J Oral Maxillofac Surg

69:885-892, 2011

Blood Loss in Orthognathic Surgery:

A Systematic Review
Alejandra Pieiro-Aguilar, DDS,*
Manuel Somoza-Martn, DDS, PhD,
Jos M. Gandara-Rey, MD, DDS, PhD, and
Abel Garca-Garca, MD, PhD

Purpose: Intraoperative blood loss during orthognathic surgery is frequently abundant and sometimes
requires blood transfusion. The aim of the present study was to conduct a systematic review of the
published data regarding intraoperative blood loss during orthognathic surgical interventions, including
Le Fort I osteotomy, mandibular ramus osteotomy, and both combined, to determine the range of
information available to help surgeons better prepare themselves, their patients, and the auxiliary
support needed for this type of surgery and the transfusion requirements.
Materials and Methods: Selected reports from the PubMed and Cochrane Library databases for
studies conducted from 1978 to 2008 were evaluated to determine whether they included information
on the volume of bleeding during surgery and the factors that might have influenced the amount of
bleeding. Of the 90 reports examined and evaluated, 7 were included in the critical analysis conducted
as a part of the present systematic review.
Results: Referring to the reports used for statistical analysis of the volume of blood loss, the mean
intraoperative bleeding volume was 436.11 mL, the mean of the standard deviations was 207.89 mL,
and mean surgery duration was 196.9 minutes.
Conclusions: Our results have shown that the intraoperative bleeding observed in patients during Le
Fort I or mandibular ramus osteotomies or both combined was less than the limits set for blood
transfusion. However, bleeding was occasionally heavier, and surgeons should be prepared for heavier
bleeding by reserving blood at a blood bank or by preparing an autotransfusion.
2011 American Association of Oral and Maxillofacial Surgeons
J Oral Maxillofac Surg 69:885-892, 2011

Orthognathic surgery involves surgical manipulation of
the facial skeletal elements to restore the anatomic and
functional relationships in patients with dentofacial skel-
etal abnormalities. Many types of osteotomy of the jaw
have been described for this purpose; however, in the
present review, we have referred to the Le Fort I osteo-
tomy of the upper jaw and mandibular ramus osteot-
omy, the most frequently performed osteotomies.
The intraoperative blood loss during these opera-
tions is frequently abundant and sometimes requires a
blood transfusion. Awareness of the possible amount
of blood loss during a given intervention is very help-
ful for clinicians when planning surgery. Accordingly,
we conducted a systematic review of the published
data regarding intraoperative blood loss during Le
Fort I osteotomies, mandibular ramus osteotomies,
and both combined.
The goal of our study was to determine the range
of information available to help surgeons better
prepare themselves, their patients, and the auxil-

*Predoctoral Researcher, Department of Oral and Maxillofacial
Surgery, Faculty of Medicine and Dentistry, University of Santiago
de Compostela, Spain.
Assistant Professor, Department of Oral and Maxillofacial Surgery,
Faculty of Medicine and Dentistry, University of Santiago de Compos-
tela, Spain.
Oral Medicine Professor, Department of Oral and Maxillofacial
Surgery, Faculty of Medicine and Dentistry, University of Santiago
de Compostela, Spain.
Oral and Maxillofacial Surgery Professor, Department of Oral
and Maxillofacial Surgery, Faculty of Medicine and Dentistry, Uni-
versity of Santiago de Compostela and University Hospital of San-
tiago de Compostela, Spain.
Address correspondence and reprint requests to Dr Garca-Garca:
Department of Maxillofacial Surgery, University of Santiago de Com-
postela Facultad de Medicina y Odontologia, C/Entrerros S/n, Santiago
de Compostela 15782, Spain; e-mail: abel.garcia@usc.es
2011 American Association of Oral and Maxillofacial Surgeons
0278-2391/11/6903-0036$36.00/0
doi:10.1016/j.joms.2010.07.019

