Oral Maxillofac Surg

DOI 10.1007/s10006-015-0525-2

ORIGINAL ARTICLE

Assessment of hematologic parameters

before and after bimaxillary orthognathic
surgery
Bruno Ramos Chrcanovic 1 & Guilherme Lacerda de Toledo 2 &
Mrcio Bruno Figueiredo Amaral 2 & Antnio Lus Neto Custdio 3,4

Received: 18 April 2015 / Accepted: 9 August 2015

# Springer-Verlag Berlin Heidelberg 2015

Abstract
Purpose The purpose of the study was to evaluate changes of
hematologic parameters in bimaxillary surgery.
Methods Fifty-three patients were prospectively evaluated
and divided into groups based on the surgical procedure and
sex (predictor variables). Hemoglobin, red blood cells, hematocrit, and platelet were the primary outcome variables, operation time the secondary outcome, and the patients age and
weight the other variables. Trial registration: NCT02364765
(U.S. National Institutes of Health, clinicaltrials.gov).
Results There was statistically significant difference between
all hematologic parameters before and after surgery, for both
men and women, and for all surgical groups. There was a
positive correlation between operative time and the decrease
(in %) of the hematologic parameters. Linear regression analysis suggested that the Hb values decrease 0.083 % for every
minute increase in the operation time, and 0.066, 0.066, and
0.010 % for RBC, Hct, and platelet count, respectively. There
was a negative correlation between weight and all hematologic parameters. Correlations between age and hematologic parameters were not statistically significant. Almost all

* Bruno Ramos Chrcanovic

bruno.chrcanovic@mah.se; brunochrcanovic@hotmail.com
1

Department of Prosthodontics, Faculty of Odontology, Malm

University, Carl Gustafs vg 34, SE-205 06 Malm, Sweden

Oral and Maxillofacial Surgery Service, Baleia Hospital, Belo

Horizonte, Brazil

Department of Morphology, Institute of Biological Sciences, Federal

University of Minas Gerais, Belo Horizonte, Brazil

Department of Oral and Maxillofacial Surgery, School of Dentistry,

Pontifcia Universidade Catlica de Minas Gerais, Belo
Horizonte, Brazil

correlations between age, weight, sex, and the surgery group

and the hematologic parameters were considered as very
weak. Only one patient was transfused.
Conclusions It is suggested that operation time and patients
weight play a bigger role than patients age and sex in the
decrease of hematologic parameters after bimaxillary surgery.
Keywords Blood parameters . Orthognathic surgery .
Bimaxillary osteotomies . Hemoglobin . Hematocrit . Red
blood cells . Platelets

Introduction
Orthognathic surgery involves surgical manipulation of the
jaws and facial skeletal structures to correct congenital or acquired dentofacial abnormalities. Although surgical techniques and hypotensive anesthesia have been developed to
minimize blood loss and significant intraoperative bleeding
is rarely encountered with the current standard method, the
risk of hemorrhage remains during the bimaxillary surgery
[13]. The reason is the extensive vascularization of the maxillofacial region and access difficulty in terms of cauterization
or ligation of the vessels involved [4].
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 collateral branches to the upper jaw in Le Fort I osteotomies. In
the case of the mandible, the bleeding occurs from the alveolar
arteries and the facial artery or branches of these [4]. The
pterygoid venous plexus is one of the most likely sources of
bleeding because of its posterior location to the pterygoid
plates. The vascular supply to the pterygoid muscles also
could be disrupted when the pterygoid plates are intentionally
fractured to allow for maxillary posterior repositioning [5].

Oral Maxillofac Surg

It was observed that bimaxillary surgery results in a major

volume of blood loss directly related to the operating time and
the magnitude of the intervention [6, 7]. The question remains
to what extent the intraoperative blood loss is significant.
Awareness of the possible amount of blood loss during a given
intervention is very helpful for clinicians when planning surgery and to prepare the auxiliary support for orthognathic
surgery and transfusion requirements [4]. Having said that,
the purpose of the present study was to compare some hematologic parameters and operation time in patients who
underwent esthetic bimaxillary surgery under hypotensive
anesthesia.

