Major vascular complications of orthognathic surgery: Hemorrhage associated with Le Fort I osteotomies

J Oral Maxillolac Surg 48:561·573. 1990

Major Vascular 'Complications of Orthognathic Surgery: Hemorrhage Associated With Le Fort I Osteotomies DENNIS T. LANIGAN, DMD, MD,* JULIANA H. HEY, DDS,t AND ROGER A. WEST, DMDt Major intraoperative or postoperative bleeding associated with Le Fort I osteotomies can be venous and/or arterial in nature. Arterial hemorrhage generally involves the maxillary artery and its terminal branches. Arterial hemorrhage tends to be more persistent and can be recurrent, which makes it more difficult to manage. Postoperative bleeding following Le Fort I osteotomies generally presents as epistaxis and usually occurs initially within the first 2 weeks following surgery. Treatment modalities that have been used to successfully arrest postoperative hemorrhage include anterior and/or posterior nasal packing; packing of the maxillary antrum; reoperating with clipping or electrocoagulation of bleeding vessels, or the use of topical hemostatic agents in the pterygomaxillary region; external carotid artery ligation; and selective embolization of the maxillary artery and its terminal branches.

artery itself can be responsible for the hemorrhage. The maxillary artery and its branches are most vulnerable to damage in their course through the pterygopalatine fossa when the' maxillary tuberosity is separated from the pterygoid plates with an osteotome? or during the downfracture procedure. Vascular abnormalities, including those involving the maxillary artery, also can exist in patients with craniofacial malformations and could increase the susceptibility to vascular damage and hemorrhagic complications.v" The posterior superior alveolar artery and the descending palatine artery may be severed during Le Fort I osteotomies because they lie in the posterolateral wall of the maxilla and the perpendicular portion of the palatine bones, respectively. Severing the posterior superior alveolar artery usually does not result in marked hemorrhage unless it is a large-diameter vessel. The descending palatine artery is usually a more important source of bleeding. Care should be taken not to damage this vessel with an osteotome when separating the lateral wall of the nose posteriorly and the posterior wall of the maxilla medially. The descending palatine artery is the most vulnerable source of bleeding during the pterygomaxillary dysjunction and downfracture due

Major hemorrhage associated with Le Fort I osteotomies is an infrequent complication in relation to the great number of these operations performed. 1 Intraoperative or postoperative bleeding can be venous and/or arterial in nature. The pterygoid plexus is the most likely source for significant venous bleeding, although marked venous or arterial bleeding could arise from tears in the pterygoid muscles. Arterial hemorrhage tends to be more persistent and may be recurrent postoperatively, which makes it more difficult to manage. The vessels most commonly involved are the terminal branches of the maxillary artery, especially the descending palatine or sphenopalatine arteries, 1,2 although the maxillary

* Associate Professor and Head , Division of Oral and Maxillofacial Surgery, University of Saskatchewan. t Formerly , Clinical Fellow, Division of Oral and Maxillofacial Surgery , University of Saskatchewan. Director, Northwest Center for Corrective Jaw Surgery, Seattle , WA. Address correspondence and reprint requests to Dr Lanigan: College of Dentistry , University of Saskatchewan, Saskatoon, Saskatchewan, S7N OWO, Canada.

*

© 1990 American Association of Oral and Maxillofacial Surgeons 0278-2391/90/4806-0006$3.00/0

561

562 to its location in the posteromedial wall of the maxillary sinus. Even after the maxilla has been successfully downfractured, this vessel can still be injured if the maxilla is advanced to a significant degree, if the maxilla is intruded posteriorly, and particularly if the maxilla is retruded. This artery can also be injured if transverse maxillary changes are accomplished via a horseshoe-shaped palatal osteotomy. If hemorrhage from this vessel is encountered intraoperatively, it should be identified and clipped if possible to try to control the bleeding and prevent postoperative hemorrhage. Even if the descending palatine arteries were not severed initially, they should be checked just before fixing the maxilla into its new position to make sure that they are still intact, with no small tears. This vessel can usually be directly visualized at the time of surgery with the maxilla downfractured unless the proximal segment of the cut vessel retracts high superiorly. If the proximal end of the vessel cannot be located to clip or cauterize it, then the pterygomaxillary region should be packed with a resorbable topical hemostatic agent. Bleeding from the descending palatine arteries can be more of a, problem if only posterior maxillary surgery or a total maxillary alveolar procedure is performed, due to a lack of visualization. Intraoperative hemorrhage in these circumstances is usually successfully controlled by packing. The splitting of the maxillary tuberosity from the pterygoid plates should be the last procedure prior to downfracturing so that if bleeding is encountered the maxilla can immediately be downfractured to try to visualize the source of the hemorrhage. Turvey and Fonseca' have shown that if a pterygomaxillary osteotome is positioned correctly the margin of safety for damaging the maxillary artery with the superior edge of the osteotome is approximately 10 mm in the adult patient. Robinson and Hendy,6 however, reported fractures of the pterygoid plates and a subsequent disruption of the pterygopalatine fossa when a curved chisel was used to achieve the pterygo maxillary dysfunction. This disruption in the pterygopalatine fossa could result in damage to the maxillary artery and its branches. Hiranuma et al? have shown that it is safer to use a swan's-neck osteotome than a curved Obwegeser osteotome when achieving the pterygomaxillary dysjunction, as the pattern of principal strain distribution suggests that there is less risk of accidental fracture of the pterygoid process with this osteotome. Trimble et al8 have advocated avoiding the pterygomaxillary fissure and making the posterior osteotomy through the maxillary tuberosity itself, whereas Epker and Fish9 and Precious and Ricard 10 have advocated not using an osteotome to achieve the pterygomaxillary

