Blood replacement practices for complex orthognathic surgery: a single surgeon's experience

Operative Time, Airway Management, Need for Blood Transfusions, and In-Hospital Stay for Bimaxillary, Intranasal, and Osseous Genioplasty Surgery: Current Clinical Practices

PURPOSE

The purpose of this study was to assess operative time, perioperative airway management, early postoperative cardiopulmonary health, need for blood transfusion, and in-hospital stay associated with simultaneous bimaxillary, intranasal, and osseous genioplasty surgery.

MATERIALS AND METHODS

The authors executed a retrospective cohort study derived from patients treated by 1 surgeon at a single institution from 2009 through 2014. The sample consisted of a consecutive series of patients with symptomatic chronic obstructed nasal breathing and a dentofacial deformity (DFD). All underwent at least a Le Fort I osteotomy, sagittal ramus osteotomies, septoplasty, inferior turbinate reduction, and osseous genioplasty. For each patient, the design of the osteotomies and the fixation techniques were consistent. The outcome variables included need for blood transfusion, operating time, success of nasotracheal intubation, time and place of extubation, early postoperative cardiopulmonary health, length of in-hospital stay, and need for readmission after surgery.

RESULTS

For the 166 patients studied, the average age was 25 years (range, 13 to 65 yr; 87 female patients [52%]). The primary patterns of presenting DFD included long face (43 of 166, 26%), maxillary deficiency (41 of 166, 25%), asymmetric mandibular excess (37 of 166, 22%), short face (28 of 166, 17%), and mandibular deficiency (15 of 166, 9%). Forty-two patients (25%) were confirmed to have symptomatic obstructive sleep apnea. The open wound operating time averaged 2 hours 59 minutes (standard deviation, 32 minutes). Only 3 of the 166 patients (1.8%) received blood transfusions. All patients underwent successful nasotracheal intubation. Ninety-six percent of patients were extubated in the operating room and the remaining 4% were extubated in the recovery room. No patients required reintubation or tracheostomy. One hundred thirty-seven patients (83%) were discharged after a 1- or 2-night in-hospital stay. Twenty-five (15%) required a 3-night stay and 4 (2%) required a 4-night hospital stay to achieve adequate oral intake. None of the patients required readmission.

CONCLUSIONS

This study confirms efficient surgical and anesthesia care for patients undergoing simultaneous bimaxillary orthognathic, intranasal, and osseous genioplasty. Anticipating safe nasotracheal intubation with extubation soon after surgery and a limited need for blood transfusion has proved to be the norm. This study confirmed an average in-hospital stay of 2 nights after complex orthognathic surgery without need for readmission.

Identifying risk factors for allogenic blood transfusion in oral and oropharyngeal cancer surgery with free flap reconstruction

PURPOSE

Several observational studies in head and neck cancer have reported that allogenic blood transfusion is associated with increased postoperative complications, increased risk of tumor recurrence, and worse prognosis. The aim of this study was to identify preoperative and intraoperative factors predicting blood transfusion in patients undergoing surgery for oral and oropharyngeal cancer.

PATIENTS AND METHODS

We conducted a retrospective cohort study of patients undergoing tumor resection and free flap reconstruction for locally advanced oral and oropharyngeal squamous cell carcinoma between 2000 and 2008. The primary outcome variable was perioperative exposure to allogenic blood transfusion. Univariate and multivariate logistic regression models were used to determine predictors of blood transfusion.

RESULTS

A cohort of 142 participants was found eligible. In a multivariate model, Charlson score ≥ 1 (OR, 5.2; 95% CI, 1.4 to 19.3; P = .01), preoperative hemoglobin levels ≤ 12 g/dl (OR, 4.4; 95% CI, 1.2 to 16.2; P = .03), bone resection (OR, 5.1; 95% CI, 1.5 to 17.8; P = .01), and osseous free tissue transfer (OR, 8.8; 95% CI, 1.0 to 74.8; P = .046) were independently associated with an increased risk of blood transfusion.

CONCLUSION

Our study identified patient- and surgery-related factors predicting a higher risk of exposure to allogenic blood transfusion. This readily available preoperative information could be used to better stratify patients according to their transfusion risk and may thereby guide blood conservation strategies in high-risk patients.

Consequences and management of nasal airway obstruction in the dentofacial deformity patient

INTRODUCTION

At the time of orthognathic surgery the maxillofacial surgeon has an opportunity to further contribute to a patient's quality of life by simultaneously addressing long-standing breathing and sinus drainage difficulties that may coexist with the jaw deformity. Breathing difficulties may range from isolated symptomatic nasal airway obstruction to obstructive sleep apnea syndrome and should not be overlooked. The impact of the combined occurrence of nasal obstruction and maxillary deformity has been recognized and discussed in the literature.

RECENT FINDINGS

Studies have established the correlation of obstructed nasal breathing with the development and predilection for specific patterns of dentofacial deformities. It is imperative that the evaluation of either obstructed nasal breathing or a presenting dentofacial deformity take into account both aspects. Treatment of maxillary dysplasia with specific emphasis of transverse expansion and correction of other intranasal sites of obstruction including deviated septum and hypertrophied inferior turbinates seeks to simultaneously address chronic difficulties with nasal breathing, sinus drainage and the presenting jaw deformity.

SUMMARY

A long-standing forced mouth breathing pattern with open mouth posture is known to impact on maxillo-mandibular growth and be a major contributing factor to developmental jaw deformities. When indicated, simultaneous management of the maxillary jaw deformity (Le Fort I osteotomy) and intranasal abnormality (septoplasty, reduction of inferior turbinates, recontouring of nasal apertures) is effective for the symptomatic relief of nasal airway obstruction. The complication rate for the intranasal procedures and Le Fort I osteotomy when completed simultaneously are minimal and not higher than expected when each procedure is carried out as an isolated event.