor by recontouring).
An interesting observation emerged from the COG-
ENT chronic rhinosinusitis study that was completed in
2001.98-101 The COG-ENT researchers found that patients
who were undergoing functional endoscopic sinus surgery
in combination with septoplasty and inferior turbinate
reduction showed even greater clinical improvement in
nasal breathing as compared with those undergoing func­
tional endoscopic sinus surgery alone. This confirms the
added value to the airway (i.e., the improved breathing)
related to carefully selected diagnosis-driven procedures
being simultaneously carried out.19,35,50,54,70,72,78
Conclusions
Orthognathic surgeons have the opportunity to improve
disease-specific quality-of-life issues for their patients at the
time of Le Fort I osteotomy by performing diagnosis-driven
intranasal procedures in those with symptomatic chronic
nasal airway obstruction and sinus drainage difficulties. The
improvement of nasal airflow often enhances the patient’s
sense of smell, sinus drainage, sleep comfort, daytime alert­
ness, dental health, and ability to perform exercise. Ignoring
any baseline nasal floor and pyriform rim skeletal deformi­
ties at the time of orthognathic surgery is also likely to result
in suboptimal facial aesthetics.

302
SECTION 1  Basic Principles and Concepts
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Orthththththththththththththththththtr ogn
gn
g atatatatatatatatatatatatatathicicicicicicicicicici Su
Su
Su
Su
Surg
r ery
ry
ry
ry
ry
ry
ry; J.C.
C.
C.
C.
C Pos
os
os
os
osnicick
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Orthththththththththtr ogn
gn
gnathicic Su
Surg
r ery
ry; J.C.
C.
C.
C Pos
os
os
os
os
osnicick
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Orthththththththththththththththtr ogn
gn
gnatatatatatatatathicicicicicicicicicicicicicicicicicicicic Su
Su
Su
Su
Su
Su
Su
Su
Su
Surg
r ery
ry
ry
ry
ry
ry
ry
ry
ry
ry
ry; J.C.
C.
C.
C.
C.
C.
C.
C.
C.
C.
C.
C Pos
os
os
os
os
os
os
os
os
osnicick
Or
Or
Orththththththththth
r ogn
gn
gn
gnatatatathicicic Su
Su
S rg
r ery
ry
ry; J.C.
C.
C. Pos
os
os
os
os
os
os
os
os
osnicici k
A
B
• Figure 10-13  A teenage girl with a long face growth pattern is treated with a comprehensive
orthodontic and surgical approach. After orthodontic (dental) decompensation, her surgical proce­
dures included a maxillary Le Fort I osteotomy in segments (vertical intrusion, horizontal advancement,
and arch expansion) bilateral sagittal split osteotomies of the mandible (horizontal advancement and
counterclockwise rotation); oblique osteotomy of the chin (vertical shortening and horizontal advance­
ment); and septoplasty, inferior turbinate reduction, and recontouring of the nasal floor. A, Frontal
views in repose before and after treatment. B, Frontal views with smile before and after treatment.
Case Presentation
A classic example of the combined occurrence of chronic
nasal airway obstruction and dentofacial deformity is seen
in the description of a 15-year-old high school student who
arrived for evaluation accompanied by her parents (see
Fig. 10-13).
Since early childhood, the patient had a forced mouth-
breathing pattern, and snoring at night was documented.
With exercise, she had difficulty getting enough air through
the nose. She was seen by an otolaryngologist/head and
neck surgeon and found to have a deviated nasal septum, a
hypertrophic inferior turbinate, and a tight nasal aperture.
However, no treatment was carried out earlier during her
life. As a teenager, she presented with a long face growth
pattern, an anterior open bite, and a Class II excess overjet

303
CHAPTER 10  Nasal Airway Considerations in the Evaluation and Treatment of Dentofacial Deformities
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
O thththththththththththththth
r ogn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
g atatatatatatatatatatatatatatatatatathicicicicicicicicicicicicic Su
Su
Su
Su
S rg
r ery
ry
r ; J.C.
C.
C Pos
os
os
osnicici k
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
O thththththththththththththth
r ogn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gnatatatatatatatatatatatatatatathicicicicicici Su
Su
Surg
r ery
ry
ry; J.C.
C. Pos
os
os
os
os
os
os
os
os
os
osnicicici k
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
O ththththththththththththththth
r ogn
gn
gn
gn
gn
gn
gn
gn
gn
g atatatatatatatathicicicicicicicicicicic Su
Su
Su
Su
Su
Su
Su
Su
Su
Surg
r ery
ry
ry
ry
ry
ry
ry
ry
ry
ry
ry
ry
ry
ry
ry
r ; J.C.
C Pos
os
os
os
os
osnicici k
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
O thththththththththth
r ogn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
g atatatatatatatatatatatata hicicicicicicicicicicicici Su
Su
Su
Su
Su
Su
Su
Su
Su
Su
Su
Su
Su
Su
Su
Su
Su
Su
Su
Surg
r e y
ry
ry
ry
ry
ry
ry
ry
ry
ry
ry; J.C.
C.
C.
C. Pos
os
os
os
os
os
os
o nicici k
C
D
After treatment
Pre surgery
E
C, Oblique facial views before and after treatment. D, Profile views before and after treatment.
E, Occlusal views with orthodontics in progress and then after surgery.
• Figure 10-13, cont’d 
Continued

304
SECTION 1  Basic Principles and Concepts
Mandibular counter-
clockwise rotation
Arch expansion
F
G
F, Articulated dental casts that indicate analytic model planning. G, Lateral cephalometric
views before and after treatment.
• Figure 10-13, cont’d 
malocclusion. There were also concerns about a gummy
smile, difficulty maintaining lip closure, speech articulation
errors, and a weak profile.
Both orthodontic and surgical consultation recom-
mended a comprehensive approach as the most biologic way
to improve the upper airway obstruction; to improve the
occlusion and the long-term dental health; to improve lip
closure; and to enhance facial aesthetics. Orthodontic treat-
ment was initiated to relieve dental compensation, and jaw
and intranasal surgery followed.
Management of Dentofacial Deformity
Required the Following:
• Maxillary Le Fort I osteotomy in three segments
• Bilateral sagittal split ramus osteotomies of the
mandible
• Oblique osteotomy of the chin
Management of Chronic Nasal Airway
Obstruction Required the Following:
• Submucous resection of deflected and buckled portions
of the nasal septum
• Reduction of the hypertrophic inferior turbinates
• Maxillary transverse expansion (Le Fort I osteotomy in
segments) with nasal aperture widening
• Recontouring (lowering) of the nasal floor and the ante-
rior nasal spine
The patient is shown before and 1 year after surgery and
the completion of orthodontic treatment.

305
CHAPTER 10  Nasal Airway Considerations in the Evaluation and Treatment of Dentofacial Deformities
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expansion on nasal airway resistance. Br J
Orthod 13(4):221–228, 1986.
103. Turvey TA: Management of the nasal
apparatus in maxillary surgery. J Oral Surg
38:331–335, 1980.
104. Turvey TA: Alteration in nasal airway
resistance following superior repositioning
of the maxilla. Am J Orthod 99:109–114,
1984.
105. Tweed CH: Clinical orthodontics, St. Louis,
1966, Mosby.
106. Valera FC, Travitzki LV, Mattar SE, et al:
Muscular, functional and orthodontic
changes in preschool children with enlarged
adenoids and tonsils. Int J Pediatr
Otorhinolaryngol 67:761, 2003.
107. Vargervik K, Mill AJ, Chierici G, et al:
Morphologic response to changes in
neuromuscular patterns experimentally
induced by altered mode of respiration. Am J
Orthod 85:115–124, 1984.
108. Walker D, Turvey TA, Warren D: Alterations
in nasal respiration and nasal airway size
following superior repositioning of the
maxilla. J Oral Maxillofac Surg 46:276–281,
1988.
109. Warren DW, Hershey HG, Turvey TA, et al:
The nasal airway following maxillary
expansion. Am J Orthod 91:111–116, 1987.
110. Weber ZJ, Preston CB, Wright PG:
Resistance to nasal air flow related to
changes in head posture. Am J Orthodon
Dentofacial Orthop 82:536–545,
1981.
111. Wenzel A, Henriksen J, Melsen B: Nasal
respiratory resistance and head posture:
effect of intra-nasal corticosteroid
(Budesonide) in children with asthma
and perennial rhinitis. Am J Orthod
84:422–426, 1983.
112. Wertz RA: Changes in nasal air flow incident
to rapid maxillary expansion. Angle Orthod
38(1):1–11, 1968.
113. West RA, McNeill RW: Maxillary alveolar
hyperplasia, diagnosis and treatment
planning. J Maxillofac Surg 3:239,
1975.
113a.  Williams BJD, Isom A, Laureano Filho JR,
O’Ryan FS: Nasal airway function after
maxillary surgery: A prospective cohort study
using the nasal obstruction symptom
evaluation scale. J Oral Maxillofac Surg
71:343–350, 2013.
114. Wriedt S, Kunkel W, Zentner A, Wahlmann
U: Surgically assisted rapid palatal expansion.
An acoustic rhinometric, morphometric and
sonographic investigation. J Orthofac Orthop
62:107–115, 2001.

308

11
Anesthesia Techniques, Blood
Loss/Fluid Replacement, Airway
Management & Convalescence
in the Treatment of
Dentofacial Deformities
JEFFREY C. POSNICK, DMD, MD
• Use of Deliberate Hypotensive Anesthesia to
Limit Blood Loss
• Use of Hemorrhage Depressors to Limit
Blood Loss
• Deliberate Hypotensive Anesthesia Used in
Orthognathic Surgery: Review of the
Literature
• The Need for Blood Replacement in
Orthognathic Surgery
• Perioperative Airway Management in the
Patient with a Dentofacial Deformity
• In-Hospital Convalescence After
Orthognathic Surgery
• At-Home Convalescence and Outpatient Care
After Orthognathic Surgery
• Patient Education Materials
procedures.58 Since then, a spectrum of pharmacologic
agents (e.g., nitroglycerine, calcium-channel blocking
agents, short-acting beta-adrenergic blockers, purine com­
pounds) and techniques have been used in a variety of
combinations in an attempt to accomplish the same
objectives.*
In 1950, Enderby and colleagues demonstrated the value
of DHA to reduce blood loss in a series of 35 patients.78-81
Eighteen of the 35 (51%) were judged to have an excellent
reduction in blood loss during deliberate hypotension, and
8 of the 35 (23%) were judged to have a moderate reduc­
tion. The authors attributed this inconsistent effectiveness
to individual vascular responses to the hypotensive drugs
that were used. They surmised that bleeding at the surgical
site could be further minimized if the wound itself was kept
uppermost (rather than dependent) through the use of
operating room table positioning (e.g., reverse Trendelen­
burg position for head and neck procedures). Through
special positioning, arterial vessels in the operative field
would have less pressure, veins would drain more easily, and
thus bleeding at the surgical site should be less.
One of the earliest studies to quantify reductions in
blood loss with DHA was performed by Eckenhoff and
Rich, who completed research in patients who were under­
going a variety of operations, including rhinoplasty,
Use of Deliberate Hypotensive
Anesthesia to Limit Blood Loss
Historical Perspective
Deliberate hypotensive anesthesia (DHA) to provide a less
bloody field and better operative conditions was first pro­
posed by Harvey Cushing in 1917 for neurosurgical
*References 5, 8, 20, 26, 33, 36, 40, 54, 55, 63, 65, 67, 82, 88, 89, 98,
99, 111, 116, 119, 128, 150, 151, 155, 160, 166, 168, 178, 181, 182,
190, 191, 196-198, 209, 219, 221, 224, 237, 241-244, 258, 265, 270,
272.

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CHAPTER 11  Anesthesia Techniques, Blood Loss/Fluid Replacement, Airway Management & Convalescence
portacaval shunt, and craniotomy for aneurysm.72,73 Half of
the patients underwent DHA (n = 115), and the other half
(n = 116) went without hypotension. For each of the pro­
cedures, blood loss decreased by 50% or more with hypo­
tension techniques. This was the first DHA study to measure
blood loss with the use of a control group. By doing so, it
greatly added to the power of the research confirming the
value of DHA.
Evidence supporting the use of DHA to reduce blood
loss has most commonly been found in studies of orthope­
dic procedures. Thompson and colleagues studied hypoten­
sive anesthesia to reduce blood loss during total hip
arthroplasty.255 The mean arterial pressure (MAP) of the
patients (n = 30) was reduced to 50 mm Hg. The tech­
niques used to do this included sodium nitroprusside (n =
12) and high inspired concentrations of halothane (n = 9);
a control group of patients (n = 9) was normotensive.
Blood loss was 1200 mL for the normotensive control sub­
jects but only 400 mL for both hypotensive groups. No
anesthesia-specific complications were seen. In 1979, Eerola
and colleagues completed a controlled study of 55 patients
who were undergoing total hip arthroplasty.76 They found
that the 38 patients who were given pentolinium tartrate
and halothane for DHA had less blood loss. That same year,
Vazeery and colleagues studied patients who were undergo­
ing total hip replacement (n = 25). The patients were given
sodium nitroprusside to lower arterial blood pressure.262
They had significantly less blood loss than the control group
(n = 25), which was not undergoing deliberate hypotension.
The value of DHA to reduce blood loss has also been con­
firmed for other procedures, including craniotomy, middle-
ear surgery, radical cancer operations, and a variety of head
and neck surgeries.
Didier and colleagues suggested that the depression of
cardiac output correlated better with a dry field than did
arterial blood pressure.66 To determine whether a decrease
in MAP or cardiac output was the primary cause of the
decreased blood loss, Sivarajan and colleagues studied
“healthy” (American Society of Anesthesiologist I) subjects
(n = 20) who were undergoing bilateral sagittal split ramus
osteotomies of the mandible.239 Cardiac output decreased
37% with the use of trimethaphan, but it decreased only
27% with sodium nitroprusside. Interestingly, blood loss
was similar for both groups, although cardiac output was
two times greater with nitroprusside. The authors con­
cluded that blood pressure rather than cardiac output was
the primary determinant of how much blood was lost.
Techniques to Induce Deliberate
Hypotensive Anesthesia
Currently, the general consensus is that most patients will
have less blood loss if the MAP is decreased to 50 mm Hg
to 65 mm Hg in the surgical field. It is also believed that
patient positioning and attention to ventilation will signifi­
cantly influence venous return and therefore play important
roles in minimizing blood loss. Clinical studies have focused
on the use of a variety of specific drugs and combinations
of drugs to keep the arterial blood pressure at the surgical
site at the level believed to significantly decrease blood loss
(i.e., 50 mm Hg to 65 mm Hg).
Body positioning (e.g., reverse Trendelenburg position
for head and neck procedures), the hemodynamic effects of
mechanical ventilation (e.g., maintaining normal or low
carbon dioxide [CO2] levels), and changes in the heart rate
and the circulatory volume are factors that can be manipu­
lated with drugs to lower blood pressure in the surgical field
to the desired level. The effective use of these physiologic
maneuvers helps to decrease the dose of potentially toxic
drugs that are needed to produce the preferred level of
hypotension.
The ideal agents for inducing hypotension should have
the following characteristics: 1) ease of administration; 2) a
predictable and dose-dependent effect; 3) rapid onset; 4)
rapid recovery from effects; 5) quick elimination without
the production of toxic metabolites; and 6) minimal effects
on blood flow to the vital organs. Many anesthetic and
vasoactive drugs have been used successfully in clinical prac­
tice to induce DHA for orthognathic procedures. These
agents primarily include volatile anesthetics; direct-acting
vasodilating drugs; beta-adrenergic receptor–blocking
drugs; and combined alpha- and beta-adrenergic receptor–
blocking drugs. Examples of such agents include sodium
nitroprusside, nitroglycerin, esmolol, and labetalol.
Clearly, one can decrease MAP by increasing the amount
of inhaled anesthetics such as sevoflurane, isoflurane, and
desflurane. Certain drugs that permit moment-to-moment
controlled blood pressure are the most popular. The differ­
ences in pharmacologic properties among these agents
suggest that combinations of these drugs may provide a
better pharmacologic profile than could be provided by any
agent used alone.234
Effects of Deliberate Hypotensive Anesthesia
on Organ Function
DHA decreases arterial blood pressure by decreasing cardiac
output, by decreasing systemic vascular resistance, or by
decreasing a combination of the two. Cardiac output must
remain sufficiently high not only to provide adequate
oxygen and energy substrates to vital organ systems but also
to remove metabolic waste products before any accumula­
tion can cause tissue damage. The effect of DHA on cardiac
output depends on the balance of its effects on preload,
afterload, myocardial contractility, and heart rate. Homeo­
static mechanisms also come into play. Other important
factors include the physical condition of the specific patient,
the anesthesiologist’s administration of additional drugs,
and the pattern of ventilation used intraoperatively. The
constant assessment of the patient’s intravascular fluid
volume throughout surgery is also required to ensure
optimal vital organ function.
Inadequate oxygen supply to the brain and myocardium
as a result of inadequate tissue blood flow or perfusion

