J Oral Maxlllofac
Surg
50:687-690. 1992
Cost of a Genioplasty Under Deep Intravenous Sedation in a Private Office Versus General Anesthesia in an Outpatient Surgical Center JOSEPH
E. VAN SICKELS,
DDS,* AND B.D. TINER,
DDS, MDt
The cases of twenty-four patients who underwent genioplasties either under deep intravenous (IV) sedation in a dental office or under general anesthesia in a surgical center were reviewed. A cost comparison of this operation in these two environments showed that it was twice as expensive to have the same procedure done in an outpatient surgical suite under general anesthesia as it was in a private office under IV sedation.
Sixteen patients were treated in the surgical center over an g-year period and 8 patients were treated in a dental office over a much shorter period. Those in the surgical center group were patients who wanted to be unconscious during the procedure, but who most likely would not require a postoperative admission. The criterion for doing the procedure in the dental office was acceptance by the patient after discussion of the procedure with the surgeon. The genioplasty procedure was similar in both groups. A two-layer dissection was done in the labial mucosa of the lip to allow access to the bony chin. A reference mark was then made in the midline below the apicies of the teeth. The bony cuts extended posterior to the first or second molars, with care taken to maintain as large a vascular pedicle as possible. Once freed, the genial segment was manipulated with a clamp to the desired position. It was then fixed with a 2-mm bone plate. The tissues were closed in layers and a pressure dressing was placed.
Multiple articles have been written about genioplasties. The majority have discussed technical aspects or stability. ‘-’ In 1980, McBride and Bell’ described doing genioplasties using general anesthesia with nasotracheal intubation. Later, in 1985, Bell2 suggested that in selected cases genioplasties could be accomplished using local anesthesia augmented by intravenous (IV) sedation. In 1987, Spear et al8 reviewed their experiences with 39 patients who underwent genioplasties on an outpatient basis with intravenous sedation and local anesthesia. The purpose of this study was to compare the cost of genioplasties done in an office under deep IV sedation and local anesthesia with those done under general anesthesia in an outpatient surgical center. Methods and Materials Twenty-four patients who underwent genioplasties with or without associated procedures in a dental office under deep IV sedation and local anesthesia or under general anesthesia in a surgical center were reviewed.
DENTAL OFFICE
From July 1990 through April 199 1, eight patients had genioplasties, with or without other associated procedures, under IV sedation and local anesthesia. Three of them also had submental liposuction. Patients were NPO and were accompanied to the office by a responsible adult. Once in the office they were seated in a dental chair in a semisupine position and an automatic blood pressure cuff, pulse oximeter, and electrocardiogram monitor were attached. An IV line was
Received from the Department of Oral and Maxillofacial Surgery, University of Texas Health Science Center at San Antonio, TX. * Professor. t Assistant Professor. Address correspondence and reprint requests to Dr Van Sickels: Department of Oral and Maxillof&ial Surgery, University of Texas Health Science Center at San Antonio. 7703 Flovd Curl Dr. San Antonio, TX 78284-7908. 0 1992 American
Association
of Oral and Maxillofacial
Surgeons
0278-2391/92/5007-0005$3.00/O
687
688
GENIOPLASTIES,DEEP SEDATION IN PRIVATE OFFICE
started and a narcotic (meperdine or fentanyl) and an anxiolytic agent (midazolam) were slowly titrated to Verrel’s sign. Local anesthesia (lidocaine with 2% epinephrine 1: 100,000) was generously used. Bilateral mandibular nerve blocks were given, and multiple injections were made in the vestibule and on the lingual aspect of the mandible from first molar to first molar. Gauze packs were placed in the buccal vestibule on either side of the mouth. After waiting approximately 10 minutes for satisfactory anesthesia, surgery was begun. Once the dissection was completed, before making a bony cut, the patient was instructed to cough. An assistant supported the patient’s mandible and a IO-mg test dose of methohexital was given. When the effects of the initial dose were assessed, an additional 20- to 30-mg dose was given. When the patient was unresponsive to verbal commands, the bony cut was made and the chin with its attached pedicle was freed. Once the osteotomy was completed, the patient was allowed to gradually awaken. Incremental doses of methohexital were given as dictated by the patient’s pulse, degree of relaxation, cooperation, and respirations during this part of the procedure. Additional medications were given as believed necessary by the