Journal of Cranio-Maxillo-Facial Surgery 49 (2021) 545e555

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Journal of Cranio-Maxillo-Facial Surgery

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Is there a hidden blood loss in orthognathic surgery and should it be

considered? Results of a prospective cohort study
Michael Schwaiger a, Jürgen Wallner a, b, *, Sarah-Jayne Edmondson c, Irene Mischak a,
Jasmin Rabensteiner d, Thomas Gary e, Wolfgang Zemann a
a
Department of Oral and Maxillofacial Surgery, Medical University of Graz, Austria
b
Department of Cranio- Maxillofacial Surgery, AZ Monica and the University Hospital of Antwerp, Antwerp, Belgium
c
Department of Plastic and Reconstructive Surgery, Guy's and St. Thomas' Hospital, London, UK
d
Clinical Institute of Medical and Chemical Laboratory Diagnostics, Medical University of Graz, Austria
e
Division of Angiology, Medical University of Graz, Austria

a r t i c l e i n f o a b s t r a c t

Article history: The aim of this prospective observational study was to investigate the parameter ‘hidden blood loss’
Paper received 28 April 2020 (HBL) in the context of orthognathic surgery, incorporating undetected bleeding volumes occurring
Accepted 25 July 2020 intra- and postoperatively.
Available online 2 August 2020
Orthognathic bleeding volumes were recorded at three different time points. At the end of the
operation the visible intraoperative blood loss (VBL) was measured. Additionally, the perioperative blood
Keywords:
loss was calculated 24 h and 48 h postoperatively using the ‘haemoglobin balance method’.
Blood loss
Analysis of the HBL was based on the difference between the visible intraoperative blood loss (VBL)
Orthognathic surgery
Hidden blood loss
and calculated blood loss (CBL), determined 48 h after surgery.
Bimaxillary surgery 82 patients (male 33, female 49) were included in this study, of whom 41 underwent bimaxillary
BSSO surgery and of whom 41 underwent Bilateral Sagittal Split Osteotomy (BSSO). Statistically significant
Gender differences with reference to the absolute bleeding volumes were found when comparing the two
treatment modalities. In terms of HBL, a bleeding volume of 287.2 ml (±265.9) in the bimaxillary group
and 346.9 ml (±271.3) in the BSSO cohort was recorded. This accounted for 32.2% (bimaxillary surgery)
and 62.6% (BSSO) of the CBL after 48 h (BIMAX vs. BSSO, p < 0.001).
HBL is a valuable adjunct to record within the perioperative management of orthognathic surgery to
further improve patient safety and postoperative outcomes.
© 2020 The Author(s). Published by Elsevier Ltd on behalf of European Association for Cranio-Maxillo-
Facial Surgery. This is an open access article under the CC BY-NC-ND license (http://creativecommons.
org/licenses/by-nc-nd/4.0/).

1. Introduction of blood loss occurring in orthognathic surgery is frequently

Orthognathic surgery aims at correcting dentofacial deformities
and associated skeletal malocclusion of varying underlying causes.
Over the last few decades there have been great advances in this
surgical field, contributing significantly to the safety of orthog-
nathic procedures (Bailey et al., 2001; Kim and Park, 2007). Despite
these advances, bleeding complications remain one of the major
concerns, due to the proximity of orthognathic surgery to the well-
vascularised areas of the midface (Pineiro-Aguilar et al., 2011;
Khanna and Dagum, 2012). Impaired visibility and limited access to
the source of bleeding have been shown to additionally increase the
risk of extensive bleeding (Khanna and Dagum, 2012). The amount
* Corresponding author. Department of Oral and Maxillofacial Surgery, Medical
University of Graz, Auenbruggerplatz 5, 8036, Graz, Austria.
E-mail address: juergenwallner@msn.com (J. Wallner).
described as excessive, potentially necessitating blood transfusion
and possible admission to an Intensive Care Unit (ICU) (Khanna and
Dagum, 2012; Al-Sebaei, 2014; Salma et al., 2017). Furthermore, a
prolonged postoperative recovery period and increased morbidity
have been linked to high bleeding volumes in orthognathic surgery
(Andersen et al., 2016; Schneider et al., 2015; Salma et al., 2017).
To address these issues and to decrease the rate of bleeding
complications, there have been multiple studies investigating the
average amount of blood loss to be expected (Moenning et al., 1995;
Panula et al., 2001; Pineiro-Aguilar et al., 2011; Faverani et al., 2014),
perioperative measures required to reduce bleeding volumes (Zellin
et al., 2004; Lin et al., 2017; Mei and Qiu, 2019), and looking into
factors which can predict the amount of blood loss in orthognathic
surgery (Madsen et al., 2012; Schneider et al., 2015; Thastum et al.,
2016; Olsen et al., 2016). The average bleeding volumes in