310
SECTION 1  Basic Principles and Concepts
acid–base status (i.e. metabolic acidosis). It also allows for
the confirmation of adequacy of oxygenation and ventila­
tion, and for serial hematocrit measurements. Electrocar­
diographic monitoring is also essential for detecting signs
of inadequate myocardial perfusion or oxygen delivery, such
as S-T segment or rhythm changes. The correlation between
end tidal CO2 and paCO2 is considered somewhat unreli­
able during hypotension. Nevertheless, capnography still
provides useful information during DHA. It may also help
to avoid hyperventilation and its resultant hypocapnea,
which could be harmful; the decrease in paCO2 could
further reduce cerebral blood flow during moderate hypo­
tension. Pulse oximetry and temperature monitoring should
also be routinely used, and the measurement of urine output
is also essential. Serum electrolyte, blood gas, and hemato­
crit levels should also be measured at intervals.
Complications Associated with Deliberate
Hypotensive Anesthesia
The precise incidence of complications with the use of
DHA is difficult to determine.19,75,41,152,179,248,253 Current
data regarding non-fatal complications indicate that hypo­
tension of 50 mm Hg to 65 mm Hg is not a risk factor for
young healthy patients (American Society of Anesthesiolo­
gists [ASA] 1 and 2). Alternatively, for those individuals
with underlying organ dysfunction, the use of DHA may
put them at increased risk. Thus, all potential candidates
should undergo a complete history and physical examina­
tion before surgery. The decision to use DHA should not
be made without careful preoperative consideration of
patient-specific risk factors.
Special Considerations for
the Orthognathic Patient
Before beginning an orthognathic procedure, the logistics
of patient positioning, the expected length of the surgery,
and the confirmation of patient-specific risk factors for
DHA should be discussed by the anesthesiologist and the
surgeon.264 Better drugs, more accurate monitoring, a
greater level of experience with the techniques, and the
consistency of the surgical procedures themselves have per­
mitted a higher percentage of patients to benefit from
DHA.* Nevertheless, relative contraindications include a
history of cerebrovascular or cardiovascular disease, renal
dysfunction, liver dysfunction, peripheral vascular disease,
and severe anemia. Fortunately, the orthognathic patient
rarely suffers from these dysfunctions. Exceptions include
older individuals who are undergoing orthognathic surgery
for the treatment of obstructive sleep apnea.228,261 Given
current demographics, this is likely to represent an ever-
increasing patient population (see Chapter 26).
pressure is the principal hazard of DHA, particularly with
regard to the effects on cerebral metabolic homeostasis.*
Studies to date have shown that the responsible use of DHA
does not produce permanent changes in cerebral hemody­
namics. For example, the cognitive performance of elderly
patients on psychological tests given several days after total
hip arthroplasty that involved DHA did not differ from
their performance before surgery. The current clinical ratio­
nale for studying a lower limit for MAP (e.g., 50 mm Hg
to 55 mm Hg) in normotensive patients is based on the
belief that this range represents the lowest MAP at which
autoregulation of the cerebral blood flow is still intact.
However, for chronically hypertensive patients or for
patients who are older, the curve is thought to shift to the
right. In other words, a higher MAP is required in these
individuals to maintain autoregulation. The partial pressure
of carbon dioxide in the blood (paCO2) is also an important
consideration during DHA. This is because cerebral blood
flow changes linearly with paCO2. Whether one drug is
better than another for preserving cerebral blood flow is
debated.
The preservation of cardiac function is essential, but it is
known to be altered by DHA techniques.† Interestingly,
cardiac function is better preserved with isoflurane than with
equal hypotensive doses of halothane. Studies have shown
that isoflurane is suitable for healthy patients who are under­
going DHA. Clinical studies also show that the cardiovas­
cular effects of general anesthetic doses of propofol are
similar to those of isoflurane. During deliberate hypoten­
sion, the maintenance of an oxygen supply that is sufficient
for the metabolic needs of the myocardium is of primary
importance. As a general rule, patients with known or sus­
pected ischemic heart disease should not undergo DHA.
Renal blood flow normally equals 20% to 25% of cardiac
output. Renal circulation is greatly influenced by autoregu­
latory mechanisms.61,110,159 Clinical studies suggests that
normovolemic patients typically experience the rapid recov­
ery of urine production after the discontinuation of DHA.255
Thompson and colleagues could find no significant changes
in serum creatinine, blood urea nitrogen, or serum or
urinary electrolytes for patients (n = 30) who had under­
gone DHA.255
Monitoring During Induced Deliberate
Hypotensive Anesthesia
Beat-to-beat measurement of arterial blood flow is manda­
tory for patients who are undergoing clinically significant
deliberate decreases in blood pressure. The usual practice is
to insert an arterial catheter for the continuous monitoring
of blood pressure. Perhaps most importantly, the catheter
allows for the intermittent sampling of arterial blood for
*References 7, 25, 38, 46, 49, 50, 68, 95-97, 100, 154, 157, 205, 211,
216, 229, 257, 266, 274.
*References 13, 14, 10, 11, 9, 12, 83, 113, 117, 133, 135, 139, 145, 158,
161, 163, 174, 178, 188, 195, 221, 249, 251, 269, 273.
†References 1-3, 18, 44, 57, 60, 74, 87, 143, 193, 208, 220.

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CHAPTER 11  Anesthesia Techniques, Blood Loss/Fluid Replacement, Airway Management & Convalescence
*References 21-23, 27, 28, 39, 41, 42, 59, 71, 77, 85, 120, 122, 125,
126, 129-132, 171, 186, 187, 214, 233, 238, 252, 254, 277.
DHA during orthognathic surgery at the University of
Göteborg Hospital since 1999. Zellin and colleagues ret­
rospectively evaluated and compared the total perioperative
blood loss for a group of patients who were assigned to
either DHA or a combination of DHA and the use of both
of these hemorrhage depressors (i.e., desmopressin and
tranexamic acid).276 Thirty orthognathic patients who were
consecutively operated on via a standardized Le Fort I oste­
otomy were assigned to either the control group (n = 15)
or the treatment group (n = 15). Both groups underwent
DHA. The treatment group received additional hemor­
rhagic depressors (i.e., both tranexamic acid and desmopres­
sin). The mean blood loss was 740 cc in the control group
and 400 cc in the treatment group. This was a statistically
significant reduction in blood loss in the treatment group
(1 g tranexamic acid intravenously and 0.3 µg per kilogram
of body weight of desmopressin subcutaneously).
Deliberate Hypotensive Anesthesia
Used in Orthognathic Surgery:
Review of the Literature
Schaberg and colleagues were the first to evaluate blood
loss and the human physiologic response with the use of
DHA in the form of sodium nitroprusside during orthog­
nathic surgery.227 They studied a consecutive series of ASA
I patients undergoing Le Fort I maxillary osteotomies. Each
was placed in reverse Trendelenburg position (10 degrees),
and sodium nitroprusside was used to induce hypotension
to not less than 80 mm Hg systolic pressure or 60 mm Hg
MAP. The mean estimated blood loss was 256 ± 35 mL. No
control group was used for comparison.
Washburn described a retrospective series of 58 indi­
viduals who underwent maxillofacial procedures (n = 53
orthognathic patients) in which morphine was used to
supplement halothane to induce hypotension.267 The goals
were to limit blood loss and to improve the surgical field.
There was one death (possibly from halothane-induced liver
failure), and only one patient required blood replacement.
Golia and colleagues studied nine patients who under­
went either maxillary or combined maxillary and mandibu­
lar osteotomies; the DHA techniques that were used
included halothane, nitrous oxide, and supplemental doses
of muscle relaxants and narcotics.106 Nitroglycerin was
added for the purpose of lowering the MAP during periods
with a high potential for increased blood loss (e.g., Le Fort
I down-fracture). Estimated blood loss averaged 439 mL
and the hemoglobin/hematocrit level fell from 13.8
hemoglobin/41 hematocrit to 12 hemoglobin/36 hemato­
crit (4.9%). The authors concluded that nitroglycerin was
a safe and efficacious agent to help control MAP and blood
loss in the surgical field during maxillary and mandibular
osteotomies. No control group was used.
McNulty and colleagues completed a study of 12
patients who underwent orthognathic procedures (i.e., Le
Fort I osteotomy or sagittal split ramus osteotomy of the
Use of Hemorrhage Depressors to Limit
Blood Loss
Tranexamic Acids
Tranexamic acid is a synthetic amino acid that inhibits
fibrinolysis and that has been shown to reduce blood
loss and the need for blood transfusion during specific surgi­
cal procedures, including total knee arthroplasty, spine
surgery, cardiac surgery, and orthognathic surgery.* It has
also been used for the treatment of postoperative bleeding
in anticoagulated patients after oral surgery (e.g., the extrac­
tion of teeth).32,212 Senghore and Harris showed that a
single intravenous preoperative dose of tranexamic acid was
effective for preventing excessive postoperative bleeding in
healthy adult patients who were undergoing third molar
extraction.232
Choi and colleagues completed a double-blind, ran­
domized, controlled trial to study the effects of tranexamic
acid on blood loss during orthognathic surgery.51 This trial
included 73 consecutive patients who were undergoing
bimaxillary orthognathic osteotomies. Each study patient
received either a bolus of tranexamic acid (20 mg/kg) or a
placebo (normal saline) intravenously just before surgery.
All patients underwent DHA in accordance with standard
hospital protocol. Intraoperative blood loss, operative time,
the transfusion of blood products, and perioperative hemo­
globin and hematocrit levels were recorded. The total blood
loss and the blood loss during the maxillary (Le Fort I)
procedure were reduced significantly in the group that
received tranexamic acid as compared with the control
group. The difference in blood loss during maxillary
surgery was 428 mL versus 643 mL. The difference in total
blood loss was 878 cc versus 1257 cc. The authors con­
cluded that the use of a preoperative intravenous bolus of
tranexamic acid (20 mg/kg) reduces blood loss as com­
pared with a placebo during bimaxillary orthognathic
osteotomies.
Desmopressin
Desmopressin acetate is an analog to the naturally occurring
hormone vasopressin.4,114,115,138,147,222,225,245 It enhances the
vascular endothelial cell release of a number of compounds,
including high multimetric von Willebrand factor, factor
7c, factor 7ag, and tissue-type plasminogen activator. Des­
mopressin by itself has been suggested to be the factor that
is responsible for the increased hemostatic activity seen in
patients with liver dysfunction and uremia. Additional
observations indicate that desmopressin may improve plate­
let function.
Both of these hemorrhage depressors—desmopressin
and tranexamic acid—have been used in combination with