HEMORRHAGE-LE FORT I OSTEOTOMIES

dysjunction to minimize the risk of damage to the maxillary artery and its branches. To date, however, there is no experimental evidence to support the conjectures that these are safer procedures. The etiologic basis for major hemorrhage following a Le Fort I osteotomy in patients who have had a previous Le Fort III osteotomy is unclear. Such patients should have, at least in theory, a greater distance between the maxillary artery and the maxillary tuberosity following the initial maxillary advancement at the Le Fort III level. Scar tissue may form postoperatively in the pterygopalatine fossa region, however, which could be disrupted and lead to tears in the maxillary artery or pterygoid venous plexus as the maxilla is advanced later at the Le Fort I level. The patients who require this treatment generally have a major craniofacial malformation and may also have an anomalous blood supply that could account for this problem. In the initial series of 15 cases of postoperative hemorrhage reported by Lanigan and West,l 8 cases of arterial bleeding occurred 7 or more days postoperatively, and 5 of these cases were recurrent in nature. Precious and Clinton!' feel that these secondary hemorrhages may be related to postoperative infections involving Klebsiella species which disrupt the initial thrombus that formed in branches of the maxillary artery that were severed or torn intraoperatively. The overgrowth of Klebsiella is felt to occur as a result of changes in the normal oral flora when patients are treated prophylactically with antibiotics such as penicillin. A more broadspectrum antibiotic such as a cephalosporin may be a better choice for prophylactic coverage before maxillary osteotomies. Case Histories

In 1986 a questionnaire on major vascular complications following orthognathic surgery was sent to oral and maxillofacial surgeons in North America. Of 5,000 questionnaires mailed, approximately 800 replies were received. Thirty-three surgeons reported 39 cases of major postoperative hemorrhage following maxillary surgery, whereas 27 surgeons reported 30 cases of major intraoperative hemorrhage. However, only 21 cases of postoperative hemorrhage, and 18 cases of intraoperative hemorrhage, were sufficiently documented to be included in the study (Tables 1 and 2). The term "major bleeding" is, of course, open to interpretation. Postoperative hemorrhage may have been classified as major more often because it is usually more difficult to deal with than if the same amount of bleeding were encountered intraoperatively when the surgeon has access to the operative site. No infer-

Table 1. Case Agel No. Sex

Major Postoperative Hemorrhage Following Maxililary Surgery Preoperative Diagnosis

Surgery

Time of Hemorrhage

Episodel Type of. Bleeding

7d

SIA

Suspected Vessel

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Blood Transfusions (units)

History and Management

~

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151F VME; apertog-

Le Fort I

nathia

Le Fort I 2 291M Malunited Le Fort I fracture 3 451M VME; mandibular Le Fort I; retrognathia BSRO Le Fort I 4 311M Maxillary retrusion

5

26/F Maxillary retrusion; mandibular prognathism

6

17/F Apertognathia

S/A

SIA

Rt sphenopalatine artery

6

10 d; 12 d

RlV

Lt pterygoid plexus

I

Intermittent over 2 wk

RlV

? Lt pterygoid venous plexus

?

2d 3d 4d

RIV

7d

S/A

Le Fort I; BSRO

5d

Le Fort I

8 281M Maxillary trans-

Le Fort I

2 4

SIA

Lt hemi-Le Fort I with RPE

?

4

Rt sphenopalatine artery Descending palatine artery

5d

7 301M Maxillary transverse constriction

verse constriction

6h

Lt descending palatine artery

?

