Life-threatening haemorrhage after 750 Le Fort I osteotomies and 376 SARPE procedures

Abstract

This study assessed the incidence, presenting symptoms, diagnosis, and management of patients with life-threatening postoperative haemorrhage after total Le Fort I osteotomy and surgically assisted rapid palatal expansion (SARPE). The medical records of 750 consecutive Le Fort I osteotomies and 376 consecutive SARPEs, both of which involved pterygomaxillary separation with a curved osteotome and a mallet, were analysed prospectively. Two cases of life-threatening haemorrhage were observed in the Le Fort I osteotomy group, both initiated on postoperative day 7. Anterior and posterior nasal packing were successful in one patient; the other required two embolizations for bleeding control (incidence of life-threatening postoperative haemorrhage: 2/750; confidence interval: 0.03–0.96%). In the SARPE group, one brisk epistaxis on the first postoperative day was controlled with anterior and posterior nasal packing under general anaesthesia. This haemorrhage was not considered life threatening (incidence of life-threatening postoperative haemorrhage: 0/376; confidence interval: 0–0.98%). In no case could the source of bleeding be established during re-explorative surgery or during diagnostic arteriography. The authors conclude that life-threatening haemorrhage is an exceptional finding after Le Fort I osteotomy; the observed incidence was 2/750, and life-threatening haemorrhage was not observed after SARPE in this series, despite the use of identical pterygomaxillary separation.

Le Fort I osteotomy is widely used to correct dentofacial deformities as an isolated procedure or in combination with other concomitant osteotomies of the facial skeleton. It is considered a safe, predictable, and reliable surgical procedure, since most complications are mild, reversible, and without permanent consequences. Some rare complications are devastating and sometimes life threatening; an excellent recent review of unusual complications is provided by S teel and C ope .

Vascular complications have been reported during and after Le Fort I osteotomy. These present as either excessive bleeding from the external carotid artery system, particularly the maxillary artery and its major terminal branches, or as bleeding or compromised blood flow in one of the branches of the ophthalmic artery, the internal carotid artery, or the cerebral vascular system . Lanigan has devoted numerous articles to exploring the vascular complications of Le Fort I osteotomy , including early and delayed haemorrhage associated with Le Fort I osteotomies . Epistaxis has been reported as a sign of postoperative excessive haemorrhage after a Le Fort I osteotomy without identification of the offending vessel , or can be due to a pseudoaneurysm or an arteriovenous fistula of the maxillary artery . Haemorrhagic complications are thought to be linked to the use of pterygoid chisels for pterygomaxillary disjunction and are reported more frequently in conjunction with the correction of syndromal maxillary hypoplasia .

Only a few case reports have detailed unusual complications after surgically assisted rapid palatal expansion (SARPE) . One case report addressed life-threatening postoperative epistaxis 12 days after surgery, which was controlled with anterior and posterior nasal packs . Most pertinent publications are anecdotal, and true figures related to the incidence of postoperative excessive haemorrhage after Le Fort I osteotomies are lacking. Only a few publications have reported the follow-up of a sufficient number of Le Fort I osteotomies .

The author addresses the following three questions in this report. What is the incidence of postoperative life-threatening haemorrhage in a large series of Le Fort I osteotomies and SARPEs? How is a working diagnosis established and a strategy designed for management of this devastating condition? Which elements contribute to these complications: the pterygomaxillary disjunction, the chisel, the downfracture, or the mobilization of the maxilla?

Materials and methods

From 1 January 1989 to 31 August 2010, 750 consecutive Le Fort I osteotomies and 376 consecutive SARPEs were performed at St. John’s Hospital, Genk, Belgium by or with the active perioperative presence of the same surgeon. No procedures were excluded in this review. All patients except 2 had a follow-up period of at least 1 year.

Two patients died before the 1 year postoperative follow-up for reasons unrelated to the surgery. Patients were counselled before the operation that rare complications such as postoperative haemorrhage do occur. Informed consent was obtained before the osteotomy. The patients were advised to go to the hospital immediately in the case of postoperative haemorrhage.