surgical team. Frequently, the patient’s airway would temporarily obstruct when the chin was first cut off and moved posteriorly. This was easily managed by placing a bone hook on the lingual aspect of the osteotomized segment and pulling it forward. Manipulation of the osteotomized segment for medium to large advancements was more difficult than performing the same procedure on a fully anesthetized and frequently paralyzed patient in an operating room. The tension in the submental tissue was readily felt. Most often this was managed by holding the chin forward in a very advanced position for several minutes. Occasionally, it was necessary to release some of the lingual attachments to allow for the desired advancement of the chin. Once the segment was positioned, it was stabilized and fixed. The average operating time was 45 minutes. The patient was dismissed from the office within 30 minutes, alert and responsive to commands. Dexamethasone, 8 to 10 mg, was given IV at the beginning of the procedure and either a cephalosporin or penicillin was used for prophylactic antibiotic coverage. Discharge medications included an antibiotic and an analgesic. Patients were seen in the office within 2 to 5 days for postoperative radiographs. SURGICALCENTER
Sixteen complete records were reviewed on patients who had genioplasties during the period of December
1982 through August 1990. Nine had associated procedures, ranging from removal of third molars to submental liposuction. No other orthognathic procedures were performed in this group. Patients treated under general anesthesia had a brief preoperative physical examination that included a hematocrit and a urinalysis. When indicated, additional laboratory studies were obtained. On the day of surgery, patients were NPO and were brought in as outpatients. After the preoperative visit by an anesthesiologist, an IV line was started prior to the patient being taken to the operating room. Standard monitoring equipment was attached to the patient and the patient underwent nasotracheal intubation. The surgical procedure was accomplished in the similar manner as for patients treated under IV sedation. Following completion of the surgery, the patients were monitored in the recovery room by a registered nurse. They were dismissed when the anesthesiologist determined they were ready for discharge. None of these patients were admitted to the hospital for prolonged observation. Antibiotic, steroid, and pain management were similar to that for patients who had IV sedation. Results DENTALOFFICE
Two patients were oversedated during the operation and went into stage II anesthesia. This minor complication was managed by allowing the patient to awaken and then completing the surgery. Airway management was not difficult. Once the osteotomy was completed, control of the airway was simple. As opposed to third molar surgery, the surgical field with a genioplasty is well controlled and bleeding and irrigation were managed with suction and the gauze packs in the buccal vestibules. In the first few cases, five to six cartridges of lidocaine 2% with epinephrine 1: 100,000 were used. In later cases, 10 cartridges of lidocaine were used and the mandibular nerve blocks were augmented with two cartridges of bupivicaine 0.5% with epinephrine 1: 200,000. The latter regimen not only improved the anesthesia, but also decreased blood loss and improved long-term pain management. Giving injections on the lingual near the inferior border also dramatically decreased blood loss. Total blood loss in the last five cases was estimated to be in the range of 20 to 40 mL for the genioplasties. The narcotic was always administered before the midazolam. Even though methohexital was subsequently added, the narcotic also was supplemented in longer cases. Although Fentanyl was used for some patients, as we gained more experience with doing gen-
VAN SICKELS
AND TINER
ioplasties in an office environment, meperidine became the drug of choice because of its longer duration of action. The average dose of midazolam given during the case was 5 mg. However, the average dose to start a case was 2 to 3 mg. Additional doses were given to decrease the overall dose of methohexital. The average dose of methohexital was 170 mg. SURGICALCENTER