312
SECTION 1  Basic Principles and Concepts
the blood loss, and the operative time with either hypoten­
sive or normotensive anesthesia during Le Fort I osteotomy.
The study patients (n = 23) were randomized into normo­
tensive or hypotensive anesthesia treatment groups. No
local anesthesia with a vasoconstrictor was used by the
surgeon. In the experimental group, hypotensive anesthesia
was maintained with propofol (3 mg/kg/hr), sufentanyl
(0.5 mg/kg/hr), and isoflurane (0.5% in 100% oxygen).
The quality of the surgical field in both groups was assessed
intraoperatively by direct observation and again postopera­
tively with video imaging. The surgical time was measured
on the videotape, and blood loss was measured by volumet­
ric and gravimetric techniques. There was a statistically sig­
nificant correlation between the surgeon’s perception of the
quality of the surgical field and the blood pressure. There
was a statistically significant reduction in blood loss when
using hypotensive anesthesia. However, there was no signifi­
cant reduction in operative time when using hypotensive
anesthesia. The authors concluded that hypotensive anes­
thesia is a valuable technique for reducing blood loss and
improving the quality of the surgical field during Le Fort I
osteotomy.
Praveen and colleagues completed a prospective ran­
domized clinical study to assess DHA and blood loss during
orthognathic surgery.204 A total of 53 patients who were
undergoing orthognathic surgery were included in the
study. The patient ages ranged from 15 to 33 years. They
were randomly allocated to have either normotensive anes­
thesia or to be given DHA. Median blood loss with DHA
was 200 mL; under normotensive anesthesia, it was 350 mL.
The authors concluded that there was a pronounced reduc­
tion in blood loss during orthognathic operations with the
patient under DHA as compared with normotensive
anesthesia.
Manola and colleagues completed a prospective ran­
domized comparison of three types of pharmacologic agents
to induce hypotension during functional endoscopic sinus
surgery.165 The patients were divided into three equal groups
in accordance with the agents used: 1) sufentanyl/
sevoflurane; 2) remifentanil/propofol; and 3) fentanyl/
isoflurane. Evaluation included surgical field rating and
measured blood loss. The authors found that the quantity
of blood loss and the visibility of the surgical field were
improved with the use of either remifentanil and sufentanyl
as compared with fentanyl.
Choi and colleagues completed a comparative study to
report about the use of three different pharmacologic drugs
to induce DHA in patients who were undergoing orthog­
nathic surgery (i.e., Le Fort I and sagittal split ramus oste­
otomies of the mandible).49 The 50 adult patients were
randomly allocated to receive either nitroglycerin (n = 25)
or remifentanil (n = 25). The MAP and the heart rate were
measured at intervals. The heart rates and blood pressures
were significantly better controlled with the use of remifen­
tanil as compared with nitroglycerin. Interestingly, there
were no significant differences in the surgical field ratings
or the measured blood loss between the two groups.
mandible) under DHA.169 The anesthesia agents that were
used included fentanyl, isoflurane, and bolus doses (i.e.,
10 mg to 20 mg) of labetalol to control the blood pressure
in an attempt to improve the surgical field and limit blood
loss. The authors reported clinical satisfaction with the
surgical field and no complications. No control group
was used.
Blau and colleagues compared esmolol in 15 patients
with sodium nitroprusside in 15 other patients as the
primary drugs for DHA to limit blood loss during Le Fort
I osteotomy.31 All study patients were physically rated as
ASA I or II. The mean MAP averaged 58 mm Hg to 60 mm
Hg, with a target range set at 55 mm Hg to 65 mm Hg.
The mean heart rate was maintained at approximately 70
beats/min with esmolol and 100 beats/min with nitroprus­
side. The surgeons generally rated bleeding as mild to mod­
erate and the surgical field as “drier” with esmolol. The total
measured blood loss was less with esmolol (i.e., 436 mL
with esmolol versus 895 mL with nitroprusside). The
authors found the advantages of esmolol as compared with
nitroprusside to include greater control of the blood pres­
sure, the reduction of blood loss, and a drier surgical field.
Precious and colleagues studied 50 orthognathic sur­
gery patients in a prospective, randomized, blocked, strati­
fied, and single-blind fashion.206 All patients underwent
either sagittal split ramus osteotomies of the mandible, Le
Fort I osteotomy, or genioplasty. One group of patients (n
= 25) received DHA, whereas the other group (n = 25)
received anesthesia with no specific attempt to reduce blood
pressure during the operation. The surgeon, who was
unaware of which group the patient had been assigned to,
rated the surgical field every 15 minutes. At the completion
of surgery, three different methods were used to estimate or
calculate blood loss. The duration of the procedure was
recorded from the time of the first incision to the time of
the last stitch placement. The estimated blood loss was
significantly less when DHA was used. The surgical field
was also rated better, but there was no significant difference
in the duration of the procedure with or without the use of
DHA. The authors concluded that DHA results in both
reduced blood loss and improved visibility in the surgical
field.
Enlund and colleagues studied 36 patients who were
undergoing orthognathic surgery.84 Each patient was ran­
domly assigned to be either hypotensive (n = 18) or nor­
motensive (n = 18) during surgery. Hypotension was
achieved with the use of isoflurane to a MAP of 50 mm Hg
to 64 mm Hg. The hypotensive group had significantly less
blood loss per minute. Only two of the patients in each
group underwent bimaxillary osteotomies. A majority of
the patients in each group underwent only mandibular
ramus osteotomies. None of the patients in either group
required blood replacement.
Dolman and colleagues completed a prospective, ran­
domized, blinded-to-the-surgeon clinical trial of DHA in a
consecutive series of orthognathic patients.69 The purpose
of the study was to compare the quality of the surgical field,

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CHAPTER 11  Anesthesia Techniques, Blood Loss/Fluid Replacement, Airway Management & Convalescence
Farah and colleagues completed a comparative study to
report on the use of two different pharmacologic protocols
to induce DHA in patients submitted to orthognathic
surgery.90 Twenty ASA 1 patients between the ages of 17
and 44 years were randomly assigned into two groups: group
1 (clonidine and remifentanil) and group 2 (dexmedetomi­
dine and isoflurane). Other drugs that were used as part of
the anesthesia regimen were common to both groups. Spe­
cific patient parameters were assessed, including arterial
blood pressure; heart rate; temperature during the intraop­
erative and postoperative periods; incidence of nausea and
vomiting; postoperative pain; awakening time; extubation
time; and postanesthesia recovery time. The results of the
study showed that there were no significant differences
between the two groups with respect to physiologic responses
or surgical time. Both study protocols proved to be effective
and safe. Each was suggested as a satisfactory option to
achieve DHA during orthognathic procedures when there
is an expectation of significant blood loss.
To review, the literature confirms that DHA is effective
for decreasing blood loss and providing better visibility in
the surgical field during orthognathic procedures. There are
many available drugs and techniques that have been used
successfully to lower arterial blood pressure to accomplish
these goals. The mechanisms of action of available drugs
differ and produce complex changes in reflexes and subse­
quently the blood flow to various organs. For the healthy
young patient, complications are rare. The anesthesiologist
and the surgeon must assess each patient carefully and con­
sider the potential risks and complications as well as the
benefits before using DHA techniques during orthognathic
surgery.
The Need for Blood Replacement
in Orthognathic Surgery
Background
For individuals who are undergoing complex orthognathic
surgery (i.e., Le Fort I and sagittal split ramus osteotomies
of the mandible)—often in combination with other simul­
taneous procedures (e.g., genioplasty, liposuction, septo­
plasty, inferior turbinate reduction, removal of wisdom
teeth)—a preoperative doctor–patient discussion of the
need for intraoperative blood replacement is not just an
academic issue.92,103,107,149,163,201 Published studies indicate
that individuals who are undergoing bimaxillary surgery
require blood replacement in the range of 2.5% to
75%.15,64,138,142,148,156,200,218,223,226,235,259,274 Rummasak and col­
leagues retrospectively studied patients who underwent
bimaxillary osteotomies (n = 208) during a 4-year time­
frame from 2005 to 2009 at a single institution. The authors
reviewed possible factors for intraoperative blood loss and
looked for statistical significance. They documented that,
with consistent anesthesia techniques, the two factors of
greatest importance for blood loss were 1) the experience of
the surgeon and 2) the overall operative time.223
Madsen and colleagues conducted a prospective study to
evaluate the predictive value of the viscoelastic properties of
whole blood samples collected preoperatively in relation to
intraoperative blood loss in patients who were undergoing
orthognathic surgery (n = 41). They concluded that, with
other variables controlled for, the etiology of intraoperative
bleeding can be predicted by means of preoperative throm­
boelastography. This is a global method that addresses
the complex interplay among coagulation factors, blood
platelets, and components of the fibrinolytic system.
Blood platelet count, activated partial thromboplastin
time, prothrombin time, plasma fibrinogen concentration,
and D-dimer concentration were determined by routine
methods. The authors conclude that thromboelastography
results in individual patients can be used for the evaluation
of bleeding risk. Further studies will be required to confirm
the validity of their findings.162
Methods to limit the need for blood replacement con­
tinue to evolve and include refinements in DHA techniques
as well as in surgical management (i.e., patient selection,
collaborative clinical efforts, and the efficiency of the opera­
tion and the postoperative care).102 Despite stringent donor
screening criteria and the rigorous testing of every unit of
blood, there remains a risk for the transmission of several
pathogens.70,93,104,108,134,177 For viruses such as the human
immunodeficiency virus (1 in 2,135,000), hepatitis B virus
(1 in 205,000), and hepatitis C virus (1 in 2,000,000), this
is due mainly to “window-period” donations.34,247 The risks
of newly emerging pathogens that can affect blood safety
(e.g., Creutzfeldt-Jakob disease) remain unclear. There are
other pathogens (e.g., cytomegalovirus, parvovirus B19)
that are common in the general donor population and that
may pose a risk in the immunosuppressed patient.213 In
addition, allogenic transfusion has been shown quantita­
tively to be an important contributor to postoperative
infection.94,260
The options of autogenous and donor-directed blood
banking and their popularity for elective surgery are attrib­
uted to their perceived safety, to refinements in blood bank
administration, and to public concern about the hazards of
allogenic blood replacement.16,86,91,105,118,167,184,210,240 In at
least one state (California) and one nation (Germany), the
preoperative discussion of blood replacement options is
mandated by law and must be documented in the medical
record. Other alternatives to allogenic transfusion include
acute normovolemic hemodilution, intraoperative blood
salvage, and perioperative therapy with recombinant human
erythropoietin (Procrit).35,101,136,170,173,180,230,231
The absolute need for and actual use of blood transfusion
in the practice of orthognathic surgery remains dependent
on considerations that relate to total whole body oxygen
delivery and its ability to meet the body’s metabolic
needs.56,121,175,189 Many individual hospitals have instituted
strict criteria for the transfusion of blood products.215
Although mandated criteria may decrease the use of blood
transfusions, it remains unclear if complications or delays
in recovery have occurred as a result.250

314
SECTION 1  Basic Principles and Concepts
Review of Study
Posnick and colleagues completed a retrospective study to
review blood replacement practices in a consecutive series
of a single surgeon’s experience with patients who all under­
went, at a minimum, simultaneous Le Fort I maxillary
osteotomy, bilateral sagittal split ramus osteotomies of the
mandible, septoplasty, and inferior turbinate reduction pro­
cedures.202 Many patients also underwent additional adjunc­
tive procedures.
A chart review of a consecutive series of the surgeon’s
patients (n = 34) who underwent elective bimaxillary
orthognathic surgery (Le Fort I osteotomy and sagittal split
osteotomies of the mandible) in combination with intrana­
sal (septoplasty and inferior turbinate reduction) and often
other simultaneous procedures during a 5-month time
frame at a single institution was carried out (see Table 11-1).
The chart review occurred at least 3 months after surgery
for all patients.
Each patient was also evaluated for complications spe­
cific to the procedures that were carried out. Potential com­
plications specific to the orthognathic procedures included
infection that required the extended use of antibiotics or
drainage procedures; dental injury; fibrous union; aseptic
necrosis; bleeding that required secondary treatment; and
oroantral, oronasal, and orocutaneous fistulas. Potential
complications specific to the intranasal procedures included
postoperative nasal bleeding that required packing or cau­
terization; the need for postoperative blood transfusion spe­
cific to nasal bleeding; the presence of septal perforation;
and postoperative nasal obstruction that required additional
procedures within 3 months after orthognathic surgery.
Potential perioperative airway compromise was also
reviewed, including the need for delayed extubation, rein­
tubation, or tracheotomy. Potential complications specific
to transfusions, including infections and autoimmune reac­
tions, were also sought. The patient records that were
reviewed included the office chart; the hospital records; and
the data stored at the Red Cross (hospital) blood bank.
Specific study data collected for each patient (n = 34) can
be found in Table 11-1.
The study group included 15 male patients and 19
female patients. The mean age was 22 years and ranged from
13 to 65 years; the median age was 22 years. Thirteen of
the 34 patients were less than 18 years old. All patients were
treated with a combined orthodontic and surgical (orthog­
nathic and intranasal) approach. The most frequent pattern
of jaw deformity that was identified for the study group was
asymmetric mandibular excess in 9 out of 34 patients
(26%); this was followed by a cleft-craniofacial syndrome
being found in 7 out of 34 patients (21%) and a long face
growth pattern in 7 out of 34 patients (21%). Additional
simultaneous facial procedures that were completed varied.
Forty-four percent of the patients (15 out of 34) underwent
the simultaneous removal of wisdom teeth. Twenty-one
percent of the patients (7 out of 34) also underwent suction-
assisted lipectomy of the neck. Eighty-eight percent of the
patients (30 out of 34) underwent an osseous genioplasty.
Eighteen percent of the patients (6 out of 34) underwent
iliac (hip) bone grafting. Fifty-nine percent of the patients
(20 out of 34) underwent maxillary (Le Fort I) segmenta­
tion. Six percent of the patient (2 out of 34) underwent
otoplasty. For all patients, the intranasal procedures included
both septoplasty (submucosal resection) and inferior turbi­
nate reduction.
All patients were either extubated in the operating room
or within the first hour after surgery while in the recovery
room. No patients required overnight intubation, reintuba­
tion, or tracheotomy. With respect to complications, no
patients required nasal packing or postdischarge blood
transfusion. No patient required a return to the operating
room for the control of bleeding or airway management.
Twenty-six of the 34 study patients (76%) elected to
auto-donate (bank) blood in advance of their surgeries. Two
of the 34 study patients auto-donated two units of blood,
whereas 24 of the 34 auto-donated just one unit. Only one
of the 26 patients that auto-donated received back her
banked blood (1 out of 34 or 3% of study patients); she
received just one unit of autogenous blood. One of the 34
study patients received a cross-matched anonymously
donated (i.e. allogenic) unit (1 out of 34 or 3%). This
patient did not elect to auto-donate blood in advance of
surgery, and she received just the one unit of blood. Actual
autogenous blood use within the group that banked blood
was assessed to determine the proportion of discarded stored
units. On the basis of the total units of blood that were
pre-donated, 28 out of 29 (97%) of the stored units were
not used and therefore discarded.
The records of each study patient (n = 34) were specifi­
cally reviewed for possible complications associated with the
harvesting of autogenous blood and receiving a blood trans­
fusion. Neither of the two patients who received packed red
blood cells (one autogenous and the other homologous)
experienced intraoperative or postoperative cardiovascular
or respiratory compromise. There was no evidence of an
adverse event such as an allergic reaction, a transfusion-
related infection, hemolysis related to incompatible blood
type, or an alteration of the immune system in either
patient. According to a review of the blood bank records
and discussions with the patients and their families, no
complications were known to have occurred as a result of
the blood-harvesting process.
Controversies in Blood Replacement for
Orthognathic Surgery
Autogenous blood transfusion is the collection and then
transfusion of a patient’s own blood. Allogenic blood is
collected from someone other than the patient. During
recent years, insights into the use of autogenous blood led
to a complete revision of the National Heart, Lung and
Blood Institute’s recommendations regarding the use of
autogenous blood. Despite the reduction of the risk of
transmitting viruses such as human immunodeficiency