A list of the patients who underwent the operations was maintained, and unusual events were recorded prospectively. A retrospective chart review was also performed. The author was involved in the follow-up of all patients.

Pterygomaxillary separation was carried out in the Le Fort I osteotomies and the SARPEs. There was no downfracture of the maxilla in the SARPE, but a midline split was made. In the Le Fort I osteotomy, the maxilla was mobilized and downfractured irrespective of whether an extrusion, intrusion, or advancement was planned. The pterygomaxillary disjunction was made with an Obwegeser or Kawamoto curved osteotome and mallet; use of the osteotome and mallet did not differ between the Le Fort I osteotomy and the SARPE, and was in accordance with the technique described by B etts and F onseca in their commentary on the article by L i concerning the location of the descending palatine artery in relation to the Le Fort I osteotomy. Superior aiming of the curved osteotome in the pterygomaxillary junction was avoided at all times . Before fixation of the maxilla, hypotensive anaesthesia was reversed to uncover and address any undetected arterial haemorrhage. After a Le Fort I osteotomy, great efforts were made to provide a gentle awakening and minimize pain, nausea or vomiting to avoid increased venous pressure. The patients were instructed to avoid Valsalva manoeuvres. During the first 4–8 postoperative hours, instructions were given to maintain the systolic blood pressure below 140 mmHg. The patient was nursed with the bed elevated at approximately 30°. Rather than using a nasopharyngeal airway tube, the staff aspirated the nasopharynx on a regular basis and kept the nasal passage humidified and decongested with nasal drops or nasal spray. No nasogastric tubes or Foley catheters were used. Postoperative sedation was tailored to each patient by the anaesthesia department, and was permitted only with continual supervision of the patient. Humidified oxygen was applied via a face mask.

An exact 95% confidence interval (CI) was calculated for the percentage of life-threatening postoperative haemorrhage. Fisher’s exact test was used to compare this percentage between the Le Fort I and SARPE groups. A meta-analysis was performed to combine the osteotomy results from the current investigation with those from previous studies. The variability between the studies was verified using a logistic model with a random study effect; a likelihood ratio test was used for the between-study variance (the heterogeneity parameter). A common incidence was reported, and the exact 95% CI (under homogeneity) was given. Analyses were performed using SAS version 9.2 (SAS System for Windows, SAS Institute Inc., Cary, NC, USA).

Results

In this series, no operative bleeding was encountered during Le Fort I osteotomy or SARPE that could not be controlled with one or a combination of unipolar coagulation, bipolar coagulation, local packing with oxidized cellulose (Surgicel ® , Ethicon, Neuchâtel, Switzerland), local packing and compression with gauze and waiting, dense packing of the fossa with cottonoid, ligation of the descending palatine artery, haemostats, haemoclips, and thrombin–gelatin haemostatic matrix FloSeal ® . Ligation of the external carotid artery via a submandibular incision was not required in any case.

In this series, haemorrhage after Le Fort I osteotomy did not necessitate any other re-entries under general anaesthesia, aside from those described below.

Mild postoperative epistaxis is a frequent finding during the early postoperative period, but is usually self-limiting in nature and resolves spontaneously. Although the occasional use of traditional anterior–posterior nasal packing with an 8 cm expandable nasal tampon sponge (Ivalon ® Nasal Packing, Medsorb Dominicana, San Pedro de Macoris, Dominican Republic) was required, it is not considered a postoperative complication due to its benign and transient course.

After a Le Fort I osteotomy, any uncontrolled bleeding from the nose or the oropharyngeal cavity causing hypovolemia, hypoxia, shock, or airway compromise is considered a life-threatening haemorrhage.

Life-threatening haemorrhages occurred on the seventh postoperative day in two patients after Le Fort I osteotomy (2/750 = 0.3%, CI: 0.03–0.96%). Re-exploration of the surgical site after the Le Fort I procedure was not considered therapeutic in these two cases. Anterior and posterior nasal packing after the Le Fort I osteotomy failed in case 1 and was successful in case 2. Embolization was attempted only in case 1. The first embolization of the most distal branches of the maxillary artery failed to arrest the bleeding permanently. Recurrence of the haemorrhage necessitated more proximal embolization of the maxillary artery in case 1.