https://doi.org/10.1016/j.jcms.2020.07.015
1010-5182/© 2020 The Author(s). Published by Elsevier Ltd on behalf of European Association for Cranio-Maxillo-Facial Surgery. This is an open access article under the CC
BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/).
546 M. Schwaiger et al. / Journal of Cranio-Maxillo-Facial Surgery 49 (2021) 545e555
orthognathic surgery have so far been shown to vary widely between
clinical centres (Samman et al., 1996; Pineiro-Aguilar et al., 2011;
Rummasak et al., 2011). These differences may be explained by dis-
tinctions in terms of the study design, pooling of various treatment
modalities for statistical analysis, as well as the use of different
methods and timings to determine blood loss. Additionally, the length
of the surgical procedure (Thastum et al., 2016), the surgeon's skills
(Kretschmer et al., 2008; Rummasak et al., 2011) and patient-specific
parameters such as age, gender and body mass index (BMI)
(Kretschmer et al., 2008; Rummasak et al., 2011; Al-Sebaei, 2014;
Olsen et al., 2016), all potentially influencing blood loss, were shown
to differ between studies. The aforementioned divergences related to
respective study designs and study variables inevitably create a het-
erogeneous study population and therefore, interfere with the
comparability of results.
Most frequently, blood loss in orthognathic surgery is measured
directly after wound closure has been performed. This is usually
calculated by subtracting the amount of irrigation fluid used from
the total amount of fluid in the suction canister (Andersen et al.,
2016; Madsen et al., 2012; Al-Sebaei, 2014; Thastum et al., 2016;
Olsen et al., 2016). In various other clinical trials, the weight of
surgical gauze and the throat pack were also added (Ueki et al.,
2005; Kretschmer et al., 2008). However, there is a potential risk
for underestimation of the actual blood loss attributed to these
methods, as bleeding volume occurring in tissues spaces and the
maxillary sinuses is not accounted for (Schaberg et al., 1976;
Kretschmer et al., 2008). Other studies have applied various
formulae to calculate the patients' blood loss up to 48 h post-
operatively (Choi et al., 2009; Stehrer et al., 2019). Findings refer-
ring to these trials suggest that the timing of measuring blood loss
may be relevant regarding the detection of bleeding volume.
The parameter ‘hidden blood loss’ (HBL) has already been
established as a reliable adjunct in various surgical specialties, such
as orthopaedic and spinal surgery (Sehat et al., 2000; Foss and
Kehlet, 2006; Smith et al., 2011; Ogura et al., 2019). It is used to
yield specific information on the amount of undetected blood loss,
including the bleeding volume occurring after wound closure. In
these specialities, HBL has been shown to account for a significant
percentage of the total blood loss, and has frequently been linked to
a substantive drop in postoperative haemoglobin levels, which may
necessitate the need for blood transfusion despite reasonably un-
remarkable low intraoperative bleeding volumes recorded (Liu
et al., 2017; Ogura et al., 2019). Furthermore, increased risk of
wound infection, delayed wound healing, as well as prolonged
postoperative rehabilitation have been discussed in conjunction
with HBL (Liu et al., 2017).
Orthognathic surgery is routinely performed as an elective
surgical intervention, which reinforces the necessity of high safety
standards and a low rate of complications (Schneider et al., 2015;
Secher et al., 2018). Bleeding complications have clearly been
shown to be a highly relevant factor in this regard, and, as of yet,
‘hidden blood loss’ related to orthognathic surgery has not been
explored or quantified in the literature.
Table 1
The number of operations performed by each of the surgeons involved.
SURGEON 1 2
OMFS Consultant
BIMAX (n ¼ 41) 29
BSSO (n ¼ 41) 25
OVERALL (n ¼ 82) 54
Thus, the purpose of this prospective study was to investigate
the parameter ‘hidden blood loss’ related to orthognathic surgery
using a homogenous study cohort. We hypothesized that the per-
centage share of the ‘hidden blood loss’ in orthognathic surgery will
represent a significant amount of the calculated blood loss up to
48 h postoperatively.
2. Material and Methods
This prospective cohort study was conducted at the Department
of Oral and Maxillofacial Surgery at the Medical University of Graz
in 2019 over a 12-month period, after approval from the local ethics
committee had been obtained (EK 31e161 ex 18/19).
The study cohort was comprised of healthy individuals with
skeletal malocclusion scheduled for orthognathic surgical correc-
tion, selected according to defined inclusion and exclusion criteria.
Male and female patients undergoing bimaxillary surgery or
bilateral sagittal split osteotomy (BSSO), categorised as grade 1 and
2 of the ASA-classification, were considered eligible for this study.
Exclusion criteria entailed: (1) additional surgical procedures
performed in the same operative session (including genioplasty);
(2) oral intake of anticoagulants; (3) coagulopathies; (4) age under
18; (5) cleft lip and palate; and (6) connective tissue disorders.
Pre- and postoperative treatment followed standardised pro-
tocols established in our unit. Blood samples were routinely taken
on the day before surgery, as well as 24 h and 48 h postoperatively
for determination of relevant blood parameters, such as haemo-
globin, haematocrit and coagulation factors. All of the procedures
were performed by experienced consultant orthognathic surgeons
or advanced surgical trainees under senior supervision, according
to standardised surgical protocols (Table 1). BSSO was performed
following the Obwegeser-Dal Pont-technique modified by Hunsuck
and Epker (Hunsuck, 1968; Epker, 1977); Le Fort I osteotomy was
performed as described by Bell (Bell et al., 1988).
Intraoperatively, patients were positioned supine with no head-
up tilt. Intravenous antibiotics (IV) were given as a single shot at
induction. Total intravenous anaesthesia (TIVA) was performed in
all patients, with a target mean arterial pressure of 60 mmHg to be
maintained. Local anaesthesia (Prilocaine 2%, 1: 200.000) was
administered intra-orally to the surgical site before mucosal inci-
sion was performed, to decrease the risk of bleeding. No anti-
fibrinolytics were administered. No surgical drains were used
postoperatively. Postoperative patient management included:
cooling for two days, adequate pain control with IV Ibuprofen
600 mg (twice-a-day on day one and two after surgery), oral
Metamizole and IV Piritramide if required. Patients were nursed at
30
.
Blood transfusions were indicated at a haemoglobin level lower
than 6 g/dl; or between 6g/dl-10 g/dl in cases of cardiorespiratory
distress related to excessive blood loss.
Bleeding volumes related to bimaxillary surgery and BSSO were
recorded. This was done at three different time points: 1. at the end
of surgery, 2. at 24 h postoperatively, and 3. at 48 h postoperatively
3 4 5
OMFS OMFS OMFS OMFS Trainee
Consultant Consultant Trainee
5 6 0 1
7 3 4 2
12 9 4 3
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(Fig. 1). For this purpose, two well-established methods to deter-
mine blood loss were applied, as detailed below. Additional data
was collected regarding the length of the operation and patient-
specific characteristics such as gender, age and BMI.
In this study, the primary outcome of interest was the parameter
‘hidden blood loss’ (HBL), calculated 48 h postoperatively. Sec-
ondary study outcomes included the parameters ‘visible blood loss’
(VBL), ‘calculated blood loss’ (CBL) and ‘relative blood loss’ (RBL).
The following parameters were analysed within this study for
each case:
2.1. Visible blood loss (VBL)
The first measurement of the bleeding volume was performed
directly after completion of surgery, incorporating the blood loss
occurring from mucosal incision to wound closure. In this context,
the amount of irrigation fluid used was subtracted from the total
amount of fluid in the suction canister. Additionally, pre- and
postoperative weight differences regarding surgical swabs and the
throat pack were added. The intraoperative bleeding volume
determined was equated to ‘visible blood loss’ (VBL).
2.2. Calculated blood loss (CBL)
Bleeding volumes were calculated based on the levels of hae-
moglobin determined preoperatively as well as those taken 24- and
Fig. 1. Study design of this prospective clinical trial.
547
48 h after surgery, by means of the ‘haemoglobin balance method’
(Table 2) (Gao et al., 2015). The patients' total blood volume was
determined, applying the Nadler formula (Table 3) (Nadler et al.,
1962). The parameters indicating the calculated blood loss 24 h
and 48 h postoperatively were referred to as CBL-24 h and CBL-
48 h, respectively.
2.3. Relative blood loss (RBL)
For all three time points, the amount of blood loss relative to the
patients' total blood volume was given (RBLVBL; RBL24h; RBL48h); (RBL
(%) ¼ BL/BV  100), (Thastum et al., 2016; Andersen et al., 2016).
2.4. Hidden blood loss (HBL)
The parameter ‘hidden blood loss’ (HBL) was defined as the
difference between the visible blood loss (VBL) and the calculated
blood loss 48 h postoperatively (CBL-48 h). Hence, it incorporated
the undetected intraoperative bleeding volume, as well as the
blood loss after wound closure occurring in the first 48 h after
surgery. For calculation of HBL, VBL was subtracted from CBL-48 h
(HBL ¼ CBL-48 h e VBL) (Ogura et al., 2019).
548 M. Schwaiger et al. / Journal of Cranio-Maxillo-Facial Surgery 49 (2021) 545e555