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CHAPTER 11  Anesthesia Techniques, Blood Loss/Fluid Replacement, Airway Management & Convalescence
TABLE
11-1 
Blood Replacement for Complex Orthognathic Surgery
Patient
Jaw Deformity
Entry
No.
Gender
Age
(in years)
Pattern
Additional
Procedures
Blood Products
Preoperative
Hematocrit
Level
Lowest
Hematocrit
Level and
Location (OR
versus RR)
1
F
63
Mand def
Chin; neck lipo
None
40
28 RR
2
F
26
Mand def
2 segs; chin
1 auto, discarded
33
29 RR
3
M
39
Max and mand
def
3 segs; chin;
ICBG; neck lipo
2 auto, discarded
38
27 RR
4
M
35
Long Face
Third molars; 2
segs; chin
2 auto, discarded
38
35 RR
5
M
20
Asym mand
excess
Third molars; 2
segs; chin
1 auto, discarded
37
32 OR
6
F
21
Asym mand
excess
2 segs; chin
1 auto, discarded
32
26 OR
7
F
20
Long Face
3 segs; chin
1 auto, discarded
35
29 OR
8
F
16
Long Face
Third molars; chin
1 auto, discarded
35
30 RR
9
M
18
Cleft Jaw
ICBG; 2 segs; chin
1 auto, discarded
37
29 RR
10
F
19
Long Face
1 seg; chin
1 homo, given
34
26 OR
11
F
19
Cleft Jaw
Chin; ICBG; third
molars
1 auto, discarded
39
27 OR
12
F
13
HFM
Third molars; chin
1 auto, discarded
38
32 RR
13
F
13
Max Def/Mand
excess
Chin; scalp exc;
third molars
1 auto, discarded
28
26 OR
14
F
14
Cleft Jaw
ICBG; 3 segs;
chin; third molars
None
35
31 OR
15
M
18
Asym mand
excess
Chin; ICBG; third
molars
1 auto, discarded
40
39 OR
16
F
16
HMF
Chin; third molars
1 auto, discarded
36
27 RR
17
F
19
Asym mand
excess
Chin
None
38
32 RR
18
M
17
Max Def/Mand
excess
3 segs; chin; third
molars
1 auto, discarded
38
33 RR
19
M
25
Asym mand
excess
2 segs
1 auto, discarded
45
39 RR
20
F
16
Max Def/Mand
excess
3 segs; chin
1 auto, discarded
38
28 RR
21
M
17
Asym mand
excess
2 segs; chin; third
molars
1 auto, discarded
35
30 RR
22
M
15
Cleft Jaw
2 segs; chin; third
molars
1 auto, discarded
40
35 RR
Continued

316
SECTION 1  Basic Principles and Concepts
undesirable for orthognathic surgery as a result of the associ­
ated saliva contamination. Acute normo-volemic hemodilu­
tion is the removal of blood and the simultaneous infusion
of cell-free solutions to maintain intravascular volume
before surgical blood loss. The removed blood is transfused
during or after surgery, as needed, to maintain the desired
hemoglobin levels. The use of this technique requires sig­
nificant clinical expertise because of its associated physio­
logic consequences, and there is increased risk with DHA
during orthognathic surgery.
The current recommendation of the National Heart,
Lung and Blood Institute’s conference report is that autog­
enous blood donations are indicated for patients who are
having surgical procedures for which blood is usually cross-
matched.185 The less likely the transfusion for a specific
virus, hepatitis B virus, or hepatitis C virus, the transfusion
of autogenous blood remains safer than that of allogenic
blood, and it is considered appropriate for properly selected
patients. However, there is still a risk of adverse reactions,
bacterial contamination, and errors in the identification of
the units. Directed donations (i.e., blood donations from a
friend or family member) for a designated patient are not
as safe as the patient’s own blood and must not be consid­
ered equivalent to an autogenous blood transfusion.
If transfusion is likely for a planned surgical proce­
dure, there are several theoretical ways of obtaining autog­
enous blood, including 1) preoperative autogenous blood
donation; 2) intraoperative blood salvage; and 3) acute
normo-volemic hemodilution. In general, autogenous
(intraoperative) blood collection techniques are considered
TABLE
11-1 
Blood Replacement for Complex Orthognathic Surgery—cont’d
Patient
Jaw Deformity
Entry
No.
Gender
Age
(in years)
Pattern
Additional
Procedures
Blood Products
Preoperative
Hematocrit
Level
Lowest
Hematocrit
Level and
Location (OR
versus RR)
23
M
22
Max Def/Mand
excess
Chin
None
43
38 RR
24
F
15
Cleft Jaw
3 segs; chin;
ICBG; neck lipo
1 auto, discarded
33
28 RR
25
F
14
Long Face
3 segs; chin;
otoplasty; third
molars; neck lipo
1 auto, given
38
26 RR
26
F
23
Max mand def
ICBG; chin; 3 segs
1 auto, discarded
33
27 OR
27
F
26
Asym mand
excess
3 segs; chin
1 auto, discarded
35
29
28
M
17
Asym mand
excess
3 segs
1 auto, discarded
39
34
29
M
14
Cleft jaw
ICBG; otoplasty;
chin; third molars
None
33
30
30
F
55
Long Face
3 segs; chin; neck
lipo
1 auto, discarded
31
26
31
F
28
Long Face
3 segs; chin
1 auto, discarded
33
30
32
M
18
Max Def/Mand
excess
Chin; third molars
1 auto, discarded
34
33
33
M
24
Max Def/Mand
excess
Chin; neck lipo
1 auto, discarded
36
34
34
M
22
Asym mand
excess
Chin
1 auto, discarded
39
35
Asym, asymmetric; auto, autologous blood donation; def, deficiency; exc, excision; F, female; HFM, hemifacial microsomia; homo, homologous blood
donation; ICBG, iliac crest bone graft; lipo, liposuction; M, male; mand, mandibular; max, maxillary; OR, Operating Room; RR, Recovery Room; seg(s),
segment(s). From Posnick JC, Rabinovich A, Richardson DT: Blood replacement for complex orthognathic surgery, J Oral Maxillofac Surg 68:54–59, 2010.

317
CHAPTER 11  Anesthesia Techniques, Blood Loss/Fluid Replacement, Airway Management & Convalescence
of DHA techniques, only a small percentage of individuals
who are undergoing even complex orthognathic and intra­
nasal surgery should require blood replacement. Close col­
laboration between the surgical and anesthesia teams and
the recovery of patients in a safely monitored environment
will continue to improve operating room and postoperative
safety and to reduce blood loss and the need for transfusion
in the orthognathic patient.
Perioperative Airway Management in
the Patient with a Dentofacial
Deformity
A basic airway decision for the surgeon and the anesthesi­
ologist to make for the individual who is to undergo orthog­
nathic surgery and who therefore requires general anesthesia
is whether to use induced anesthesia and then directly intu­
bate with or without the use of a Glide Scope (Bell Medical
Inc., St. Louis, MO); to use awake fiber-optic intubation;
or to use a percutaneous technique (e.g., cricothyroidotomy
and tracheostomy). The patient with a dentofacial defor­
mity who presents for general anesthesia should be consid­
ered to have a difficult airway until it is proven otherwise
(Fig. 11-1).45,48,123,127,141,146,172,203,207,217
Head and Neck Examination
The head and neck examination of a patient who is sched­
uled to undergo endotracheal intubation should include his
or her mouth-opening ability; the ability to protrude the
lower jaw; any limitations of neck extension; the measure­
ment of the thyromental distance; and the Mallampati
test.140,164,165 These parameters cover the standard reference
points to determine whether or not to expect a difficult
airway. These parameters represent components of the basic
head and neck airway evaluation recommended in the
guidelines of the American Society of Anesthesiologists.6
1. Mouth-opening ability. This is measured as the interinci­
sor distance. A value of less than 4 cm has been proposed
as an indicator of possible difficult intubation. Fibrous
or bony temporomandibular joint ankylosis will abso­
lutely diminish mouth opening. Muscle spasms or pain
may also limit mouth opening, but these factors can be
overcome with muscle relaxants and analgesics.
2. The inability of the individual to protrude the lower jaw
forward. When the mandibular incisors cannot protrude
in front of the maxillary incisors, this is considered to
be an indicator of a difficult intubation. It is often an
indirect test for mandibular retrognathia. In addition, it
can be a deceiving indicator of normal jaw morphology
in the individual with a normal mandible but with max­
illary deficiency.
3. Limited neck extension. An angle of less than 20 degrees
as measured between the occlusal surface of the maxillary
teeth and the neck when it is in full extension is felt
to be suggestive of a difficult direct laryngoscopy. A
procedure, the more likely that donated blood will not be
used. The recommendations are that patients should not be
encouraged to donate blood for autogenous use during
surgery unless there is a greater than 10% likelihood that
they will need it. The historic literature indicates a wide
range (i.e., 2.5% to 75%) with regard to the use of transfu­
sion during bimaxillary orthognathic surgery. The review
study performed by Posnick and colleagues indicated only a
6% need.202 In current practice, the need for blood replace­
ment during bimaxillary orthognathic surgery may be closer
to 2%. The high-risk individual (e.g., an adult with obstruc­
tive sleep apnea and other comorbidities) can usually be
recognized from the outset, and preparations can be made
in advance (i.e., blood typing and cross-matching).
Unfortunately, it is not possible to give a quantitative
answer to the question, “When should autogenous or allogenic
blood be transfused?” Practical guidelines have been based on
hemoglobin levels, but the inadequacy of this parameter is
well known. In general, transfusions should be strongly
considered when the patient’s hemoglobin level is at 7.0 g
per liter (hematocrit = 21) or less. However, in the majority
of cases, orthognathic surgery is carried out in young,
healthy patients who are free of systemic disease. Thus, there
is no absolute hemoglobin level that should automatically
trigger a transfusion. A transfusion should be given only on
the basis of sound clinical judgment.
Another common question is, “Should the indications for
the use of autogenous blood transfusion differ from those for the
use of allogenic blood transfusion?” If precise indications for
a blood transfusion could be defined, autogenous blood
would not be given more frequently than allogenic.
Although the benefits of allogenic and autogenous blood
transfusions are the same, the risks are not. Therefore, the
risk-to-benefit ratio clearly supports the more liberal use of
autogenous blood. It has been documented that patients
who preoperatively donate blood are more likely to be trans­
fused earlier and more frequently than patients who do not
auto-donate. Studies have challenged the use of autologous
blood donations for elective surgery, because there is the
possibility of blood overcollection, the wasting of autolo­
gous units, and the costs of preparation and storage. Cohen
developed an interesting mathematical model to analyze the
use of preoperative autogenous blood donation.53 The
model clarifies how clinicians can customize autogenous
blood collection for individual patients to minimize waste
(i.e., the need to discard non-transfused blood).
A limited survey of hospitals in the United States deter­
mined that the fee generated by the blood bank for each
unit of autologous blood that is harvested is estimated to
be $255. This includes the storage and delivery of the blood
to the operating room or for the disposal of the blood
product (i.e., hazardous waste) if it is not used. This fee is
typically paid in full by the patient’s medical insurance
carrier. If the operative procedure for which the blood is
donated is not covered by the patient’s medical insurance
carrier, then the patient is expected to pay the fee.
A critical review of the literature and the evaluation of
current clinical practice indicates that, with the effective use