One brisk postoperative epistaxis that required anterior and posterior nasal packing under general anaesthesia occurred on the first post-SARPE day (case 3). This event was not considered a life-threatening haemorrhage after SARPE (0/376, CI: 0–0.98%). The difference between the Le Fort I and SARPE groups was not significant ( P < 0.56).

No other vascular incidents were observed during the follow-up period in either group.

Case 1

A 17-year-old healthy Caucasian female underwent a Le Fort I advancement for maxillary hypoplasia. Before surgery, she received presurgical orthodontics consisting of an orthodontic rapid palatal expansion followed by orthodontic alignment of the upper and lower jaw. Her medical history was unremarkable. The Le Fort I procedure took place on 26 August 1999, and was uneventful. No pre- or perioperative difficulties were encountered. Pterygomaxillary disjunction was performed with the curved Obwegeser osteotome, and easy mobilization of the maxilla was achieved, leaving the descending palatine arteries intact. Fixation of the upper jaw was accomplished using four miniplates, and no postoperative intermaxillary fixation was applied. The patient received prophylactic broad-spectrum antibiotics.

The first postoperative appointment on an outpatient basis took place on 1 September 1999. No problems such as abnormal swelling or nasal discharge were observed, and the patient reported no complaints. The next day (the seventh postoperative day), the patient was admitted to the emergency department of a nearby hospital with a brisk anterior and posterior epistaxis. With the patient under general anaesthesia, anterior and posterior packing of the nose was applied by the ears, nose, and throat surgeon and resulted in control of the bleeding. No blood transfusion was given. The patient was then transferred to hospital. No signs of infection were present. Computed tomography revealed a clean separation at the pterygomaxillary junction without evidence of pathological fractures. A haematological examination revealed no coagulopathy or bleeding disorder of any kind. Two days later, the nasal packing was removed.

On 5 September 1999, heavy bleeding from the nasal cavity was observed, leading to the decision to conduct urgent surgical exploration of the Le Fort I surgical site. No bleeding vessels could be located, but haemoclips were placed on both the left and right greater palatine arteries. No nasal packing was applied. Four days later, massive bleeding from the oral cavity and profuse bleeding through the left nasal cavity were observed. The patient was placed under general anaesthesia, and a Rüsch inflatable nasal tube size 3 (Rüsch, Kernen, Germany) was inserted in both nasal cavities and inflated. Four units of packed cells were administered.

An arteriogram did not visualize a bleeding source or any arteriovenous malformation. Supraselective embolization of the left descending palatine artery and the sphenopalatine artery with micro-coils was performed by the neuroradiologist to control the haemorrhage as close to the bleeding point as possible . At that time, the cause of the bleeding was thought to be close to the greater palatine artery. Most branches of the maxillary artery were left patent, including the deep auricular artery, the infraorbital artery, the inferior alveolar artery, the superior alveolar artery, the masseteric arteries, the middle meningeal artery, the deep temporal branches, and some thyrohyoideal branches.

Despite these measures, a new episode of brisk bleeding through the oral and nasal cavities occurred 14 days later on 23 September 1999. Two units of packed cells were administered, and another arteriogram was performed by a neuroradiologist. The source of bleeding could not be determined. This time it was decided to embolize the left maxillary artery at a very proximal position, distal to the middle meningeal artery using Gianturco-Wallace coils. Since this intervention, the patient has remained free of bleeding episodes. No ischaemic damage was observed in the maxilla or in any other part of the face. No relapse has occurred, and the patient remains very satisfied about the end result of the orthognathic treatment.