The average time of surgery for those patients who had isolated genioplasties under general anesthesia was 67 minutes, whereas the total anesthesia time was 92 minutes. The average recovery time for all patients was 2 hours and 1 minute. Discussion Technically, general anesthesia was used in both environments as methohexital was used, to briefly render the patient unconscious when the osteotomy was being performed. However, both before and after the osteotomy, the patient was merely sedated. This was in distinct contrast to the surgical center, where the patients underwent induction and intubation to render them unconscious during the entire procedure. When one bears in mind the large number of cosmetic procedures not covered by third-party payers, cost becomes an important consideration. However, there are many other variables to consider when examining the results of patients treated in these two environments. The time of the surgery is one of them. The average time of surgery for those patients who had isolated genioplasties under general anesthesia was 67 minutes, and the total anesthesia time was 92 minutes. It is difficult to estimate exactly how long the same procedure took under IV sedation. It was estimated that the technical aspects of the genioplasty took 30 to 45 minutes under IV sedation and the entire time the patient was in the chair was 60 to 70 minutes. It was believed that the procedure was slightly quicker under IV sedation than when general anesthesia was used because less time was consumed in stabilizing the nasotracheal tube, preparing the patient, and removing the tape used to secure the tube at the end of the procedure. While this small time advantage may be debated, the convenience of operating in the same office where one does other routine procedures cannot be underestimated. This is true from both the standpoint of efficiency and familiarity. There is also no time wasted traveling from the office to the surgical center, and one can care for the next patient and still be in close proximity to the one recovering from the last surgery.
689 To assure safety, two surgeons and two assistants were used in every case done under IV sedation. One assistant’s sole responsibility was control of the airway. Oxygen was supplemented through a nasal cannula. The monitoring equipment used was standard in our office for all IV sedation. The two patients who went into stage II anesthesia were easily managed. From a cost-effective viewpoint, several issues are relevant: surgeon’s fees, anesthesia fees, facility charges, and hardware costs. Surgeon’s fees may not be the same in both environments. With outpatient general anesthesia, the patient also has both laboratory fees and the anesthesiologist’s fees. Facility charges in an outpatient surgery setting include the operating room and recovery room time. Hardware charges usually are billed as part of the facility charges. In the office, patients may be charged separately or as part of an office facility charge. Doing a genioplasty in an office may require additional equipment, and one may need to purchase an electrocautery unit and a reciprocating saw. During our first few cases arrangements were made with our hospital to reimburse them for hardware used from their miniplate system. After that, we acquired our own miniplate system. When a comparison was made between a genioplasty on a ASA class I patient done in the office and one done in the surgical center with an anesthesia time of 90 minutes and a 2-hour recovery room period, it was found that the cost to the patient was twice as much in the surgical center. The important differences were the recovery room fee, the anesthesia fee, and supply fees. There was no difference in surgeon’s fee in either environment. From a patient’s viewpoint, several issues need to be considered: overall cost, recovery from anesthesia, equivalency of the results, and the anxiety about the surgical event. There is no question that the operation is much cheaper in an office than in a surgical center. Average time of recovery from IV sedation was also less, being between 10 and 20 minutes, with 30 minutes being the maximum, versus an average time of 2 hours and 1 minute for all procedures accomplished under general anesthesia. The surgical results were similar in both environments. There were no infections in either group, and the esthetic results were also the same. The anxiety associated with the surgical event is an important issue. Years ago, patients routinely had their third molars removed under general anesthesia, and many patients expected to be put into the hospital for the procedure. As time progressed, IV sedation became the standard mode of treatment. However, there are still patients who are terrified of having surgery done with anything less than a full general anesthetic. None of the patients treated under IV sedation had to be
690
DISCUSSION
converted to a general anesthesia because of failure to control anxiety with the agents used. Perhaps this could present a problem with certain individuals. However, converting an IV sedation to a general anesthetic, when necessary, should not be difficult, considering the training and office environment of the average oral and maxillofacial surgeon.
3.
4. 5.
6.
References
7.
1. McBride KL, Bell WH: Chin surgery, in Bell WH, Proffit WR, White RP (eds): Surgical Correction of Dentofacial Deformities, vol 2. Philadelphia, PA, Saunders, 1980, p 1218 2. Bell WH: Genioplasty strategies, in Bell WH (ed): Surgical Cor-
J Oral Maxllofac 50:690.
