Post-operative avascular necrosis of the maxilla: a rare complication following orthognathic surgery
Identifieur interne : 001F22 ( Pmc/Corpus ); précédent : 001F21; suivant : 001F23Post-operative avascular necrosis of the maxilla: a rare complication following orthognathic surgery
Auteurs : Trevor A. Teemul ; Jean Perfettini ; David O. Morris ; John L. RussellSource :
- Journal of Surgical Case Reports [ 2042-8812 ] ; 2017.
Abstract
We present a patient with sickle cell trait who suffered avascular necrosis of the maxilla as a complication of maxillary osteotomy. Understanding the blood supply of the maxilla and how possible patient related, anaesthetic and operative factors affect it, is important in understanding how the vascularity of the maxilla can become compromised in a surgical procedure. The perioperative parameters were analysed to identify any prognostic elements. Avascular necrosis of the maxilla is a rare complication of orthognathic surgery with few cases reported in the literature. There are identifiable risk factors that can influence the blood supply of the maxilla. Careful preoperative assessment is required to exclude patient factors that have the potential to affect tissue vascularity. This in conjunction with sound anaesthetic and surgical technique should all minimize the risk of avascular necrosis. Even so it is still possible for this rare complication to occur.
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DOI: 10.1093/jscr/rjw240
PubMed: 28122898
PubMed Central: 5266080
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<record><TEI><teiHeader><fileDesc><titleStmt><title xml:lang="en">Post-operative avascular necrosis of the maxilla: a rare complication following orthognathic surgery</title><author><name sortKey="Teemul, Trevor A" sort="Teemul, Trevor A" uniqKey="Teemul T" first="Trevor A." last="Teemul">Trevor A. Teemul</name><affiliation><nlm:aff id="rjw240af1"><addr-line>Oral and Maxillofacial Surgery Department, Hull Royal Infirmary, Hull HU3 2JZ</addr-line>,<country>UK</country></nlm:aff></affiliation></author><author><name sortKey="Perfettini, Jean" sort="Perfettini, Jean" uniqKey="Perfettini J" first="Jean" last="Perfettini">Jean Perfettini</name><affiliation><nlm:aff id="rjw240af2"><addr-line>Anaesthetic Department, Leeds General Infirmary, Leeds LS1 3EX</addr-line>,<country>UK</country></nlm:aff></affiliation></author><author><name sortKey="Morris, David O" sort="Morris, David O" uniqKey="Morris D" first="David O." last="Morris">David O. Morris</name><affiliation><nlm:aff id="rjw240af3"><addr-line>Orthodontic Department, Leeds Dental Institute, Clarendon Way, Leeds LS2 9 LU</addr-line>,<country>UK</country></nlm:aff></affiliation></author><author><name sortKey="Russell, John L" sort="Russell, John L" uniqKey="Russell J" first="John L." last="Russell">John L. Russell</name><affiliation><nlm:aff id="rjw240af4"><addr-line>Oral and Maxillofacial surgery Department, Leeds Dental Institute, Clarendon Way, Leeds LS2 9 LU</addr-line>,<country>UK</country></nlm:aff></affiliation></author></titleStmt><publicationStmt><idno type="wicri:source">PMC</idno><idno type="pmid">28122898</idno><idno type="pmc">5266080</idno><idno type="url">http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5266080</idno><idno type="RBID">PMC:5266080</idno><idno type="doi">10.1093/jscr/rjw240</idno><date when="2017">2017</date><idno type="wicri:Area/Pmc/Corpus">001F22</idno><idno type="wicri:explorRef" wicri:stream="Pmc" wicri:step="Corpus" wicri:corpus="PMC">001F22</idno></publicationStmt><sourceDesc><biblStruct><analytic><title xml:lang="en" level="a" type="main">Post-operative avascular necrosis of the maxilla: a rare complication following orthognathic surgery</title><author><name sortKey="Teemul, Trevor A" sort="Teemul, Trevor A" uniqKey="Teemul T" first="Trevor A." last="Teemul">Trevor A. Teemul</name><affiliation><nlm:aff id="rjw240af1"><addr-line>Oral and Maxillofacial Surgery Department, Hull