Case 2

A 22-year-old healthy Caucasian male was treated for posterior vertical maxillary excess and an interincisal anterior open bite of 22 mm. Le Fort I osteotomy with posterior impaction and a bilateral extra-oral vertical ramus osteotomy was performed on 30 September 1996. The osteotomy was uneventful, and the patient received prophylactic broad-spectrum antibiotics. Owing to the necessity of posterior impaction, both palatine arteries were freed, removing considerable amounts of bone in the vicinity of the artery to allow unimpeded posterior impaction. Both arteries remained patent. The preoperative and perioperative periods proceeded unremarkably. Owing to family circumstances the patient planned to be hospitalized for at least a week.

Seven days later, a few hours prior to the planned hospital discharge, the patient presented with profuse bilateral haemorrhaging through the oral and nasal cavities. No specific bleeding source was identified. The patient reported that he felt ‘something’ bothering him in the back of his throat. Trying to take it out by himself, he removed the intermaxillary fixation, which was applied with elastics. His fingers then entered the back of his throat, manipulating what probably was a clot and eliciting a massive haemorrhage from the oral and nasal cavities (left and right epistaxis). Within 1 h, the patient was brought under general anaesthesia, and a bilateral Rüsch inflatable nasal tube size 3 was inserted through the nose and inflated, successfully controlling the bleeding. He remained intubated until the next day, when surgical exploration of the osteotomy was performed. It was hypothesized that due to manual manipulation by the patient, a bone spicula could have penetrated the artery, resulting in profuse bleeding. No specific source or damaged vessel was identified. Owing to oozing of the left retrotuberal area, dense packing was performed with oxidized cellulose (Surgicel ® ). Both arteries were healthy and patent and were kept as such. No controlled hypotension was administered. The perioperative systolic blood pressure remained about 110 mmHg. The inflated Rüsch nasal tube was kept in place, and it was decided to awaken the patient gradually over the next 24 h. No new episode of bleeding has since been witnessed. In total, two units of packed cells were administered. No arteriogram was done. It remains unclear whether the patient elicited the bleeding with his finger or whether the clot in the nasopharynx was a sign of an imminent bleeding episode.

Case 3

A 23-year-old male was treated with a SARPE with a bone-borne transpalatal distractor on 1 August 2005. The surgery was uneventful, and the patient was discharged the same day. The patient was re-admitted the next day due to profuse epistaxis through the left nasal cavity. Initial packing with 8 cm expandable nasal tampon sponges (Ivalon ® ) was not effective. This postoperative bleeding was considered non-life-threatening but required reintervention under general anaesthesia without blood transfusion. The patient was placed under general anaesthesia, and a double-lumen balloon (dual-balloon epistaxis device) was tugged back into the nasopharynx abutting the posterior choana and insufflated in the left nasal cavity. The bleeding immediately came under control.

Over the next few days, the balloon was gradually deflated, and it was removed 3 days later. No new episode of bleeding was witnessed. The patient continued orthodontic alignment and underwent an operation on 5 November 2007 to correct a class III malocclusion. A bimaxillary orthognathic procedure consisting of a Le Fort I advancement of 6 mm and a bilateral sagittal split osteotomy setback procedure was performed. Both greater palatine arteries were visualized during the operation and remained patent. The perioperative and postoperative periods were uneventful.

Results

In this series, no operative bleeding was encountered during Le Fort I osteotomy or SARPE that could not be controlled with one or a combination of unipolar coagulation, bipolar coagulation, local packing with oxidized cellulose (Surgicel ® , Ethicon, Neuchâtel, Switzerland), local packing and compression with gauze and waiting, dense packing of the fossa with cottonoid, ligation of the descending palatine artery, haemostats, haemoclips, and thrombin–gelatin haemostatic matrix FloSeal ® . Ligation of the external carotid artery via a submandibular incision was not required in any case.

In this series, haemorrhage after Le Fort I osteotomy did not necessitate any other re-entries under general anaesthesia, aside from those described below.

Mild postoperative epistaxis is a frequent finding during the early postoperative period, but is usually self-limiting in nature and resolves spontaneously. Although the occasional use of traditional anterior–posterior nasal packing with an 8 cm expandable nasal tampon sponge (Ivalon ® Nasal Packing, Medsorb Dominicana, San Pedro de Macoris, Dominican Republic) was required, it is not considered a postoperative complication due to its benign and transient course.

