Orthognathic Surgery: Pre-Surgical Instructions
This information is intended as a fundamental overview of what you might expect during your surgical experience. We have tried to make this as comprehensive as possible. It is anticipated that you may have questions after reading this information, and you are encouraged to ask about any areas of concern.
Preparation for Surgery
Prior to scheduling your operation, the surgeon will carefully review your medical history. It is most important that you advise him of any past and present medical problems, illnesses, operations, medications you are currently taking (both prescription and over-the-counter), allergies, and any adverse reactions to medications or to a previous general anesthetic.
It is essential that the use of Aspirin (and all medications containing Aspirin) be discontinued two (2) weeks prior to surgery. If you are not certain whether Aspirin is an ingredient of a medicine you regularly take, be sure to check with your doctor or surgeon.
Having a strong positive attitude towards the surgical procedure and outcome will serve to make the whole experience a more positive one. If you are feeling negative or very skeptical about things, DO NOT have the procedure performed. Arrange for family or friends to be with you during the first two or three days. Their support is important.
For several weeks before your surgery, avoid substances to which you are allergic. Try to get some physical exercise, sleep well and allow yourself to rest. Our bodies heal while we sleep and rest. If you are a cigarette smoker, it is best to minimize if not eliminate the amount you smoke before and after surgery. Stopping smoking before surgery will help your body cope better with the anesthesia. Smoking following surgery can interfere with the tissue healing and cause wound breakdown.
Admission to the Hospital
Waiting lists are currently long due to reduced hospital availability. You will receive notification indicating the date, place and time of hospital admission and surgery. A history and physical examination will be completed by your physician before admission. Arrangements for this will be discussed with you by the surgeons office. Routine laboratory tests will sometimes be performed prior to surgery. Donation of your own blood before surgery is normally not required. Your surgeon will discuss this option with you if it is deemed necessary.
Day of Surgery and Anesthesia
You may receive medications in preparation for the general anesthesia and to reduce any pre-surgical anxiety. An intravenous (I.V.) will be placed in your arm; this is to provide a means of delivering both fluids and medications, eliminating the need for repeated injections. This tube may remain in place for a few days. It will be necessary for the anesthesiologist to pass a breathing tube (endotracheal tube) from the nose into the trachea (wind pipe). This will be done while you are asleep. After the completion of the surgical procedure, the endotracheal tube will be removed as soon as possible. Operations of this type are generally between 2 and 6 hours in length depending on the exact nature of the procedure.
Following completion of surgery, you will be transferred to the recovery room. There you will be monitored closely by nurses until you are sufficiently awake. From the recovery room, you may be transferred to the intensive care unit (I. C. U.) depending on your type of surgery. An I.V. will be in place and in addition, a bulky pressure dressing (to minimize swelling) may be secured around your head and the sides of your face. These will be removed individually as your recovery progresses.
Nasal congestion and Throat Soreness
For the first day or two after surgery, you might experience nasal congestion. The nasal tubes used for your anesthesia may cause your nose to feel stuffy and your throat to feel irritated when you wake up. This is very similar to the way you would feel if you had a common cold and sore throat. You will be given decongestants if needed, and the condition should resolve within a few days.
Significant facial swelling should be anticipated following your surgery. Generally, it will decrease within two weeks to the point where it will not be noticeable to anyone but yourself, family and possibly close acquaintances. During your surgery and hospital stay, steps are taken to minimize the swelling. The head of your bed will be kept elevated after surgery and this position should be maintained while you are lying down for about 10 days after you leave the hospital. It is generally easier for you to bend your mattress by placing something solid under the “head” of the mattress instead of trying to sleep upright with pillows.
Ice packs will be placed on each side of your face as you awake from the surgery. These are reusable and you will be sent home with them for use over the next two days. After the second day, they generally will not be of any value in controlling swelling but some people like them for comfort. Moist heat to your face can be started after the fifth day and this will assist in resolving the swelling and stiffness. Warm towels can be used at 20 – 30 minute intervals for this purpose.
Patients are concerned about nausea and vomiting. You should be aware that this occurs quite infrequently. You will have a suction apparatus near your hospital bed. Nausea does not present as much of a problem as you may fear. If nauseated, you should remain calm. There are medications that can be given to help control nausea. If you start having nausea once you are at home, please follow these simple rules:
- Stay down–movement, especially walking around will increase the likelihood of nausea
- Drink clear fluids or possible carbonated beverages (7 Up or Ginger Ale)
- Stop taking narcotic pain medication and try using Tylenol or Ibuprofen (Motrin, Advil)
- If there is no relief, call your surgeon for advice
You will be given a pain control medication upon discharge from the hospital and this should be used to manage any significant pain you might have. Often you will be able to control most discomfort by using “over the counter” pain medications such as aspirin, acetaminophen (Tylenol), and ibuprofen (Advil, Nuprin, Motrin, etc.).Usually, over the counter ibuprofen 200mg is the best since it can be taken safely in prescription dosages (600 – 800mg) and are small enough to swallow easily after surgery.