Royal Infirmary, Hull HU3 2JZ</addr-line>,<country>UK</country></nlm:aff></affiliation></author><author><name sortKey="Perfettini, Jean" sort="Perfettini, Jean" uniqKey="Perfettini J" first="Jean" last="Perfettini">Jean Perfettini</name><affiliation><nlm:aff id="rjw240af2"><addr-line>Anaesthetic Department, Leeds General Infirmary, Leeds LS1 3EX</addr-line>,<country>UK</country></nlm:aff></affiliation></author><author><name sortKey="Morris, David O" sort="Morris, David O" uniqKey="Morris D" first="David O." last="Morris">David O. Morris</name><affiliation><nlm:aff id="rjw240af3"><addr-line>Orthodontic Department, Leeds Dental Institute, Clarendon Way, Leeds LS2 9 LU</addr-line>,<country>UK</country></nlm:aff></affiliation></author><author><name sortKey="Russell, John L" sort="Russell, John L" uniqKey="Russell J" first="John L." last="Russell">John L. Russell</name><affiliation><nlm:aff id="rjw240af4"><addr-line>Oral and Maxillofacial surgery Department, Leeds Dental Institute, Clarendon Way, Leeds LS2 9 LU</addr-line>,<country>UK</country></nlm:aff></affiliation></author></analytic><series><title level="j">Journal of Surgical Case Reports</title><idno type="eISSN">2042-8812</idno><imprint><date when="2017">2017</date></imprint></series></biblStruct></sourceDesc></fileDesc><profileDesc><textClass></textClass></profileDesc></teiHeader><front><div type="abstract" xml:lang="en"><p>We present a patient with sickle cell trait who suffered avascular necrosis of the maxilla as a complication of maxillary osteotomy. Understanding the blood supply of the maxilla and how possible patient related, anaesthetic and operative factors affect it, is important in understanding how the vascularity of the maxilla can become compromised in a surgical procedure. The perioperative parameters were analysed to identify any prognostic elements. Avascular necrosis of the maxilla is a rare complication of orthognathic surgery with few cases reported in the literature. There are identifiable risk factors that can influence the blood supply of the maxilla. Careful preoperative assessment is required to exclude patient factors that have the potential to affect tissue vascularity. This in conjunction with sound anaesthetic and surgical technique should all minimize the risk of avascular necrosis. Even so it is still possible for this rare complication to occur.</p></div></front><back><div1 type="bibliography"><listBibl><biblStruct><analytic><author><name sortKey="Pereira, Fl" uniqKey="Pereira F">FL Pereira</name></author><author><name sortKey="Yaedu, Ryf" uniqKey="Yaedu R">RYF Yaedu</name></author><author><name sortKey="Sant Ana, Ap" uniqKey="Sant Ana A">AP Sant'Ana</name></author><author><name sortKey="Sant Ana, E" uniqKey="Sant Ana E">E Sant'Ana</name></author></analytic></biblStruct><biblStruct><analytic><author><name sortKey="Siebert, Jw" uniqKey="Siebert J">JW Siebert</name></author><author><name sortKey="Angrigiani, C" uniqKey="Angrigiani C">C Angrigiani</name></author><author><name sortKey="Mccarthy, Jg" uniqKey="Mccarthy J">JG McCarthy</name></author><author><name sortKey="Longaker, Mt" uniqKey="Longaker M">MT Longaker</name></author></analytic></biblStruct><biblStruct><analytic><author><name sortKey="Bell, Wh" uniqKey="Bell W">WH Bell</name></author><author><name sortKey="You, Zh" uniqKey="You Z">ZH You</name></author><author><name sortKey="Finn, Ra" uniqKey="Finn R">RA Finn</name></author><author><name sortKey="Fields, T" uniqKey="Fields T">T Fields</name></author></analytic></biblStruct><biblStruct><analytic><author><name sortKey="Vichinsky, Ep" uniqKey="Vichinsky E">EP Vichinsky</name></author><author><name sortKey="Haberkern, Cm" uniqKey="Haberkern C">CM Haberkern</name></author><author><name sortKey="Neumayr, L" uniqKey="Neumayr L">L Neumayr</name></author><author><name sortKey="Earles, An" uniqKey="Earles A">AN Earles</name></author><author><name sortKey="Black, D" uniqKey="Black D">D Black</name></author><author><name