After a Le Fort I osteotomy, any uncontrolled bleeding from the nose or the oropharyngeal cavity causing hypovolemia, hypoxia, shock, or airway compromise is considered a life-threatening haemorrhage.

Life-threatening haemorrhages occurred on the seventh postoperative day in two patients after Le Fort I osteotomy (2/750 = 0.3%, CI: 0.03–0.96%). Re-exploration of the surgical site after the Le Fort I procedure was not considered therapeutic in these two cases. Anterior and posterior nasal packing after the Le Fort I osteotomy failed in case 1 and was successful in case 2. Embolization was attempted only in case 1. The first embolization of the most distal branches of the maxillary artery failed to arrest the bleeding permanently. Recurrence of the haemorrhage necessitated more proximal embolization of the maxillary artery in case 1.

One brisk postoperative epistaxis that required anterior and posterior nasal packing under general anaesthesia occurred on the first post-SARPE day (case 3). This event was not considered a life-threatening haemorrhage after SARPE (0/376, CI: 0–0.98%). The difference between the Le Fort I and SARPE groups was not significant ( P < 0.56).

No other vascular incidents were observed during the follow-up period in either group.

Case 1

A 17-year-old healthy Caucasian female underwent a Le Fort I advancement for maxillary hypoplasia. Before surgery, she received presurgical orthodontics consisting of an orthodontic rapid palatal expansion followed by orthodontic alignment of the upper and lower jaw. Her medical history was unremarkable. The Le Fort I procedure took place on 26 August 1999, and was uneventful. No pre- or perioperative difficulties were encountered. Pterygomaxillary disjunction was performed with the curved Obwegeser osteotome, and easy mobilization of the maxilla was achieved, leaving the descending palatine arteries intact. Fixation of the upper jaw was accomplished using four miniplates, and no postoperative intermaxillary fixation was applied. The patient received prophylactic broad-spectrum antibiotics.

The first postoperative appointment on an outpatient basis took place on 1 September 1999. No problems such as abnormal swelling or nasal discharge were observed, and the patient reported no complaints. The next day (the seventh postoperative day), the patient was admitted to the emergency department of a nearby hospital with a brisk anterior and posterior epistaxis. With the patient under general anaesthesia, anterior and posterior packing of the nose was applied by the ears, nose, and throat surgeon and resulted in control of the bleeding. No blood transfusion was given. The patient was then transferred to hospital. No signs of infection were present. Computed tomography revealed a clean separation at the pterygomaxillary junction without evidence of pathological fractures. A haematological examination revealed no coagulopathy or bleeding disorder of any kind. Two days later, the nasal packing was removed.

On 5 September 1999, heavy bleeding from the nasal cavity was observed, leading to the decision to conduct urgent surgical exploration of the Le Fort I surgical site. No bleeding vessels could be located, but haemoclips were placed on both the left and right greater palatine arteries. No nasal packing was applied. Four days later, massive bleeding from the oral cavity and profuse bleeding through the left nasal cavity were observed. The patient was placed under general anaesthesia, and a Rüsch inflatable nasal tube size 3 (Rüsch, Kernen, Germany) was inserted in both nasal cavities and inflated. Four units of packed cells were administered.

An arteriogram did not visualize a bleeding source or any arteriovenous malformation. Supraselective embolization of the left descending palatine artery and the sphenopalatine artery with micro-coils was performed by the neuroradiologist to control the haemorrhage as close to the bleeding point as possible . At that time, the cause of the bleeding was thought to be close to the greater palatine artery. Most branches of the maxillary artery were left patent, including the deep auricular artery, the infraorbital artery, the inferior alveolar artery, the superior alveolar artery, the masseteric arteries, the middle meningeal artery, the deep temporal branches, and some thyrohyoideal branches.