318
SECTION 1  Basic Principles and Concepts
surgery. It is also recommended that the evaluation docu­
ment the following:
• The status of the teeth (e.g., mobility, missing teeth,
removable and fixed appliances, general oral heath);
• The neck circumference (this is an indirect indicator of
obstructive sleep apnea)
• The overall body habitus
• Any presenting dentofacial deformity (e.g., maxillo-
mandibular deficiency)
• Any anatomic cause of nasal airway obstruction (e.g.,
septal deviation, posterior choanal atresia, enlarged
turbinates)
Prevention of Complications during
Tracheal Intubation
According to the American Society of Anesthesiologists,
four principles are central to the prevention of complica­
tions during tracheal intubation:
1. The maintenance of oxygenation is essential. Preoxygen­
ation is performed before the induction of anesthesia.
Mask ventilation is also used in between attempts at
tracheal intubation.
2. Trauma to the upper airway must be prevented. The first
attempt at tracheal intubation should be performed
under optimal conditions (i.e., patient positioning, pre­
oxygenation, and equipment preparation).
3. The anesthesiologist should have a backup plan in place
before initiation of the primary technique. He or she must
have the skills and equipment needed to execute the
percentage of dentofacial deformity patients will have
cervical spine anomalies that prevent adequate and safe
neck extension.
4. The Mallampati test. The visibility of the pharyngeal
structures when the mouth is wide open is considered
to be of limited use as an individual assessment. However,
when this is considered in combination with other phys­
ical findings, it is of some value. The dentofacial defor­
mity patient with baseline obstructive sleep apnea is
likely to have a Class IV Mallampati classification. The
Mallampati classification is determined by having the
awake patient in the sitting position open his or her
mouth widely and then protrude the tongue completely
forward. The clinician then documents which structures
can be visualized.
Class I:  The soft palate, the fauces, the entire uvula,
and the pillars are visualized.
Class II:  The soft palate, the fauces, and a portion of
the uvula are visualized.
Class III:  The soft palate and the base of the uvula are
visualized.
Class IV:  Only the hard palate is visualized.
5. The thyromental distance. This is often used as an in­
direct gauge of mandibular morphology. The ratio of a
patient’s overall height to his or her thyromental distance
may be used as an indirect assessment of mandibular
deficiency.
All patients with dentofacial deformities should have
documentation by the anesthesiologist of the airway exami­
nation, as stated previously. The preoperative evaluation
maybe conducted in a clinic setting or immediately before
• Figure 11-1  Perioperative risk to the airway and its management should be considered during all phases of orthognathic surgery, including
before nasotracheal intubation, during surgery, at the time of extubation, and soon after extubation. Individuals who are scheduled for orthog­
nathic surgery who have been recognized to be at high risk for airway compromise should be discussed in advance with the anesthesia
team to arrange for special needs. Three patient examples in which these issues came into play are shown: an adult with Noonan syndrome;
a teenage girl with Treacher Collins syndrome; and a teenager with the Klippel–Feil anomaly. Each of these patients also has the potential
for cervical spine anomalies with limited neck range of motion. The Risk of spinal cord injury should also be evaluated before orthognathic
surgery.
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CHAPTER 11  Anesthesia Techniques, Blood Loss/Fluid Replacement, Airway Management & Convalescence
NOTE: In the patient with a dentofacial deformity,
serious airway morbidity (e.g., cardiopulmonary arrest, or
unnecessary tracheostomy)—although infrequent—is
a much worse outcome than performing an awake
fiber-optic intubation that may not have been necessary.
The practical guidelines for the management of the dif­
ficult airway have been reported by the American Society
of Anesthesiologists Task Force on Management of the Dif­
ficult Airway.6 The guidelines recommend the following: 1)
a detailed evaluation of the airway; 2) a general physical
examination; 3) additional patient-specific evaluations, as
needed; 4) basic preparation for difficult airway manage­
ment; 5) a strategy for the intubation of the difficult airway;
6) a strategy for the extubation of the difficult airway; and
7) arranging for follow-up care.
The anesthesiologist should have a preformulated strat­
egy for the intubation of the patient with a dentofacial
deformity and a difficult airway. This strategy should include
the following:
1. An assessment of the likelihood and anticipated clinical
impact of four basic problems that may occur alone or
in combination:
• Difficult ventilation
• Difficult intubation
• Difficulty with patient cooperation
• Difficult tracheostomy (cricothyroidotomy)
2. A consideration of the relative clinical merits and feasi­
bility of the three basic airway management choices:
• Awake fiber-optic intubation versus intubation after
the induction of general anesthesia
• The use of noninvasive techniques for the initial
approach to intubation (e.g., direct conventional
laryngoscopy, laryngeal mask airway–assisted airway
attainment, video-assisted laryngoscopy) versus the
use of invasive techniques (e.g., percutaneous crico­
thyroidotomy, tracheostomy)
• The preservation of spontaneous ventilation during
intubation attempts versus the ablation of spontane­
ous ventilation during intubation attempts
3. The anesthesiologist must select a primary approach to
the difficult airway:
• Awake fiber-optic intubation in the patient who
cannot be adequately ventilated and who will be dif­
ficult to intubate
• The patient who can be adequately ventilated but who
will be difficult to intubate
• The life-threatening situation in which the patient
cannot be ventilated or intubated and who will require
immediate cricothyroidotomy or tracheostomy
4. The anesthesiologist should formulate in advance an
alternative plan in the event that the primary approach
is ineffective.
Special Airway Considerations in the Patient
with a Dentofacial Deformity
The patient with a dentofacial deformity who is scheduled
to undergo orthognathic surgery requires nasotracheal intu­
bation as a first choice. The consideration of patient-specific
intubation difficulties should be discussed between the
surgeon and the anesthesiologist before arrival in the operat­
ing room (see Figure 11-1).
backup plan for the patient with a difficult airway. The
recent introduction of video-assisted laryngoscopy
instruments have lessened the need for more invasive
methods to secure the airway, such as the use of a fiber-
optic bronchoscope and percutaneous techniques. The
backup plan should include the eventuality that, if non­
invasive techniques do not restore oxygenation, then
cricothyroidotomy (which is generally the percutaneous
airway method of choice) is ready to go. In an actual
“cannot intubate—cannot ventilate” situation, immediate
percutaneous access to the cricothyroid membrane is
essential.
4. The anesthesiologist should seek the best help available as
soon as difficulty with tracheal intubation is experienced.
He or she should be aware of available backup personnel
or colleagues who can be quickly called in to assist
during an emergency.
Video 5
The presurgical airway evaluation by an experienced anes­
thesiologist provides a reasonable indication of potential
intubation difficulty and should always be performed. The
anesthesiologist must then make a judgment regarding
whether anesthesia induction followed by direct laryngos­
copy (as a first effort) followed by mask ventilation with
percutaneous rescue (if direct laryngoscopy cannot be accom­
plished) is likely to be successful. The intrinsic limitations of
the pre-anesthesia airway assessment mean that the prepara­
tion of an airway strategy for the management of unantici­
pated difficulties is the ultimate key to safe practice.
When the patient with a dentofacial deformity is felt to
be at high risk for challenging airway management, advance
planning ensures that necessary equipment and skilled per­
sonnel are available. The “difficult airway” is defined as the
clinical situation in which a conventionally trained anesthe­
siologist experiences difficulty with face-mask ventilation of
the upper airway, difficulty with tracheal intubation, or
both. By definition, the difficult airway represents a com­
bination of patient-specific factors, the specific clinical
setting, and the skills of the individual practitioners.
Adequate face-mask ventilation may not be possible as a
result of inadequate mask seal, excessive gas leak, or exces­
sive resistance to the ingress or egress of gas. Difficulty with
laryngoscopy is said to occur when it is not possible to
visualize any portion of the vocal cords. Difficult tracheal
intubation is defined as a tracheal intubation that has
required multiple attempts in the presence or absence of
true tracheal pathology. Failed intubation is defined as the
inability to place an endotracheal tube after multiple intu­
bation attempts.

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SECTION 1  Basic Principles and Concepts
in the retro and superior positioning of all of the soft
tissues of the floor of the mouth and the anterior
neck. This will result in limited visualization of the
vocal cords. This may be true even for a non-obese
patient in the neck-extended position during a full
jaw-thrust maneuver.
Difficulty with visualizing the vocal cords as a result of
limitations in the range of motion of the neck:
• A percentage of patients with dentofacial deformities
will have congenital limitations in the range of motion
of the neck (e.g., hemifacial microsomia [Goldenhar
variant], Klippel–Feil anomaly). This should be
assessed before the patient arrives in the operating
room.
• For the patient with baseline cervical spine anomalies,
evaluation by a spine surgeon and specialized radio­
graph studies may be indicated in the outpatient
setting before arrival in the operating room.
• Possible advantages of intraoperative spinal monitor­
ing should be discussed before arrival in the operating
room.
It is likely that the orthognathic surgeon will be most
familiar with the nasal, oral, pharyngeal, temporoman­
dibular joint, and cervical spine patient-specific anatomy.
Potential locations of obstruction and limitations in neck
and jaw range of motion should be discussed before arrival
in the operating room. The surgeon should be ready to
assist with the passage of the nasotracheal tube through the
external nasal valve and the nasal cavity and into the oro­
pharynx. The anesthesiologist will then complete direct
laryngoscopy, video-assisted laryngoscopy (i.e., Glide­
Scope), or fiber-optic intubation to pass the endotracheal
tube through the vocal cords.144,146 In anticipation of the
possible need for percutaneous airway management, the
team should have the skill and readiness of equipment to
complete either a cricothyroidotomy or a formal tracheos­
tomy, as indicated.
Immediate Preintubation Preparation
of the Airway
Preparation of the nasopharynx is useful before attempting
nasotracheal intubation. It begins with questioning the
awake patient about the ease of breathing through one nares
versus the other. Preparation of the nasal airway with topical
agents just before entering the operating theater is also
routine; this allows the agents to reach peak effect before
intubation. Topical vasoconstrictors such as oxymetazoline
(a direct-acting sympathomimetic vasoconstrictor) or Neo-
Synephrine (an alpha-adrenergic agonist and a potent vaso­
constrictor) will reduce nasal mucosal edema, thereby
improving the patency of the nares and also reducing the
potential for bleeding.
After the nasal airway is decongested and sufficiently
anesthetized, sequential dilation with a nasopharyngeal
Difficulty with passing the endotracheal tube through
the external nasal valve and the nasal cavity:
• The dentofacial deformity patient will often have an
obstructed nasal airway as a result of a combination
of scarred external nasal valves; a deviated septum;
hypertrophic turbinates; a constricted bony nasal
cavity (e.g., floor of the nose, lateral nasal walls); or
posterior choanal atresia.
Difficulty with passing the endotracheal tube past the
soft palate and nasopharyngeal walls into the oropharynx:
• In the patient with a cleft palate, a pharyngoplasty
may be in place. This will result in limited lateral ports
if a superiorly based pharyngeal flap is in place. There
may be a limited central port if an orticochea (sphinc­
teroplasty) flap is in place. Either of these forms of
pharyngoplasty in the patient with a cleft palate may
interfere with the passage of a nasotracheal tube.
• If the endotracheal tube cannot be passed through
the nose and into the oropharynx, then the insertion
of the endotracheal tube through a submental (skin)
incision maybe carried out. This will accomplish
intubation objectives but avoid interference with the
occlusion during surgery. To accomplish the sub­
mental approach, the endotracheal tube is first passed
through the oral cavity and into the pharynx. With
the use of a laryngoscope, it is then passed through
the vocal cords. The patient will be adequately venti­
lated while the submental approach is accomplished.
A sharp submental incision is made, and this is fol­
lowed by blunt dissection just behind the mandible
and then into the mouth. The end of the endotra­
cheal tube is pulled through the floor of the mouth
and out of the submental incision for the administra­
tion of anesthesia.
Difficulty with inserting and using the laryngoscope
to visualize the vocal cords as a result of limited mouth
opening:
• The presenting dentofacial malformation may result
in limited mouth opening (e.g., Treacher Collins syn­
drome, hemifacial microsomia)
• Temporomandibular joint pathology (bony or fibrous
ankylosis) will limit the extent of mouth opening (i.e.,
the interincisal distance).
• Masticatory muscle spasm will limit mouth opening
and may be confused with bony or fibrous temporo­
mandibular joint ankylosis.
Difficulty with visualizing the vocal cords as a result of
mandibular hypoplasia with a retro and superior positioned
tongue within a limited floor of the mouth space:
• The presenting mandibular malformation or defor­
mity (e.g., moderate to severe hypoplasia) will result

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CHAPTER 11  Anesthesia Techniques, Blood Loss/Fluid Replacement, Airway Management & Convalescence
• Excessive sedation with the inadequate return of
reflexes
• Continued intranasal or intraoral hemorrhage with
pooling in the pharynx, which may go unrecognized
and cannot be easily suctioned
• Excessive swelling within the intranasal, intraoral, and
pharyngeal components of the upper airway
• Laryngeal swelling or spasm
• The
potential
for
immediate
postextubation
vomiting
• The patient-specific presence of in-place intermaxil­
lary wires, elastics, or intra-oral splints
The formulated extubation strategy should include the
following:
• Strong consideration of the advantages of awake
extubation versus extubation before the return of
consciousness
• The formulation of an airway management plan to be
implemented if the patient is not able to maintain
adequate ventilation after extubation
• An evaluation of the general and patient specific clini­
cal factors that may result in difficulty with mask
ventilation after extubation
• Consideration for the short-term maintenance of
a device that can serve as a guide for expedited rein­
tubation. A semi-rigid airway device called a tube
exchanger can be inserted through the lumen of the
nasotracheal tube and into the trachea before the
nasotracheal tube is removed. This device can then be
used to facilitate the reinsertion of the nasotracheal
tube should reintubation be required. It also allows
for the limited ability to both oxygenate and ventilate
the patient during the performance of reintubation
maneuvers.
• A plan for percutaneous intubation (i.e., cricothyroid­
otomy or tracheostomy) with available equipment at
the location of patient extubation (i.e., operating
room, recovery room, or intensive care unit) with the
skilled personnel required to complete the procedure,
if required
• Discussion between surgeon and the anesthesiolo­
gist regarding patient-specific limitations in mouth
opening (e.g., intermaxillary wires, elastics, mastica­
tory muscle spasms, intra-oral splints)
Extubation Criteria for
the Orthognathic Patient
With the administration of neuromuscular blocking agents
as well as multiple combinations of various classes of drugs
including opioids, barbiturates, and benzodiazepines, the
modern hypothesis of general anesthesia has evolved to be
understood as a process that requires a state of unconscious­
ness of the brain as well as a blockade of noxious stimuli,
both centrally and peripherally. Recognition of the stage or
plane of anesthesia by the clinician is important at all times
airway tube (nasal trumpet) is recommended to clarify the
expected ease or difficulty of passage of the nasotracheal
tube. The nasopharyngeal airways should be lubricated
with either standard surgical lubricant or topical lidocaine
jelly, which may also be mixed with topical vasoconstrictor.
The use of benzocaine spray as a topical anesthetic is
another option; however, as a result of the rapid uptake of
this drug, the high rate of absorption through the mucus
membranes, and the risk of toxicity judicious use is war­
ranted. Methemoglobinemia has been reported to occur
with benzocaine spray and other local anesthetics. This may
occur when the ferrous ion (Fe+2) of the hemoglobin mol­
ecule is converted into the ferric ion (Fe+3), thereby result­
ing in decreased oxygen-carrying capacity. If this occurs,
treatment includes supplemental oxygen and intravenous
methylene blue.
Glycopyrrolate (Robinul) is a synthetic quaternary amine
with muscarinic anticholinergic and antisialagogue proper­
ties. The expected sympathetic reflex that occurs during the
induction of general anesthesia may result in copious secre­
tions in the oropharynx, thereby obscuring laryngoscopy
and making a successful intubation difficult. Secretions can
be managed with an antisialagogue (e.g., glycopyrrolate),
which will also improve the oropharyngeal surgical field.
However, glycopyrrolate will tend to increase heart rate and
blood pressure as a result of its anticholinergic effects. This
may need to be attenuated with appropriate beta-blocker or
vasodilator therapy.
A commonly used protocol for the preintubation
preparation of the nasopharyngeal airway includes the
following:
• Pretreatment with the judicious use of a topical vaso­
constrictor (e.g., oxymetazoline, Neo-Synephrine) to
shrink the nasal mucosa
• Pretreatment with a topical anesthetic, including
topical lidocaine jelly
• Sequential dilation with lubricated nasopharyngeal
airways (i.e., the nasal trumpets) to ease the passage
of the nasotracheal tube
Strategy for Extubation after
Orthognathic Surgery
After orthognathic surgery, all patients should be considered
to have a difficult airway at the time of extubation. An
extubation strategy is a logical extension of the planned
intubation strategy for the patient with a difficult airway.
The extubation strategy should be specific to the patient,
and it should take into account preoperative anatomic
factors; preexisting medical conditions; intraoperative find­
ings; patient-specific swelling and intra-oral bleeding; and
the patient’s response to the anesthesia techniques that were
used.37,43,62,124,257,278
Factors to consider include the following:
• Baseline preoperative obstructive sleep apnea
• Baseline limited neck range of motion