Following surgery, you will experience areas of altered sensation or partial numbness of the lips, and tissues adjacent to the surgical site (chin, tongue, cheeks and teeth). During the first three to six months, the small nerve fibers are regenerating and recovering. As healing takes place, you may encounter sensations of warmth and tingling in the affected areas. These may remain longer than six months and in some cases, altered sensation may persist for extended periods. Our experience has been that those individuals with areas of residual altered sensation generally find they are able to adjust without great difficulty.
At first, you may have difficulty communicating and may want to have a small notebook on hand to write messages. You will be unable to answer the telephone in your usual manner. You should warn your friends who plan to call you in the hospital or at home that they may have some difficulty understanding you at first. Most people are able to communicate relatively clearly. It is advisable not to carry on lengthy conversations, as you may experience fatigue.
Following any kind of surgery, a patient may go through a stage of mild depression. This is a natural response. We feel that, if you are aware of the potential from the start, you will work at minimizing this by keeping your mind and body active. By the fourth or fifth day, you should return to good spirits. You must remember that your recovery involves only a few weeks of inconvenience and good attitude will help the time to pass quickly.
If you have been given an antibiotic after the surgery, make sure you take it as prescribed until finished. If you had an upper jaw surgery, please avoid blowing your nose for two (2) weeks, since this would increase your chance of infection and could also provoke a nose bleed. Call our office if you notice any signs of infection; such as: increases swelling after five (5) days, swelling that is painful/hard/hot, a fool taste or odour in your mouth or a temperature above 100F/38C.
Moderate to severe bruising is to be expected for most patients. The bruising will normally appear shortly after surgery and may last for two (2) weeks.
It is normal to bleed or ooze for some time after jaw surgery. It is not unusual to have blood in the saliva or on your pillow for up to one (1) week after surgery. To control some of the bleeding, please keep your head elevated and apply ice packs over the area. If gauze packs are not available, then a clean cloth folded as a pack or a tea bag may be used as a substitute. If you encounter a significant bleed from the surgical site or your nose, please contact your surgeon, or you should consider going to the emergency department of your local hospital ASAP.
Orthognathic surgery may require fixation of your teeth (using wires or elastics). If your teeth are fixated together, you will be limited to a strictly liquid diet. If your teeth are not fixated together, you should be able to resume a soft diet within a few weeks after your surgery. You will receive a diet book prior to admission to the hospital to use during the postoperative period. Routinely, the hospital provides a large plastic syringe with rubber tubing. The end of the tubing can be placed in the back of the mouth to allow passage of liquids or pured food. By lubricating the rubber plunger of the syringe with cooking oil, the syringe should function throughout the fixation healing period.
During the first weeks after surgery some weight loss is to be expected. Your dietary intake is very important. Your tissues will be in a state of healing and your nutritional requirements will be great.This is no time to go on a diet! We recommend that you fortify your diet with liquid vitamins and other dietary supplements. A liquid multi-vitamin preparation can be obtained prior to your surgery. There are many nutritional supplements on the market.
As examples, Ensure, Meritene, and Sustacal are available in assorted flavors and are excellent canned preparations found in most drug stores. Many grocery stores carry Instant Breakfast type nutritional supplements. Essential nutrients must all be present to promote complete soft tissue healing and boney union at the surgical site. Nutrients such as calcium, iron, vitamins A, C, and D, and protein will be especially important in your diet. At times, you may not feel like eating, but please remember that good healing requires a sufficient dietary intake and this may require five to six meals per day. A blender may be used to pure almost any food. Fruit and raw eggs are excellent nutritional additions to milk shakes.
Do not use Listerine or Scope for 2 weeks, instead mix two parts water (or mouthwash) with one part hydrogen peroxide for this purpose.
Pressured oral rinsing systems such as “Water Pik” should not be used until at least one week after surgery. Even then, the pressure setting should be kept at the lowest possible and care be used to insure the water is directed only at the teeth. Do not use a straw for two (2) weeks. It is recommended that you start brushing your teeth as soon as possible, concentrating on the teeth only. The use of a small “baby” tooth brush may be helpful.