sortKey="Koshy, M" uniqKey="Koshy M">M Koshy</name></author></analytic></biblStruct><biblStruct><analytic><author><name sortKey="Ho, Mw" uniqKey="Ho M">MW Ho</name></author><author><name sortKey="Boyle, Ma" uniqKey="Boyle M">MA Boyle</name></author><author><name sortKey="Cooper, Jc" uniqKey="Cooper J">JC Cooper</name></author><author><name sortKey="Dodd, Md" uniqKey="Dodd M">MD Dodd</name></author><author><name sortKey="Richardson, D" uniqKey="Richardson D">D Richardson</name></author></analytic></biblStruct><biblStruct><analytic><author><name sortKey="Lanigan, D" uniqKey="Lanigan D">D Lanigan</name></author><author><name sortKey="Hey, Jh" uniqKey="Hey J">JH Hey</name></author><author><name sortKey="West, Ra" uniqKey="West R">RA West</name></author></analytic></biblStruct><biblStruct><analytic><author><name sortKey="Pineiro Aguilar, A" uniqKey="Pineiro Aguilar A">A Pineiro-Aguilar</name></author><author><name sortKey="Somoza Martin, M" uniqKey="Somoza Martin M">M Somoza-Martin</name></author><author><name sortKey="Gandara Rey, Jm" uniqKey="Gandara Rey J">JM Gandara-Rey</name></author><author><name sortKey="Garcia Garcia, A" uniqKey="Garcia Garcia A">A Garcia-Garcia</name></author></analytic></biblStruct><biblStruct><analytic><author><name sortKey="Rodrigo, C" uniqKey="Rodrigo C">C Rodrigo</name></author></analytic></biblStruct><biblStruct><analytic><author><name sortKey="Choi, Bk" uniqKey="Choi B">BK Choi</name></author><author><name sortKey="Yang, Ej" uniqKey="Yang E">EJ Yang</name></author><author><name sortKey="Oh, Ks" uniqKey="Oh K">KS Oh</name></author><author><name sortKey="Lo, Lj" uniqKey="Lo L">LJ Lo</name></author></analytic></biblStruct></listBibl></div1></back></TEI><pmc article-type="case-report"><pmc-dir>properties open_access</pmc-dir>
<front><journal-meta><journal-id journal-id-type="nlm-ta">J Surg Case Rep</journal-id><journal-id journal-id-type="iso-abbrev">J Surg Case Rep</journal-id><journal-id journal-id-type="publisher-id">jscr</journal-id><journal-id journal-id-type="hwp">jscr</journal-id><journal-title-group><journal-title>Journal of Surgical Case Reports</journal-title></journal-title-group><issn pub-type="epub">2042-8812</issn><publisher><publisher-name>Oxford University Press</publisher-name></publisher></journal-meta><article-meta><article-id pub-id-type="pmid">28122898</article-id><article-id pub-id-type="pmc">5266080</article-id><article-id pub-id-type="doi">10.1093/jscr/rjw240</article-id><article-id pub-id-type="publisher-id">rjw240</article-id><article-categories><subj-group subj-group-type="heading"><subject>Case Report</subject></subj-group></article-categories><title-group><article-title>Post-operative avascular necrosis of the maxilla: a rare complication following orthognathic surgery</article-title></title-group><contrib-group><contrib contrib-type="author"><name><surname>Teemul</surname><given-names>Trevor A.</given-names></name><xref ref-type="aff" rid="rjw240af1">1</xref><xref ref-type="corresp" rid="rjw240cor1">*</xref></contrib><contrib contrib-type="author"><name><surname>Perfettini</surname><given-names>Jean</given-names></name><xref ref-type="aff" rid="rjw240af2">2</xref></contrib><contrib contrib-type="author"><name><surname>Morris</surname><given-names>David O.</given-names></name><xref ref-type="aff" rid="rjw240af3">3</xref></contrib><contrib contrib-type="author"><name><surname>Russell</surname><given-names>John L.