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SECTION 1  Basic Principles and Concepts
removal of elastics and be difficult at best. The inability to
adequately mask or reintubate the patient either orally or
nasally will necessitate an emergency cricothyroidotomy or
tracheotomy.
Negative pressure pulmonary edema is an uncommon
complication that occurs during the extubation of the
trachea in approximately 0.1% of cases.29 It is believed to
be a result of laryngospasm. Upper airway obstruction from
glottis closure leads to marked inspiratory efforts, which
generates negative intrathoracic pressure. This may cause
negative-pressure pulmonary edema and, rarely, hemopty­
sis. Immediately after extubation, the patient will be noted
to have marked respiratory distress followed by edema fluid
and decreased arterial oxygen saturation, with rising partial
pressure of CO2 levels. A chest radiograph will likely show
bilateral pulmonary infiltrates. The most effective form of
management is reintubation followed by positive end-
expiratory pressure for 12 to 24 hours.
Before the Extubation of
the Orthognathic Patient
• Any deliberate hypotensive techniques should be ceased
with a return to preoperative hemodynamic stability.
• Any hypothermia should be addressed with rewarming
techniques, including temperature-controlled intrave­
nous fluids and warming blankets.
• The patient’s breathing pattern should be regular, with
adequate tidal volume (i.e., 6 to 10 mL/kg) and rate of
respiration (i.e., 10 to 20 breaths/min).
If the patient was chemically paralyzed, this must be
reversed with appropriate agents, (e.g. neostigmine and an
anticholinergic agent such as glycopyrrolate). Reversal
should be monitored with a twitch monitor, which consists
of two electrodes placed at a motor nerve. The ulnar nerve
is commonly stimulated to observe the contraction of the
adductor pollicis muscle. The return of train-of-four
twitches with a ratio of more than 0.9 and with sustained
tetany is a method that is used to provide information about
the depth of neuromuscular blockade throughout the case
and through its reversal at the end. It also allows for the
differentiation of depolarizing and nondepolarizing neuro­
muscular blockade.
• If bispectral index monitoring is used to assess the depth
of anesthesia, a return to preoperative levels should be
documented.
• Adequate analgesia is maintained with appropriate
opioids, but titration with maintenance to a physiologic
respiratory rate and tidal volume is required.
• The patient should be sufficiently awake and should have
spontaneous eye opening with a conjugate gaze.
• The patient should be able to follow commands (e.g.,
sustained head lift and hand grip).
• A nasopharyngeal airway (i.e., a nasal trumpet) may be
placed to assist with ventilation after extubation.
but especially at the end of the operation, when the patient
must be recovered in a safe, efficient manner.
There are four classically described stages of anesthesia
that are based on physical signs (e.g., respiratory status,
hemodynamic status, ocular signs, muscle tone) that dem­
onstrate the depth of anesthesia.
• Stage I is present when there is analgesia and amnesia
but no loss of consciousness.
• Stage II is the period after a loss of consciousness at
which point the patient’s reflexes are still present, the
breathing pattern is irregular, and there may be excit­
ability. The pupils will be dilated, and there will be a
disconjugate gaze.
• Stage III is considered surgical anesthesia, when there
will be lack of response to surgical stimulation. Loss
of the eyelash reflex is a reliable indicator of this stage.
Within Stage III, there are additional planes or levels
of consciousness that correspond with the amount of
anesthetic delivered. The plane of anesthesia that is
desired depends on the surgery being performed.
• Stage IV describes cardiovascular and respiratory
failure as a result of the overadministration of anes­
thetic, which results in brain stem and medullary
depression. This is potentially fatal.
When the need for surgical anesthesia is over, the inha­
lational and intravenous agents are stopped, and the patient
will emerge from Stage III anesthesia (i.e., the surgical plane
of anesthesia). It is important to support the patient through
Stage II and into Stage I, which is when he or she can gener­
ally be safely extubated.
Potential pitfalls of the premature extubation of any
patient include laryngospasm, excessive secretions or bleed­
ing leading to airway compromise or aspiration, and inad­
equate airway drive as a result of residual anesthetic agents
or narcotics, with the resultant need for reintubation.
Patients who are undergoing orthognathic surgery have addi­
tional and unique immediate postextubation airway concerns.
Consequently, these patients need to meet more strin­
gent criteria for extubation than would be anticipated
for a non-intranasal or non-intraoral procedure. Mouth
opening will be limited as a result of the presence of surgical
trauma and swelling of the muscles of mastication. Guiding
elastics to secure the jaws together and an intra-oral (occlu­
sal) splint are likely to be in place. Concerns about osteot­
omy stability may limit the forces that can be safely applied
on the jaws should either mask ventilation or reintubation
be required. Partial obstruction of the nasopharynx as a
result of varied degrees of mucous, fresh blood, and clotting
is to be expected. For all of these reasons, in the event of
an airway emergency after extubation, the orthognathic
patient will be difficult to mask ventilate, and there will be
only limited time to consider an alternative approach to
resecure the airway. The option of blind nasotracheal intu­
bation will be even more difficult than it would have been
before surgery. Orotracheal intubation will require the

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CHAPTER 11  Anesthesia Techniques, Blood Loss/Fluid Replacement, Airway Management & Convalescence
*References 17, 30, 47, 52, 72, 109, 112, 137, 141, 148, 153, 176, 183,
192, 194, 199, 246, 268, 271, 275.
Checklist of Benchmark Airway Parameters
Before Extubation
1. Spontaneously ventilating
2. Paralysis reversed adequately (i.e., sustained tetany
without fade for >5 sec)
3. Vital signs stable
4. No longer in Stage II anesthesia
5. Negative inspiratory force of <−20 mm Hg (i.e., you can
take off the bag, cover the hole with your hand, and have
the patient suck in while you are watching the pressure
gauge)
6. “Leak test” for the evaluation of pharyngeal and laryn­
geal edema
7. Benchmark respiratory parameters:
• Tidal volume >6 cc/kg
• Vital capacity >15 cc/kg
• Blood oxygen saturation >90%
• Respiratory rate <25 breaths/min
• paCO2 <45 mmHg
In-Hospital Convalescence After
Orthognathic Surgery
After extubation, initial management takes place in a recov­
ery room setting. Transfer to a monitored bed either in an
intensive care unit or a step-down or telemetry unit is gener­
ally preferred. Continuous awareness of the potential for
impending respiratory compromise and the need for moni­
toring to confirm hemodynamic stability is essential early
after extubation.263
Airway Needs
Respiratory issues are of immediate postoperative concern
in the orthognathic surgery patient.* The individual must
be able to maintain his or her airway as documented by the
ability to adequately oxygenate and ventilate. Multiple
factors may compromise the airway, including limitations
in nasal breathing as a result of the following: 1) the Le Fort
I down-fracture with tears in the nasal mucosa; 2) specific
intranasal procedures that were carried out (i.e., septoplasty,
inferior turbinate reduction); and 3) edema after nasotra­
cheal tube removal. The oral airway will be partially
obstructed by the following: 1) ongoing bleeding, secre­
tions, and swelling; 2) the use of guiding elastics; and 3) the
presence of an acrylic intra-oral occlusal splint secured to
the maxillary dentition. A nasopharyngeal trumpet may be
helpful to improve the nasal airway early after extubation.
The guiding elastics should be removed, if needed, to
improve the oral airway. Active and frequent bedside suc­
tioning is carried out. Supplemental oxygen given via a face
tent provides an additional reserve through the nose and
mouth; it is titrated to maintain pulse oximetry (i.e., oxygen
saturation) of more than 95%, as described later in this
chapter.
Monitoring Equipment
Continuous pulse oximetry is essential. This allows for the
beat-to-beat monitoring of hemoglobin saturation. It uses
a pair of light-emitting diodes to measure the amount of
hemoglobin in the oxyhemoglobin formation as a percent­
age. Normal oxygen saturation ranges from 97% to 100%.
It is important to remember that pulse oximetry is not a
measure of ventilation but rather of oxygenation. Factors
that can result in errors of the “pulse ox” reading include
hypoperfusion of the extremity being used for monitoring,
high central venous pressures, and carboxyhemoglobin with
carbon monoxide poisoning or methemoglobinemia. For
these reasons, pulse oximetry does not replace arterial blood
gas sampling for a precise measurement of arterial oxygen­
ation. Neither technique is a substitute for a direct physical
examination. Recently, technology advances have allowed
for the monitoring of both pulse oximetry and capnography
in one device. This is done with the use of microstream
capnography via bedside nasal prongs along with pulse
oximetry. These modalities together improve the ability to
assess the adequacy of ventilation and oxygenation during
the perioperative period.
Five-lead electrocardiography allows for the monitoring of
the cardiac waveform. The most commonly used leads are
II and V5 for diagnosing cardiac arrhythmias and cardiac
ischemia.
Noninvasive blood pressure monitoring should be used
even when an arterial line is also present postoperatively.
The continuous invasive arterial blood pressure monitor
may be maintained for 12 to 24 hours postoperatively.
This will assist with the monitoring of the patient’s arterial
blood pressure in a beat-to-beat manner. It may allow for
the improved accuracy of diagnosis and better direct the
treatment of hypovolemia and hypotension. The arterial
line can also be used to draw blood for postoperative
laboratory values instead of subjecting the patient to a fresh
needlestick.
Whenever there is use of DHA as well as a risk of post­
operative bleeding, the maintenance of the intraoperatively
placed Foley catheter to monitor urine output soon after
surgery is useful. A catheter may be helpful to assess the
success of fluid resuscitation and for patient comfort. As a
baseline, normal hourly urine output for an adult is 0.5 mL/
kg/hr; for a child, it is 1 mL/kg/hr.
Measuring the patient’s temperature both intraopera­
tively and postoperatively is important. Temperature eleva­
tion is a late sign of malignant hyperthermia, which is very
rare (i.e., 1 in 50,000 for adults). More commonly, through
temperature monitoring, the patient is found to be hypo­
thermic secondary to peripheral vasodilation caused by
inhaled anesthetic gases and exposed extremities. Hypother­
mia can cause the patient to become coagulopathic and to

324
SECTION 1  Basic Principles and Concepts
develop arrhythmias and disorders of the metabolism. Core
body temperature can be measured via a temperature-
sensing Foley catheter. For this modality, the Foley catheter
houses a thermistor at the tip that allows for continuous
core-temperature monitoring in a safe and minimally inva­
sive manner.
Sequential compression devices placed on the lower
extremities are used intraoperatively and maintained during
the postoperative period to limit the formation of deep
venous thrombosis. These devices increase the velocity of
venous blood return to the heart, thereby decreasing venous
stasis. In addition, the mechanical compression results in
increased fibrinolytic activity within the vascular system.
Stockings should be maintained while the patient is immo­
bilized. On postoperative day 1, the patient should be
ambulated with assistance, at which point the compression
stockings may be discontinued. Multiple studies have docu­
mented that early ambulation improves recovery and results
in a decreased risk of deep venous thrombosis, the return
of bowel function, and earlier hospital discharge.6
Wound Care
Intraoral hygiene with Peridex (chlorhexidine 0.12%)
and toothbrushing are performed three to five times daily.
This is to decrease the bacterial load and the levels of biofilm
in the oral cavity. This is especially important, because there
are orthodontic brackets, elastics, splints, and exposed
sutures in place near and at the incisions. An active oral
hygiene routine is initiated the night after surgery by a
health care professional. The patient and his or her family
are specifically instructed in the techniques by the day after
surgery.
In general, there are no external bandages after orthog­
nathic surgery. The patient is encouraged to shower and
shampoo his or her hair and to wash his or her face the day
after surgery and at least daily thereafter.
Diet
Initial hydration, electrolyte balance, and nutrition are
maintained though intravenous fluids. The night of surgery,
oral intake is initiated. The orthognathic patient must toler­
ate liquids for adequate nutrition and hydration before dis­
charge. Inadequate liquid intake may occasionally result in
dehydration and the need for readmission after discharge.
Caloric requirements in the healthy, non-hospitalized, and
non-stressed individual is 15 to 20 Kcal/kg/day. The caloric
need will increase substantially in the postsurgical patient,
who is, by definition, under stress. A general guideline of
caloric need in the patient after orthognathic surgery is 25
Kcal/kg/day. In addition, protein requirements can be
doubled from 1 gm/kg of ideal body weight per day to 2
gm/kg of ideal body weight per day.
Surgical trauma to the lips and cheeks initially results
in the diminished ability to achieve full lip seal. Without
sufficient lip seal, the ease with which one can swallow
liquids or drink from a cup is limited (see Chapter 8). A
feeding syringe with a soft wide bore tip is initially used. It
is placed in the vestibule between the cheek and the poste­
rior teeth to facilitate the direction and depth of entry of
liquids. The fluid bolus is injected, and the patient then seals
the lips and swallows. The clear liquid diet is rapidly
advanced to full liquids to achieve the needed caloric and
nutritional intake. The patient transitions from syringe
feeding to the use of a “sippy cup” or a squeezable water
bottle and then to drinking from a soft glass as soon as he
or she is able.
Nausea and Vomiting Management
Postoperative nausea and vomiting are common anesthetic
concerns for the patient. If these conditions are not
managed, they may in rare cases result in aspiration.236,256
Steps taken to decrease their likelihood include gastric
suctioning at the end of the procedure before extubation
and the use of prophylactic medications. All orthognathic
patients are given prophylactic antiemetic therapy. A medi­
cation regimen may include the following: glucocorticoids
such as dexamethasone at the onset of surgery; ondansetron
(Zofran) or granisetron (Kytril) 15 minutes before the con­
clusion of surgery; metoclopramide (Reglan); and the judi­
cious intake of liquids immediately after extubation.
Multimodal antiemetic therapy in the recovery room should
be employed for refractory cases of nausea and vomiting;
this may include promethazine, compazine, and repeat
doses of ondansetron-like agents. Appropriate postoperative
patient monitoring and bedside access to a mouth-
suctioning device are essential. As long as the patient can
maintain protective airway reflexes, episodes of vomiting
(with only liquids on the stomach) should have minimal
serious sequelae.
Intravenous Fluid Therapy
The preoperative number of hours of “nothing-by-mouth”
status, the individual’s body weight, and the intraoperative
fluids given and lost need to be quantified. This process
allows for a precise representation of the patient’s fluid
balance and ongoing fluid and electrolyte needs. The intra­
venous fluid needs must account for both sensible and
insensible losses. Once maintenance fluids are calculated, a
determination of estimated fluid deficit (EFD) should be
made. Intraoperative third space loss and blood loss will also
be taken into account. Fluid administration needs to be
titrated to maintain hydration and desired urine output.
A starting point to estimate maintenance fluid needs
after surgery can be given with the use of the following
formula:
• 4 mL/kg/hr for the first 10 kg of body weight
• 2 mL/kg/hr for the next 10 kg of body weight
• 1 mL/kg/hr for every 1 kg of body weight above
20 kg