8.
rection of Dentofacial Deformities, New Concepts, vol 3. Philadelphia, PA, Saunders, 1985, p 60 Davis WH, Davis CL, Daly BW: Long-term bony and soft tissue stability following advancement genioplasty. J Oral Maxihofac Surg 46:731, 1988 Bell WH, Gallagher DM: The versatility of genioplasty using a broad pedicle. J Oral Maxillofac Surg 4 1:736, 1983 Precious DS, Delair J: Correction of anterior mandibular vertical excess: The functional genioplasty. Oral Surg Oral Med Oral Path01 59:229, 1985 Ellis E, DeChow PC, McNamara JA, et al: Advancement genioplasty with and without soft tissue pedicle: An experimental investigation. J Oral Maxillofac Surg 42:637, 1984 Collins PC, Epker BN: Improvement in the augmentation genioplasty via suprahyoid muscle repositioning.J Oral Maxillofac Surg 11:116, 1983 Spear SL, Mausner ME, Kawamoto HK: Sliding genioplasty as a local anesthesia outpatient procedure: A prospective two center trial. Plast Reconst Surg 80:55, 1987
Surg
1992
Discussion Cost of a Genioplasty Under Deep Intravenous Sedation in a Private Office Versus General Anesthesia in an Outpatient Surgical Center Norman Trieger, DMD, MD Montefiore Medical Center, Bronx, NY, and Albert Einstein College of Medicine
It comes as no surprise that ambulatory anesthesia and surgery in the oral and maxillofacial surgeon’s office is more efficient for the operator and less costly to the patient. However, one must be wary when the engine driving this train is a locomotive fueled by finances. It is commendable to be creative and facilitate indicated treatments even though they be regarded as “cosmetic” and ineligible for third-party reimbursement. There are, however, several very important concerns in regard to this article’s apparent recommendation that genioplasties be done on an obtunded, nonintubated patient, Experience gained with only eight cases is far from an adequate series to support “safety,” considering the risk/ benefit ratio when applied to this particular surgery. The authors acknowledge difficulty in maintaining the patient’s airway when the chin was cut off, and further difficulty gaining a tensionless position of the chin to achieve immobilization and fixation. I also am aware of the large amounts of blood and irrigation fluid which attend this particular surgery. It often outstrips the ability of the assistant to keep the field dry enough to see well, let alone ensure a clear airway. Frenetic high-flow suctioning, saturated gauze packs, copious irrigating, and a
threatened airway do not make for tranquil or effective surgery. I would express my preference, and even my enthusiasm, for these patients to be electively intubated (orally, if wished) to create advantages in the office similar to those in a surgical center. The comparison of recovery times in this study is spurious: apples and oranges. In one instance we are dealing with a full general anesthetic from beginning to end, and in the other sedation, plus general anesthesia, plus sedation again, and a recovery period while the procedure is completed and the drugs are wearing off. I must also react to the “cookbook” method used to effect sedation and anesthesia. An opiate, either meperidine or fentanyl, was infused. With experience, meperidine became the drug of choice. No indication of dosage is stated. This administration was followed by midazolam and local anesthesia. Doses are given as averages, ie, 2 to 3 mg of midazolam to start and 5 mg or more for later. Methohexital averaged 170 mg for the eight office patients. Perhaps the red flag should go up when the use of local anesthesia is described. The authors used lidocaine 2% with 1: 100,000 epinephrine “generously.” “In later cases, ten cartridges of lidocaine were used and the mandibular nerve blocks and infiltrations were augmented with two cartridges of bupivacaine 0.5% with epinephrine 1:200,000.” The total dose given comes very close to the 400-mg toxic dose usually cited for a 70-kg man. Was it really necessary to test this boundary line too? I believe that a well-administered and well-monitored general anesthetic with a secured airway for surgery that takes 1 hour or more to perform can be safely and expeditiously done in an oral and maxillofacial surgeon’s office. This will provide economic, esthetic, and health benefits.