</given-names></name><xref ref-type="aff" rid="rjw240af4">4</xref></contrib><aff id="rjw240af1"><label>1</label><addr-line>Oral and Maxillofacial Surgery Department, Hull Royal Infirmary, Hull HU3 2JZ</addr-line>,<country>UK</country></aff><aff id="rjw240af2"><label>2</label><addr-line>Anaesthetic Department, Leeds General Infirmary, Leeds LS1 3EX</addr-line>,<country>UK</country></aff><aff id="rjw240af3"><label>3</label><addr-line>Orthodontic Department, Leeds Dental Institute, Clarendon Way, Leeds LS2 9 LU</addr-line>,<country>UK</country></aff><aff id="rjw240af4"><label>4</label><addr-line>Oral and Maxillofacial surgery Department, Leeds Dental Institute, Clarendon Way, Leeds LS2 9 LU</addr-line>,<country>UK</country></aff></contrib-group><author-notes><corresp id="rjw240cor1"><label>*</label>Correspondence address. Oral and Maxillofacial Surgery Department, Hull Royal Infirmary, Hull HU3 2JZ, UK. Tel: +<phone>441482674225</phone>; Fax: +<fax>441482675064</fax>; E-mail: <email>trevor.teemul@nhs.net</email></corresp></author-notes><pub-date pub-type="collection"><month>1</month><year>2017</year></pub-date><pub-date pub-type="epub"><day>25</day><month>1</month><year>2017</year></pub-date><volume>2017</volume><issue>1</issue><elocation-id>rjw240</elocation-id><history><date date-type="received"><day>17</day><month>11</month><year>2016</year></date><date date-type="accepted"><day>31</day><month>12</month><year>2016</year></date></history><permissions><copyright-statement>Published by Oxford University Press and JSCR Publishing Ltd. All rights reserved. © The Author 2017.</copyright-statement><copyright-year>2017</copyright-year><license license-type="creative-commons" xlink:href="http://creativecommons.org/licenses/by-nc/4.0/"><license-p>This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (<ext-link ext-link-type="uri" xlink:href="http://creativecommons.org/licenses/by-nc/4.0/">http://creativecommons.org/licenses/by-nc/4.0/</ext-link>), which permits non-commercial re-use, distribution, and reproduction in any medium, provided the original work is properly cited. For commercial re-use, please contact journals.permissions@oup.com</license-p></license></permissions><self-uri content-type="pdf" xlink:href="rjw240.pdf"></self-uri><self-uri xlink:role="icon" xlink:href="rjw240_thumb.gif"></self-uri><abstract><p>We present a patient with sickle cell trait who suffered avascular necrosis of the maxilla as a complication of maxillary osteotomy. Understanding the blood supply of the maxilla and how possible patient related, anaesthetic and operative factors affect it, is important in understanding how the vascularity of the maxilla can become compromised in a surgical procedure. The perioperative parameters were analysed to identify any prognostic elements. Avascular necrosis of the maxilla is a rare complication of orthognathic surgery with few cases reported in the literature. There are identifiable risk factors that can influence the blood supply of the maxilla. Careful preoperative assessment is required to exclude patient factors that have the potential to affect tissue vascularity. This in conjunction with sound anaesthetic and surgical technique should all minimize the risk of avascular necrosis. Even so it is still possible for this rare complication to occur.</p></abstract><counts><page-count count="3"></page-count></counts></article-meta></front><body><sec sec-type="intro" id="rjw240s1"><title>INTRODUCTION</title><p>Orthognathic maxillary surgery is a safe, predictable and stable procedure. The incidence of perioperative complications is low and the number of life-threatening complications with this surgery is even lower. However, avascular necrosis of the maxilla after Le Fort I osteotomy is a rare complication that has been reported to occur in <1% of cases [<xref rid="rjw240C1" ref-type="bibr">1</xref>].</p><p>During down fracture of the maxilla, the blood supply is by the ascending pharyngeal artery, the ascending palatine branch of the facial artery and the rich mucosal alveolar network overlying the maxilla [<xref rid="rjw240C2" ref-type="bibr">2</xref>]. Table <xref ref-type="table" rid="rjw240TB1">1</xref> outlines the factors that may result in impaired blood supply to the maxillary segments and increase the risk of ischaemia. When the descending palatine artery is sacrificed, the main blood supply of the maxilla will now be the soft tissue pedicle, which incorporates the anterior faucial pillar and the palatal mucosa (see Fig. <xref ref-type="fig" rid="rjw240F1">1</xref>).