885
886
FIGURE 1. Flow diagram of the selection data process.
Pieiro-Aguilar et al. Blood Loss in Orthognathic Surgery. J Oral
Maxillofac Surg 2011.
iary support for orthognathic surgery and transfu-
sion requirements.
Materials and Methods
LITERATURE SEARCH STRATEGIES
The PubMed and Cochrane Library databases were
searched for studies published from 1978 to 2008
using the keywords bleeding volume, orthognathic
surgery, and blood loss. Other references cited in
the retrieved reports were also reviewed, and, if rel-
evant, were included in our study. The studies con-
sidered relevant to our review were thoroughly ex-
amined, and a set of criteria were applied for their
selection and inclusion in this systematic review (Fig
1). The abstracts and full texts were read and classi-
fied to select only those that provided the information
necessary for our review. They were also sorted ac-
cording to the potential risk of any type of bias.
Table 1. CLASSIFICATION OF STUDIES IN 3 GROUPS ACCORDING TO TYPE AND SELECTION CRITERIA REFERRING
TO BLEEDING PARAMETERS
Study Type
Systematic review of RCTs
Individual RCTs
Case series
Systematic review of cohort studies
Individual cohort studies (including poor-quality RCTs)
Result studies
Systematic review of case and control studies
Individual case-control studies
Case series and poor quality cohort and case-control studies
Expert opinion without explicit critical appraisal or based
on physiology, bench research, or first principles
Abbreviation: RCT, randomized controlled trial.
Pieiro-Aguilar et al. Blood Loss in Orthognathic Surgery. J Oral Maxillofac Surg 2011.
BLOOD LOSS IN ORTHOGNATHIC SURGERY
SELECTION CRITERIA
Table 1 lists the 3 groups in which the reports were
classified according to the information they provided.
To perform an assessment and classification of the 3
groups described, the studies were selected accord-
ing to the inclusion and exclusion criteria.
The inclusion criteria were English-language re-
ports and randomized clinical trials (RCT), reviews of
RCTs, case series, cohort studies, and expert opinions
in regard to bleeding during orthognathic surgery.
The exclusion criteria were studies that had not col-
lected or quantified information on blood loss during
surgery and studies of patients with clotting prob-
lems, or with diseases that can affect bleeding.
CRITICAL APPRAISAL
The selected articles were critically evaluated ac-
cording to the following characteristics: inclusion/
exclusion criteria; information on the volume of
bleeding during surgery; description of the surgical
technique; information on the duration of surgery;
information on the type of anesthesia used (normo-
tensive or hypotensive); and information on the tech-
niques, drugs, and materials used to reduce or in-
crease bleeding or promote clotting.
The selected studies were evaluated and catalogued
to determine whether they were valid for inclusion in
the present systematic review. We also accounted for
information on the volume of bleeding during surgery
and information on factors that might have influenced
the amount of bleeding (Table 2).
STATISTICAL ANALYSIS
For the data collected from the studies classified in
group 1, we determined the mean value of the mean
and standard deviation provided for surgical blood
loss and surgery duration.
Group Selection Criteria
1 Four bleeding parameters well described and
defined and data on mean intraoperative blood
loss volume collected
2 Four bleeding parameters well described and
defined and intraoperative blood loss
mentioned; data on mean intraoperative blood
loss volume might or might not have been
collected
3 Opinions on factors influencing bleeding volume
or studies on this subject
PIEIRO-AGUILAR ET AL 887

EXCLUDED STUDIES TO CALCULATE THE MEAN

Table 2. INTRAOPERATIVE BLEEDING VOLUME
PARAMETERS
Description of type of surgery
Collection of data on intraoperative bleeding volume
during surgery
Description of anesthetic technique (normotensive or
hypotensive)
Duration of the intervention
Description of drugs modifying bleeding volume
Pieiro-Aguilar et al. Blood Loss in Orthognathic Surgery. J Oral
Maxillofac Surg 2011.
Results
INCLUDED STUDIES
A total of 90 studies were retrieved, 87 from
PubMed1-87 and 3 from the Cochrane Library.88-90 These
90 reports were examined and evaluated comprehen-
sively (by reading the full text, including the abstract);
17 articles1-17 were selected as meeting the criteria of
our systematic review: 15 clinical studies1-12,15-17 of
RCTs, case report series, or reviews of RCTs and 2
expert opinions.13,14 After the critical assessment, 7
were included in group 11,3-5,7,8,15 and 8 in group
2,2,6,9-12,16,17 with the 2 expert opinions in group
313,14 (Table 3).
Accordingly, the 7 reports classified as group
11,3-5,7,8,15 were those that provided the most rele-
vant information for the present systematic review
(Table 4).
BLOOD LOSS
The study by Stewart et al15 and the control group
from the study by Praveen et al4 were excluded to
calculate the mean blood loss. In the study by Stewart
et al,15 the administration of heparin could have
skewed the results about bleeding volume. In the
second study, the patients had received normotensive
anesthesia, which does not contribute to control
bleeding. However, the treatment group from the
study by Praveen et al4 was included. In the treatment
group, the type of anesthesia used was the same as in
the other reported studies used to calculate these data
(Table 5).
STATISTICAL ANALYSIS
The mean intraoperative blood loss volume was
436.11 mL. The mean of the standard deviations was
207.89 mL.1,3-5,7,8 The mean surgery duration was
196.9 minutes.1,3-5,7,8,15 The mean of all surgery dura-
tion mean values (both treatment and control groups)
for the studies was 185 minutes.1,3-5,7,8,15
Discussion
Systematic reviews are an effective scientific ap-
proach to identifying and summarizing intervention
evidence and its effectiveness, enabling consistency
to be determined and the generalization of findings
for the benefit of scientists. A critical assessment of