Surg
50:687-690. 1992
Cost of a Genioplasty Under Deep Intravenous Sedation in a Private Office Versus General Anesthesia in an Outpatient Surgical Center JOSEPH
E. VAN SICKELS,
DDS,* AND B.D. TINER,
DDS, MDt
The cases of twenty-four patients who underwent genioplasties either under deep intravenous (IV) sedation in a dental office or under general anesthesia in a surgical center were reviewed. A cost comparison of this operation in these two environments showed that it was twice as expensive to have the same procedure done in an outpatient surgical suite under general anesthesia as it was in a private office under IV sedation.
Sixteen patients were treated in the surgical center over an g-year period and 8 patients were treated in a dental office over a much shorter period. Those in the surgical center group were patients who wanted to be unconscious during the procedure, but who most likely would not require a postoperative admission. The criterion for doing the procedure in the dental office was acceptance by the patient after discussion of the procedure with the surgeon. The genioplasty procedure was similar in both groups. A two-layer dissection was done in the labial mucosa of the lip to allow access to the bony chin. A reference mark was then made in the midline below the apicies of the teeth. The bony cuts extended posterior to the first or second molars, with care taken to maintain as large a vascular pedicle as possible. Once freed, the genial segment was manipulated with a clamp to the desired position. It was then fixed with a 2-mm bone plate. The tissues were closed in layers and a pressure dressing was placed.
Multiple articles have been written about genioplasties. The majority have discussed technical aspects or stability. ‘-’ In 1980, McBride and Bell’ described doing genioplasties using general anesthesia with nasotracheal intubation. Later, in 1985, Bell2 suggested that in selected cases genioplasties could be accomplished using local anesthesia augmented by intravenous (IV) sedation. In 1987, Spear et al8 reviewed their experiences with 39 patients who underwent genioplasties on an outpatient basis with intravenous sedation and local anesthesia. The purpose of this study was to compare the cost of genioplasties done in an office under deep IV sedation and local anesthesia with those done under general anesthesia in an outpatient surgical center. Methods and Materials Twenty-four patients who underwent genioplasties with or without associated procedures in a dental office under deep IV sedation and local anesthesia or under general anesthesia in a surgical center were reviewed.
DENTAL OFFICE
From July 1990 through April 199 1, eight patients had genioplasties, with or without other associated procedures, under IV sedation and local anesthesia. Three of them also had submental liposuction. Patients were NPO and were accompanied to the office by a responsible adult. Once in the office they were seated in a dental chair in a semisupine position and an automatic blood pressure cuff, pulse oximeter, and electrocardiogram monitor were attached. An IV line was
Received from the Department of Oral and Maxillofacial Surgery, University of Texas Health Science Center at San Antonio, TX. * Professor. t Assistant Professor. Address correspondence and reprint requests to Dr Van Sickels: Department of Oral and Maxillof&ial Surgery, University of Texas Health Science Center at San Antonio. 7703 Flovd Curl Dr. San Antonio, TX 78284-7908. 0 1992 American
Association
of Oral and Maxillofacial
Surgeons
0278-2391/92/5007-0005$3.00/O
687
688
GENIOPLASTIES,DEEP SEDATION IN PRIVATE OFFICE
started and a narcotic (meperdine or fentanyl) and an anxiolytic agent (midazolam) were slowly titrated to Verrel’s sign. Local anesthesia (lidocaine with 2% epinephrine 1: 100,000) was generously used. Bilateral mandibular nerve blocks were given, and multiple injections were made in the vestibule and on the lingual aspect of the mandible from first molar to first molar. Gauze packs were placed in the buccal vestibule on either side of the mouth. After waiting approximately 10 minutes for satisfactory anesthesia, surgery was begun. Once the dissection was completed, before making a bony cut, the patient was instructed to cough. An assistant supported the patient’s mandible and a IO-mg test dose of methohexital was given. When the effects of the initial dose were assessed, an additional 20- to 30-mg dose was given. When the patient was unresponsive to verbal commands, the bony cut was made and the chin with its attached pedicle was freed. Once the osteotomy was completed, the patient was allowed to gradually awaken. Incremental doses of methohexital were given as dictated by the patient’s pulse, degree of relaxation, cooperation, and respirations during this part of the procedure. Additional medications were given as believed necessary by the surgical