Table 2
The formula used to calculate blood loss 24 h and 48 h postoperatively (CBL-24 h; CBL-48 h).

HAEMOGLOBIN BALANCE METHOD (Gao et al., 2015)

Equation Index

Hbloss total ¼ BV x (Hbpre e Hbpost) x 0.001 þ Hbt BV (ml) ¼ Patient's total blood volume before surgery
CBL ¼ 1000  (Hbloss total/Hbpre) Hbpre (g/L) ¼ preoperative haemoglobin level
Hbpost (g/L) ¼ postoperative haemoglobin level
Hbt (g/L) ¼ total volume of blood transfusion
1 Unit banked blood is considered to contain 52 g (±5.4) haemoglobin
Hbloss total (g) ¼ The loss volume of haemoglobin
CBL (ml) ¼ Calculated blood loss

Table 3
The formula used to estimate the patient's total blood volume as introduced by Nadler et al. (1962).

ESTIMATION OF TOTAL BLOOD VOLUME (BV) (Nadler et al., 1962)

Equation Index

Male BV (ml) ¼ Patient's total blood volume before surgery

BV ¼ 0.3669  H3 þ 0.03219  W þ 0.6041 H ¼ height in metres
Female W ¼ weight in kilograms
BV ¼ 0.3561  H3 þ 0.03308  W þ 0.183

2.5. Statistical analysis
Statistical analysis was performed using SPSS software, using
the t-test for independent samples. The Pearson correlation coef-
ficient was used to assess relevant correlations, including correla-
tions between the length of the operation, age and BMI with the
bleeding volumes determined (VBL, RBL, CBL, HBL). A p-value of
<0.05 was defined as the cut off for statistical significance.
A detailed depiction of the study design and respective path-
ways is shown in Fig. 1.
3. Results
82 patients (male 33, female 49) were included in the final
analysis of this study (Fig. 1). Data was assessed according to the
treatment modality applied. Furthermore, a subgroup analysis
focusing on gender-related differences was conducted. 41 patients
underwent bimaxillary surgery (male-female-ratio 1: 1.3, mean age
28,3 ± 10.4 years, BMI 24.2 ± 3.6). In the remaining 41 subjects,
BSSO was performed (male-female-ratio 1: 1.7, mean age 27,2 ± 8.4
years, BMI 22.5 ± 2.9). The mean operating time (OT) in the
bimaxillary group amounted to 133,7 min (IQR 80 min); a signifi-
cantly shorter surgical time was observed in the BSSO group (mean
70 min; IQR 49 min), (p < 0.001) (Table 4). In none of the patients,
blood transfusion nor admission to the ICU were indicated.
RBL, indicating the percentage of blood loss relative to the pa-
tient's total estimated blood volume, was calculated. For the
bimaxillary group, RBL made up 12% (±5.9), 15% (±6.9) and 18.4%
(±5.7) of the patient's total blood volume with reference to the
three time points. In the BSSO group, respective percentages were
found to be 2.7% (±1.8), 6.9% (±5.6), and 11.4% (±6.3). A statistically
significant difference was observed between the two surgical
techniques regarding relative blood loss, which was higher in the
bimaxillary group (p < 0.001); (Fig. 3).
3.2. Hidden blood loss (HBL)
The analysis of the parameter ‘hidden blood loss’ (HBL), repre-
senting the difference between the VBL and CBL after 48 h, equated
to a considerable amount of undetected blood loss in both groups.
With respect to the bimaxillary group a mean HBL of 287.2 ml
(±265.9 ml) was found. Similar findings in the BSSO group were
reported, with a mean HBL of 346.9 ml (±271.3 ml). No statistically
significant differences were found to occur when comparing the
surgical techniques in terms of HBL (p ¼ 0.294), (Fig. 4). Considering
the percentage share of HBL relative to CBL-48 h, statistically sig-
nificant differences between the two groups were observed
(p < 0.001). In this regard, HBL was found to account for 32.2% of
CBL-48 h in the bimaxillary group and for 62.6% of CBL-48 h in the
BSSO group (Fig. 5).

3.1. Visible blood loss (VBL), calculated blood loss (CBL) and relative
3.3. Gender-specific analysis
blood loss (RBL)
In the bimaxillary cohort (male 43.9%; female 56.1%), male
With regards to bimaxillary surgery there was a mean bleeding
gender was found to be associated with significantly increased
volume of 543.9 ml (±236.2), referring to the parameter VBL
bleeding volumes relative to female gender. This was true for the
measured immediately after surgery. The CBL-24 h showed a mean
bleeding volume of 676.1 ml (±317.5). 48 h after surgery, the
calculated blood loss (CBL-48 h) was 831.1 ml (±259.2) in the Table 4
bimaxillary group. Regarding blood loss in the BSSO group, the The operating time with regards to the treatment modality, as well as to gender.
following bleeding volumes in the parameters ‘VBL’, ‘CBL-24 h’ and Operating time (min) min max mean SD IQR p*Value
‘CBL-48 h’ were calculated: VBL of 148.7 ml (±100.0); CBL-24 h and
BIMAX male 73 279 154.2 55.7 74 p ¼ 0.025
CBL-48 h were 301.2 ml (±243.7) and 495.6 ml (±278.6), respec- female 61 231 117.7 45.0 75
tively. Statistically significant differences between the two treat- overall 61 279 133.7 52.6 80 p < 0.001
ment modalities in all of the measurements were observed (VBL BSSO male 33 247 69.1 53.2 43 p ¼ 0.917
p < 0.001; CBL-24 h p < 0.001; CBL-48 h p < 0.001), indicating a female 27 195 70.6 38.7 49
overall 27 247 70.0 43.9 49 p < 0.001
significantly higher blood loss in the bimaxillary group (Fig. 2).
 M. Schwaiger et al. / Journal of Cranio-Maxillo-Facial Surgery 49 (2021) 545e555 549

Fig. 2. Mean bleeding volumes regarding bimaxillary surgery and BSSO, determined at the time points end of surgery (VBL), 24 h (CBL-24 h) and 48 h (CBL-48 h) postoperatively. A
steady increase from VBL to CBL-48 h can be observed in both groups. Statistically significant differences between the bimaxillary group and the BSSO group in terms of the amount
of blood loss were detected (p < 0.001).

Fig. 3. Percentage share of blood loss determined, relative to the patients' total blood volume. Similar to the absolute bleeding volumes shown in Fig. 2, an increase of the relative
blood loss in the first 48 h after surgery is demonstrated. Statistically significant differences between the two treatment modalities were observed.

parameters ‘VBL’ and ‘CBL-48 h’ (p ¼ 0.021 and p ¼ 0.026,
respectively) (Fig. 6). No such differences with regards to CBL-24 h,
RBL and HBL were observed.
In the BSSO group (male 36.6%, female 63.4%), similar bleeding
volumes were seen between male and female subjects, although
there was a slightly higher RBL in females compared with males
(Fig. 7). No statistically relevant gender-specific differences were
observed in any of the groups in terms of HBL (Fig. 8).
3.4. Correlation analysis
Surgical time, age and BMI were set in correlation with all pa-
rameters used to analyse the amount of blood loss.
Surgical time was found to correlate with VBL and the corre-
sponding relative blood loss (RBLvbl) in both the bimaxillary group
and the BSSO cohort, indicating that VBL increases with duration of
surgery (Table 5), (Fig. 9; Fig. 10).
550 M. Schwaiger et al. / Journal of Cranio-Maxillo-Facial Surgery 49 (2021) 545e555

Fig. 4. Mean hidden blood loss (HBL) determined 48 h postoperatively with reference to the bimaxillary group and the BSSO group. No statistically significant differences between
the two surgical procedures were found to occur, referring to the absolute amount of the hidden blood loss detected (p ¼ 0.294).

Fig. 5. Percentage share of the hidden blood loss (HBL) relative to the calculated blood loss after 48 h (CBL-48 h). Statistically significant differences between bimaxillary surgery
and BSSO were noted (p < 0.001).

In terms of age, correlations with reference to bimaxillary sur-
gery were found. With increasing age, decreasing blood loss was
found to occur (Table 5). No correlations between BMI and blood
loss were established.
All correlations being statistically significant are shown in Table 5
includingrespectivep-valuesandPearsoncorrelationcoefficients(r).
4. Discussion
Orthognathic surgery, performed in highly vascularised mid-
facial areas, has frequently been associated with excessive bleeding
(Pineiro-Aguilar et al., 2011; Khanna and Dagum, 2012). Large
bleeding volumes confer additional risks and negative side-effects
and as such, great efforts have been made within the field of
orthognathic surgery to try to reduce and predict the amount of
blood loss (Lin et al., 2017; Mei and Qiu, 2019; Stehrer et al., 2019).
There have been numerous trials focused on determining the
average bleeding volume linked to orthognathic procedures;
however, variations of study design are common, potentially
impairing the validity of comparing respective findings. In this re-
gard, a wide range of bleeding volumes determined in orthognathic
surgery have been reported (Yu et al., 2000; Choi et al., 2009;
Apipan and Rummasak, 2010; Pineiro-Aguilar et al., 2011). Reasons
for this are multifactorial, however, amid factors contributing to
these findings such as the treatment modality used and the
administration of antifibrinolytics, the method and timing of
measuring blood loss appear relevant (Schaberg et al., 1976;
Kretschmer et al., 2008; Choi et al., 2009; Secher et al., 2018; Mei
and Qiu, 2019; Stehrer et al., 2019).
Multiple methods of how to determine surgical blood loss are
currently available (Gao et al., 2015; Thastum et al., 2016; Olsen
et al., 2016; Ogura et al., 2019). None of these approaches, howev-
er, has proven superior and therefore no consensus on the optimal
method to be used has been found as of yet. Subtracting the amount
of irrigation fluid used from the total amount of blood loss in the
suction canister is a well-established, easily feasible and repro-
ducible method to calculate the patient's intraoperative blood loss.
Limitations with this refer to potential underestimation of the
actual bleeding volume (Schaberg et al., 1976; Kretschmer et al.,
2008). Furthermore, this method does not take into account any
blood loss occurring after wound closure has been performed.
Various formulae can be used instead to determine the amount
of blood loss on the basis of the patient's estimated blood volume
and the blood parameters, haemoglobin or haematocrit (Hurle
 M. Schwaiger et al. / Journal of Cranio-Maxillo-Facial Surgery 49 (2021) 545e555 551

Fig. 6. The analysis of gender-specific blood loss revealed statistically significant differences in the bimaxillary group in terms of the parameters visible blood loss (VBL) and
calculated blood loss 48 h postoperatively (CBL-48 h), with men bleeding significantly more.

Fig. 7. Subgroup analysis according to gender: In terms of the relative blood loss (RBL), no differences between male and female gender were noted.

et al., 2004; Johansson et al., 2005; Gao et al., 2015; Ogura et al.,
2019). These formulae were shown to better incorporate the
amount of undetected blood loss relative to the timing of the
measurement. Gao et al. highlighted that the use of different
formulae in a single patient undergoing knee arthroscopy may
evoke largely different results (Gao et al., 2015). Their findings
suggested, however, that the ‘haemoglobin balance method’ stands
out as the most accurate formula to determine blood loss in this
regard. Currently, no such data exists for orthognathic surgery,
however, this specific method and minor modifications of this
method have already been used to calculate blood loss related to
orthognathic surgical procedures in the literature (Choi et al., 2009;
Stehrer et al., 2019). Therefore, in our study the ‘haemoglobin bal-
ance method’ was applied.
In other surgical specialties, the amount of undetected blood
loss has frequently been shown to be of high medical importance
(Sehat et al., 2000; Foss and Kehlet, 2006; Smith et al., 2011; Ogura
et al., 2019). Despite low intraoperative bleeding volumes and
552 M. Schwaiger et al. / Journal of Cranio-Maxillo-Facial Surgery 49 (2021) 545e555

Fig. 8. Amount of hidden blood loss detected relative to treatment modality and gender. No statistically significant differences were observed.

Table 5
Statistically significant correlations determined in this study.

Correlation analysis Treatment modality BLOOD LOSS Pearson correlation coefficient p*Value

OPERATION LENGTH BIMAX Visible blood loss (VBL) r ¼ 0.493 p < 0.001
Relative blood lossVBL (RBLVBL) r ¼ 0.311 p ¼ 0.048
BSSO Visible blood loss (VBL) r ¼ 0.497 p < 0.001
Relative blood lossVBL (RBLVBL) r ¼ 0.497 p < 0.001
AGE BIMAX Visible blood loss (VBL) r ¼ 0.401 p ¼ 0.009
Relative blood lossVBL (RBLvbl) r ¼ 0.436 p ¼ 0.004
Hidden Blood Loss (HBL) r ¼ 0.400 p ¼ 0.010

Fig. 9. Statistically significant correlation between the length of the operation and the amount of the visible blood loss (VBL) regarding bimaxillary surgery (r ¼ 0.493; p ¼ 0.001).
 M. Schwaiger et al. / Journal of Cranio-Maxillo-Facial Surgery 49 (2021) 545e555
Fig. 10. Correlation between the length of the operation and the amount of the visible blood loss (VBL) with reference to BSSO (r ¼ 0.497; p ¼ 0.001).
minimal postoperative surgical drainage, patients have often been
found to develop postoperative anaemia requiring blood trans-
fusion (Smith et al., 2011). To date, this specific bleeding parameter,
referred to as the ‘hidden blood loss’ (HBL) has not been investi-
gated in the context of orthognathic surgery.
In our study cohort comprising patients undergoing BSSO or
bimaxillary surgery, the visible intraoperative blood loss (VBL) and
the calculated blood loss 24 h and 48 h (CBL-24 h; CBL-48 h) after
surgery were analysed. Based on VBL and CBL-48 h, the amount of
HBL was assessed. With respect to both surgical techniques ana-
lysed, a steady increase in terms of the bleeding volumes was
observed, referring to the different timings of the measurements.
Unsurprisingly, blood loss associated with bimaxillary surgery was
found to be significantly higher in all of the measurements relative
to the BSSO group. This conforms to the results from other studies
reporting on blood loss during orthognathic surgery (Schneider
et al., 2015; Thastum et al., 2016; Stehrer et al., 2019) In our study
this can be explained by the significantly longer operating time
related to bimaxillary surgery in combination with the vascular
anatomy of the maxilla frequently being linked to excessive
bleeding. The blood loss noted within our study corresponds to the
ranges observed in other publications (Choi et al., 2009; Pineiro-
Aguilar et al., 2011; Schneider et al., 2015; Stehrer et al., 2019).
We have also included relative bleeding volumes in our study to
allow for better comparison to other studies (Thastum et al., 2016;
Andersen et al., 2016). Pineiro et al. identified the mean blood loss
in orthognathic surgery to amount to 436.11 ml, following
reviewing outcomes of seven studies (Pineiro-Aguilar et al., 2011).
Choi et al. quoted significantly higher average bleeding volumes,
having measured the blood loss 48 h postoperatively (Yu et al.,
2000; Choi et al., 2009).
Our results strongly suggest that the timing of measuring blood
loss in orthognathic surgery is important, specifically where the
amount of bleeding volume detected is concerned. This is reflected
by the aforementioned increase in bleeding volumes in a single
patient developing over time. For detection of the visible blood loss
a different method had to be used, yet, calculation of CBL-24 h and
553
CBL-48 h was performed using the same formula for both time
points. Choi et al. used a similar formula to estimate bleeding vol-
umes in orthognathic surgery, however, suggested calculating
blood loss 48 h postoperatively to ensure normalised blood vol-
umes (Choi et al., 2009). Stehrer et al. did not provide any infor-
mation on the timing of the postoperative blood sample, which
may have affected respective bleeding volumes in their study
(Stehrer et al., 2019). The analysis of the HBL in our study indicates
firstly that a certain amount of blood loss remains undetected
during surgery and secondly, that after completion of surgery a
certain amount of blood loss is still to be expected.
With reference to the bimaxillary cohort, HBL accounted for
32.2% of CBL-48 h. Looking at the corresponding parameter in the
BSSO group, significantly higher percentages were demonstrated,
with a percentage share of 62.6% relative to CBL-48 h. It has to be
considered that the amount of HBL determined did not differ
greatly between the bimaxillary group (287.2 ± 265.9 ml) and BSSO
group (346.9 ± 271.3 ml). However, absolute bleeding volumes
determined in the BSSO cohort were shown to be significantly
lower compared to the bimaxillary group, which led to these per-
centage differences.
Similar to other investigations (Gong et al., 2002; Nkenke et al.,
2005; Ueki et al., 2005) blood transfusion was not required in any of
the patients included in our study. However, we believe that in
cases of higher intraoperative bleeding volumes recorded, an
approximate amount of 300 ml undetected blood loss to be added
to the visible blood loss 48 h after surgery may become relevant in
this regard.
We acknowledge that postoperative surgical drainage can be
useful in terms of detecting blood loss after surgery. However, is-
sues relying solely on this method, including blockage and
displacement of the surgical drain, have regularly been reported,
which can lead to underestimation of blood loss (Ogura et al., 2019).
The amount of the HBL might further be relevant for postoperative
quality of life, but this has not yet been investigated. Interestingly,
the length of surgical procedure did not appear to influence the
554 M. Schwaiger et al. / Journal of Cranio-Maxillo-Facial Surgery 49 (2021) 545e555
amount of HBL in our study, but correlated significantly with the
amount of VBL and RBLvbl.
Male gender has frequently been associated with higher
bleeding volumes in orthognathic surgery; however, the influence
of gender on blood loss remains controversial (Faverani et al., 2014;
Olsen et al., 2016; Moenning et al., 1995; Rummasak et al., 2011;
Secher et al., 2018). Thus, we also studied the effect of gender on the
amount of blood loss occurring in our study population. Similar to
the study published by Olsen et al., significantly increased bleeding
volumes in male subjects relative to female subjects in terms of VBL
(intraoperative blood loss) were noted related to bimaxillary sur-
gery (Olsen et al., 2016). Additionally, a statistically significantly
higher CBL-48 h in male patients was detected in our study for this
group. Referring to our results, we believe that this cannot be
attributed to gender alone, as increased operation times in male
participants were also observed. This has also been demonstrated
by Olsen et al. who found that operation times in men exceeded
those recorded in women by 30 min in their study cohort (Olsen
et al., 2016). Rummasak et al. stated that men bled significantly
more in their study, but did not specify the operation time relative
to gender; however, they noted that blood loss was found to in-
crease with the length of the procedure (Rummasak et al., 2011). In
our study, correlations between the length of the procedure and the
amount of the visible absolute and relative blood loss (VBL and
RBLvbl) were observed. No such correlations for CBL-48 h were
noted. When looking at the relative bleeding volumes determined
in male and female patients in our study, the aforementioned sta-
tistically significant differences are voided, revealing equal per-
centages of blood loss with reference to gender. Thastum et al. came
to a similar conclusion, reporting on relative bleeding volumes in
orthognathic surgery (Thastum et al., 2016).
Whereas obvious gender-specific differences regarding VBL and
CBL-48 h in the bimaxillary group were observed, no gender-
related distinctions with regards to HBL were found in our study.
Limitations of this study are the risk of preoperative dehydration
or postoperative blood dilution, potentially affecting calculated
bleeding volumes, as associated with the use of any formula to
determine blood loss. However, we believe that this risk can be
considered very low for our study cohort. This is because: (1)
preoperative blood samples were taken on the day before surgery,
at which point patients did not need to be fasted; (2) IV fluids were
mainly administered intraoperatively and within the immediate
postoperative period (6e8 h postoperatively); and, most impor-
tantly, (3) appropriate time points were chosen (24 h and 48 h
postoperatively) to calculate the bleeding volumes, where nor-
malised blood volumes are already to be expected.
Additional points of criticism related to this study may refer to
calculated blood loss relying on estimation of the patient's total
blood volume. Similar to calculating blood loss, no gold standard in
terms of the formula to be used to most accurately estimate the
patient's total blood volume exists. In this study, Nadler's formula
was applied (Nadler et al., 1962). This approach has already been
used in other studies assessing blood loss in orthognathic surgery
and takes into account the patient's body weight, height and
gender (Stehrer et al., 2019). To investigate the influence of differing
formulae on the patient's estimated blood volume and the blood
loss determined, Lopez-Picado et al. compared three commonly
used approaches: Moore's formula, Nadler's formula and ICSH-
formula (Lopez-Picado et al., 2017). No significant differences,
with reference to the estimated total blood volumes and more
importantly the blood loss determined, were detected in this re-
gard. These findings suggest that the choice of method to estimate
the patient's total blood volume will not alter the overall results
significantly. Therefore, Nadler's formula represents a valid method
in this context.
5. Conclusion
According to the results of this study, analysis of the parameter
‘hidden blood loss’ might be an important adjunct to be considered
in the context of orthognathic surgery, as it is already done in other
medical fields (Sehat et al., 2000; Foss and Kehlet, 2006; Smith
et al., 2011; Ogura et al., 2019). Especially in orthognathic surgery,
blood loss needs to be monitored closely since these interventions
are mainly elective and are performed in young and generally
healthy patients that do not have frequent surgeries or invasive
procedures.
We believe that considering the ‘hidden blood loss’ in orthog-
nathic surgery is particularly relevant, as currently more and more
orthognathic surgical interventions are performed in a day-surgical
setting. Furthermore, with more extensive osteotomies, additional
genioplasty and concomitant bone harvesting performed, the
‘hidden blood loss’ might be even greater than reported in this
study.
Recording ‘hidden blood loss’, as a standard measurement, in a
routine orthognathic operation setup may result in adaption of
perioperative bleeding management, allowing further improve-
ment of patient-safety, postoperative quality of life, as well as
postoperative outcomes related to this surgical field. This particu-
larly refers to the widespread administration of antifibrinolytics in
orthognathic surgery, which have frequently been shown to
decrease intraoperative blood loss (Mei and Qiu, 2019; Secher et al.,
2018). Based on the analysis of the parameter ‘hidden blood loss’,
introduction of different dosing regimens and time points
regarding the administration of antifibrinolytics would be advis-
able, not only to address the intraoperative blood loss, but also to
adequately reduce perioperative bleeding in orthognathic surgery.
However, further prospective research into this specific parameter
will be required to better understand and predict respective effects
and consequences.
Funding
The work received funding from the Austrian Scientific Fund
(FWF-KLIF): Grant No.: KLI-678-B31.
Ethical approval
This study was approved by ethics committee of the Medical
University of Graz, Austria - EK No.: EK 31e161 ex 18/19.
Author contribution statement
Conceived and designed this work: MS, JW. Contributed re-
agents/materials/analysis tools: MS, JW, SJE, IM, JR, TG, WZ. Sta-
tistical analysis: MS, IM. Wrote the paper: MS, SJE, JW.
Declaration of Competing Interest
The authors have no conflicts of interest to declare.
Acknowledgements
The anonymised source data were stored in a fig-share re-
pository to reproduce the results of this study. These data can be
found online and freely downloaded under: https://figshare.com/
articles/Is_there_a_hidden_blood_loss_in_orthognathic_surgery_/
12202586.
This investigation was conducted as a prospective observational
study. Due to the observational character this study was not
registered in a trial database.
 M. Schwaiger et al. / Journal of Cranio-Maxillo-Facial Surgery 49 (2021) 545e555 555

