Orthognathic Surgery: Anesthetic Considerations and Perioperative Management

Orthognathic surgery presents a unique perioperative landscape for plastic surgeons and anesthesiologists alike including blood loss and pain control, as well as postoperative complications such as shivering, nausea and vomiting, emergence agitation, and prolonged ventilation. Blood loss is a major concern due to the inherent rich vascularity of the facial skeleton and significant muscular and bone marrow dissection. Effective hemostatic strategies are critical in preventing excessive blood loss, with the 2 primary strategies being judicial hypotensive anesthesia and use of hemostatic agents. Pain control is a consideration throughout all surgical phases with preoperative nerve blocks, anesthetic agents for induction and maintenance of anesthesia, and postoperative analgesia. Preoperative nerve blocks, regardless of technique either a single injection at the pterygopalatine fossa or ultrasound guided, have demonstrated increased hemodynamic stability and decreased need for postoperative opioid use. While nausea, vomiting, shivering, emergence agitation, and prolonged ventilation can be observed in other procedures, these postoperative complications need additional consideration in the setting of orthognathic surgery. Maxillomandibular fixation increases the risk of aspiration in the presence of nausea and vomiting, while delayed extubation, emergence agitation and shivering can contribute to airway disturbance and other complications. Given the cross-specialty complexity in these procedures, the present paper sought to provide a comprehensive review of the evidence-based literature on perioperative anesthetic practices with a focus on hypotensive anesthesia, hemostasis, nerve blocks, and management of postoperative complications.