Perioperative management in orthognathic surgery—a narrative review

Introduction

Orthognathic surgery, also known as corrective jaw surgery, entails a complex process including comprehensive diagnosis and treatment planning, the surgical execution and perioperative phase, and surgical convalescence (1). High-quality perioperative care can reduce complications, improve outcomes, improve patient satisfaction, and reduce healthcare costs (2). The perioperative period is divided into three parts: preoperative, intraoperative, and postoperative. Each portion of perioperative care contains its challenges and barriers to success, so it is critical the healthcare team is abreast of the most recent advances in the field.

Today, orthognathic surgery is performed primarily for indications such as developmental dentofacial disharmony, cleft jaw disharmony, and retrognathia-associated obstructive sleep apnea (OSA) to improve the long-term dental occlusion, relieve sites of upper airway obstruction, and restore facial aesthetics. Many advancements have been made to orthognathic surgery techniques since the first mandibular osteotomy was described in 1849 (3). In these early days of orthognathic surgery, only ether anesthesia was available at the time, and local anesthesia and antibiotics had not been discovered yet (4). The quality and quantity of surgical strategies in the field have increased immensely since 1849 and so has the associated perioperative management. In recent years, there has been greater emphasis on multimodal anesthesia and enhanced recovery pathways to improve outcomes and the patient experience. Multimodal analgesia, which involves the use of different classes of analgesics with varying mechanisms of action, is a cornerstone in managing postoperative pain and minimizing the reliance on opioids (5).

Despite many advances, there has not been a comprehensive review article on advances in perioperative management in orthognathic surgery. The objective of this narrative review is to compile the newest recommendations in perioperative care in orthognathic surgery patients with the goal of improving outcomes for patients. We present this article in accordance with the Narrative Review reporting checklist (available at https://joma.amegroups.com/article/view/10.21037/joma-24-14/rc).

Methods

The methods utilized to write this article are presented in Table 1. A literature review utilizing PubMed, Google Scholar, and Cochrane Database of Systematic Reviews was conducted to investigate perioperative management strategies in orthognathic surgery. Publications were considered for review if written between 2000–2024 and written in the English language. Peer-reviewed journals with original articles, systematic reviews, narrative reviews, controlled trials, and cohort studies were included as well as relevant textbooks. Editorials, abstracts only, and publications written in languages other than English were excluded. Searching the terms individually as well as in combination yielded numerous articles, and their titles and abstracts were subsequently reviewed. Relevant studies were included in the narrative review. References contained in these articles were also reviewed and included if deemed relevant by the authors. Of note, a full critical appraisal of all evidence was not performed.

Key content and findings

Eighty-one studies were included in this narrative review. Evidence level 1 studies made up over 30% of the studies with the vast majority of studies being evidence level 1, 2, or 3 studies. Perioperative management can be organized into three phases: preoperative, interoperative, and postoperative care.

Preoperative assessment

The preoperative assessment of the patient remains a crucial component of proper management of the orthognathic surgery patient. This preoperative assessment typically occurs on the day of surgery in the preoperative ward, but some centers perform this prior to the day of surgery. Vital signs are taken, an intravenous (IV) line is established, labs are drawn, and the patient is prepared for surgery. Due to the risk of significant blood loss, a complete blood count and type and screen are routinely ordered. Many women who undergo orthognathic surgery are of child-bearing age, so a pregnancy test on the day of surgery should be obtained as indicated. Patients with medical syndromes or OSA are at increased risk for additional comorbidities such as hypertension, diabetes, and heart arrhythmias. Therefore, additional tests should be ordered accordingly reflecting a patient’s health and risk factors. Any irregular findings should be clearly communicated to the anesthesia and surgery teams. If deliberate hypotensive anesthesia is planned, determine if the patient will be able to tolerate periods of hypotension.

Proper consent for the surgery should be obtained and verified by appropriate parties. Inadequate health literacy remains a prevalent issue as it has been shown to affect 15% of orthognathic surgery patients (6). In addition, performing adequate patient counseling before surgery on their perioperative course can help achieve patient buy-in to the process. This includes reviewing postoperative recovery milestones as well as reviewing the postoperative diet requirements which may include syringes or squeeze bottles for nutrition.