References Mei A, Qiu L: The efficacy of tranexamic acid for orthognathic surgery: a meta-
analysis of randomized controlled trials. Int J Oral Maxillofac Surg 48:
1323e1328, 2019
Al-Sebaei MO: Predictors of intra-operative blood loss and blood transfusion in
Moenning JE, Bussard DA, Lapp TH, Garrison BT: Average blood loss and the risk of
orthognathic surgery: a retrospective cohort study in 92 patients. Patient Saf
requiring perioperative blood transfusion in 506 orthognathic surgical pro-
Surg 8: 41, 2014
cedures. J Oral Maxillofac Surg 53: 880e883, 1995
Andersen K, Thastum M, Norholt SE, Blomlof J: Relative blood loss and operative
Nadler SB, Hidalgo JH, Bloch T: Prediction of blood volume in normal human adults.
time can predict length of stay following orthognathic surgery. Int J Oral
Surgery 51: 224e232, 1962
Maxillofac Surg 45: 1209e1212, 2016
Nkenke E, Kessler P, Wiltfang J, Neukam FW, Weisbach V: Hemoglobin value
Apipan B, Rummasak D: Efficacy and safety of oral propranolol premedication to
reduction and necessity of transfusion in bimaxillary orthognathic surgery.
reduce reflex tachycardia during hypotensive anesthesia with sodium nitro-
J Oral Maxillofac Surg 63: 623e628, 2005
prusside in orthognathic surgery: a double-blind randomized clinical trial.
Ogura Y, Dimar JR, Gum JL, Crawford 3rd CH, Djurasovic M, Glassman SD, et al:
J Oral Maxillofac Surg 68: 120e124, 2010
Hidden blood loss following 2- to 3- level posterior lumbar fusion. Spine J 19:
Bailey LJ, Haltiwanger LH, Blakey GH, Proffit WR: Who seeks surgical-orthodontic
2003e2006, 2019
treatment: a current review. Int J Adult Orthodont Orthognath Surg 16:
Olsen JJ, Ingerslev J, Thorn JJ, Pinholt EM, Gram JB, Sidelmann JJ: Can preoperative
280e292, 2001
sex-related differences in hemostatic parameters predict bleeding in orthog-
Bell WH, Mannai C, Luhr HG: Art and science of the Le Fort I down fracture. Int J
nathic surgery? J Oral Maxillofac Surg 74: 1637e1642, 2016
Adult Orthodon Orthognath Surg 3: 23e52, 1988
Panula K, Finne K, Oikarinen K: Incidence of complications and problems related to
Choi WS, Irwin MG, Samman N: The effect of tranexamic acid on blood loss during
orthognathic surgery: a review of 655 patients. J Oral Maxillofac Surg 59:
orthognathic surgery: a randomized controlled trial. J Oral Maxillofac Surg
1128e1136, 2001
67(133): 125, 2009
Pineiro-Aguilar A, Somoza-Martin M, Gandara-Rey JM, Garcia-Garcia A: Blood loss in
Epker BN: Modifications of the sagittal osteotomy of the mandible. J Oral Surg 35:
orthognathic surgery: a systematic review. J Oral Maxillofac Surg 69: 885e892, 2011
157e159, 1977
Rummasak D, Apipan B, Kaewpradup P: Factors that determine intraoperative
Faverani LP, Ramalho-Ferreira G, Fabris AL, Polo TO, Poli GH, Pastori CM, et al:
blood loss in bimaxillary osteotomies and the need for preoperative blood
Intraoperative blood loss and blood transfusion requirements in patients un-
preparation. J Oral Maxillofac Surg 69: 456e460, 2011
dergoing orthognathic surgery. Oral Maxillofac Surg 18: 305e310, 2014
Salma RG, Al-Shammari FM, Al-Garni BA, Al-Qarzaee MA: Operative time, blood
Foss NB, Kehlet H: Hidden blood loss after surgery for hip fracture. J Bone Jt Surg Br
loss, hemoglobin drop, blood transfusion, and hospital stay in orthognathic
88: 1053e1059, 2006
surgery. Oral Maxillofac Surg 21: 259e266, 2017
Gao FQ, Li ZJ, Zhang K, Sun W, Zhang H: Four methods for calculating blood-loss
Samman N, Cheung LK, Tong AC, Tideman H: Blood loss and transfusion re-
after total knee arthroplasty. Chin Med J (Engl) 128: 2856e2860, 2015
quirements in orthognathic surgery. J Oral Maxillofac Surg 54: 21e26, 1996
Gong SG, Krishnan V, Waack D: Blood transfusions in bimaxillary orthognathic
Schaberg SJ, Kelly JF, Terry BC, Posner MA, Anderson EF: Blood loss and hypotensive
surgery: are they necessary? Int J Adult Orthodon Orthognath Surg 17: 314e317,
anesthesia in oral-facial corrective surgery. J Oral Surg 34: 147e156, 1976
2002
Schneider KM, Altay MA, Demko C, Atencio I, Baur DA, Quereshy FA: Predictors of
Hunsuck EE: A modified intraoral sagittal splitting technic for correction of
blood loss during orthognathic surgery: outcomes from a teaching institution.
mandibular prognathism. J Oral Surg 26: 250e253, 1968
Oral Maxillofac Surg 19: 361e367, 2015
Hurle R, Poma R, Maffezzini M, Manzetti A, Piccinelli A, Taverna G, et al: A simple
Secher JJ, Sidelmann JJ, Ingerslev J, Thorn JJ, Pinholt EM: The effect of tranexamic
mathematical approach to calculate blood loss in radical prostatectomy. Urol Int
acid and gender on intraoperative bleeding in orthognathic surgery-A ran-
72: 135e139, 2004
domized controlled trial. J Oral Maxillofac Surg 76: 1327e1333, 2018
Johansson T, Engquist M, Pettersson LG, Lisander B: Blood loss after total hip
Sehat KR, Evans R, Newman JH: How much blood is really lost in total knee
replacement: a prospective randomized study between wound compression
arthroplasty? Correct blood loss management should take hidden loss into
and drainage. J Arthroplasty 20: 967e971, 2005
account. Knee 7: 151e155, 2000
Khanna S, Dagum AB: A critical review of the literature and an evidence-based
Smith GH, Tsang J, Molyneux SG, White TO: The hidden blood loss after hip fracture.
approach for life-threatening hemorrhage in maxillofacial surgery. Ann Plast
Injury 42: 133e135, 2011
Surg 69: 474e478, 2012
Stehrer R, Hingsammer L, Staudigl C, Hunger S, Malek M, Jacob M, et al: Machine
Kim SG, Park SS: Incidence of complications and problems related to orthognathic
learning based prediction of perioperative blood loss in orthognathic surgery.
surgery. J Oral Maxillofac Surg 65: 2438e2444, 2007
J Craniomaxillofac Surg 47: 1676e1681, 2019
Kretschmer W, Koster U, Dietz K, Zoder W, Wangerin K: Factors for intraoperative
Thastum M, Andersen K, Rude K, Norholt SE, Blomlof J: Factors influencing intra-
blood loss in bimaxillary osteotomies. J Oral Maxillofac Surg 66: 1399e1403,
operative blood loss in orthognathic surgery. Int J Oral Maxillofac Surg 45:
2008
1070e1073, 2016
Lin S, McKenna SJ, Yao CF, Chen YR, Chen C: Effects of hypotensive anesthesia on
Ueki K, Marukawa K, Shimada M, Nakagawa K, Yamamoto E: The assessment of blood
reducing intraoperative blood loss, duration of operation, and quality of surgical
loss in orthognathic surgery for prognathia. J Oral Maxillofac Surg 63: 350e354,
field during orthognathic surgery: a systematic review and meta-analysis of
2005
randomized controlled trials. J Oral Maxillofac Surg 75: 73e86, 2017
Yu CN, Chow TK, Kwan AS, Wong SL, Fung SC: Intra-operative blood loss and
Liu X, Liu J, Sun G: A comparison of combined intravenous and topical adminis-
operating time in orthognathic surgery using induced hypotensive general
tration of tranexamic acid with intravenous tranexamic acid alone for blood
anaesthesia: prospective study. Hong Kong Med J 6: 307e311, 2000
loss reduction after total hip arthroplasty: a meta-analysis. Int J Surg 41: 34e43,
Zellin G, Rasmusson L, Palsson J, Kahnberg KE: Evaluation of hemorrhage de-
2017
pressors on blood loss during orthognathic surgery: a retrospective study. J Oral
Lopez-Picado A, Albinarrate A, Barrachina B: Determination of perioperative blood
Maxillofac Surg 62: 662e666, 2004
loss: accuracy or approximation? Anesth Analg 125: 280e286, 2017
Madsen DE, Ingerslev J, Sidelmann JJ, Thorn JJ, Gram J: Intraoperative blood loss
during orthognathic surgery is predicted by thromboelastography. J Oral
Maxillofac Surg 70: 547e552, 2012