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CHAPTER 11  Anesthesia Techniques, Blood Loss/Fluid Replacement, Airway Management & Convalescence
Pain Management
The postoperative orthognathic patient has pain require­
ments that are similar to those of any other surgical patient.
Analgesia is required for the progression of the patient to
recovery. Initial postoperative requirements are best main­
tained with intravenous medication, whether it is admin­
istered by the nursing staff or patient controlled. Multiple
studies have confirmed that patient-controlled analgesia is
safe, effective, and not likely to result in oversedation or
respiratory compromise. Intravenous morphine sulfate is
routinely used. By the morning after surgery, the patient
is transitioned to a liquid form of opioid that taken at
4- to 6-hour intervals as needed for analgesia. It would be
unusual for the patient to require or request opioid pain
control by the second week after surgery. The transition
from intravenous analgesics to an oral form is essential for
the patient’s discharge and his or her comfortable transi­
tion to home care.
Antibiotics
Multiple studies have confirmed the benefit of prophylactic
doses of antibiotics for clean-contaminated (Class II)
surgery and specifically for orthognathic surgery to decrease
wound infection rates. This is typically initiated as a pro­
phylactic dose of the first-generation cephalosporin cefazo­
lin (Ancef); 15 to 20 mg/kg and up to 1 g is given before
surgical incision and then every 6 hours. The postoperative
course of intravenous antibiotics continues while the patient
is still in the hospital. Antibiotics are then given orally upon
discharge for a total of no more than a 5-day course. Opin­
ions vary with regard to the extent of use of antibiotics for
orthognathic surgery. Bentley and colleagues performed a
randomized controlled trial that compared a 1-day regimen
with a 5-day regimen of antibiotics for patients who were
undergoing orthognathic surgery.24 A group of 30 patients
who were undergoing combined maxillary and mandibular
osteotomies was divided equally. Nine out of 15 patients in
the 1-day antibiotic group developed postoperative infec­
tion, whereas only 1 out of 15 patients in the 5-day antibi­
otic group did. The authors concluded that a 5-day course
of antibiotics is useful to decrease the risk of postoperative
infection (see Chapter 16).
Nasal Medications
The use of specific nasal medications after surgery varies
by surgeon preference. Many surgeons recommend that,
after surgery, several days of an intranasal decongestant
be given to open the nasal airway and improve patient
comfort. These can include Neo-Synephrine nasal spray,
oxymetazoline (Afrin) nasal spray, or a corticosteroid such
as Rhinocort. In addition, saline nasal spray improves the
humidification of the nasal passages and limits the drying
of the nasal mucosa, which may decrease the risk of epistaxis
and improve patient comfort. A pure nasal saline spray has
the advantage of not having a rebound effect as compared
with the pharmacologic agents. This is the requirement that
I prefer.
Criteria for Discharge from Hospital
Discharge planning for the orthognathic patient should
begin before surgery. There should be ample preoperative
communication with the patient and the patient’s family or
significant others to prepare for the anticipated postopera­
tive care requirements, including medications, diet, oral and
body hygiene needs, and activity level. Basic criteria for
discharge from the hospital include the following:
• The ability to ingest sufficient liquids orally (i.e.,
hydration and nutrition)
• The absence of significant fever
• Stable vital signs, including the maintenance of pulse-
oximetry documented oxygenation while sleeping
• The absence of continued nausea and vomiting
• Sufficient ambulation to carry out necessary activities
of daily living in conjunction with a designated family
member, friend, or caregiver
• Adequate pain control with oral analgesia while in the
hospital
• The demonstrated ability to achieve required body
and oral hygiene
At-Home Convalescence and
Outpatient Care After
Orthognathic Surgery
When feasible, our preferred outpatient regimen involves
weekly office visits for 5 weeks after orthognathic surgery.
Although the frequency and duration of routine postopera­
tive office visits will vary from surgeon to surgeon, there is
no substitute for a face-to-face discussion and a hands-on
examination with the patient to clarify expected progress,
to identify potential problems, and to institute timely treat­
ment during the early phases of healing.
Important aspects to monitor early after orthognathic
surgery include the following: 1) diet, hydration, and nutri­
tion; 2) oral and body hygiene; 3) physical activity level; 4)
emotional well-being; 5) medication use; 6) swelling and
wound healing; 7) occlusion and jaw mobility; and 8) ade­
quacy of the oral and nasal airways. The need for physical
therapy related to A) lip seal and control exercises, B)
sensory retraining exercises, and C) mouth-opening exer­
cises is also assessed. Each of these parameters is addressed
during each postoperative office visit. When weekly visits
with the surgeon are not geographically convenient, an
appropriate clinician closer to home (i.e., an orthodontist
and surgeon) can generally be found. This is best supple­
mented with a phone call and the viewing of e-mailed facial
photos sent to the primary surgeon.

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SECTION 1  Basic Principles and Concepts
Patient Education Materials
Patient Instructions for Orthognathic Surgery
The purpose of these basic instructions is to help you prepare and then recover from your operation with as little
discomfort and inconvenience as possible.
Preoperative Instructions
1. During the 2 to 6 weeks before your planned operation, you will return to my office to have current dental and facial
records taken; to undergo further head and neck examination; and to allow for the completion of analytic model
planning.
2. During the 2 to 6 weeks before your surgery, make arrangements for a physical examination by your family
physician that includes necessary laboratory tests to confirm your health. We will provide you with a form for your
general physician to complete.
3. Do not take any aspirin, aspirin-like products, or any other medications that may increase bleeding for at least
3 weeks before surgery. Aspirin and aspirin-like products tend to increase bleeding during surgery and bruising
postoperatively.
4. If you take or have taken a bisphosphonate medication (e.g., for osteoporosis or osteopenia therapy), you must let
us know, because your risk for bone-healing difficulties may be increased.
5. Be sure that you do not smoke and that there are no nicotine products in your bloodstream for at least 3 weeks
before and 2 weeks after surgery. Nicotine in the bloodstream jeopardizes wound healing. Smoke that is chronically
ingested by the lungs may result in pulmonary complications that will hinder optimal healing.
6. Starting 2 days before surgery, we request that you shampoo your hair and shower at least once per day. The
morning of surgery, you may also shower and shampoo your hair again.
7. Do not eat or drink anything after midnight the night before surgery, not even a sip of water. You may brush your
teeth, but do not swallow the water.
Postoperative Instructions
1. In general, you will remain in the hospital for 1 or 2 nights during your initial recovery. When you are up and
around, drinking enough fluids, and have recovered some of your strength, you will be able to return home to the
care of your family.
2. Instructions for a high-protein blenderized (pureed) diet will be discussed with you. In general, the pureed
(blenderized) diet will continue for 5 weeks, after which you will gradually return to the eating of regular foods.
3. Exercising your lips (e.g., squeezing them together for closure) during the first several days after surgery is helpful.
By doing so, you will more rapidly regain lip control, reduce facial swelling, and find it easier to swallow fluids and
control your saliva.
4. You will begin brushing your teeth with a soft toothbrush the day of the operation. We will prescribe a special
antimicrobial mouth rinse to reduce the plaque (bacteria) buildup on your teeth.
5. In general, no facial bandages will be used after surgery. You should take a shower and wash your hair and face
the day after surgery. Initially, you should have someone close by when you shower, because you may feel
unsteady on your feet.
6. It is advisable to sleep with your head in an elevated position (e.g., on two pillows) for at least the first week after
surgery. This helps with the natural drainage of fluids in the facial area, and it also helps to decrease swelling.
7. Nasal congestion (i.e., difficulty breathing through the nose) is to be expected immediately after surgery. The
congestion generally takes 5 to 7 days to significantly clear. Until then, frequent steamy showers and the use
of saline nasal sprays will be helpful. You should avoid blowing your nose after surgery, because doing so may
increase the risk of bleeding. When you sneeze, let the air go through your mouth to limit the pressure in your
nose.

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CHAPTER 11  Anesthesia Techniques, Blood Loss/Fluid Replacement, Airway Management & Convalescence
8. When you get home, you should take the prescribed pain medication as needed. Tylenol may be substituted when
your pain has diminished. Avoid taking aspirin or aspirin-like products for an additional 2 weeks after surgery.
9. Your sleep schedule will be irregular during the initial weeks after surgery. You may substitute Benadryl for the pain
medication to assist with sleeping, but only after permission is received from your surgeon.
10. You will be given a prescription for an antibiotic. Take it as directed until the supply is exhausted. If you develop a
skin rash, diarrhea, or a vaginal infection, stop the medication and contact your surgeon, because these problems
may be related to your prescription.
11. Do not drink any beverages that contain alcohol, take any non-prescribed medications, or drive a motorized
vehicle until you have been given permission to do so.
Additional Considerations
1. A cold pack placed over the cheek and neck region on each side of the face is useful during the initial 24 to 36
hours after surgery to limit swelling. Nevertheless, you will be swollen, and your skin will be discolored (i.e., black,
blue, green, and yellow) for several weeks after surgery. The swelling and discoloration are never the same on the
two sides of the face and neck, and they will be seen halfway down your chest. Remember that each side of
the face heals somewhat independently. The initial soft-tissue swelling will not influence the final results. Although
the swelling decreases significantly by 5 weeks after surgery, 6 to 12 months is required for all swelling to subside.
2. There will be numbness or decreased sensation in specific regions of your mouth and face. This takes some time to
get used to, and it will improve considerably. The location of the diminished sensibility of the skin of the face and
the mucous membranes of the mouth will be dependent on the specific procedures that are carried out. I will
explain this to you in detail at your first consultation and again during office visits before your operation; this
information will also be found on your informed consent document.
3. In general, at 5 weeks after surgery, basic healing is sufficient enough for you to gradually return to physical
activities such as jogging, bicycling, and aerobics. At this stage, progression to a more regular (chewing) diet is also
encouraged.
Physical Therapy after Orthognathic Surgery
1. Early after orthognathic surgery the loss of full lip control/seal results in drooling and difficulty swallowing a bolus of
liquid. The lip-control difficulty results from a combination of factors, including A) surgical trauma to the soft tissues
of the lips; B) the expected diminished sensation; C) the change in the position of the jaws and teeth; and D) the
presence of an intra-oral occlusal splint, elastics and orthodontic lugs. Instituting active lip closure and control
exercises beginning the day after surgery will help you to regain lip-seal control for ease of swallowing and
managing your saliva.
2. Within the first few weeks after surgery, instructions will be given to help you to achieve the gradual return of normal
mouth opening. If the adequate return of mouth opening, speech articulation, and lip control are slow in coming,
then the institution of active range-of-motion mouth exercises and speech therapy will be arranged.
3. Some individuals have more difficulty than others adjusting to the expected loss of sensation after a Le Fort I
maxillary osteotomy (involving the infra-orbital nerves) or sagittal split ramus osteotomies of the mandible (involving
the inferior alveolar nerves). The institution of sensory retraining exercises may be helpful to desensitize you to the
altered sensibility and the expected gradual recovery in specific facial and oral locations.
Jeffrey C. Posnick, DMD, MD
Director, Posnick Center for Facial Plastic Surgery

328
SECTION 1  Basic Principles and Concepts
Physical Therapy after Orthognathic Surgery
• Lip Closure/Control Exercises
• Mouth-Opening Exercises
• Sensory Retraining Exercises
LIP CLOSURE/CONTROL EXERCISES
Patient Instructions (to begin the day after surgery)
Keep in mind that many patients with jaw deformities (e.g., long face growth pattern) have never been able to easily
obtain full lip seal. Beginning the day of surgery, we encourage active lip closure/control exercises. Initially, the
exercises are carried out by the patient under the direction of a health care professional. The patient should look at his
or her lips with the use of a handheld mirror. Attempting to squeeze the lips together while viewing them in a mirror
generally provides for a successful lip seal within 12 to 24 hours. Until lip seal can be achieved, it is difficult to
effectively swallow liquids without drooling a portion of the liquid out of the mouth. After a consistent lip seal is
achieved, the ability to swallow saliva and to drink sufficient quantities of liquids for the maintenance of hydration and
adequate caloric intake is the norm. With diligent effort, the required level of lip control is generally achievable by 24 to
48 hours after surgery.
MOUTH-OPENING EXERCISES (MODIFIED UNIVERSITY OF NORTH CAROLINA INSTRUCTIONS)
Level I Patient Instructions (2 to 5 weeks after surgery)
Basic Mouth-Opening Exercises
Do these mouth-opening exercises at least three times a day for 2 to 3 minutes each time: once in the morning, once
at midday, and again in the evening.
1. First, remove the elastics, and then practice opening your mouth and moving your jaw side to side by just using
your jaw muscles.
2. Do not try to open or move beyond what causes only mild discomfort for a short period of time. Do not force the
opening if it hurts.
3. Do not do the mouth-opening exercises with your elastics on. Avoid forcefully opening your mouth by straining
against the rubber bands that hold your jaws together.
By the end of the third week, you may be able to open your mouth wide enough to get one finger between your
front teeth when the elastics are off. By the end of the fifth week, you may be able to get two fingers between your
teeth when your elastics are off.
Hold-and-Relax Exercises
If you cannot open your mouth wide enough to get one finger between your front teeth at the end of the third week,
start these hold-and-relax exercises.
1. Open your mouth about half of the amount that is comfortable.
2. Fold your hand into a fist, and place your fist under your lower jaw.
3. Using gentle pressure, push up with your fist as if you are trying to close your mouth.
4. Use your jaw muscles to try and open your mouth against the pressure of your fist. Hold this pressure for about
5 seconds, and then remove your fist and close your mouth.
5. Next, spend 30 to 60 seconds moving your jaw side to side and gently stretching and opening your mouth just
using your jaw muscles.
6. Repeat the hold-and-relax exercise followed by moving the jaw side to side about five times.
Level II Patient Instructions (5 to 9 weeks after surgery)
Hold-and-Relax Exercise
Do two or three repetitions of the hold-and-relax exercise three times a day: in the morning, at midday, and in the
evening. (See the Level I instructions for this exercise.)
Finger-Stretch Exercise
1. Place your middle finger on your lower teeth in the bicuspid region, and place your thumb on your upper teeth in
the bicuspid region.
2. Apply pressure with your fingers so that it creates the feeling that you are stretching the jaw muscles. There will be
some feeling of tightness or mild discomfort. Hold this for 5 seconds, and then release your fingers and close your
mouth.