A thorough head and neck examination is indicated prior to orthognathic surgery, including an airway evaluation. Patients with a dentofacial disharmony or retrognathia-associated OSA are common in orthognathic surgery and should be considered to have a difficult airway until proven otherwise (7). Inquire to the patient if they have had a previous history of difficult intubation. In addition, orthognathic surgery patients may have a pharyngeal flap following previous surgeries for cleft palate repair; thus, these patients need to be identified preoperatively as extra precautions and techniques will be utilized to obtain successful intubation (8). To examine the patient’s airway, evaluate their mouth opening, ability to protrude the jaw, extent of neck extension, Mallampati score, thyromental distance, and patency of nares (7,9). If a difficult airway is anticipated, the anesthesia team should be prepared to use adjunctive tools such as video-assisted laryngoscopy, fiberoptic intubation, or using percutaneous techniques.

Before moving the patient to the operating room, a patient may receive an anxiolytic medication such as midazolam intravenously to decrease anxiety, although a recent Cochrane Systematic Review supported this with only low-quality evidence (10).

Intraoperative management

The intraoperative phase of surgical care has numerous considerations pertaining to body systems, such as the pulmonary, cardiovascular, neurologic, gastrointestinal, renal, and urinary systems. This portion of the narrative review describes techniques and recommendations from the latest studies in orthognathic surgery regarding these systems and their intraoperative management.

Pulmonary

The airway assessment should be performed preoperatively and appropriate arrangements should be made for proper intubation equipment. Nasotracheal intubation is preferred, however in select cases a submental intubation or tracheostomy may be indicated. A traditional Macintosh or Miller laryngoscope may be utilized for intubation, but studies have demonstrated video laryngoscopy provides improved visualization of the glottis, faster intubation, and less use of the Magill forceps (11,12). A nasal Ring-Adair-Elwyn (RAE) tube is commonly utilized to prevent kinking of the endotracheal tube, more reliably secure the tube, and decrease the risk of pressure necrosis to the nasal alae (13,14). Before placement of the nasal RAE, oxymetazoline nasal spray (or a similar vasoconstrictor) is commonly utilized in the nares to decrease the risk of traumatic bleeding during nasotracheal intubation.

Not all patients may be candidates for nasotracheal intubation such as those with nasal blockages from conditions such as choanal atresia or severe facial trauma. In addition, many orthognathic surgery patients have a history of cleft palate, as such, they may have a pharyngeal flap that should be handled with care and may offer considerably smaller space for a nasotracheal tube to pass. Therefore, in these circumstances where nasotracheal intubation is not feasible, submental intubation may be considered. If a patient is expected to experience significant postoperative soft tissue swelling, alterations in their airway anatomy, or may require additional surgical procedures, an elective tracheostomy may be considered as well (13).

After appropriate induction of anesthesia, the nasal endotracheal tube is placed, the position is confirmed, and then the tube is secured. There are multiple techniques to secure the nasal endotracheal tube—one common technique is suturing the tube to the nasal septum and/or scalp in addition to utilizing a head wrap and pieces of styrofoam and tape to secure the tube. Once the surgeon begins the operation, the anesthesiologist must remain vigilant for any circuit leakages or disconnections as the surgical site is in close proximity to the endotracheal tube and intraoperative reintubation may present challenges (15).

Many strategies may be employed intraoperatively to ensure proper pulmonary management under general anesthesia. Corticosteroids have been utilized to decrease airway inflammation and facial edema, and it has been shown to decrease nausea and vomiting (16). Many steroid regimens exist with mixed evidence on the ideal regimen; therefore, steroids should be used with caution as psychological disturbances and peptic ulcers are possible side effects (17).

