Surgeon(s): ***

‍Assistant Surgeon(s):  ***

‍Preoperative Diagnosis: ***

‍Postoperative Diagnosis: Same

‍Procedure(s): ***

‍Anesthesia: General

‍Implants: None

‍Specimen:***

‍Drains: None

‍Fluids: See anesthesia record

‍EBL: Minimal

‍Complications: None

‍Counts:  Correct x2

‍Indications: ​***

‍Findings: As expected

‍Procedure in Detail:

‍The patient was seen in the preoperative holding area with a H&P was updated, consents were verified, surgical site marked, and all questions and concerns related to the proposed procedure were discussed in detail.  The patient was transferred to the operating room by the anesthesia team.  The patient underwent general anesthesia with endotracheal intubation. Tegaderms were placed over the eyes. The patient was prepped and draped in the standard fashion for maxillofacial procedures.  A time-out was performed and the procedure began.

Teeth were brushed with Betadine and rinsed with saline irrigation. A K-wire was placed at the nasofrontal junction and the reference vertical height to maxillary incisor bracket was measured. Occlusal interferences were removed with a round diamond bur. Next, attention was turned to the patient's right mandibular vestibule. A #15 blade was used to make a BSSO type incision. The incision was carried out through mucosa to muscle and then carried horizontally down to bone. Then using a #9 periosteal elevator, dissection continued inferiorly and posteriorly to expose the inferior border of the mandible. Dissection then proceeded medially with a #9 elevator to expose the medial lingual surface of the mandibular ramus. The inferior alveolar nerve was identified and protected with a Seldin retractor. Next a reciprocating saw was used to make the sagittal osteotomy. Following this, wooden handle osteotomes were used to mobilize the proximal and distal segments of the mandible taking care to ensure mobility of the inferior border as well as the lingual surface. The sagittal split was completed without complication and the inferior alveolar nerve was dissected out of the proximal segment.  A periosteal elevator was used to extract tooth #32 from inside the split – rongeurs were used to remove the dental follicle.  The inferior border of the proximal/distal segment of the mandible was then stripped free of its soft tissue attachments. The surgical site was then copiously irrigated and packed off with moist gauze. Attention was then turned to the patient's left mandibular vestibule where an identical type procedure was carried out.

Again, a #15 blade was used to make a BSS type incision. Incision was carried out through mucosa to muscle and then carried horizontally down to bone. Then using a #9 periosteal elevator dissection carried inferiorly and posteriorly to expose the entire inferior border of the mandible. Dissection then proceeded medially with a #9 elevator to expose the medial lingual surface of the mandibular ramus. The inferior alveolar nerve was identified and protected with a Seldin retractor. Next a reciprocating saw was used to make the sagittal osteotomy. Following this, wooden handle osteotomes were used to mobilize the proximal and distal segments of the mandible taking care to ensure mobility of the inferior border as well as the lingual surface. The sagittal split was completed without complication and the inferior alveolar nerve was identified to be in the distal segment. A periosteal elevator was used to extract tooth #17 from inside the split – rongeurs were used to remove the dental follicle. The inferior border of the proximal/distal segment of the mandible was then stripped free of its soft tissue attachments The surgical site was then copiously irrigated and packed off with moist gauze.

Next using a prefabricated intermediate occlusal stent the patient was placed in maxillomandibular fixation using 26-gauge wire loops and J-wires. Afterwards, the proximal and distal segments were noted to be free of interference and the mandibular condyles were noted to be easily seated in their most superior and posterior position, taking care not to seat them with too much pressure. Both sides were then accessed with a trocar system, first making a small nick incision on the cheek and then inserting a trocar through to the intraoral surgical site. Finally, both proximal distal segments were fixated using 3x KLS bicortical screws at the superior border.  The patient was then released from maxillomandibular fixation.  It was noted that the patient was biting easily into the splint without any interferences or slides and then without the splint in place the occlusion was noted to be stable and reproducible without slides or interferences. The midlines were noted to be on at this point.

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The patient's face was then cleaned and the posterior pharynx was suctioned. An OG tube was used to suction out the contents of the stomach. Tegaderms were removed from the eyes. Dressings were placed. The patient was then transferred back to the care of the anesthesia team for extubation and recovery.

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