team. Frequently, the patient’s airway would temporarily obstruct when the chin was first cut off and moved posteriorly. This was easily managed by placing a bone hook on the lingual aspect of the osteotomized segment and pulling it forward. Manipulation of the osteotomized segment for medium to large advancements was more difficult than performing the same procedure on a fully anesthetized and frequently paralyzed patient in an operating room. The tension in the submental tissue was readily felt. Most often this was managed by holding the chin forward in a very advanced position for several minutes. Occasionally, it was necessary to release some of the lingual attachments to allow for the desired advancement of the chin. Once the segment was positioned, it was stabilized and fixed. The average operating time was 45 minutes. The patient was dismissed from the office within 30 minutes, alert and responsive to commands. Dexamethasone, 8 to 10 mg, was given IV at the beginning of the procedure and either a cephalosporin or penicillin was used for prophylactic antibiotic coverage. Discharge medications included an antibiotic and an analgesic. Patients were seen in the office within 2 to 5 days for postoperative radiographs. SURGICALCENTER
Sixteen complete records were reviewed on patients who had genioplasties during the period of December
1982 through August 1990. Nine had associated procedures, ranging from removal of third molars to submental liposuction. No other orthognathic procedures were performed in this group. Patients treated under general anesthesia had a brief preoperative physical examination that included a hematocrit and a urinalysis. When indicated, additional laboratory studies were obtained. On the day of surgery, patients were NPO and were brought in as outpatients. After the preoperative visit by an anesthesiologist, an IV line was started prior to the patient being taken to the operating room. Standard monitoring equipment was attached to the patient and the patient underwent nasotracheal intubation. The surgical procedure was accomplished in the similar manner as for patients treated under IV sedation. Following completion of the surgery, the patients were monitored in the recovery room by a registered nurse. They were dismissed when the anesthesiologist determined they were ready for discharge. None of these patients were admitted to the hospital for prolonged observation. Antibiotic, steroid, and pain management were similar to that for patients who had IV sedation. Results DENTALOFFICE
Two patients were oversedated during the operation and went into stage II anesthesia. This minor complication was managed by allowing the patient to awaken and then completing the surgery. Airway management was not difficult. Once the osteotomy was completed, control of the airway was simple. As opposed to third molar surgery, the surgical field with a genioplasty is well controlled and bleeding and irrigation were managed with suction and the gauze packs in the buccal vestibules. In the first few cases, five to six cartridges of lidocaine 2% with epinephrine 1: 100,000 were used. In later cases, 10 cartridges of lidocaine were used and the mandibular nerve blocks were augmented with two cartridges of bupivicaine 0.5% with epinephrine 1: 200,000. The latter regimen not only improved the anesthesia, but also decreased blood loss and improved long-term pain management. Giving injections on the lingual near the inferior border also dramatically decreased blood loss. Total blood loss in the last five cases was estimated to be in the range of 20 to 40 mL for the genioplasties. The narcotic was always administered before the midazolam. Even though methohexital was subsequently added, the narcotic also was supplemented in longer cases. Although Fentanyl was used for some patients, as we gained more experience with doing gen-
VAN SICKELS
AND TINER
ioplasties in an office environment, meperidine became the drug of choice because of its longer duration of action. The average dose of midazolam given during the case was 5 mg. However, the average dose to start a case was 2 to 3 mg. Additional doses were given to decrease the overall dose of methohexital. The average dose of methohexital was 170 mg. SURGICALCENTER