Table 3. STUDIES MEETING STUDY CRITERIA (N 17) AND POTENTIAL BIAS

Investigator Year Potential Bias Group

Kretschmer et al9 2008 Did not specify lost blood volume 2

Did not describe method of randomization
Modig et al3 2008 Nil 1
Kok-Leng Yeow et al10 2008 Did not define exclusion criteria 2
Did not mention intervention duration or anesthesia type
Choi et al6 2008 Did not specify lost blood volume 1
de Lange et al7 2008 Nil 1
Paul et al11 2007 Included nonorthognathic surgery 2
Did not specify intervention duration
Kim et al2 2007 Did not specify lost blood volume 2
Did not mention intervention duration or anesthesia type
Chow et al12 2007 Did not mention bleeding as surgery complication 2
Did not mention intervention duration or anesthesia type
Shepherd et al13 2007 Expert opinion 3
Kurian14 2004 Expert opinion 3
Zellin et al8 2004 Nil 1
Stewart et al15 2001 Did not mention intervention duration 1
Panula et al1 2001 Did not describe the anesthetic drugs used 1
Praveen et al4 2001 Did not mention intervention duration 1
Yu et al5 2000 Nil 1
Samman et al16 1996 Did not mention intervention duration or anesthesia type 2
Moenning et al17 1995 Did not mention intervention duration 2
Did not define exclusion criteria
Pieiro-Aguilar et al. Blood Loss in Orthognathic Surgery. J Oral Maxillofac Surg 2011.
 888
Table 4. GROUP 1 STUDIES (N 7): SUMMARY DATA

Sample Anesthesia Intervention Blood Loss

Investigator Year Size Surgery Type Duration (min) Volume (mL) Bleeding/Clotting Control Results

Modig et al3 2008 ND Hypotensive 212 (55-495) 266 (25-1,560) Administration of tranexamic No transfusions required
acid (100 mg/mL) or No variation in bleeding rate
desmopressin according to gender
Local anesthesia with No excessive intraoperative bleeding
adrenaline Only some hematomas observed as
complications
de Lange et al7 2008 30 Le Fort I Hypotensive Treatment: Treatment: Cocaine (100 mg) No relationship between age and
Treatment 91 (55-115) 144 (75-275) administered nasally to bleeding volume
(n 15) Control: Control: treatment group Significant differences in volume lost
Control 105 (60-150) 346 (100-700) Adrenaline between groups
(n 15) No considerable differences in
surgery duration between groups
No secondary effects caused by
drugs used
Zellin et al8 2004 30 Le Fort I Hypotensive Treatment: Treatment: Treatment group managed Transfusion required for 2 patients
Treatment 227.5 (140-280) 397.7 (150-800) with bleeding depressants in control group
(n 15) Control: Control: (tranexamic acid 1 g No transfusion required for
Control 236.3 (130-310) 736.7 (200- intravenous or treatment group
(n 15) 1,400) desmopressin 0.3 g/kg) Significant differences in volume lost
between groups
Stewart et al15 2001 30 Le Fort I Normotensive Treatment: Administration of aprotinin Transfusion required for 1 patient in
Treatment BSSO 473 150 on the treatment group treatment group
(n 15) GP Control: Administration of sodic Transfusion required for 9 in control
Control Graft 986 356 heparin (5,000 U at 1 h group
(n 14) before surgery) 52% reduction in average bleeding
volume in treatment group
No secondary effects caused by
drugs used
Panula et al1 2001 655 Le Fort I Hypotensive 162.2 (40-450) 451 Considerable bleeding in 6 patients
BSSO One BSSO intervention canceled
because of excessive bleeding

BLOOD LOSS IN ORTHOGNATHIC SURGERY

Most significant blood loss during
bimaxillary surgery followed by
Le Fort I surgery
Praveen et al4 2001 53 Le Fort I Treatment: Treatment: Administration of Significant differences in volume lost
Treatment BSSO hypotensive 200 (90-400) nitroglycerin and esmolol between groups
(n 24) Control: Control: to treatment group
Control normotensive 350 (150-1,575)
(n 29)
Yu et al5 2000 29 Le Fort I Hypotensive 269 77.6 617 438.9 Bleeding reduced by 40% with
BSSO hypotensive anesthesia
SARPE Transfusion required for 1 patient
GP Longest interventions were
combined procedures
Most significant blood loss occurred
in combined procedures
Relationship found between surgery
duration and blood loss volume