When the surgery is nearing its conclusion, the anesthesiologist may begin to decrease the inhaled volatile anesthetics in preparation for extubation. However, in orthognathic surgery, one may consider “deep” extubation which entails the removal of the endotracheal tube while the patient is still deeply anesthetized and not yet awake or following commands. Paralytic reversal must be complete and the patient must be adequately spontaneously ventilating. Successful deep extubation provides a smoother, less stimulating emergence from anesthesia compared to awake extubation. The benefits of deep extubation are minimized coughing, bucking, bronchospasm, and increased intracranial pressure, which are all associated with awake extubation. Most importantly, this technique may mitigate the patient’s stress response to extubation, thereby reducing the risk of hypertensive episodes which may lead to postoperative bleeding.

During extubation, the anesthesia team must remain vigilant of the risk of laryngospasm, a potentially catastrophic event. Further, when patients inspire forcefully against the obstructed airway such as in laryngospasm, the extreme negative intrathoracic pressure creates a pressure gradient allowing fluid to be pulled from the pulmonary capillaries into the interstitial and alveolar spaces resulting in pulmonary edema. This negative pressure pulmonary edema (NPPE) is a rare but potentially serious complication of laryngospasm and upper airway obstruction (18). Laryngospasm accounts for more than 50% of reported cases of acute NPPE (19). These events occur more commonly in younger patients, which is a large proportion of orthognathic surgery patients.

The extubation process should be performed carefully to maintain fixation. Aggressive manipulation of the chin and mandible may result in the loss of fixation. Postoperative reintubation may present unique challenges in orthognathic surgery as well. The act of reintubation may cause loss of fixation and the resulting jaw mobility may make reintubation more challenging.

Cardiovascular

Aspects of orthognathic surgery may place strain on a patient’s cardiovascular system. First, the maxillofacial skeleton is a highly vascular area that may experience significant blood loss during surgery. Blood transfusions, while uncommon, are occasionally indicated with orthognathic surgery; therefore, it is prudent to have a plan in place for blood product retrieval and administration if significant blood loss occurs. Multiple techniques have been implemented to mitigate blood loss. First, the patient is placed in the lawn-chair position with their head placed over their heart to limit blood loss. The surgeon should carefully navigate anatomy, avoiding vascular structures when possible and obtaining adequate hemostasis when needed. The “down fracture” of the maxilla during orthognathic surgery is a particular point in the surgery that may have increased potential for blood loss. The descending palatine arteries, pterygoid plexus, and sinus mucosa may be disrupted resulting in hemorrhage. The surgeon may request anesthetists to intentionally transition the patient into a hypotensive state, to mitigate blood loss and improve the surgical visual field. Hypotensive anesthesia has been defined in multiple ways, but a commonly accepted definition of hypotension is a 30% reduction from baseline mean arterial pressure. This reduction typically results in an intraoperative mean arterial pressure ranging between 50–65 mmHg (20-22). A meta-analysis of 10 studies with 358 participants demonstrated that hypotensive anesthesia was effective in reducing blood loss and improving the quality of the surgical field (23). These studies utilized different techniques for obtaining deliberate hypotensive anesthesia as currently there is not a consensus on the most effective way. Common methods include increasing inhalation anesthetics, using beta-blockers such as esmolol, using alpha-2 agonists such as clonidine, using vasodilatory drugs such as nitroglycerin and sodium nitroprusside, or using a combination of the aforementioned techniques (23-25). Decreasing the patient’s mean arterial pressure effectively decreases operative blood loss, and while there is low risk to healthy patients, it has been associated with ischemia of the kidneys, heart, and brain. Therefore, the anesthesia literature has suggested moving away from controlled intraoperative hypotension (26,27).

Tranexamic acid (TXA), an antifibrinolytic medication, has been utilized in orthognathic surgery to decrease blood loss and improve surgical field visualization (28-30). TXA is typically administered as 1 gram intravenously immediately before surgical incision. It is contraindicated in those with a history of thromboembolic or ischemic events, known defective color vision, or a known allergy to TXA (31-33). TXA results in decreased intraoperative blood loss during orthognathic surgery. Many studies suggest a more than 150 mL blood loss reduction in addition to requiring over 200 mL less irrigation fluid during surgery (34,35). In addition, TXA may supplant the need for hypotensive anesthesia, as its use was associated with less time under hypotensive anesthesia for the patient (22).

