Accepted Manuscript

Post-Operative Swelling After Orthognathic Surgery: A Prospective Volumetric

Analysis

Madelon Van Der Vlis, Kelley M. Dentino, Bob Vervloet, Bonnie L. Padwa, D.M.D,
M.D.

PII: S0278-2391(14)00458-3
DOI: 10.1016/j.joms.2014.04.026
Reference: YJOMS 56308

To appear in: Journal of Oral and Maxillofacial Surgery

Received Date: 3 February 2014

Revised Date: 17 April 2014
Accepted Date: 18 April 2014

Please cite this article as: Van Der Vlis M, Dentino KM, Vervloet B, Padwa BL, Post-Operative Swelling
After Orthognathic Surgery: A Prospective Volumetric Analysis, Journal of Oral and Maxillofacial Surgery
(2014), doi: 10.1016/j.joms.2014.04.026.

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Post-Operative Swelling After Orthognathic Surgery: A Prospective Volumetric

Analysis

Madelon Van Der Vlisa, Kelley M. Dentinob, Bob Vervloeta, Bonnie L. Padwa, D.M.D, M.D.c

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Medical student, Erasmus University Medical Centre, Rotterdam, Netherlands.
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Dental student, Harvard School of Dental Medicine, Boston, Massachusetts.

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c
Associate Professor of Oral and Maxillofacial Surgery, Harvard School of Dental Medicine,
Department of Plastic and Oral Surgery, Boston Children’s Hospital, Boston, Massachusetts.

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Address correspondence to:

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Dr. Bonnie L. Padwa

Boston Children’s Hospital
Department of Plastic and Oral Surgery
300 Longwood Avenue
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Boston, MA 02115
Telephone: 617-355-6359
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Fax: 617-738-1657
E-mail: bonnie.padwa@childrens.harvard.edu.
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Abstract

Purpose: Three-dimensional stereophotogrammetry is a reliable, accurate, and non-invasive tool for

measuring changes in soft-tissue volume over time. The purpose of this prospective study was to quantify

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changes in post-operative swelling after orthognathic surgery using serial 3D photographs.

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Methods and patients: Three-dimensional photographs of forty-nine orthognathic surgery patients (Le

Fort I and/or BSSO) were captured using the 3D VECTRA imaging system pre-operatively (T0) and at

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one week (T1), two weeks (T2), three weeks (T3) , four weeks (T4), six weeks (T5), three months (T6), six

months (T7) and one year (T8) post-operatively. Canfield Mirror imaging software was used to quantify

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volume differences between serial 3D images. Descriptive statistics and repeated measures analysis of
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variance were calculated. Data were stratified by gender, pre-operative BMI, and procedure performed.
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Results: On average, approximately 50% of the initial swelling resolved after the third post-operative

week (T3), and after three months (T6), only 20% of the initial edema remained. Patients with higher
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BMI had the greatest amount of swelling and fastest rate of resolution in the initial weeks following
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surgery. Patients with lower BMI had less post-operative edema, and a slower rate of reduction between

all time points. Initial swelling and resolution did not vary significantly by gender or type of
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malocclusion.

Conclusion: Facial edema resolves rapidly during the first three post-operative weeks; significant
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decrease in soft tissue swelling still occurs between 6-12 months post-operatively.
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Introduction

Recently, an increased focus on patient-centered outcomes has underscored the need to consider the

patient’s experience as an indicator of operative success in addition to more objective clinical measures.1,2
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Patient-provider communication has become crucial for positive surgical outcomes.3,4 This is especially

true in orthognathic procedures, because even patients with long-term improvements in function and

quality of life will experience significant discomfort and functional limitation in the short-term.5

However, they are more likely to perceive this experience positively if they are given accurate

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information prior to surgery about what to expect during the recovery period.6,7

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Common sequelae after orthognathic surgery include pain, swelling, nausea and vomiting, trismus, and

social/functional impairment.8,9 All of these symptoms usually resolve within the first post-operative

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week except for facial swelling.10 Accurately quantifying the extent and duration of post-operative

swelling is important for the orthognathic surgeon working with patients who are eager to reach the final

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esthetic result. However, this task poses a challenge. Prospective surveys of the recovery period cannot
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accurately quantify swelling resolution, and traditional imaging measures of soft tissue volume, such as

MRI or CBCT, cannot justifiably be used for large prospective studies given the high cost and exposure
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levels of ionizing radiation. Fortunately, recent advances in three-dimensional surface imaging

technology have provided the oral-maxillofacial surgeon with powerful tools for fast, accurate, and non-
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invasive capture of soft tissue volume data.11

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Three-dimensional (3D) photography, also known as stereophotogrammetry, has tremendous utility for

the craniofacial surgeon as it captures fully textured, true-to-scale, 360° surface contour data in
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milliseconds.12 Furthermore, the images produced have an unparalleled degree of accuracy, precision, and

reliability.13-15 Anthropometric measurements on 3D photographic images are demonstrably more

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accurate and reliable than two-dimensional image data16 and are comparable to the measurements that can
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be obtained from a CBCT scan.17,18 Reproducible soft tissue landmarks have been identified and

described for this modality, and demonstrate excellent reliability and validity both within and between

providers.15,19,20 Compared to 3D-laser surface imaging, 3D photography is especially attractive for the

pediatric provider given the speed of data capture and image processing.20,21
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The purpose of this prospective study was to quantify the volume, duration, and reduction rate of post-

operative swelling in orthognathic surgery patients using serial 3D images taken for one year post-

operatively. We sought to evaluate the rate of reduction and identify whether gender, pre-operative body

mass index (BMI), or type of procedure performed had any measurable effect on initial swelling volume

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or rate of resolution. Measuring this data provides an opportunity to expand a critical aspect of the pre-

operative consultation. The surgeon who can provide accurate information about surgical sequelae and

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recovery will have a profound influence on the patient’s perception of a successful outcome and the

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psychological impact of the post-operative experience.

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Materials and Methods
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This study was approved by the Boston Children’s Hospital Committee on Clinical Investigation, and

informed consent was obtained. The sample included subjects who had a Le Fort I osteotomy and/or
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bilateral sagittal split osteotomy (BSSO). All patients were operated on by the senior author and had
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follow-up care at Boston Children’s Hospital between 2010 and 2013. A standardized course of peri-

operative corticosteroids was administered which consisted of 10 mg dexamethasone intra-operatively

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followed by 10 mg in the evening, 8 mg bid on post-operative day one, and 4 mg on post-operative day

two. Subjects were excluded from the study if they had a history of prior maxillary or mandibular
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procedures, or if they had adjunct surgical procedures of the head and/or neck during the follow-up
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period.

Images were captured pre-operatively (T0) and at one week (T1), two weeks (T2), three weeks (T3), four

weeks (T4), six weeks (T5), three months (T6), six months (T7) and one year (T8) post-operatively. All

images were captured with the Canfield Vectra M3 Imaging System (Canfield, NJ). This system consists

of three stereoscopic cameras which capture and synchronize multiple two-dimensional images in 3.5
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milliseconds. The accuracy, precision, and reliability of data capture within this system have previously

been demonstrated.20,22 All photographs were captured according to an established protocol that

minimizes the potential for error related to movement or facial expression.12-14 All images were captured

by the same clinician to control for inter-operator error.

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3D images were processed and analyzed using the Canfield Mirror Software according to previously

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established protocol for volumetric measurements of facial images.12,20,23 Serial photographs registered to

an axis grid are superimposed on a baseline image according to triangulated soft tissue landmarks, and

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surface area differences between superimposed images are measured to calculate a volume delta in terms

of cubic centimeters (cm3) (Figure 1).

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Because the supporting skeletal structures of the middle and lower face are altered by orthognathic
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surgery, we chose landmarks above the maxilla. For the same reason, pre-operative photographs could not

be used to provide a baseline for comparison of soft tissue changes. Assuming stable soft tissue volume
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twelve months after surgery, we used the one year post-operative photograph (T8) as the baseline image.
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For all photographs, both anatomic and patient-specific landmarks were identified. Anatomic landmarks

included medial canthus (en), lateral canthus (ex), tragus (t), and nasion (n); the accuracy and
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reproducibility of these soft tissue markers in 3D photography has been demonstrated with negligible

intra-rater error23. For each patient, at least one patient-specific landmark such as a distinct scar, mole, or
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freckle was also triangulated. All photos were analyzed by one investigator (MV).
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Volume calculations were obtained as the calculated deviation between shells generated from select
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corresponding surface areas on superimposed images (Figure 1). Surface area shells were generated to

include soft tissue overlying middle and lower facial skeletal structures excluding the nose. Mean volume

difference in cm3 and relative reduction expressed as a percentage were calculated for each photograph

(T1-T7) in comparison to the baseline (T8) for every patient. Volume changes were also calculated between
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serial time points. For percentage calculations, the one-week post-operative photograph was considered to

represent 100% swelling and the baseline photograph (T8) to represent 0% swelling, or 100% resolution.