I

6

Infiltration of Lt greater palatine area with 3 mL of 2% lidocaine with I: 100,000 epinephrine in combination with pressure-arrested hemorrhage Maxilla redownfractured and Surgicel packed in pterygomaxillary region Rt anterior-posterior nasal packs for 4 d

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The descending palatine artery had been coagulated intraoperatively Maxillary was redownfractured; the descending palatine artery was hemoclipped and Surgicel packed in the pterygomaxillary region Patient did not respond to anterior-posterior nasal packing Selective embolization of Rt sphenopalatine artery with Gelfoam pledgets Intermittent bleeding from Lt side of nose and mouth Twelve d postoperatively developed profuse nasal bleeding and rebled several times that day In OR the Lt pterygomaxillary region was packed with pressure packs of Gelfoam and Surgicel Constant dripping started from the Lt nostril 2 wk postop Did not respond to nasal packing Through a Lt Caldwell-Luc opening the Lt pterygomaxillary junction was packed with Avitene and the sinus with iodoform gauze (I wk) Intermittent oozing for 3 d Nasal packings, then cauterization ENT consultant noted bleeding from middle turbinate area; felt it might be secondary to a traumatic intubation Nasal packings, (5 times) then cauteriza-

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Table 1.

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Major Postoperative Hemorrhage Following Maxililary Surgery (Cont'd)

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Case Age/ No . Sex 9

Preoperative Diagnosis

161M Cleft lip and palate; maxillary retrusion

Surgery Le Fort I; bilateral

Time of Hemorrhage

Ep isode / Type of Bleeding

Suspected Vessel

IS d

RiA

A terminal branch of Lt maxillary artery

II d 12 d I3d 7d IOd

RiA

Descending palatine or sphenopalatine artery Rt maxillary artery

tubinateectomies

10 23/F VME

11

Le Fort 1

23/F VME; mandibular Le Fort I; retrognathia BSRO

RiA

Le Fort 1

2h

RiA

Terminal branch of Lt maxillary artery

13* 18/F VME; mandibular Le Fort I retrognathia

6d 7d 8d

RiA

Terminal branch of Rt maxillary artery

12 32/F VME

14* 161M VME; mand ibular Le Fort I; retrognathia

IS

171M Apertognathia

BSRO ; genioplasty

Le Fort I

Le Fort I; 16* 23/M Apertognathia; maxillary retruBSRO sion; rnandibular progn athi sm

9d I3d

3d 7d 14 d IOd

RiA

RiA

RiA

Lt descending palat ine artery

Major branch of Rt maxillary artery Lt maxillary artery or a major branch

Blood Transfusions (unit s)

History and Management

2

Lt anterior nasal pack initially resulted in good control of epistaxis 2 h later patient rebled briskly through the packing; a Ruter Epistaxis Catheter with anterior and posterior nasal balloons controlled the hemorrhage 5 Maxilla redown fractured in OR; arterial bleeder clipped caiterized Posterior nasal pack for I wk 7 No major bleeding intraoperatively Descending palatine arteries clipped intraoperatively 7th postop day marked Rt epistaxis ; anterior/posterior nasal packing for 3 d; rebled when removed so packs replaced for 2 more d 4 Heavy, persistent bleeding from Lt nostril was not controlled with nasal packing Lt maxillary sinus was packed for 10 d with iodoform-petroleum jelly gauze 8 d postop received Initial bleeding stopped with Rt anteriorposterior nasal balloons 3 U RBC, 4 U FFP,4 U platelets Maxilla redownfractured 8th postop day ; bleeding site in right pterygomaxillary region was cauterized, Surgicel was placed over the area, and an iodoform gauze pack was placed 7 U RBC, 3 U FFP 3 anterior-posterior nasal packs placed over a 4-d perio d ; 13th postoperative prior to 2nd operaday take to OR; Lt de scending palation ; 5 U RBC, 2 U FFP intraopera- tine artery was clipped, Surgicel was placed over the vessel, and the Lt antively; 4 U RBC, trum was packed with iodoform gauze I U FFP postoperatively Anterior-po sterior nasal packing used for 12 initial 2 episodes ; third episode ligation of Rt external carotid artery Anterior-posterior nasal packs failed to 18 U RBC, 12 U FFP, 16 U platecontrol the bleeding Maxilla was redownfractured , resulting lets in profuse hemorrhage from Ll prery-

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17* 181M Maxillary retru-

Le Fort I

sion

Intraoperatively; Id

RIA

Rt maxillary artery

4

6

18

181M Maxillary retru-

Le Fort I

5wk

RIA

?