The monitoring of blood pressure is usually performed via a non-invasive continuous monitoring blood pressure cuff with pressures obtained every 3 to 5 minutes. Surgeons may advocate for an arterial line for beat-to-beat monitoring of the patient’s blood pressure (36). This may make it easier to titrate hypotensive medications, but complications such as hematomas, pseudoaneurysms, and nerve injuries have been described in 2.7–12.3 per 10,000 patients with arterial line placement (20,37). In addition to real-time hemodynamic monitoring, arterial lines also offer easy access to arterial blood samples, if needed. One retrospective study demonstrated that non-invasive blood pressure cuff monitoring was as effective as the arterial line for performing controlled hypotensive anesthesia (20). Therefore, most surgeons and anesthesia teams opt for non-invasive blood pressure monitoring as it does not require additional time for placement, eliminates the risk of bloodborne contamination, and prevents complications from arterial line placement (36,38).

Neurologic

Induction

The choice of induction agents may significantly impact the neurologic status of patients undergoing orthognathic surgery. Propofol, a widely used IV anesthetic, has been associated with neuroprotective properties and a reduced incidence of postoperative delirium and cognitive dysfunction, particularly in elderly patients (39,40). Additionally, dexmedetomidine, an alpha-2 agonist, has gained popularity due to its ability to reduce postoperative agitation, delirium, and cognitive impairment when used as an adjunct to general anesthesia (41). Further, dexmedetomidine has been shown to reduce intraoperative blood loss by limiting intraoperative hypertension (42,43).

Maintenance & analgesia

Postoperative pain can be effectively managed through a multimodal analgesic approach. This approach not only improves pain control but also reduces the risk of opioid-related side effects, such as respiratory depression, nausea, and cognitive impairment. Non-opioid analgesics such as acetaminophen, non-steroidal anti-inflammatory drugs (NSAIDs), and gabapentinoids should be incorporated into the multimodal regimen when appropriate to further enhance pain control and minimize opioid consumption.

Regional anesthesia techniques, including peripheral nerve blocks, can provide excellent analgesia and contribute to the multimodal approach (44). Maxillofacial surgeons are well-versed in administering regional nerve blocks, which can be employed both intraoperatively and postoperatively to optimize pain management. Commonly used nerve blocks include the inferior alveolar nerve block, mental nerve block, infraorbital nerve block, and suprazygomatic blocks (45,46).

Long-acting local anesthetics, such as bupivacaine or ropivacaine, can be infiltrated into the surgical site, providing prolonged postoperative pain relief (47). Local anesthetics are often combined with adjuncts. Most commonly, epinephrine is mixed with the local anesthetic of choice, increasing the density and duration of the block, while the local anesthetic dose can be decreased. Alternative adjuncts include alpha-2 agonists and corticosteroids. Liposomal bupivacaine (Exparel) injections have a multivesicular liposomal system that slowly releases bupivacaine with pain relief lasting up to 96 hours (48,49). In a retrospective study of 19 patients undergoing bimaxillary orthognathic surgery, patients in the group who received a liposomal bupivacaine injection used an average of 9.3 morphine milligram equivalents (MME) during their postoperative course while those who did not receive liposomal bupivacaine used an average of 25 MME (50). These regional techniques not only provide effective intraoperative anesthesia but also contribute to postoperative pain relief, reducing the need for systemic analgesics and their associated side effects (51).

Through incorporating multimodal analgesia, regional anesthesia techniques, and judicious use of local anesthetic infiltration, orthognathic surgery can be performed with optimal pain management, minimizing the risk of neurologic complications, and enhancing the overall patient experience (52).

Emergence

Airway compromise after orthognathic surgery is a common concern. Orthognathic procedures involving surgical repositioning of the maxilla and mandible can lead to significant swelling and edema in the airway structures, increasing the risk of airway obstruction in the postoperative period. This risk is further exacerbated by the residual effects of general anesthesia, which may impair the patient’s ability to maintain a patent airway. Hastened emergence from general anesthesia is an important consideration during orthognathic surgery to ensure postoperative airway protection thereby reducing potential complications.