Abbreviation: ND, not described; BSSO, bilateral sagittal split osteotomy; GP, genioplasty; SARPE, surgically assisted rapid palatal expansion genioplasty.
Pieiro-Aguilar et al. Blood Loss in Orthognathic Surgery. J Oral Maxillofac Surg 2011.
PIEIRO-AGUILAR ET AL
Table 5. FACTORS INFLUENCING INTRAOPERATIVE
BLEEDING VOLUME
Factor Result
Duration of intervention Increased bleeding volume
Anticoagulant drugs
Hypotensive anesthesia Reduced bleeding volume
Local vasoconstrictors
Pieiro-Aguilar et al. Blood Loss in Orthognathic Surgery. J Oral
Maxillofac Surg 2011.
studies is one method of exploring any potential in-
consistencies that might occur.
The blood loss during orthognathic surgery can be
considerable. The mean volume of intraoperative
bleeding was 436.11 mL for the studies included in
our review. The reason for the extensive blood loss is
the extensive vascularization of the maxillofacial re-
gion and access difficulty in terms of cauterization or
ligation of the vessels involved. This bleeding is
caused by the palatal large vessels (sphenopalatine
artery and descending palatine artery), the pterygoid
plexus, and the internal maxillary artery and its col-
lateral branches to the upper jaw in Le Fort I osteot-
omies. The maxillary artery and its branches are the
most vulnerable to injury during pterygomaxillary
dysjunction or maxillary down fracture, specifically,
the descending palatine artery. It can also be damaged
if the maxilla is advanced to a significant degree,
intruded posteriorly, or retruded.
In the case of the mandible, the bleeding occurs
from the alveolar arteries and the facial artery or
branches of these. In concrete with bilateral sagittal
split osteotomy, hemorrhage results from laceration
of the maxillary artery. However, this is unlikely to
occur when the soft tissues are reflected properly and
when appropriate precautions are taken with retrac-
tors to protect the vessels.
Bimaxillary surgery results in a major volume of
blood loss directly related to the operating time and
the magnitude of the intervention.5
Blood transfusion is an expensive procedure that
can also lead to complications, such as the transmis-
sion of disease or graft versus host reactions. Trans-
fusions should be avoided, if possible, by taking steps
to reduce bleeding that does not ultimately cause
harm to the patient.
It seems to be well established that a directly pro-
portional relationship exists between the duration of
the intervention and the bleeding volume. The oper-
ative time and blood loss are greater for bimaxillary
surgery than for surgery affecting only the upper jaw
or the mandible.
889
BLOOD LOSS REDUCTION
Controlling intraoperative bleeding to prevent ex-
cessive blood loss requires a good view of the surgical
field, a good knowledge of anatomy, and the exercise
of care during the intervention.15 Bleeding can be
minimized by respecting the margins for the various
vessels in the surgical field. The surgeons skill is
particularly important in terms of compressing the
area with gauze and/or cauterizing or ligating the
vessels responsible for bleeding.
To reduce bleeding, locally applied drugs, such as
tranexamic acid, desmopressin, adrenaline, and so
forth, can be used.2,8 de Lange et al7 found noticeable
differences between the control and treatment
groups that had received nasally applied cocaine (a
gauze strip with 100-mg cocaine and 2 mL 1:100,000
adrenaline) without side effects. This drug has been
used during nasal surgery to reduce blood loss and
enhance visibility, and it can be combined with adren-
aline for an increased vasoconstrictor effect without
increasing the cardiovascular complications. Cocaine
causes vasoconstriction by blocking the reuptake of
noradrenaline and adrenaline at the sympathetic
nerve endings. The simultaneous use of adrenaline
allows a high concentration of local catecholamines
to be reached. Cocaine must be used with propanolol
as a general anesthetic to reduce the risk of arrhyth-
mia, and its use should be avoided in children because
of their lower tolerance to this drug.7
Other investigators15 have used bleeding depres-
sants, such as intravenous aprotinin (50 mL/hour dur-
ing the intervention), a protease that can, however,
cause hypersensitivity reactions.14 Aprotinin acts on
plasmin, trypsin, and kallikrein and has been used in
cardiac surgery as an inhibitor of fibrinolysis and to
preserve platelet function. It has also been used to
reduce blood loss during procedures, such as hip re-
placement, urologic surgery, liver transplantation, and
aortoiliac surgery without the risk of thrombosis.15
Stewart et al15 found a quite high incidence of
bleeding in 2 study groups, especially in the group
that had received bleeding depressants. One possible
reason was the administration of heparin to all pa-