Smoking is discouraged the week before surgery and 2-4 weeks after the surgery. Smoke irritates and can lead to infection and delayed healing.
We suggest taking Vitamin C, 1000mg. 2 or 3 times daily. It will strengthen your immune system, promote healing and lessen pain. However, do not take it the night before surgery as Vitamin C can lessen the effects of anesthesia. Resume taking it after surgery as soon as approved by your surgeon. Vitamin E is also an important supplement. It functions as the most important antioxidant found in the body. Recommended doses of Vitamin E are 400 800 IU daily. Always begin Vitamin E supplements in small amounts. Stop Vitamin E two (2) days before surgery and do not take it for five(5) to six(6) days afterward. High amounts of Vitamin E could potentially contribute to excessive bleeding. Multivitamins with iron are also necessary to replace any blood loss and should be taken starting at least two months before surgery.
Your Hospital Stay and Recall Visits
You should anticipate a total hospital stay of approximately one (1) to four (4) days. Plan to return to see the surgeon once a week for the next several weeks for routine care and observation. Once he is satisfied with the surgical stability, your recall visits will be less frequent.
The sooner you return to normal activities, the more rapid will be your recovery. The recovery from surgery and accompanying anesthesia can deplete your energy and increased bed rest may be necessary. However, staying in bed all day simply delays your recover and many times results in an inability to sleep at night. Short walks or other mild activity during the first few days postoperatively will commonly be of great benefit. As your strength returns, increase your activity toward your normal level. The only activity restriction we recommend is that of contact sports – those in which there is a risk of hitting your face with any significant force – not be attempted for at least 10 weeks after surgery.
Your Return to Work
You are encouraged to return to school or work as soon as you feel up to it. Each individual will differ in speed of recover. You should anticipate absence form work or school or about two (2) weeks but allow yourself flexibility should a longer period of time be needed.
A clear plastic template (splint) may be constructed to your predetermined new bite. During surgery, the teeth are wired and indexed together into the splint to establish and maintain the correct jaw position. This splint will generally be removed before the end of surgery but may remain in place for several weeks.
Length of Fixation
In the unlikely event that your jaws are wired closed, wire cutters should be obtained before discharge from the hospital to be used to release the fixation in an unexpected emergency. It is extremely uncommon and unlikely that a need to cut the wires will arise and it should be kept in mind that doing so prior to completion of healing would generally require further surgery and possibly compromise the overall result of your treatment. You should discuss the rare indications and technique for removal of the fixation wires with your surgeon.
During dental fixation, oral hygiene will be more difficult. You will be unable to easily clean the tongue and sides of your teeth. It is therefore essential for you to make an effort in applying the following recommendations:
- You must brush your teeth as thoroughly as possible
- A child size SOFT toothbrush is recommended. Since your cheeks may become swollen, the small toothbrush permits easier access
- If you keep your teeth relatively free from feed debris, you will feel more tolerant of the elastics.
Caution: Do not use a Water-Pik for the first two weeks after surgery. Food debris could be forced through the incision sites.
Although it is not common, there is a possibility that a tooth can become devitalized (dead) after some types of surgery. It does not mean that you will necessarily loose the tooth. It can most likely be resolved by endodontics (root canal) treatment.
Change in Facial Appearance
It is most important to realize that surgical repositioning of the jaws will be accompanied by some change in facial appearance. These changes are generally favorable and desirable. The nature of the changes in your particular situation will be explained prior to surgery. Becoming accustomed to the new appearance often time requires a period of emotional adjustment for you as well as close friends and relatives.
Temporomandibular Joint (TMJ)
Much attention recently has been focused on the temporomandibular joint (the hinge around which the lower jaw opens and closes). Symptoms in this joint can develop secondary to an improper jaw relationship and are one of the reasons people such as yourself seek orthognathic surgery to correct the discrepancy. Establishment of a more harmonious relationship between the upper and lower jaws can reduce abnormal stresses on the TMJ. We cannot promise a favorable outcome of any TMJ Symptoms if you undergo surgery. In fact, dysfunction or degenerative changes in the joints may develop in spite of jaw repositioning. If you have concerns regarding TMJ symptoms, please talk to your surgeon.
We suggest you review this information with your family to inform them of the anticipated course of your surgery. You might also consider discussing it with close friends, such as people at work or teachers at school so that they might develop appropriate expectations. You will need their understanding and support throughout the weeks following the operation. This will help you make a speedier adjustment to your surgical experience.
If you have any unanswered questions, we will be happy to clarify any of this information. We want to make your hospital stay and the subsequent weeks as pleasant as possible. Please let us know how we can be of further assistance to you.