Emergence agitation, a state of increased psychomotor activity and disorientation during the recovery phase from general anesthesia, can compromise airway patency and increase the risk of airway obstruction (53). The choice of inhalational anesthetic agent can influence the incidence of emergence agitation, with desflurane being associated with a lower risk compared to sevoflurane in patients undergoing orthognathic surgery (54). A common technique to help offset the risk of emergence agitation is an intraoperative bolus or infusion of an alpha-2 agonist.

To mitigate the risk of airway compromise and facilitate early postoperative airway protection, several strategies can be employed to hasten emergence from general anesthesia. The first focuses on inhalational anesthetic selection. Choosing an anesthetic agent with a lower incidence of emergence agitation, such as desflurane, can facilitate a smoother recovery and reduce the risk of airway obstruction. The second strategy suggests utilizing short-acting opioid analgesics. The use of short-acting opioid analgesics, such as fentanyl or remifentanil, can allow for a more rapid emergence and earlier return of protective airway reflexes. The third strategy is the initiation of a multimodal analgesic technique. Incorporating multimodal analgesia reduces the requirement for large doses of opioids and facilitates a faster recovery (55). The last strategy stresses appropriate neuromuscular monitoring. Vigilant monitoring of neuromuscular blockade and appropriate reversal can ensure adequate muscle strength and airway patency during the emergence phase.

By implementing these strategies, orthognathic surgery patients can benefit from a hastened emergence, allowing for reduced incidences of emergence agitation, earlier postoperative airway protection, and reduced risk of airway compromise and associated complications.

Gastrointestinal

Postoperative nausea and vomiting (PONV) may occur after orthognathic surgery, affecting 40–72% of patients (56-61). PONV can result in additional negative outcomes such as additional medical complications, delayed patient discharge, decreased patient satisfaction, and increased hospital costs (56,57). It may occur commonly in orthognathic surgery due to the highly vascular surgical site, in addition to potential periods of hypotension, increase in swallowed blood, as well as diet limitations in the postoperative period (56).

Formulating a strategy to limit PONV begins preoperatively. One should identify common risk factors in their patient such as the female gender, non-smoking history, and history of PONV or motion sickness (56,61). Agents such as 5-HT3 antagonists (e.g., ondansetron, granisetron), dexamethasone, and subanesthetic doses of propofol can be employed for PONV prophylaxis (48,56,62,63).

The mechanical prevention of PONV revolves around limiting blood loss. If a surgeon achieves improved hemostasis, subsequently less blood loss ensues, and less blood will be swallowed into the stomach—a common risk factor for PONV. Surgeons may place a throat pack in efforts to decrease the amount of blood traveling to the stomach, but multiple studies have questioned its effectiveness in decreasing PONV (64-68). Commonly, a vented nasogastric tube can be placed to evacuate gastric contents such as swallowed blood, at the end of surgery, but this is not supported by conclusive evidence (62).

Renal/urinary

Due to the length of surgeries and amount of fluids administered, the surgery and anesthesia team must be mindful of urinary retention. In recent years, there has been a push to limit urinary catheterization to decrease the rate of urinary tract infections. According to the American College of Surgeons National Safety and Quality Improvement Project, urinary catheters are utilized for surgeries lasting longer than 3 hours and should be considered to provide intraoperative monitoring of urinary output which can be an indirect measure of kidney perfusion (36). There has not been a comprehensive review regarding urinary catheterization in the unique orthognathic surgery population to compare outcomes of different catheterization strategies.

In addition, there is not a consensus regarding IV fluid administrations strategies in orthognathic surgery patients. Many vouch for euvolemia as excessive IV fluids may result in edema, and impair cardiac and pulmonary function, while too little of fluids would cause hypovolemia with resultant risk for organ dysfunction (69,70). A retrospective study of 168 orthognathic surgery patients did not show an association between IV fluid administration amount and length of hospital stay (69). Generally, IV fluids are given to maintain hemodynamic stability, making up for any losses during the preoperative “nothing by mouth” period. One should consider the fluid deficit present for each patient and personalize their care by calculating a sufficient maintenance rate, as well as accounting for third spacing and intraoperative blood loss (7).