tients 1 hour before the intervention. It is noteworthy
that none of the studies considered the complications
that can result from the use of drugs to control bleed-
ing. Zellin et al8 found that bleeding was reduced
with intravenously administered bleeding depres-
sants, such as desmopressin (0.3 g/kg) and
tranexamic acid (1 g). Modig et al3 found no excessive
bleeding after intravenously administering tranexamic
acid or desmopressin.
Tranexamic acid has been used to reduce blood
loss and the subsequent need for transfusion in ortho-
pedic, spinal, and cardiac surgery. Tranexamic acid is
890
a synthetic derivative of the amino acid lysine. Its
antifibrinolytic effects are caused by the reversible
blockade of lysine-binding sites on plasminogen mol-
ecules. It has also been used in dentistry and oral
surgery as a mouthwash for patients with anticoagu-
lation or hemorrhagic problems.
Different dosages have been reported, ranging from
a bolus administration of 1 g to 100 mg/kg within 15
minutes and continued with an infusion of 10 mg/kg/
hour until wound closure. This drug does not have
any significant adverse effects.3,8
Desmopressin acetate is an analog of the hormone
vasopressin. It has been shown to increase the plasma
concentration of endothelial factor VII, increasing co-
agulant activity; however, its role as a hemostatic
agent during surgery is doubtful.8
Despite these data, however, insufficient evidence
is available in favor of using these drugs to reduce the
number of transfusions. Two patients in the study by
Zellin et al8 required blood transfusions; 6 patients in
the study by Panula et al1 bled excessively, with the
consequent necessity of suspending one of the inter-
ventions; and 1 patient in the study by Stewart et al15
and by Yu et al5 required a transfusion.
Another method to reduce operative bleeding is
to induce controlled hypotension during sur-
gery.1,3-5,7,12,13 Making a comparative analysis be-
tween the variables in each of the studies, we ob-
served that hypotensive anesthetic techniques were
used in most to intentionally reduce the blood pres-
sure to 55 to 80 mm Hg in normotensive patients. The
safety margin for blood pressure in patients with
American Society of Anesthesiologists Class I is a
mean arterial pressure of 55 mm Hg or greater or a
systolic blood pressure of 80 mm Hg or greater. How-
ever, monitoring during intervention of patients un-
dergoing hypotensive anesthesia is still essential (elec-
trocardiography, arterial oxygen saturation, temperature,
measurement of arterial pressure, end tidal carbon
dioxide tension, and urine output). This technique is
also indicated for any patient, including children, and
in different surgical procedures.
For some investigators, the anesthetic technique
has enabled a good control of blood loss in most
patients and its benefits are greater than the potential
risks.5,6 Moreover, hypotensive anesthesia is indi-
cated for lengthy procedures in which a large amount
of blood loss and consequent transfusion are ex-
pected, such as bimaxillary osteotomies.6
Praveen et al4 compared normotensive and hypo-
tensive anesthesia and reported significant differ-
ences between the 2 groups. In the hypotensive
group, the average blood loss was 200 mL (maximum
400) compared with 350 mL (maximum 1,575 mL) in
the normotensive group. Zellin et al,8 however, re-
ported an average of 736.7 mL blood loss during Le
BLOOD LOSS IN ORTHOGNATHIC SURGERY
Fort I surgery conducted using hypotensive anesthe-
sia. Thus, contradictory results have been reported by
different investigators.
The question remains to what extent the intraop-
erative blood loss in orthognathic surgery is signifi-
cant. The effect of the loss of red blood cells on the
hemodynamics and the development of anemia will
depend on the total blood volume of the patient,
which, in turn, is related to the patients weight. The
lower the patients weight, the greater the effect of
intraoperative blood loss on hemodynamics and ane-
mia development.
Investigators such as Nath and Pogrel31 concluded
that the transfusion needs for most oral and maxillo-
facial surgery have been overestimated. They also
reported that the option of autologous transfusions
cost more than homologous.
From our review, we have concluded that intraop-
erative bleeding observed in patients undergoing Le
Fort I and mandibular ramus osteotomies, alone or
combined, has generally been less than the limits set
to determine the need for a blood transfusion (indi-
cated in healthy adults when the hemoglobin is less
than 7 g/dL). However, bleeding can sometimes reach
or surpass the threshold limits for a blood transfusion,
and this event should be anticipated by reserving
blood at a blood bank or by preparing an autotrans-
fusion.16,17,26,31,34,37,41,51
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