Perioperative therapies to reduce edema after orthognathic surgery: a systematic review and meta-analysis

Evaluation of the effect of the neutrophil-to-lymphocyte ratio on facial oedema after orthognathic surgery: a 12-month follow-up study

Orthognathic surgery to correct dentofacial deformities has been performed safely for many years. Postoperative facial oedema occurs to varying degrees in almost all patients. The aim of this study was to evaluate the relationship between the preoperative neutrophil-to-lymphocyte ratio (NLR) and the severity of postoperative facial oedema using 3D stereophotogrammetry. Thirty patients (Le Fort I + BSSO) were included in this study. They were divided into two groups according to their NLR: ≥2.00 (n = 13) and <2.00 (n = 17). Patients were followed for 12 months and facial oedema was measured on days 1, 2, 3 and 10, and months 1 and 6, using the 12-month image as the reference. Postoperative facial oedema was significantly greater in the NLR ≥2.00 group in the first 10 days (days 1, 2, 3, 10: P = 0.011, P = 0.010, P = 0.040, P = 0.032), while no significant difference was observed for the long-term measurements (months 1, 6: P = 0.693, P = 0.374). The results of this study suggest that NLR may serve as a potential biomarker to predict the severity of postoperative facial oedema and may assist clinicians in their decision-making process when managing the postoperative inflammatory response.

Factors affecting postoperative nasal morphology after Le Fort I osteotomy on multiple regression analysis

Changes in external nasal morphology after Le Fort I osteotomy can lead to reduced patient satisfaction and diminished quality of life postoperatively. Despite various modifications such as alar cinch suture and subspinal osteotomy to overcome such changes, the external nasal morphology may vary unexpectedly on an individual basis. This report investigated the factors influencing the changes in external nasal morphology, by considering the patient's preoperative external nasal morphology as well as the surgical technique, and the direction of repositioning of maxilla. Multiple regression analysis identified the patient's preoperative nasal width as a factor that increased the alar base width of the nose, in addition to incision (oral vestibular incision) and the amount of anterior and superior movements at point A of the maxilla. The factors that caused the nasal tip to turn upward were the amount of anterior and superior movements at point A and the absence of subspinal osteotomy. The direction of surgical maxillary movement was influenced not only by anterior movement, but also by superior movement and surgical technique. The patient's preoperative nasal morphology should also be considered during the preoperative planning for orthognathic surgery to ensure optimal esthetic and functional outcomes.

Perioperative pain management for cleft palate surgery: a systematic review and procedure-specific postoperative pain management (PROSPECT) recommendations

BACKGROUND/IMPORTANCE

Cleft palate surgery is associated with significant postoperative pain. Effective pain control can decrease stress and agitation in children undergoing cleft palate surgery and improve surgical outcomes. However, limited evidence often results in inadequate pain control after cleft palate surgery.

OBJECTIVES

The aim of this review was to evaluate the available evidence and to develop recommendations for optimal pain management after cleft palate surgery using procedure-specific postoperative pain management (PROSPECT) methodology.

EVIDENCE REVIEW

MEDLINE, Embase, and Cochrane Databases were searched for randomized controlled trials and systematic reviews assessing pain in children undergoing cleft palate repair published in English language from July 2002, through August 2023.

FINDINGS

Of 1048 identified studies, 19 randomized controlled trials and 4 systematic reviews met the inclusion criteria. Interventions that improved postoperative pain, and are recommended, include suprazygomatic maxillary nerve block or palatal nerve block (if maxillary nerve block cannot be performed). Addition of dexmedetomidine to local anesthetic for suprazygomatic maxillary nerve block or, alternatively, as intravenous administration perioperatively is recommended. These interventions should be combined with a basic analgesic regimen including acetaminophen and nonsteroidal anti-inflammatory drugs. Of note, pre-incisional local anesthetic infiltration and dexamethasone were administered as a routine in several studies, however, because of limited procedure-specific evidence their contribution to pain relief after cleft palate surgery remains unknown.

CONCLUSION

The present review identified an evidence-based analgesic regimen for cleft palate surgery in pediatric patients.

PROSPERO REGISTRATION NUMBER

CRD42022364788.

High dose glucocorticoids for treatment of postoperative pain: A systematic review of the literature and meta-analysis

STUDY OBJECTIVE

Glucocorticoids as a component of multimodal analgesia have been studied for many years and their post-operative analgesic effects appear to be dose-dependent. We conducted a systematic review of randomized controlled trials (RCTs) to evaluate the evidence of peri-operative high dose corticosteroid therapy in comparison to placebo (placebo drug) or control group (no treatment) for improving the quality of post-operative analgesia as indicated by a reduction of 10 mm in 100 mm Visual Analogue Scale (VAS) or reduction of 1 point in a 0-10 point VAS scale, or a reduction of 1 point in an 11-point Numerical Rating Scale (NRS) score, or reduction of rescue opioid analgesia, in patients undergoing all types of surgery.

DESIGN

Systematic review of RCTs with meta-analysis.

SETTING

Acute postoperative pain treatment in non-obese adult population.

INTERVENTIONS

Perioperative administration of high dose of Dexamethasone (≥ 0,2 mg/Kg or ≥ 15 mg), or a corresponding dose of a systemic glucocorticoid.

MEASUREMENTS

Primary outcomes were postoperative pain measured in 0-100 mm VAS score at 24 h after surgery upon rest and movement. Secondary outcomes were postoperative pain 0-100 mm VAS score 48 h after surgery, postoperative rescue analgesic requirement, postoperative nausea and vomiting (PONV), relevant adverse events.

MAIN RESULTS

47 RCT's were included (3943 patients). The Mean Difference (MD) of 100 mm VAS scores for pain at rest 24 h after surgery was -6.18 mm 95% CI [-8.53, -3.83], at motion -8.86 mm 95% CI [-11.82, -5.89]. Opioid analgesic requirements evaluated in Oral Morphine Equivalents (OME) was -10.00 mg 95% CI [-13.65, -6.34]. PONV events Odds Ratio of 0.29 95%CI [0.24, 0.36]. Major adverse events OR was 0.88 95% CI [0.65, 1.19]. Minor adverse events OR 1.29 95% CI [0.86, 1.92].

CONCLUSION

High doses of glucocorticoids are one of the many possible tools available in multimodal postoperative analgesia, possibly reducing opioids consumption and recurrence of PONV but with no relevant effects in terms of reduction of postoperative VAS score. Available data show a safe therapeutic profile, without increase adverse events.

PROTOCOL REGISTRATION

CRD42020137119.