Infectious disease

As orthognathic surgery is considered a clean-contaminated surgery, prophylactic antibiotics are recommended before surgery, but the type and course length of antibiotic prophylaxis has been a contested topic (71-74). A Cochrane analysis compared short term antibiotic prophylaxis (anytime before surgery or less than 24 hours after surgery) versus long term antibiotic prophylaxis (antibiotic prophylaxis lasting longer than 24 hours after surgery) (73). The review found that patients who received long-term antibiotic prophylaxis compared to with short-term prophylaxis experienced absolute risk reduction of developing a surgical site infection (SSI; 168 SSIs per 1,000 surgeries for short-term antibiotics versus 71 SSIs per 1,000 surgeries for long-term antibiotics) (73). The Cochrane analysis stated this is as moderate quality evidence and recommended there is “probably a benefit when administering long-term prophylaxis instead of short-term” in terms of SSI incidence, yet the studies did not report antibiotic impact on systemic infection, adverse events, duration of hospital stay, or quality of life measures (73). The study also notes single preoperative antibiotic versus short term antibiotic dosing has had inconclusive results (73).

Postoperative care

Following extubation and stabilization, the patient is then typically transferred to the post anesthesia care unit (PACU) for further recovery. The patient’s vital signs and ability to maintain their airway continue to be monitored as the patient becomes progressively more aware. The patient may experience continued bleeding, secretions, swelling, and limited oral opening with guiding elastics or an occlusal splint. Adjuncts such as nasal or oral airways may be indicated, especially in the OSA patient population. Postoperative laboratory tests such as hemoglobin and hematocrit are routinely ordered.

With more awareness, the patient may begin to feel pain, anxiety, nausea, and vomiting—all common sequelae of orthognathic surgery. Multiple strategies have been formulated to combat these issues and promote a faster recovery compared to traditional means. Enhanced recovery after surgery (ERAS) protocols are evidence-based, multidisciplinary care pathways designed to optimize perioperative care and facilitate a faster recovery. These standardized protocols typically include preoperative patient education, protocolized anesthetic and analgesic regimens, early mobilization, and early resumption of oral intake (75). In the context of orthognathic surgery, ERAS protocols emphasize the use of multimodal analgesia, minimizing opioid use, and implementing strategies to reduce PONV.

Various versions of ERAS protocols have been postulated. Despite discrepancies between these protocols, reported outcomes are similar amongst studies such as a decrease in opioid use, decrease in nausea and vomiting, and decreased length of stay (14,58,76-78). These studies utilized useful adjuncts such as antiemetics, dexamethasone, TXA, dexmedetomidine, less inhaled anesthetics and limiting opioids intra- and post-operatively in attempts to achieve less PONV, less blood loss, and less opioid consumption.

Utilizing these various techniques, patients may be discharged earlier from the hospital or surgical center (14). Traditionally, patients have spent at least one night in the hospital prior to discharge, but new studies have demonstrated the feasibility of same day discharge when applicable. A study by Farrell and Tucker describing orthognathic surgery in the ambulatory setting with 675 subjects had a same day discharge rate of 99.6% following bimaxillary orthognathic surgery in the office setting (79). Additionally, in a study by Ferrara et al., 86.7% of 189 patients in their ERAS protocol were discharged on the same day (14). Discharge criteria may vary per surgeon and facility, but it centers around key concepts. These criteria can include stable vital signs, absence of fever, adequate pain control, demonstrated oral hygiene ability, and the ability to ingest liquids, ambulate, and void (7,14).

A surgeon may prescribe standardized postoperative medications depending on their preferences. This may include pain medication, peridex, nasal spray, as well as continuation of antibiotics. Non-opioid analgesics such as acetaminophen and NSAIDs may decrease the patient’s need for opioids which can have negative addictive effects as well as side effects such as respiratory depression and drowsiness. A study by Bousquet et al. concluded that with prioritizing acetaminophen and NSAIDs, patients did not use 74% of the 15 oxycodone doses prescribed; therefore, they recommend surgeons decrease their empirical opioid prescribing as they may be overestimating a patient’s opioid need (80).