<fig id="rjw240F1" fig-type="featured" orientation="portrait" position="float"><label>Figure 1:</label><caption><p>Blood supply of the maxilla. (<bold>A</bold>) Nasopalatine artery, (<bold>B</bold>) Descending palatine artery, (<bold>C</bold>) Greater palatine artery, (<bold>D</bold>) Lesser palatine artery, (<bold>E</bold>) Maxillary artery, (<bold>F</bold>) Ascending pharyngeal artery, (<bold>G</bold>) Ascending palatine artery, (<bold>H</bold>) Facial artery, (<bold>I</bold>) External carotid artery, (<bold>J</bold>) Le Fort I downfracture.</p></caption><graphic xlink:href="rjw240f01"></graphic></fig><table-wrap id="rjw240TB1" orientation="portrait" position="float"><label>Table 1</label><caption><p>Factors increasing the risk of avascular necrosis of the maxilla</p></caption><table frame="hsides" rules="groups"><colgroup span="1"><col align="left" span="1"></col><col align="left" span="1"></col></colgroup><thead><tr><th align="left" rowspan="1" colspan="1">Local</th><th align="left" rowspan="1" colspan="1">Systemic</th></tr></thead><tbody><tr><td rowspan="1" colspan="1">Radiation treatment</td><td rowspan="1" colspan="1">Cigarette smoking</td></tr><tr><td rowspan="1" colspan="1">Infection</td><td rowspan="1" colspan="1">Pregnancy</td></tr><tr><td rowspan="1" colspan="1">Trauma</td><td rowspan="1" colspan="1">Chemotherapy</td></tr><tr><td rowspan="1" colspan="1">Surgery related</td><td rowspan="1" colspan="1">Haematological conditions</td></tr><tr><td rowspan="1" colspan="1"> Sacrifice of descending palatine artery</td><td rowspan="1" colspan="1"> Sickle cell disease</td></tr><tr><td rowspan="1" colspan="1"> Perforation/stripping palatal mucosa</td><td rowspan="1" colspan="1"> Leukaemia</td></tr><tr><td rowspan="1" colspan="1"> Adrenaline injected into mucosa</td><td rowspan="1" colspan="1"> Gaucher's disease</td></tr><tr><td rowspan="1" colspan="1"> Perioperative vascular thrombosis</td><td rowspan="1" colspan="1"> Thalassaemia</td></tr><tr><td rowspan="1" colspan="1"> Segmental osteotomies</td><td rowspan="1" colspan="1">Caisson disease</td></tr><tr><td rowspan="1" colspan="1"> Extensive advancement</td><td rowspan="1" colspan="1">Systemic lupus erythematosis</td></tr><tr><td rowspan="1" colspan="1">Anatomy related</td><td rowspan="1" colspan="1">Diabetes mellitus</td></tr><tr><td rowspan="1" colspan="1"> Craniofacial dysplasias</td><td rowspan="1" colspan="1">Vasculitis</td></tr><tr><td rowspan="1" colspan="1"> Orofacial clefts</td><td rowspan="1" colspan="1">Inflammatory bowel disease</td></tr><tr><td rowspan="1" colspan="1"> Vascular anomalies</td><td rowspan="1" colspan="1">Drugs</td></tr><tr><td rowspan="1" colspan="1">Previous surgery</td><td rowspan="1" colspan="1"> Vasoconstrictors</td></tr><tr><td rowspan="1" colspan="1"> Cleft palate repair</td><td rowspan="1" colspan="1"> High dose steroid</td></tr><tr><td rowspan="1" colspan="1"> Surgically assisted rapid palatal expansion</td><td rowspan="1" colspan="1"></td></tr></tbody></table></table-wrap></p></sec><sec id="rjw240s2"><title>CASE REPORT</title><p>We report a case of a 45-year-old Afro-Caribbean female who underwent orthognathic surgery to correct her malocclusion. She was previously investigated for a fibro-osseous lesion, which presented as a hyperplastic right maxillary tuberosity (see Fig. <xref ref-type="fig" rid="rjw240F2">2</xref>). This was biopsied and reported as normal lamellar bone. Relevant past medical history included hypertension and sickle cell trait. Her medications included Lisinopril and Indapamide.