Materials and methods

In this prospective study, the study population was composed
of all consecutive patients listed for elective bimaxillary
osteotomies for orthognathic correction by one surgical team
and admitted from January 2010 until December 2011, at the
Baleia Hospital, Belo Horizonte, Brazil. The surgical procedures were carried out by residents under the supervision of an
experienced surgeon (A.L.N.C.: at least 800 cases of any type
of orthognathic surgery and more than 20 years of experience)
or by the experienced surgeon himself.
Patients who were having single maxillary osteotomies, Le
Fort II and III osteotomies; those with general contraindications for extensive surgical intervention; syndromic patients;
those with cleft palate; and those with general diseases or
hematological disorders were excluded. Written informed
consent was obtained from each patient before the surgical
procedure. The protocol of the current study followed the
Declaration of Helsinki on medical research protocols, and
ethics was approved by the Department of Morphology Ethics
Committee, Institute of Biological Sciences, Federal University of Minas Gerais, Belo Horizonte, Brazil.
A standardized modified Obwegeser sagittal split
osteotomy was performed bilaterally in the lower jaw together
with a standardized Le Fort I osteotomy. In addition, six patients had a genioplasty. The patients were operated under
hypotensive anesthesia, with a mean remifentanil administration of 0.3 mg/kg/h. The incision areas were infiltrated with a
local anesthetic containing adrenaline (lidocaine 2 % with
adrenaline 1:100.000). The peri- and postoperative analgesic
and anti-inflammatory treatment was standardized for all patients. Right after the induction of the general anesthesia, the
patients received dexamethasone IV 10 mg and cefazolin IV
2 g. Intraoperative volume replacement was achieved with
5 % glucose solution (1 mL/kg/h) with additional 1 mL/kg
to replace fasting-induced losses, in a maximum period of
6 h. Insensible and translocation losses were replaced with
saline (4 mL/kg/h), and lost blood was replaced with saline
(3 mL per milliliter lost).

After the surgery and under the usual 24 h of hospitalization, the patients received dipyrone IV 2 mL 6/6 h, ketoprofen
IV 100 mg 6/6 h, and cefazolin IV 1 g 6/6 h. Stabilization of
the osteotomies was usually performed by rigid fixation with
four L-shaped 2.0-mm titanium miniplates in the maxilla, and
two straight 2.0-mm titanium miniplates in the mandible.
When genioplasty was performed, it was stabilized with a
2.0-mm H-shape plate.
The following details of each patient were recorded in the
database: age (years); sex; weight (kg); indication for operation (mandibular advancement or setback, maxillary impaction or advancement, genioplasty); hemoglobin (g/dL; Hb);
red blood cells (cells/mcL; RBC); hematocrit (volume %;
Hct); platelet (cells/mcL); duration of operation (minutes),
whether a transfusion was given; and length of hospital stay
(days). Blood was collected immediately before the surgery
and 24 h after operation. The decision for transfusion was at
the discretion of the anesthetist or the attending physician. A
hemoglobin concentration of 7.0 g/dL was regarded as the
threshold for transfusion, based on recommendations [8].
The following normal ranges for blood parameters were
considered: (a) Hb concentration 1317 g/dL in men and
1216 g/dL in women; (b) RBC count/mcL 4.25.2106 in
men and 3.84.8106 in women; (c) Hct 40.750.3 % in men
and 36.144.3 % in women; and (d) platelet count 150,000
400,000/mcL.
Patients were divided into groups based on the surgical
procedure, patients sex, age and weight, and the operation
time (the predictor variables). The operating time was calculated from the time of mucosa incision to the completion of the
mucosal suture. The outcome variables were the blood parameters as measured by the change in Hb, RBC count, Hct, and
platelet count.
Two patients were excluded from the analysis when the
surgery procedure was considered as the predictor variable,
due to being the only ones submitted to a certain combination
of surgeries; one submitted to maxillary impaction and mandibular setback, and the other one to maxillary advancement,
mandibular setback, and genioplasty. Thus, there were two
surgical groups: (a) maxillary advancement+mandibular setback and (b) maxillary impaction+mandibular advancement.
The data were tabulated, and from these measurements
mean, standard deviation, minimum, and maximum were calculated. KolmogorovSmirnov test was performed to evaluate
the normal distribution of the variables. Levene test evaluated
homoscedasticity. The performed tests for two independent
groups were Students t test and MannWhitney test and for
two dependent groups were paired t test and Wilcoxon test,
when indicated. Pearson correlation and linear regression
were performed in order to verify the relationship between
the decrease in percentage of the values of the hematologic
parameters and the operating time, the patients age, and the
patients weight. Spearman correlation was performed in

Oral Maxillofac Surg

order to verify the relationship between the decrease in percentage of the values of the hematologic parameters and sex
and the surgery group. The degree of statistical significance
was considered p<0.05. All data were statistically analyzed
using the software Statistical Package for the Social Sciences
(SPSS) version 20 (SPSS Inc., Chicago, IL, USA).

Results
Fifty-three patients were included in the analysis, with a mean
age of 28.38.0 years (range 1855); there were 39 women
and 14 men (ratio, 2.79:1). Prior to the surgery, the American
Society of Anesthesiologists status (ASA) was determined,
and all patients were classified as ASA I. None of the patients
had cardiovascular, cerebrovascular, or coagulation disorders
or renal disease. Blood pressure of the patients varied between
118137 and 7688 (systolic/diastolic). The patients details
are summarized in Table 1. There was a statistically significant
difference in weight between the sexes (p=0.002), but no
difference between age (p=0.114). The mean duration of the
operations was 253.6 min (SD 36, range 190330). The patients remained 14 days hospitalized (mean 1.450.64, median 1 day). Genioplasty was performed on five of the patients
who had maxillary impaction+mandibular advancement. All
the 53 patients were included in the analysis when sex was
considered as the predictor variable. The blood parameter variables for each sex are summarized in Table 2. There was
statistically significant difference between all hematologic parameters before and after surgery, for both men and women.
There were no statistically significant differences in the
study variables between the surgical groups at baseline. There
was a statistically significant difference between all hematologic parameters before and after surgery for the two surgical
groups. The operative and blood variables for each treatment
group are summarized in Table 3.
There was a positive correlation between operative time
and the decrease (in %) of the values of the hematologic parameters (Figs. 1, 2, 3, and 4). The results of the linear regression analysis suggested that the Hb values decrease 0.083 %
Table 1

Patients details distinguished by sex (39 women, 14 men)

Age (years)
Male
Female
Weight (kg)
Male
Female
SD standard deviation
a

MannWhitney test

MeanSD (range)

p valuea

24.84.3 (2037)
29.68.7 (1855)

0.114

74.77.2 (6284)
65.211.3 (4798)

0.002

for every minute increase in the operation time (Fig. 1). In the
same way, for every additional minute of surgery, the RBC
count decreases an additional 0.066 % (Fig. 2), the Hct decreases 0.066 % (Fig. 3), and the platelet count decreases
0.010 % (Fig. 4). However, the correlations were weak (Hb,
RBC, Hct) or very weak (platelet) (Table 4). There was a
negative correlation between weight and the hematologic parameters, suggesting that an increase in the patients weight
will result in less decrease of the hematologic parameters
values, even though not all of them were significant. All correlations between age and the hematologic parameters were
not statistically significant. Almost all correlations between
age, weight, sex, and the surgery group and the hematologic
parameters were considered as very weak (Table 4).
No anesthetic complications were observed during surgery.
Only one patient required a 600-mL postoperative blood
transfusion. This patient was a 29-year-old woman, weighting
51 kg and submitted to maxillary impaction, mandibular advancement, and genioplasty. The operation time was 310 min.
Her blood parameters were (pre-/postoperative): 12.5/6.7 g/dL
hemoglobin, 5.04/2.81106 red blood cells/mcL, 39.0/20.7 %
hematocrit, and 191,000/145,000 platelets/mcL.
As only one patient required a blood transfusion, the statistics were done again, but now removing this single patient
from the statistics (considering it as an outlier), in order to
verify whether it was misleading the results of the present
study. All the comparisons between the pre- and postoperative
parameters remained statistically significant.

Discussion
Direct measurement of blood loss by weight of surgical
gauzes and the contents of suction bottles underestimates the
true blood loss, as the blood, for example, in the sinuses, the
tissue spaces, and the stomach, cannot be calculated [9].
Moreover, there are clear differences in the amount of blood
loss between studies, even after accounting for differences in
the methods of measuring blood loss [10]. Therefore, blood
loss was measured by the change in hematologic parameters
in this study.
The present findings showed a statistically significant difference between all hematologic parameters before and after
surgery for both sexes and for all surgical groups. However,
the decrease in the hematologic parameters was lower than the
limit required for transfusion in almost all patients. Transfusion was needed in only one female patient, weighting 51 kg,
with an operation time of 310 min. Rummasak et al. [11]
suggested that blood transfusion has to be considered in small
female patients who have long expected operative times.
The transfusion rate found in this study (1.9 %) is similar to
the results of Moenning et al. [12] (0.8 %), Umstadt et al. [13]
(3 %), Yu et al. [6] (4.8 %), Dhariwal et al. [14] (3.5 %

Oral Maxillofac Surg

Table 2

Hematologic parameters measured before and after bimaxillary operations, distinguished by sex (39 women, 14 men)
p valuea

Decrease of the values (%; meanSD)

p valueb

12.21.4 (10.015.4)
10.71.5 (6.714.0)

0.001
<0.001

19.59.8
18.68.8

0.872

4.210.43 (3.675.24)
3.560.43 (2.444.56)

0.001
<0.001

20.07.1
19.27.7

0.672

36.93.6 (31.4-45.0)
31.64.3 (20.741.7)

0.001
<0.001

18.67.4
19.58.2

0.896

27881 (159399)
22853 (145404)

0.001
<0.001

6.52.8
9.44.8

0.028

MeanSD (range)
Preoperative

Postoperative

Hemoglobin (g/dL)
Male
Female

15.21.4 (13.518.5)
13.21.1 (10.815.2)

Red blood cells (million cells/mcL)

Male
5.280.46 (4.575.95)
Female
4.410.40 (3.215.14)
Hematocrit (volume %)
Male
45.54.4 (40.2-54.1)
Female
39.23.3 (32.045.8)
Platelet (thousand cells/mcL)
Male
Female

29784 (171414)
25154 (163411)

SD standard deviation
a

Wilcoxon signed-rank test

MannWhitney test

Table 3

Operative and hematologic variables for each treatment group

Maxillary advancement+mandibular setback Maxillary impaction+mandibular advancement p value
(a)
(b)
(a)(b)c

Patients (n)
Male/female (n; ratio)

33
9/24 (1:2.67)

18
4/14 (1:3.5)

0.695

Patients age (years; meanSD)

27.97.4

29.39.5

0.737

Duration of operation (min;

meanSD)
Patients weight (kg; meanSD)
Hospitalization (days; meanSD)

25137

26136

0.386

69.511.8
1.30.5

64.09.9
1.70.8

0.090
0.050

Hemoglobin (g/dL; meanSD)

Preoperative

13.91.6

13.51.4

0.380

Postoperative
11.41.5
p value
<0.001a
Red blood cells (million cells/mcL; meanSD)
Preoperative
4.690.56
Postoperative
3.820.50

10.61.9
<0.001b

0.170

4.50.6
3.50.5

0.425
0.291

p value
<0.001a
Hematocrit (volume %; meanSD)
Preoperative
41.14.9
Postoperative
33.84.4
p value
<0.001a
Platelet (thousand cells/mcL; meanSD)
Preoperative
26767
Postoperative
24564
p value
<0.001a

<0.001b

SD standard deviation
a

Paired samples t test

Wilcoxon signed-rank test

MannWhitney test

40.44.1
31.45.2
<0.001b

0.548
0.274

25368
23169
<0.001b

0.253
0.214

Oral Maxillofac Surg

Fig. 1 Scatter plot of the
decrease of hemoglobin (in %) in
function of surgery time

considered appropriate), Kessler et al. [15] (2.5 %),

Kretschmer et al. [16] (1.6 %), and Kretschmer et al. [17]
(1.8 %) for patients undergoing bimaxillary osteotomies
Fig. 2 Scatter plot of the
decrease of red blood cells count
(in %) in function of surgery time

without preoperative donation of autologous blood. Some

studies did not even perform transfusion in any patient [2, 3,
10, 18, 19]. It is important to stress that in our study, we had no