Data were collected on age, gender, operation, type of malocclusion, and pre-operative height and weight.

BMI was calculated for all patients pre-operatively (T0) based on height squared (m2) and weight (kg)

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using the Center for Disease Control and prevention Child and Teen BMI calculator. Patients were

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considered underweight if their BMI was at or below the5th percentile, normal-weight if their BMI fell

between the 5th and 85th percentile, and over-weight if their BMI was at or above the 85th percentile for

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age and gender. Age, gender, type of malocclusion (Class I, IIa, IIb, or III), and operative data were

obtained through review of the medical record.

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Means were calculated for the following variables: age, BMI, swelling volume (cm3) and percent
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reduction for all time points. Frequency distributions were also calculated for gender, BMI category, and

surgery type. Repeated measures analyses of variance (ANOVAs) were used to compare swelling volume
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between all time points within subjects. ANOVAs, with Tukey post-hoc tests when necessary, were also
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used to compare initial swelling between groups for the following variables: BMI category, surgery type,

gender, and skeletal malocclusion. Pearson’s correlations were obtained to compare linear rate of change
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in the first three weeks after surgery.

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Results
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Eighty orthognathic surgery patients operated on by the senior author between 2010 and 2012 met the

inclusion criteria for the study. Thirty-one of these subjects, all of whom had Le Fort I osteotomy, were

excluded because either they did not have images taken for all eight post-operative time points (n=27) or

had facial hair growth during the follow-up period which interfered with landmark identification (n=4).

This left forty-nine patients, nineteen males (39%) and thirty females (61%), for inclusion in the analysis.

Thirty-two (65%) subjects had a BSSO, eleven (23%) had a Le Fort I osteotomy, and six (12%) had a
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bimaxillary procedure. The mean BMI for all subjects was 23.15 ± 4.37, with 72% (n=35) patients

considered normal-weight, 22% (n=11) overweight/obese, and 6% (n=3) underweight.

As expected, all patients experienced a reduction in swelling over time. Average swelling volume at each

time point is given in Table 1, the means show a significant difference (p≤0.002). Table 1 also shows the

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volume reduction, amount of elapsed time, and statistical significance of change from the previous

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measurement. On average, approximately 50% of the swelling was resolved after the third post-operative

week (T3), and after three months (T6), only 20% of the initial swelling remained (Figure 2).

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The rate and quantity of swelling reduction was stratified according to gender, surgery type, and BMI

category. Although differences in initial swelling volume correlated with BMI category (Figure 3), they

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were not statistically significant (p=0.448). Over-weight subjects had the most edema, and did not see a
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statistically significant decrease in swelling until the third post-operative week (p=0.019). Among under-

weight patients, no statistically significant change in swelling volume occurred between any two time
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points (data not shown). The percent reduction in facial swelling by post-operative week is presented in
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Table 2 for each BMI group. Of note, normal and over-weight subjects reached 90% resolution of edema

around week 26, while under-weight subjects achieved 90% resolution just four to six weeks after
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surgery.
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When subjects were stratified according to type of surgical procedure, all three groups were found to

experience a statistically significant reduction in swelling between all time points regardless of procedure
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(p<.05). Patients undergoing a single-jaw procedure experienced less initial swelling than patients who
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had a combined Le Fort I and BSSO (Figure 4); this difference was statistically significant for subjects

having a maxillary advancement (p=.004) but not for those who had a BSSO. The difference in initial

swelling volume between single-jaw surgery groups was not statistically significant.

Initial swelling and resolution did not vary significantly by gender or type of malocclusion.
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Discussion

The aim of this study was to quantify changes in post-operative swelling after orthognathic surgery using

serial 3D photographs. The one-year post-operative image was used as a baseline, assuming no persistent

swelling after twelve months.

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A previous study evaluated swelling in orthognathic surgery patients using a 3D laser scanner.24 This is

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another accurate surface imaging modality; however, important differences exist. In 3D laser imaging,

right and left sided scans are performed over an average of 7.5 seconds.24 These images must be merged

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and corrected for scanning distortions via computer processing and manual input from the user to

generate a shell image of surface contour. Our 3D photography system captures accurate, complete, fully

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textured soft tissue surface data in a matter of milliseconds without any operator input required for image
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processing.20 The speed and completeness of image capture make stereophotogrammetry an ideal research

tool for quickly evaluating contour and volume changes, especially in pediatric research populations, with
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minimal inconvenience to the patient.12

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This study measured soft tissue volume according to baseline data obtained one year after surgery.
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Previous work assumed stable soft tissue volume after six months and used this as a baseline.24 We have

shown that, on average, 11.2% of the initial swelling volume still persists at six months (Figure 2), and
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soft tissue volume continues to decline at a statistically significant rate between six and twelve months

(Table 1). The previous study also quantified volume changes for the entire face. We focused on changes
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in the soft tissues immediately overlying the skeletal areas affected by surgery (Figure 1), as the majority
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of volume changes have been shown to occur in this region.25 Our study (n=49) is four times larger than

the previous (n=12).24 In addition, we measured volume at more frequent and regular post-operative

intervals. These differences give our results more precision and greater statistical power.

Overall, the rate of swelling reduction is greatest during the first three post-operative weeks, with

approximately 50% resolution, and declines thereafter, with roughly 30% additional resolution in the
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ensuing three weeks (Figure 2). These data are intriguing in light of a recent survey of post-operative

sequelae in orthognathic surgery patients, who reported a perceived complete resolution of swelling three

weeks after surgery.9 While it is difficult to quantify what volume of facial edema is clinically

perceptible, we have shown that soft tissue volume continues to decline at three, six and 12 months post-

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operatively, albeit slowly.

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Interestingly, the volume of initial swelling did correlate with BMI category (Figure 3); however, the

statistical power of our stratification was limited by sample size. Higher BMI patients had the greatest

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amount of swelling and the fastest rate of resolution in the initial weeks following surgery. Lower BMI

patients had less initial swelling volume, and a slower rate of swelling reduction between all time points.

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The role of increased soft tissue volume loss due to weight loss must be considered. It can be expected
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that overweight patients will lose greater volume of excess subcutaneous fat than a patient who is more

lean. The investigators may consider a similar study where the rate of swelling resolution is controlled for
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changes in weight following the procedure.

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Swelling behavior did not vary significantly by gender, type of malocclusion, or pre-existing condition.

Of clinical significance, any appreciable volume difference between surgical groups was generally
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corrected by the third post-operative week. In other words, subjects with greater initial swelling

experienced faster resolution of swelling in the immediate recovery period such that volume and
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reduction rates were generally comparable by week four. Our study suggests that this phenomenon even

applies in the case of increased swelling volume following bimaxillary surgery compared to single jaw
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surgery (data not shown).

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In conclusion, 50% of facial swelling resolves within the first three post-operative weeks, 20% persists

after 3 months and there is a significant decrease in swelling that occurs through the end of the first post-

operative year. Patients who are thin approach the final esthetic result earlier than their average and
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overweight peers. This study provides the oral and maxillofacial surgeon with more detailed and accurate

information to counsel their patients about the post-operative course following orthognathic surgery.

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Figure 1a-d.
a) Images registered to three-dimensional axis grid according to reproducible soft tissue landmarks.
b) Area of interest selected and post-operative soft tissue surface superimposed on corresponding surface in baseline
image.
c) Contour differences between soft tissue surface area shells are registered.
d) Volume change calculated as area between corresponding soft tissue surface shells.

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Figure 2. Swelling reduction by post-operative week

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Figure 3. Swelling decrease over time by BMI
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Table 1. Mean swelling volume per time point with amount reduction, interval length, and statistical significance of
change between time points

Time Swelling Time elapsed ∆ V (cm3) ∆ V (%) Significance

point Volume (weeks) (p value)
(cm3 + SD )

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T1 31.10 + 20.73 --- --- --- ---
T2 17.63 + 11.92 1 13.47 43.3% p<.001
T3 12.00 + 7.61 1 5.63 31.9% p<.001

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T4 11.51 + 8.62 1 0.49 4.0% p<.001
T5 8.24 + 8.41 2 3.27 28.4% p<.001

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T6 5.08 + 4.92 6 3.16 38.3% p<.001
T7 1.91 + 2.45 14 3.17 62.4% p<.001
T8 0.00 + 0.00 26 1.91 100% p<.001

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Table 2. Percent resolution of facial swelling by BMI

Post-op Normal-weight Under-weight Over-weight

Week (n=36) (n=11) (n=3)
1 0% 0% 0%

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2 43.9% 52.6% 39.5%
3 56.0% 81.6% 70.9%
4 60.6% 87.5% 66.0%

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6 70.5% 94.4% 80.2%
12 85.7% 95.7% 78.9%
26 93.3% 98.9% 94.6%

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52 100% 100% 100%

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