Bilateral periorbital subcutaneous emphysema following Le Fort I osteotomy: a case report

Subcutaneous emphysema is a rare but recognised complication of orthognathic surgery. When it extends to the periorbital region after a Le Fort I osteotomy (LFI), the eyelid swelling can be alarming for the patient and may delay early functional recovery. Periorbital extension and the possible contribution of a transient postoperative rise in intranasal pressure remain underemphasised in the oral surgery literature. A 20-year-old Japanese woman underwent an LFI combined with bilateral sagittal split ramus osteotomy (SSRO) under general anaesthesia with nasotracheal intubation. During down-fracture, a 12-mm left nasal-floor mucosal laceration occurred and was sutured. Five hours after surgery, swelling with crepitation appeared in the bilateral cheeks and upper and lower eyelids; at that time the patient had severe bilateral nasal obstruction, and postoperative coughing and vomiting were noted. Computed tomography (CT) showed continuous subcutaneous air extending from the bilateral cheeks to the bilateral lower eyelids and the left upper eyelid, with complete bilateral nasal obstruction. After excluding haematoma, oedema, infection and orbital complications, subcutaneous emphysema was diagnosed. The patient was managed conservatively with antibiotic prophylaxis and observation, and the emphysema and nasal obstruction resolved completely by one month postoperatively, without recurrence. Periorbital subcutaneous emphysema is a rare complication of LFI. In this case, a transient rise in intranasal pressure was considered the most plausible driving force; this was presumed to have resulted from complete bilateral nasal obstruction together with postoperative coughing and vomiting, and possibly forceful nasal breathing, although the mechanism was not directly observed or measured. The compressed air is presumed to have entered the maxillary sinus through gaps in the sutured nasal-floor mucosa and to have reached the buccal and periorbital tissues along the anterior maxillary osteotomy line. Practical preventive strategies include atraumatic handling and tight closure of the nasal mucosa during LFI, preoperative counselling about the risk of subcutaneous emphysema, postoperative instruction to avoid increased intranasal pressure such as forceful nasal breathing and nose blowing, and selective deferral of intermaxillary fixation in patients with extensive maxillary mobilisation or nasal mucosal injury.