The average time of surgery for those patients who had isolated genioplasties under general anesthesia was 67 minutes, whereas the total anesthesia time was 92 minutes. The average recovery time for all patients was 2 hours and 1 minute. Discussion Technically, general anesthesia was used in both environments as methohexital was used, to briefly render the patient unconscious when the osteotomy was being performed. However, both before and after the osteotomy, the patient was merely sedated. This was in distinct contrast to the surgical center, where the patients underwent induction and intubation to render them unconscious during the entire procedure. When one bears in mind the large number of cosmetic procedures not covered by third-party payers, cost becomes an important consideration. However, there are many other variables to consider when examining the results of patients treated in these two environments. The time of the surgery is one of them. The average time of surgery for those patients who had isolated genioplasties under general anesthesia was 67 minutes, and the total anesthesia time was 92 minutes. It is difficult to estimate exactly how long the same procedure took under IV sedation. It was estimated that the technical aspects of the genioplasty took 30 to 45 minutes under IV sedation and the entire time the patient was in the chair was 60 to 70 minutes. It was believed that the procedure was slightly quicker under IV sedation than when general anesthesia was used because less time was consumed in stabilizing the nasotracheal tube, preparing the patient, and removing the tape used to secure the tube at the end of the procedure. While this small time advantage may be debated, the convenience of operating in the same office where one does other routine procedures cannot be underestimated. This is true from both the standpoint of efficiency and familiarity. There is also no time wasted traveling from the office to the surgical center, and one can care for the next patient and still be in close proximity to the one recovering from the last surgery.
689 To assure safety, two surgeons and two assistants were used in every case done under IV sedation. One assistant’s sole responsibility was control of the airway. Oxygen was supplemented through a nasal cannula. The monitoring equipment used was standard in our office for all IV sedation. The two patients who went into stage II anesthesia were easily managed. From a cost-effective viewpoint, several issues are relevant: surgeon’s fees, anesthesia fees, facility charges, and hardware costs. Surgeon’s fees may not be the same in both environments. With outpatient general anesthesia, the patient also has both laboratory fees and the anesthesiologist’s fees. Facility charges in an outpatient surgery setting include the operating room and recovery room time. Hardware charges usually are billed as part of the facility charges. In the office, patients may be charged separately or as part of an office facility charge. Doing a genioplasty in an office may require additional equipment, and one may need to purchase an electrocautery unit and a reciprocating saw. During our first few cases arrangements were made with our hospital to reimburse them for hardware used from their miniplate system. After that, we acquired our own miniplate system. When a comparison was made between a genioplasty on a ASA class I patient done in the office and one done in the surgical center with an anesthesia time of 90 minutes and a 2-hour recovery room period, it was found that the cost to the patient was twice as much in the surgical center. The important differences were the recovery room fee, the anesthesia fee, and supply fees. There was no difference in surgeon’s fee in either environment. From a patient’s viewpoint, several issues need to be considered: overall cost, recovery from anesthesia, equivalency of the results, and the anxiety about the surgical event. There is no question that the operation is much cheaper in an office than in a surgical center. Average time of recovery from IV sedation was also less, being between 10 and 20 minutes, with 30 minutes being the maximum, versus an average time of 2 hours and 1 minute for all procedures accomplished under general anesthesia. The surgical results were similar in both environments. There were no infections in either group, and the esthetic results were also the same. The anxiety associated with the surgical event is an important issue. Years ago, patients routinely had their third molars removed under general anesthesia, and many patients expected to be put into the hospital for the procedure. As time progressed, IV sedation became the standard mode of treatment. However, there are still patients who are terrified of having surgery done with anything less than a full general anesthetic. None of the patients treated under IV sedation had to be
690
DISCUSSION
converted to a general anesthesia because of failure to control anxiety with the agents used. Perhaps this could present a problem with certain individuals. However, converting an IV sedation to a general anesthetic, when necessary, should not be difficult, considering the training and office environment of the average oral and maxillofacial surgeon.
3.
4. 5.
6.
References
7.
1. McBride KL, Bell WH: Chin surgery, in Bell WH, Proffit WR, White RP (eds): Surgical Correction of Dentofacial Deformities, vol 2. Philadelphia, PA, Saunders, 1980, p 1218 2. Bell WH: Genioplasty strategies, in Bell WH (ed): Surgical Cor-
J Oral Maxllofac 50:690.