Patients will likely experience increased facial edema and discomfort in the postoperative period. Traditionally, ice packs have been utilized to combat swelling. A newer technology termed hilotherapy uses a facially-contoured mask to provide a steady flow of cold water at a regulated temperature next to the skin (81). In a systematic review, hilotherapy was well tolerated by patients and significantly reduced swelling and pain in the early postoperative period, especially postoperative day two and three (81).

Patient education is vital to success in the postoperative period. The patient and their caregiver should be given extensive instructions for postoperative care both before and after the surgery. Many orthognathic surgery patients rely on caregivers for support; therefore, caregivers should be heavily involved in receiving the education. Expectations should be set for postoperative care by the surgeon, and this may ease postoperative concerns that may arise. Pain, edema, and fatigue may limit mouth opening and subsequent oral intake in patients postoperatively. Therefore, it is of value that the patient and caregiver are educated on nutritional needs which will be in the liquid or pureed form. Poor nutrition can impair wound healing and also put the patient at risk for dehydration, both which can result in readmission if significant enough. Oral hygiene is also critical to wound healing; therefore, oral hygiene techniques must be emphasized and the patient and caregiver should show competence in this skill before discharge. Adequate follow-up must be arranged as well as arranging appropriate means for the patient to communicate with the surgical team if postoperative problems may arise after discharge.

Strengths and limitations

The strength of this narrative review is it covers a broad range of topics in the perioperative management of the orthognathic surgery patient. It has numerous references to provide multiple perspectives over a wide span of years [2000–2024] to provide the reader a more complete perspective of this topic and advances in the field. In terms of limitations, this review is not a comprehensive review of all literature available. Perioperative medicine is a very dense and extensive topic, and only relevant articles as determined by the authors were included and described. In addition, articles written in a language other than English were excluded, which limits exposure to potential differences in care in different geographic regions or cultures. Another limitation is that not all studies included in the review were level 1 evidence. Level 1 studies made up over 30% of the studies reviewed with the vast majority of studies included being evidence level 1, 2, or 3 studies. This narrative review presents current literature recommendations and guidelines. Some included studies reached inconclusive conclusions, so the exact clinical impact of certain perioperative techniques in orthognathic surgery has not been fully delineated and needs further study. Despite the advances described and various ERAS protocols formulated, they have not been tested against each other for superiority. Therefore, there is still not a consensus in the surgical protocol from start to finish, and protocols may vary depending on the patient and resources available. Further studies comparing ERAS protocols directly may assist in forming an ideal standard guideline for perioperative medications.

Conclusions

Despite many improvements, there has not been a comprehensive narrative review article on advances in perioperative management in orthognathic surgery. The perioperative period begins with the preoperative period where labs, consent, and patient education are reviewed in addition to an exam, particularly an airway exam, to ensure a patient is ready to proceed with surgery. In recent years, standardized ERAS protocols utilizing multimodal anesthesia have been developed to improve patient outcomes. Intraoperatively, adjunctive medications such as ondansetron, dexamethasone, propofol, dexmedetomidine, TXA, local anesthesia, and non-opioid alternatives may be utilized to decrease the incidence of PONV, decrease blood loss, and decrease opioid usage. Postoperatively, the patient is monitored closely to ensure airway patency in addition to attempts to decrease pain, anxiety, and PONV. Patient education throughout the entire perioperative period is crucial for success in orthognathic surgery. Utilizing the techniques and recommendations from the latest studies to improve perioperative care can improve outcomes for orthognathic surgery patients, particularly in terms of decreasing PONV, opioid usage, blood loss, and length of hospital stay.

Acknowledgments

Funding: None.

Footnote

Reporting Checklist: The authors have completed the Narrative Review reporting checklist. Available at https://joma.amegroups.com/article/view/10.21037/joma-24-14/rc

Peer Review File: Available at https://joma.amegroups.com/article/view/10.21037/joma-24-14/prf

Conflicts of Interest: All authors have completed the ICMJE uniform disclosure form (available at https://joma.amegroups.com/article/view/10.21037/joma-24-14/coif). The authors have no conflicts of interest to declare.

Ethical Statement: The authors are accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved.

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