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CHAPTER 11  Anesthesia Techniques, Blood Loss/Fluid Replacement, Airway Management & Convalescence
3. Next, move your jaw side to side and open and close your mouth using your jaw muscles for 30 to 60 seconds.
4. Repeat the finger-stretch exercise but with your fingers on just one side of your mouth at a time. Follow this with
the side-to-side exercise.
Do the finger-stretch exercise three times on each side. Each time, try to slightly increase the finger pressure to
produce more opening. Producing a feeling of mild discomfort is okay, but do not push enough to create pain.
SENSORY RETRAINING EXERCISES (MODIFIED UNIVERSITY OF NORTH CAROLINA INSTRUCTIONS)
Level I Patient Instructions (2 to 5 weeks after surgery)
Basic Touch Exercises
Do the touch exercises with a brush (i.e., a toothbrush, hairbrush, or makeup brush) at least three times a day for 2 to
3 minutes each time: in the morning, at midday, and in the evening.
1. Start by looking in the mirror, and watch what you are doing with the brush.
2. First, alternate touching and stroking your face with the brush.
3. When you start the exercise, make long strokes that extend from one side of the face to the other.
4. As you do the exercises, vary where you first touch your face before starting the stroke. Do this on different parts of
your face (i.e., forehead, cheeks, chin, and upper and lower lip).
5. The brush should be moved at the same rate that you might use your fingertips to touch or examine a piece of
cloth.
6. Be sure to move the brush around on both sides of your face. Do not spend all of your time on any one spot.
Additional “Touch” Exercises
Close your eyes, and either touch or stroke your face with the brush. Tell yourself whether you are going to touch or
stroke your face with the brush before you do it. If you have someone at home to help you with the exercises, ask him
or her to either touch or stroke your face with the brush.
For the first five or so tries, be sure that your partner tells you before the brush touches your face whether it will be
a touch or a stroke.
Try keeping your eyes closed, and then let your partner either touch or stroke your face with the brush without
telling you what to expect.
If you can easily tell a touch from a stroke, that’s great. Remember to decrease the length of the stroke about a
quarter of an inch every other day; this will make the task more difficult.
The length of the stroke should result in it being challenging (but not impossible) for you to tell the difference
between a touch and a stroke. Remember also to use both side-to-side strokes and up-and-down strokes. If you have
difficulty even with long strokes, do not become frustrated. Most individuals sense little change from day to day. It is
important that you be patient and persistent.
You can practice the touch exercises as many times during the day as you wish. Looking in the mirror while you
practice is very important. If you do not have a brush with you, simply use a light finger touch.
Level II Patient Instructions (5 to 9 weeks after surgery)
Basic Touch Exercises
Do the touch exercises with the brush at least three times a day for 2 to 3 minutes each time: in the morning, at
midday, and in the evening. When you begin, look in the mirror and watch the movement.
1. At first, alternate stroking your face side to side or up and down.
2. As you do the exercises, vary where you make the strokes on your face.
3. When you begin the exercises, start the side-to-side exercise on one side of the face, and stroke across the entire
region to the other side of the face. For example, move from the bottom of your ear across your upper lip to the
bottom of your other ear.
4. When you stroke up and down, start on your neck, and go all the way up and down your face. For example, move
from your neck all the way up the side of your face to the forehead, or start just below your eye and stroke down
to your neck.
5. While doing the exercise, tell yourself that whatever sensation you feel is normal and expected.
Continued

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SECTION 1  Basic Principles and Concepts
6. Seeing the orientation of the stroke and the area of the face that you are touching reflected in the mirror and telling
yourself that all of the sensations you feel are normal and expected is important.
7. Be sure to move the brush around on both sides of your face. Do not spend all your time on any one spot.
Additional Touch Exercises
Close your eyes. Before you stroke your face with the brush, tell yourself whether you are going to stroke your face
side to side or up and down with the brush. If you have someone at home to help you with the exercises, for the first
five or so tries, be sure your partner tells you before the brush touches your face whether it will be a side-to-side or
up-and-down stroke. Next, try keeping your eyes closed, and let your partner do the exercise again without telling you
what to expect.
If you can easily tell an up-and-down stroke from a side-to-side stroke, that’s great! Remember to decrease the
length of the stroke by about a quarter of an inch every other day; this will make the task more difficult. The length of
the stroke should result in it being challenging (but not impossible) for you to tell the difference between an up-and-
down stroke and a side-to-side stroke.
If you have difficulty even with long strokes, do not become frustrated. Most patients sense little change from day
to day. It is important that you be patient and persistent.
You can practice the touch exercises as many times during the day as you wish. Looking in the mirror while you
practice is very important. If you do not have a brush with you, simply use a light finger touch.
Do the touch exercises with the brush at least three times a day for 2 to 3 minutes each time: in the morning, at
midday, and in the evening. When you begin, look in the mirror and watch the movement.
Jeffrey C. Posnick, DMD, MD
Director, Posnick Center for Facial Plastic Surgery
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1982.

336
SECTION 1  Basic Principles and Concepts
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47:616, 1989.

337

12
Orthognathic Surgery
Treatment Planning
JEFFREY C. POSNICK, DMD, MD
SECTION 2  Planning, Surgical Technique, and Complications
Part I: The Importance of Proportions and
Symmetry to Establish Ideal Facial Aesthetics
• Fundamental Concepts
• Evolution in Thinking
• Current Philosophy
Part II: Clinical Evaluation of the Patient with
a Dentofacial Deformity
• Background
• Global Head and Neck Assessment: Seven
Critical Aspects
• Detailed Maxillomandibular Surgical
Planning: Eight Critical, Quantitative, To-the-
Millimeter Decisions
• Conclusions
mean ratio when, as the whole line is to the greater segment,
so is the greater to the lesser.”98,99 (Fig 12-1) This ratio was
defined by Euclid as the “golden ratio.” Interestingly, this
ratio represents a never-ending (irrational) number
1.6180339887…. The common symbol for the golden ratio
is the Greek letter tau (τ), the meaning of which is “the cut”
or “the section.” It was later renamed phi (Ψ) after the
Greek sculptor Phidias, who was said to have employed it61;
this is described in more detail later in this chapter.
A definition of the word beauty can be found in Webster’s
unabridged dictionary as “the quality which makes an
object seem pleasing or satisfying in a certain way.”63
The golden ratio is said to be an important feature that is
found in many classically beautiful works of art, architec­
tural structures, objects designed for human use, the music
of the great composers, and most of what is found in
nature.17,18,20,45,49,57,58,67,68 “Perfect” proportions are found
throughout the art world and throughout the centuries.
Objects of “classic” beauty and “attractive” forms found in
nature consistently reveal the golden ratio.40 However, an
important question remains: “Does form really follow func­
tion?” Richard Buckminster Fuller (1895-1983), a great
American architect and writer, once stated, “When I am
working on a problem, I never think about beauty. I think
only of how to solve the problem. But when I finish, if the
solution is not beautiful, I know it is wrong.”61
In their simplest form, attractive facial images—whether
in drawings, in photographs, or in reality—seem to incor­
porate a consistent symmetry of proportion. It has been stated
that most people have a common appreciation of what is
attractive when they visualize it even if they cannot quite
explain why. This has been demonstrated across cultures and
throughout the ages, and it has been relatively consistent in
art and photography.6,19,27,32,48,53,54,63,77,81,80 A strict mathe­
matical formula may not be required to define classic attrac­
tiveness, but the question remains: “Can the golden ratio
(a mathematical formula) be found in these commonly
agreed upon beautiful images?”
Part I: The Importance of
Proportions and Symmetry to
Establish Ideal Facial Aesthetics
Fundamental Concepts
We use the word proportion to describe the comparative
relationship between parts of things in an attempt to
describe harmonious and disharmonious relationships
between different parts of a whole.13,14,49,92 The first clear
and still unsurpassed definition of what has become known
as the “golden ratio” was put into words by Euclid of Alex­
andria around 300 B.C.5,29,42-44,61 Euclid is best known as
the founder of geometry, which is a branch of mathematics
that involves the use of deductive reasoning.68 In the most
pure way, Euclid defined a harmonious proportion derived
from the simple division (sectioning) of a line into what he
called its “extreme and mean ratio.”61 In Euclid’s own words,
“[a] straight line is said to have been cut in extreme and

338 SECTION 2  Planning, Surgical Technique, and Complications
• Figure 12-1  Golden ratio (section) of a straight line.
a
ab
b
ab is to a as a is to b
• Figure 12-2  Pythagorean theorem as described through a
triangle.
a
b
c
• Figure 12-3  Doryphoros by Polykleitos. From
.org/wiki/File:Doryphoros_MAN_Napoli_Inv6011-2.jpg Photograph by
Marie-Lan Nguyen. Creative Commons License: Attribution.
Evolution in Thinking
Pythagoras (570 B.C.-522 B.C.) coined the terms philoso­
phy, defined as “a love of wisdom,” and mathematics, defined
as “that which is learned.”47 He described a philosopher as
someone who “gives himself up to discovering the meaning
and purpose of life itself—to uncover the secrets of
nature.”100,42,61 Pythagoras and his followers (i.e., Pythago­
reans) are best known for their role in the development of
mathematics and the application of mathematic principles
to the concept of order in the world. The Pythagorean
theorem states that, in a right-angle triangle, the square of
the hypotenuse (i.e., the side opposite the right angle) is
equal to the sum of the squares of the other two sides; in
other words, a2 + b2 = c2 (Fig. 12-2).9
According to legend, Pythagoras discovered that musical
notes could be translated into an orderly mathematical
equation by observing a blacksmith at work. He thought
that the sounds emanating from the blacksmith’s anvils,
when they were struck, were both beautiful and harmoni­
ous. By studying the blacksmith’s tools, Pythagoras discov­
ered that the emanating sounds were “simple ratios of each
other and that one was half the size of the first and so
on.”61,100 He then constructed metal bells with each sized in
equal ratio to the next. When he struck the proportionately
sized bells, harmonious tunes resulted in the same way that
he had observed with the anvils. The harmony that resulted
when striking the proportionately sized bells or anvils,
according to Pythagoras, was beautiful.
Pythagoreans also believed that “harmony existed with
the spheres of the planets and stars according to a similar
strict mathematical equation and thus produced a similar
“planetary symphony.”61,100 Pythagoras later discovered
flaws in the purity of mathematics. He was the first to write
of having knowledge of a number that is “neither a whole—
nor a ratio of two whole numbers.”61,100 This discovery was
said to have overwhelmed his perspective of a world based
on the intrinsic properties of whole numbers and their
ratios. He could not find a role for irrational numbers in
this world.44 Pythagoreans believed that the existence of
such irrational numbers was so horrific that such numbers
represented some sort of cosmic mistake and thus should
be suppressed and kept secret.
Pythagoras and the Pythagorean school made a great
impact in various fields, from sculpture to philosophy.55
Polykleitos (450 B.C.) is a vivid example of the positive
influence of Pythagoras’ ideas. Polykleitos consciously
created a new approach to sculpture that is immortalized in
his treatise Kanon and visually depicted in his design of the
male nude (also known as Kanon), which exemplified his
aesthetic theories regarding the mathematical basis of artis­
tic perfection.69 His general artistic aims were clarity,
balance, and completeness. The Kanon’s basic principles are
represented in Polykleitos’ best-known bronze sculptures,
including Doryphoros (Fig 12-3); Diadumenos (Fig 12-4);
and Astragalizontes. These sculptures are said to have a
precise commensurability (i.e., “symmetria”) of all of the
parts with one another. The idea of “symmetria” comes from
the Hippocratic principles of “equilibrium” and “rhyth­
mos.”100 Polykleitos also said that “perfection comes about
little by little through many numbers.”61,100 This meant that

339
CHAPTER 12  Orthognathic Surgery Treatment Planning
• Figure 12-4  Diadumenos by Polykleitos. Image Copyright © The
Metropolitan Museum of Art, Image source: Art Resource, NY.
a statue should be composed of clearly definable parts, all
of which are related to one another through a system of
ideal mathematical proportions and balance. This was
expressed in terms of the ratios established by Pythagoras,
including in the perfect intervals of the musical scale: 1 : 2
(octave), 2 : 3 (harmonic fifth), and 3 : 4 (harmonic fourth).
The Polykleitos school continued after Polykleitos’ death
and included at least 20 sculptors and artisans through early
200 B.C. They were defined by their adherence to the
Kanon and its principles of balance and definition (i.e., clarity
in the separation and relationship of the parts to the whole).
Polykleitos’ students would think beyond sculpture in
bronze; this included the work of Polykleitos’ son, Polyklei­
tos the Younger, whose architectural design of the great
theater of Epidaurus was remarkable for its harmony and
balance (Fig. 12-5).100 Within the theater, the place for
spectators was divided into two tiers: the first one had 34
rows of places, and the second one had 21 rows (i.e., 34/21
= 1.61…). The angle between the theatron and the scene
divides the circumference of the basis of the amphitheater
in a ratio of 1.618…. Interestingly, both of these meet the
standards of the golden section, which was soon to be pre­
cisely and clearly defined by Euclid, as described later in
this chapter.
Polykleitos’ greatest work is said to be the sculpture
Doryphoros (i.e., “spear-bearer”), which is considered one of
the best-known sculptures of the classic era.100 During the
second century A.D., Galen would write about Doryphoros
as the perfect visual expression of Greece’s search for
harmony and beauty, which is rendered in the perfectly
proportioned sculpted male nude. Galen stated the
following:
• Figure 12-5  Theater of Epidaurus in Epidaurus, Greece. Copyright
2013 BootsnAll Travel Network, LLC. All Rights Reserved.
.greecelogue.com/the-ancient-theater-of-epidaurus.html.
Chrysippos [or Doryphoros, the spear-bearer] holds beauty
to consist not in the commensurability or “symmetria”
[i.e., proportions] of the constituent elements [of the body],
but in the commensurability of the parts, such as that of
finger to finger, and of all the fingers to the palm and
wrist, and of those of the forearm, and of the forearm to
the upper arm, and in fact, of everything to everything
else, just as it is written in the Canon of Polyclitus
[Polykleitos]. For having taught us in that work all the
proportions of the body, Polyclitus supported his treatise
with a work: he made a statue according to the tenets of
his treatise and called the statue, like the work, the
“Canon” [i.e., Kanon].61,100
A contemporary of Polykleitos was Phidias (480 B.C.),100
who is regarded as one of the greatest sculptors of bronze,
gold, and ivory from Greek antiquity. Phidias’ statue of Zeus
at Olympia was considered one of the seven manmade
wonders of the Ancient World (Fig. 12-6). He also created
the statue of the Goddess Athena on the Athenian Acropolis
(Fig. 12-7) as well as the Athena Promachos (i.e., a bronze
statue of Athena) adjacent to the entrance of the Acropolis
in Athens (Fig. 12-8). The influence of Pythagorean math­
ematics, the Kanon (i.e., the relationship of the parts to the
whole), and the golden ratio (although not spoken of as a
specific number) are clearly represented in all of Phidias’
works.
Pythagoras’ writings also influenced Plato (428 B.C.-337
B.C.), who is considered one of the most extraordinary
minds of Ancient Greece and of Western civilization in
general.100 His text, the Republic, states that mathematics is
an absolute must for the education of all state leaders and
philosophers (Fig. 12-9). Plato was intrigued by the five
regular polyhedrons that are now considered the Platonic
solids (Fig. 12-10). He used their design to emphasize the
importance of proportions for the achievement of “ideal”
beauty. His thinking must have also been greatly influenced
by Polykleitos’ sculptures and written words in the Kanon.
Plato is quoted as follows: