What is the management of bleeding during a LeFort osteotomy?

From the Guidelines

Bleeding during a LeFort osteotomy should be managed with a combination of preoperative preparation, intraoperative techniques, and postoperative care, including the use of pro-hemostatic options such as tranexamic acid mouthwash, as recommended by the American College of Chest Physicians clinical practice guideline 1. Managing bleeding during a LeFort osteotomy requires a comprehensive approach. Before surgery, patients should discontinue anticoagulants and antiplatelet medications when possible. Intraoperatively, local infiltration with epinephrine and direct control measures such as electrocautery and ligation or clipping of larger vessels can be employed.

• Key intraoperative techniques include:
  • Local infiltration with epinephrine (1:100,000 or 1:200,000 concentration) to achieve vasoconstriction
  • Electrocautery for small vessels
  • Ligation or clipping of larger vessels like the descending palatine artery
• Topical hemostatic agents such as bone wax, oxidized cellulose (Surgicel), or thrombin-soaked gelatin sponges (Gelfoam) can be effective for diffuse bleeding.
• The use of tranexamic acid, either orally as a mouthwash or intravenously, is supported by recent guidelines 1 and can inhibit fibrinolysis, reducing blood loss. Postoperatively, head elevation, careful blood pressure monitoring, and cold compresses help minimize continued bleeding. Persistent bleeding may require reoperation to identify and address the source. These techniques are essential because the maxillofacial region is highly vascular, and proper hemostasis prevents complications like hematoma formation, infection, and compromised surgical outcomes.

From the Research

Management of Bleeding during LeFort Osteotomy

• The management of bleeding during a LeFort osteotomy can be challenging, with both venous and arterial bleeding possible 2.
• Arterial hemorrhage tends to be more persistent and can be recurrent, making it more difficult to manage 2.
• Treatment modalities for postoperative hemorrhage include:
  • Anterior and/or posterior nasal packing
  • Packing of the maxillary antrum
  • Reoperating with clipping or electrocoagulation of bleeding vessels
  • Use of topical hemostatic agents in the pterygomaxillary region
  • External carotid artery ligation
  • Selective embolization of the maxillary artery and its terminal branches 2
• Intraoperative vascular complications can occur, with the descending palatine artery (DPA) being a common source of bleeding 3.
• The use of hemostatic agents, such as a hemostatic matrix with thrombin, can be effective in controlling venous bleeding 3.
• Hypotensive anesthesia can be used to reduce blood loss during orthognathic surgery, and the addition of hemorrhage depressors, such as tranexamic acid and desmopressin, can further reduce blood loss 4.
• The risk of complications, including bleeding, can be increased in patients with anatomical irregularities, such as craniofacial dysplasias or vascular anomalies 5.
• Surgeons should be prepared for heavier bleeding by reserving blood at a blood bank or by preparing an autotransfusion, as bleeding can occasionally be heavier than expected 6.