Oral Maxillofac Surg

Fig. 3 Scatter plot of the
decrease of hematocrit (in %) in
function of surgery time

cases of segmentation of the maxilla, and only six

genioplasties were performed. It is widely accepted that the
more complicated the operations are, the greater the amount of
Fig. 4 Scatter plot of the
decrease of platelets count (in %)
in function of surgery time

blood loss to be expected. Factors such as segmentation of the

maxilla, grafts from the iliac crest, or additional osteotomies
raise the likelihood of transfusion significantly [6, 12, 14, 16].

Oral Maxillofac Surg

Table 4 Relationship between
the operating time, age, weight,
and the decrease (in %) of the
values of the hematologic
parameters and linear regression
equation

Parameter
Operating timea
Hemoglobin

R2

p value

Correlation

Equation

0.331

0.109

0.016

Weak

y=2.127+0.083x

Red blood cells

Hematocrit

0.315
0.299

0.099
0.089

0.022
0.072

Weak
Weak

y=2.815+0.066x
y=2.477+0.066x

Platelet

0.082

0.007

0.569

Very weak

y=5.979+0.010x

Agea
Hemoglobin

0.008

<0.001

0.955

Very weak

y=19.193+0.011x

0.031
0.041

0.001
0.002

0.825
0.772

Very weak
Very weak

y=20.2640.029x
y=18.118+0.041x

0.103

0.011

0.475

Very weak

y=6.964+0.058x

0.172

0.030

0.217

Very weak

y=31.1440.172x

Red blood cells

Hematocrit

0.161
0.097

0.026
0.009

0.251
0.490

Very weak
Very weak

y=26.7430.108x
y=23.9450.069x

Platelet
Sexb
Hemoglobin
Red blood cells
Hematocrit

0.286

0.082

0.044

Weak

y=16.7730.119x

0.031
0.059
0.018

0.001
0.003
<0.001

0.827
0.676
0.897

Very weak
Very weak
Very weak

0.315

0.099

0.026

Weak

0.002
0.000

<0.001
<0.001

0.987
0.999

Very weak
Very weak

0.069
0.101

0.005
0.010

0.629
0.493

Very weak
Very weak

Red blood cells

Hematocrit
Platelet
Weighta
Hemoglobin

Platelet
Surgery groupb
Hemoglobin
Red blood cells
Hematocrit
Platelet
a

Pearson correlation

Spearman correlation

The blood loss in the study of Yu et al. [6] during segmental

maxillary osteotomies was almost twice that of single-piece
Le Fort I osteotomies. Moenning et al. [12] also observed a
higher mean blood loss in the group of bimaxillary surgery
with segmented maxilla than in the group without
segmentation.
An increased knowledge of the basic biology of
bimaxillary surgery, the development of instrumentation specifically designed for the operation, and the use of hypotensive
anesthesia have dramatically decreased the morbidity and the
transfusion requirements [2]. The results of a review observed
that the intraoperative bleeding observed in patients during
bimaxillary surgery was less than the limits set for blood transfusion and that there is little risk of marked bleeding in routine
orthognathic surgery, suggesting that transfusion would be a
nonessential routine for this kind of surgery [4]. According to
Messmer [20], it is not essential, or even desirable, to replace
all blood lost in adult patients with normal cardiopulmonary
function because they can compensate by homeostasis for a
blood loss of up to 20 % (approximately 1100 mL) of their
circulating blood volume. These findings may also help to

reduce over-ordering of blood for bimaxillary osteotomies,

which can result in blood shortage and is costly.
The present study found a positive correlation between
operative time and the decrease (in %) of the values of the
hematologic parameters. A correlation between operating time
and blood loss was also observed in other studies [6, 10, 11,
17, 21]. It seems to be well established that a directly proportional relationship exists between the duration of the intervention and the bleeding volume. These findings suggested the
importance of surgical practice to shorten the operative time
[11]. Therefore, particularly careful consideration should be
given to the question of the need for transfusion when longduration operations are planned [10]. The operation time can
be shortened by use of hypotensive anesthesia, accurate and
precise simulation surgery, a consistent surgical routine performed by the same surgeons and staff, and ensuring that
adequate equipment and an adequate selection of instruments
are available for each procedure [10].
There were no statistically significant differences in the
study variables between the surgery groups at baseline, which
suggested that the final differences between the two groups

