Prospective Evaluation of Perioperative Steroid Dosing on Postsurgical Edema in Orthognathic Surgery
Prospective Evaluation of Perioperative Steroid Dosing on Postsurgical Edema in Orthognathic Surgery
The current standard of care at the Oral and Maxillofacial Department at the CDHA is the use
 of one gram of methylprednisolone administered intravenously prior to orthognathic surgery.
 This is largely based on the work of Habal. The administration of one gram of
 methylprednisolone can be concerning for the anesthesiologist since this is an unusually
 large dose of steroid in comparison to use in other surgical specialties. As with most
 medications, the chances of steroid-related complications increase with increasing doses of
 steroids.

 The researchers are proposing a prospective, double-blind randomized control trial to
 determine if a smaller dose of methylprednisolone (125mg) can be used safely and effectively
 instead of one gram of methylprednisolone.
Orthognathic surgery is a commonly performed surgery to correct facial functional and
 esthetic deformities. At the Atlantic Centre of Oral and Maxillofacial Surgery in Halifax,
 Nova Scotia, over 300 of these surgeries are carried out yearly. Orthognathic surgery is
 comprised of procedures performed in both the maxilla and mandible which include Lefort 1,
 bilateral sagittal split and functional (BSSO) and functional genioplasty. Common sequelae
 after orthognathic surgery include post-operative pain and swelling.

 Swelling occurs almost universally to some degree after orthognathic surgery. Steroid therapy
 has long been advocated for the reduction of post-operative swelling in oro-facial surgeries,
 as there is good evidence to support its use for this purpose. In 1978, Habal showed that one
 gram of methylprednisolone administered in a controlled dog model reduced post-operative
 swelling. He later carried this over to his practice of cosmetic facial surgeries. His
 studies have laid the much of the ground work for the use of steroid therapy in head and neck
 surgeries today.

 Other studied benefits of steroid use in facial surgery include decreased post-operative
 pain, trismus, nausea and vomiting as well as decreased length of hospital stays.
 Complications of steroid use include compromised healing or infection, sleep disturbances,
 hyperglycemia, avascular necrosis of bone, steroid-related acne and adverse psychiatric
 effects.

 The use of perioperative steroids as a means of swelling control is the current standard of
 care in the practice of orthognathic surgery. Despite this fact, there is little consensus on
 the ideal steroid regimen (i.e. type and dosing) to use for surgery. As such, the use of
 steroids in Oral and Maxillofacial surgical practices are based primarily on surgeon's
 preference and familiarity with a particular steroid regimen. This is likely due to the weak
 evidence in published literature in favor of a steroid regimen to mitigate post-operative
 swelling.

 Most literature in favor of particular steroid regimens involves crude or arbitrary
 measurements of swelling. In 1978, Habal showed that one gram of methylprednisolone
 administered in a controlled dog model reduced post-operative swelling. This observation was
 made by a trained observer against a control group who received no steroid. Other studies
 have had trained observers look at post-operative photographs of patients who had undergone
 orthognathic surgery to stratify which had "more" or "less" swelling. Another study attempted
 to quantify the degree of post-operative swelling by measuring the distance between the
 earlobes under the chin. These authors acknowledged that this could be altered by the facial
 movements produced during orthognathic surgery and that better means of measurement of facial
 swelling should be employed in future research.

 The current standard of care at the Oral and Maxillofacial Department at the CDHA is the use
 of one gram of methylprednisolone administered intravenously prior to orthognathic surgery.
 This is largely based on the work of Habal. The administration of one gram of
 methylprednisolone can be concerning for the anesthesiologist since this is an unusually
 large dose of steroid in comparison to use in other surgical specialties. As with most
 medications, the chances of steroid-related complications increase with increasing doses of
 steroids.

 The researchers are proposing a prospective, double-blind randomized control trial to
 determine if a smaller dose of methylprednisolone (125mg) can be used safely and effectively
 instead of one gram of methylprednisolone, which is the current standard of care in our
 department. One hundred and twenty-five milligrams of methylprednisolone is a readily
 available dose of steroids and has been shown in several studies to be effective in the
 reduction of swelling after oral surgeries and other swelling-related conditions. In their
 systematic literature review of corticosteroid administration in oral and orthognathic
 surgery, Dan et al. concluded that a preoperative dose of methylprednisolone >85mg results in
 a significant decrease in post-operative oedema. The researchers hypothesize that there will
 be little difference between groups with regards to primary study outcome measure of
 post-operative swelling.
Inclusion Criteria:

 -  All patients age 14 and over undergoing orthognathic surgery at the Atlantic Centre of
 Oral and Maxillofacial Surgery in Halifax, Nova Scotia will be included in our study.
 The clinic is located in the Victoria General Hospital in Halifax, Nova Scotia.
 Orthognathic surgery includes any combination of Lefort 1, Bilateral Sagittal Split
 Osteotomy (BSSO) and functional genioplasty procedures.

 Exclusion Criteria:

 -  Patients with pertinent medical history that precludes the use of high-dose steroids
 will be excluded from our study. This includes:

 -  Known hypersensitivity to steroids

 -  Type 1 diabetic patients who may have a severe elevation of blood sugars with
 steroid use.

 -  Systemic fungal infections

 -  Arrested tuberculosis

 -  Herpes simplex keratitis

 -  Acute psychoses

 -  Cushing's syndrome

 -  Peptic ulcer disease

 -  Pregnant patients and patients with current infections will be excluded Breast
 feeding mother