<fig id="rjw240F2" orientation="portrait" position="float"><label>Figure 2:</label><caption><p>Preoperative orthopantomograph showing expansion of the right maxillary tuberosity.</p></caption><graphic xlink:href="rjw240f02"></graphic></fig></p><p>As seen in Fig. <xref ref-type="fig" rid="rjw240F3">3</xref>, there was good oral hygiene. The patient had lost her lower posterior teeth and there was downward displacement of the upper right posterior segment into the edentulous area of the lower posterior jaw.
<fig id="rjw240F3" orientation="portrait" position="float"><label>Figure 3:</label><caption><p>Pre-surgical photographs.</p></caption><graphic xlink:href="rjw240f03"></graphic></fig></p><p>The operation planned was a Le Fort I osteotomy with a right posterior segment osteotomy, which would set back the upper incisors by 6 mm, impact the upper left second molar by 4 mm and impact the posterior segment from the upper right first premolar (by 5 mm) to the upper right first molar (by 12 mm). No forward movement of the maxilla was planned. The segmental osteotomy was performed following down fracture of the maxilla and the final occlusion was aligned to a full coverage occlusal splint. The right descending palatal artery was sacrificed.</p><p>The maxillary mucosa appeared pale during the procedure, but showed capillary refill. The patient presented with wound infection and avascularity of the maxilla 1 week after the procedure. She was treated with intravenous Co-amoxiclav for 2 weeks. A course of hyperbaric oxygen treatment was organized at 14 and 18 days post-operatively. She was started on therapeutic doses of Pentoxyfylline and Vitamin E to improve capillary blood flow.</p><p>As shown in Fig. <xref ref-type="fig" rid="rjw240F4">4</xref>, most of the maxilla was affected, the right side to a greater degree. Despite treatment, over time those areas which remained devascularised began to demarcate. An oro-antral fistula developed in the upper right quadrant, as seen in Fig. <xref ref-type="fig" rid="rjw240F5">5</xref>.
<fig id="rjw240F4" orientation="portrait" position="float"><label>Figure 4:</label><caption><p>Photographs at 26 days post surgery.</p></caption><graphic xlink:href="rjw240f04"></graphic></fig><fig id="rjw240F5" orientation="portrait" position="float"><label>Figure 5:</label><caption><p>Photographs at 6 months post surgery.</p></caption><graphic xlink:href="rjw240f05"></graphic></fig></p></sec><sec sec-type="discussion" id="rjw240s3"><title>DISCUSSION</title><p>Blood flow to the maxilla is reduced by 50% in the first post-operative day after sacrifice of the descending palatine arteries [<xref rid="rjw240C3" ref-type="bibr">3</xref>]. However, there is excellent collateral blood supply particularly if only one artery is sacrificed, as in this case. Experimental studies have shown that loss of the descending palatine arteries results in a transient ischaemic period that is compensated for by a vascular proliferation that allows tissue healing. The collateral microvasculature from other vessels including the ascending pharyngeal and facial arteries (Fig. <xref ref-type="fig" rid="rjw240F1">1</xref>), maintains the viability of the palatine pedicle. The pedicle can withstand stretching greater than 10 mm of anterior repositioning of the maxilla.</p><p>The patient had sickle cell trait. The haemogloblinopathy screen confirmed Hb A (Adult Haemoglobin) and Hb S (Sickle Haemoglobin). The Hb F (Foetal Haemoglobin) level was <0.5% and the Hb S level was 39.4%. These parameters are typical for sickle cell trait. However, for patients in Sickle Cell crisis or those expected to be exposed to severe hypoxia, Hb S level <30% is advised [<xref rid="rjw240C4" ref-type="bibr">4</xref>].</p><p>Craniofacial dysplasias may represent areas of anatomical variation where the blood supply may be susceptible to disruption. Although the patient had a biopsy showing normal bone, the maxillary tuberosity was expanded and hyperplastic clinically. This in itself would not however have accounted for the degree of avascularity seen in this case.</p><p>Literature suggests that segmental osteotomy is at a higher risk of ischaemic complications [<xref rid="rjw240C5" ref-type="bibr">5</xref>, <xref rid="rjw240C6" ref-type="bibr">6</xref>]. Necrosis of the maxilla can be minimized in the following ways:
<list list-type="simple"><list-item><p>– Divide into as few segments as possible and avoid small segments anteriorly.</p></list-item><list-item><p>– Maintain the integrity of the palatal mucosa.</p></list-item><list-item><p>– Perform sagittal segmentation in paramedian sites as the mucosa is thicker and the bone thinner than the midline.</p><p>Although hypotensive anaesthesia was not purposely utilized for the procedure, it is a technique commonly used to help maintain a bloodless surgical field [<xref rid="rjw240C7" ref-type="bibr">7</xref>]. A mean arterial blood pressure (MAP) 30% below a patient's usual MAP, with a minimum MAP of 50 mm Hg in American society of anesthesiologists Class I patients and a MAP not <80 mm Hg in the elderly, is suggested to be clinically acceptable [<xref rid="rjw240C8" ref-type="bibr">8</xref>]. It is recommended that with respect to hypotensive anaesthesia:</p></list-item><list-item><p>– It should be adjusted in relation to the patient's preoperative blood pressure rather than to a specific target pressure.</p></list-item><list-item><p>– It should be limited to that level necessary to reduce bleeding in the surgical field.</p></list-item><list-item><p>– It should be confined to that part of the surgical procedure deemed to benefit by it.</p></list-item><list-item><p>– There is little need for blood transfusion perioperatively [<xref rid="rjw240C9" ref-type="bibr">9</xref>].</p></list-item></list></p><p>The anaesthetic concerns include the management of perioperative hypoxia, acidosis, hypovolaemia and hypothermia.</p><p>Points to consider with this case are:
<list list-type="order"><list-item><p>Hypoxia never occurred and is usually avoided as anaesthetised patients are always maintained with an FiO<sub>2</sub> >0.35.</p></list-item><list-item><p>Acidosis may trigger a vaso-occlusive crisis and would affect all micro-circulation; it is easily prevented by proper perfusion and maintaining circulating blood volume.</p></list-item><list-item><p>Hypothermia was prevented by patient warming.</p></list-item><list-item><p>Hypovolaemia could be contentious, especially with hypotension.</p></list-item></list></p><p>With this patient, the mechanism of avascular necrosis could not clearly be explained. In the analysis of patient, surgical and anaesthetic factors, there seemed to be issues that may have implied a greater risk.</p></sec><sec id="rjw240s4"><title>CONFLICT OF INTEREST STATEMENT</title><p>None declared.</p></sec></body><back><ref-list><title>REFERENCES</title><ref id="rjw240C1"><label>1</label><mixed-citation publication-type="journal"><person-group person-group-type="author"><name name-style="western"><surname>Pereira</surname><given-names>FL</given-names></name>, <name name-style="western"><surname>Yaedu</surname><given-names>RYF</given-names></name>, <name name-style="western"><surname>Sant'Ana</surname><given-names>AP</given-names></name>, <name name-style="western"><surname>Sant'Ana</surname><given-names>E</given-names></name></person-group><article-title>Maxillary aseptic necrosis after Le Fort I osteotomy: a case report and literature review</article-title>. <source>J Oral Maxillofac 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