Oral Maxillofac Surg

were not influenced by the initial characteristics, thus allowing

the postoperative results to be compared. The present findings
showed that the pre- and postoperative hematologic variables
were not significantly different between the surgery groups.
This may be explained by the fact that all patients were submitted to the same standardized techniques (modified
Obwegeser sagittal split and Le Fort I osteotomies) with no
segmentation of the maxillae.
Concerning the differences between the sexes, Moenning
et al. [12] found that male patients had higher mean blood loss
than female patients. This assumption comes from the fact the
male patients weight and baseline hematologic parameters
levels are usually greater than those in female patients, as also
observed in the present study. However, we found that mean
estimated decrease in the hematologic parameters for male
patients was not significantly greater than that for female patients, agreeing with the finding of Kretschmer et al. [17]. The
subject still needs further study.
Our results found a negative correlation between weight
and the hematologic parameters, suggesting that an increase
in the patients weight will result in less decrease of the hematologic parameters values. In fact, the lower the patients
weight, the greater the effect of intraoperative blood loss on
hemodynamics and anemia development [4].
There was no correlation between blood loss and the age of
the patients. Moenning et al. [12] also found that mean blood
loss was not affected significantly by patient age [11].
Kretschmer et al. [17] found no correlation between age and
the reduction in hemoglobin concentration.
The fact that the surgical procedures were carried out by
residents under the supervision of an experienced surgeon
may have exert some influence on the blood loss. However,
Kretschmer et al. [16] could not find any difference in terms of
blood loss between the resident group and the experienced
surgeons group in their study.
The subjects included in the present study did not have
major systemic medical conditions, and the blood pressure
of all patients was considered normal or prehypertension. This
could probably rule out a strong influence of the patients
systemic health on the blood loss.
A possible limitation of the present study was the age distribution of the study population. Because the surgeries were
performed mostly for esthetic purposes, the study population
included relatively young patients. Thus, the results of this
study might be implemented restrictively for the clinical setting in which most patients planned for esthetic bimaxillary
surgery are young adults.
It is important to stress that controlling intra- and postoperative complications, including excessive blood loss, requires
a good view of the surgical field, a good knowledge of anatomy, and the exercise of care during the intervention [2227].
Bleeding can be minimized by respecting the margins for the
various vessels in the surgical field, with an atraumatic

approach [4, 18]. The surgeons skill is important in terms

cauterizing or ligating the vessels responsible for bleeding,
plus a short duration of operation [4]. Moreover, it is suggested that reduction of blood loss can also be achieved by
locally applying drugs, such as adrenaline, cocaine,
desmopressin acetate, and tranexamic acid [28, 29]; using
bleeding depressants, such as intravenous aprotinin [22]; inducing hypotensive anesthesia during surgery [2, 6, 9, 29];
performing the technique of acute normovolemic hemodilution; preoperative administering of recombinant erythropoietin [30]; using intraoperative cell salvage and autologous
blood transfusion [31]; and maintaining perioperative normothermia [32]. The patient should also be correctly positioned
to keep the surgical field above the level of the heart [18].

Conclusions
It is suggested that operation time and the patients
weight play a bigger role than the patients age and
sex in the decrease of hematologic parameters after
bimaxillary surgery. Transfusion is generally not required during bimaxillary surgery.
Acknowledgments None.
Compliance with ethical standards This study involves human subjects. Ethical approval was acquired from the Department of Morphology
Ethics Committee, Institute of Biological Sciences, Federal University of
Minas Gerais, Belo Horizonte, Brazil. Clinical trial registration number:
NCT02364765 (clinicaltrials.gov). Patient permission was acquired. All
authors have viewed and agreed to the submission.
Conflict of interest The authors declare that they have no competing
interests.

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