8.
rection of Dentofacial Deformities, New Concepts, vol 3. Philadelphia, PA, Saunders, 1985, p 60 Davis WH, Davis CL, Daly BW: Long-term bony and soft tissue stability following advancement genioplasty. J Oral Maxihofac Surg 46:731, 1988 Bell WH, Gallagher DM: The versatility of genioplasty using a broad pedicle. J Oral Maxillofac Surg 4 1:736, 1983 Precious DS, Delair J: Correction of anterior mandibular vertical excess: The functional genioplasty. Oral Surg Oral Med Oral Path01 59:229, 1985 Ellis E, DeChow PC, McNamara JA, et al: Advancement genioplasty with and without soft tissue pedicle: An experimental investigation. J Oral Maxillofac Surg 42:637, 1984 Collins PC, Epker BN: Improvement in the augmentation genioplasty via suprahyoid muscle repositioning.J Oral Maxillofac Surg 11:116, 1983 Spear SL, Mausner ME, Kawamoto HK: Sliding genioplasty as a local anesthesia outpatient procedure: A prospective two center trial. Plast Reconst Surg 80:55, 1987
Surg
1992
Discussion Cost of a Genioplasty Under Deep Intravenous Sedation in a Private Office Versus General Anesthesia in an Outpatient Surgical Center Norman Trieger, DMD, MD Montefiore Medical Center, Bronx, NY, and Albert Einstein College of Medicine
It comes as no surprise that ambulatory anesthesia and surgery in the oral and maxillofacial surgeon’s office is more efficient for the operator and less costly to the patient. However, one must be wary when the engine driving this train is a locomotive fueled by finances. It is commendable to be creative and facilitate indicated treatments even though they be regarded as “cosmetic” and ineligible for third-party reimbursement. There are, however, several very important concerns in regard to this article’s apparent recommendation that genioplasties be done on an obtunded, nonintubated patient, Experience gained with only eight cases is far from an adequate series to support “safety,” considering the risk/ benefit ratio when applied to this particular surgery. The authors acknowledge difficulty in maintaining the patient’s airway when the chin was cut off, and further difficulty gaining a tensionless position of the chin to achieve immobilization and fixation. I also am aware of the large amounts of blood and irrigation fluid which attend this particular surgery. It often outstrips the ability of the assistant to keep the field dry enough to see well, let alone ensure a clear airway. Frenetic high-flow suctioning, saturated gauze packs, copious irrigating, and a
threatened airway do not make for tranquil or effective surgery. I would express my preference, and even my enthusiasm, for these patients to be electively intubated (orally, if wished) to create advantages in the office similar to those in a surgical center. The comparison of recovery times in this study is spurious: apples and oranges. In one instance we are dealing with a full general anesthetic from beginning to end, and in the other sedation, plus general anesthesia, plus sedation again, and a recovery period while the procedure is completed and the drugs are wearing off. I must also react to the “cookbook” method used to effect sedation and anesthesia. An opiate, either meperidine or fentanyl, was infused. With experience, meperidine became the drug of choice. No indication of dosage is stated. This administration was followed by midazolam and local anesthesia. Doses are given as averages, ie, 2 to 3 mg of midazolam to start and 5 mg or more for later. Methohexital averaged 170 mg for the eight office patients. Perhaps the red flag should go up when the use of local anesthesia is described. The authors used lidocaine 2% with 1: 100,000 epinephrine “generously.” “In later cases, ten cartridges of lidocaine were used and the mandibular nerve blocks and infiltrations were augmented with two cartridges of bupivacaine 0.5% with epinephrine 1:200,000.” The total dose given comes very close to the 400-mg toxic dose usually cited for a 70-kg man. Was it really necessary to test this boundary line too? I believe that a well-administered and well-monitored general anesthetic with a secured airway for surgery that takes 1 hour or more to perform can be safely and expeditiously done in an oral and maxillofacial surgeon’s office. This will provide economic, esthetic, and health benefits.