Despite these measures, a new episode of brisk bleeding through the oral and nasal cavities occurred 14 days later on 23 September 1999. Two units of packed cells were administered, and another arteriogram was performed by a neuroradiologist. The source of bleeding could not be determined. This time it was decided to embolize the left maxillary artery at a very proximal position, distal to the middle meningeal artery using Gianturco-Wallace coils. Since this intervention, the patient has remained free of bleeding episodes. No ischaemic damage was observed in the maxilla or in any other part of the face. No relapse has occurred, and the patient remains very satisfied about the end result of the orthognathic treatment.

Case 2

A 22-year-old healthy Caucasian male was treated for posterior vertical maxillary excess and an interincisal anterior open bite of 22 mm. Le Fort I osteotomy with posterior impaction and a bilateral extra-oral vertical ramus osteotomy was performed on 30 September 1996. The osteotomy was uneventful, and the patient received prophylactic broad-spectrum antibiotics. Owing to the necessity of posterior impaction, both palatine arteries were freed, removing considerable amounts of bone in the vicinity of the artery to allow unimpeded posterior impaction. Both arteries remained patent. The preoperative and perioperative periods proceeded unremarkably. Owing to family circumstances the patient planned to be hospitalized for at least a week.

Seven days later, a few hours prior to the planned hospital discharge, the patient presented with profuse bilateral haemorrhaging through the oral and nasal cavities. No specific bleeding source was identified. The patient reported that he felt ‘something’ bothering him in the back of his throat. Trying to take it out by himself, he removed the intermaxillary fixation, which was applied with elastics. His fingers then entered the back of his throat, manipulating what probably was a clot and eliciting a massive haemorrhage from the oral and nasal cavities (left and right epistaxis). Within 1 h, the patient was brought under general anaesthesia, and a bilateral Rüsch inflatable nasal tube size 3 was inserted through the nose and inflated, successfully controlling the bleeding. He remained intubated until the next day, when surgical exploration of the osteotomy was performed. It was hypothesized that due to manual manipulation by the patient, a bone spicula could have penetrated the artery, resulting in profuse bleeding. No specific source or damaged vessel was identified. Owing to oozing of the left retrotuberal area, dense packing was performed with oxidized cellulose (Surgicel ® ). Both arteries were healthy and patent and were kept as such. No controlled hypotension was administered. The perioperative systolic blood pressure remained about 110 mmHg. The inflated Rüsch nasal tube was kept in place, and it was decided to awaken the patient gradually over the next 24 h. No new episode of bleeding has since been witnessed. In total, two units of packed cells were administered. No arteriogram was done. It remains unclear whether the patient elicited the bleeding with his finger or whether the clot in the nasopharynx was a sign of an imminent bleeding episode.

Case 3

A 23-year-old male was treated with a SARPE with a bone-borne transpalatal distractor on 1 August 2005. The surgery was uneventful, and the patient was discharged the same day. The patient was re-admitted the next day due to profuse epistaxis through the left nasal cavity. Initial packing with 8 cm expandable nasal tampon sponges (Ivalon ® ) was not effective. This postoperative bleeding was considered non-life-threatening but required reintervention under general anaesthesia without blood transfusion. The patient was placed under general anaesthesia, and a double-lumen balloon (dual-balloon epistaxis device) was tugged back into the nasopharynx abutting the posterior choana and insufflated in the left nasal cavity. The bleeding immediately came under control.

Over the next few days, the balloon was gradually deflated, and it was removed 3 days later. No new episode of bleeding was witnessed. The patient continued orthodontic alignment and underwent an operation on 5 November 2007 to correct a class III malocclusion. A bimaxillary orthognathic procedure consisting of a Le Fort I advancement of 6 mm and a bilateral sagittal split osteotomy setback procedure was performed. Both greater palatine arteries were visualized during the operation and remained patent. The perioperative and postoperative periods were uneventful.

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Jan 26, 2018 | Posted by in Oral and Maxillofacial Surgery | Comments Off on Life-threatening haemorrhage after 750 Le Fort I osteotomies and 376 SARPE procedures
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