3

sion

19

171M Apert's syndrome Le Fort I (previous Le Fort

RIA

Maxillary artery or a major branch

20

6d 7d

RIA

6

14 d 26 d

RIA

Major branch of Rt maxillary artery (? sphenopalatine) Lt sphenopalatine artery

Intraoperatively;

18 h

III)

20* 23/F Apertognathia,

Le Fort I; BVRD; genioplasty Le Fort I; 201M Maxillary retruBVRD; sion; mandibugeniolar prognathism plasty bimaxillary protrusion

21

31 d

2

2

gomaxillary region; packing unsuccessful and severed vessel was unable to be clamped; Lt external carotid artery ligated and Lt maxillary sinus was packed with gauze Massive bleeding from Rt pterygomaxillary region intraoperatively controlled by packing Major hemorrhage I d postop; failed to respond to packing; the Rt external carotid and its major branches were ligated Bleeding started during exertion at work Bilateral anterior-posterior nasal packs did not control the bleeding; 3 d later he underwent bilateral external carotid artery ligation Massive intraoperative hemorrhage ultimately controlled by packing Postoperative hemorrhage did not respond to nasal packing or unilateral carotid artery ligation; bilateral external carotid artery ligation controlled the bleeding Initially managed with anterior nasal packing followed by a Nasal Stat tube Selective embolization of Rt maxillary artery and its terminal branches Episode I: Lt anterior nasal pack Episode 2: Lt anterior-posterior nasal pack Episode 3: Lt anterior-posterior na sal pack and immediate selective embolization of Lt sphenopalatine artery

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Abbreviations: VME, vertical maxillary excess; BSRD, bilateral sagittal ramus osteotomies; S, single; R, recurrent; A, arterial; V, venous; Lt,left; Rt, right; DR, operating room; RPE, rapid palatal expansion; FFP, fresh-frozen plasma; BVRD, bilateral vertical oblique ramus osteotomies, U, units; RBe, red blood cells.

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Table 2.

Major Intraoperative Hemorrhage During Maxillary Surgery Suspected Vessel

EBL transfusions

V

-

?

Le Fort I; BSRO

V

-

6U

Le Fort I; BSRO Le Fort I; genioplasty

V

-

5U

191M

VME; mandibular retrognathia VME

V

-

5,000 mL; 6U

5

26/F

VME

Le Fort 1

V

Pterygoid plexus

2U

6

19/F

VME

Le Fort 1

V

Aberrant pterygoid plexus

4U

7

24/F

Maxillary retrusion

Le Fort 1

V;A

Lt pterygoid plexus; Rt descending palatine artery

2,400 mL; 4U

Pterygoid muscle; descending palatine artery Rt pterygoid plexus; major branch of Lt maxillary artery

5U

Age/Sex

Preoperative Diagnosis

32/F

Facial asymmetry

Le Fort 1

2

34/F

VME; mandibular retrognathia

3

221M

4

Case No.

Surgery

Type of Bleeding

8

221M

VME; mandibular retrognathia

Le Fort; BSRO; genioplasty

V;A

9

211M

Lt cleft lip and palate deformity; maxillary retrusion

Le Fort 1

V;A

10

20/F

VME

Le Fort 1

V;A

Lt pterygoid plexus; major branch of Lt maxillary artery

8U

8U

History and Management Previously undiagnosed von Willebrand's disease Controlled by cryoprecipitate Persistent generalized oozing throughout surgery Coagulation screen negative Possible aspirin ingestion preop in cold medication Continuous oozing throughout surgery Excessive aspirin ingestion preop Generalized oozing from the time of the initial incision until completion of the surgery Coagulation screen negative Bleeding stopped with pressure pack in pterygomaxillary region Hemorrhage following pterygomaxillary dysjunction Vascular clips placed on bleeding vessels Bleeding started immediately after difficult downfracture Rt descending palatine artery was clipped and Lt pterygoid plexus hemorrhage responded to a pressure pack Hemorrhage following downfracture Descending palatine artery was clipped and pressure pack in pterygomaxillary region Marked bleeding from Lt pterygomaxillary region following downfracture Bleeding not controlled after I h of packing, cautery and hemoclips Lt external carotid artery was ligated which reduced hemorrhage to manageable proportions Clamping, cauterization, and pressure packs used to try to control persistent bleeding from Lt pterygomaxillary region Nasal balloon finally stopped hemorrhage

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II

18/F

VME

Le Fort I

A

12

50/F

Apertognathia

Total maxillary alveolar osteotomy

A

13

30/F

VME

Le Fort I

A

Rt descending palatine Rt descending palatine

2U

Rt and Lt descending palatine arteries

1,500 mL; 3U

1,600 mL; 2U

Le Fort I

A

Sphenopalatine

3U

201M

Posttraumatic maxillary retrusion Apertognathia

Le Fort I

A

Rt maxillary artery

2U

16

16/F

VME

Le Fort I

A

Maxillary artery

17

141M

VME; apertognathia

Le Fort I

A

Rt maxillary artery

18

161M

Crouzon's disease

Le Fort I (Le Fort III 8 yr previously)

V;A

Pterygoid venous plexus; maxillary artery

14

261M

15

Hemoclip placed on Rt descending palatine artery Major bleeding noted during mobilization of Rt posterior segment Hemoclip placed with difficulty on Rt descending palatine vessel Major bleeding following maxillary downfracture Descending palatine arteries clipped and coagulated Bleeding eventually controlled with anterior-posterior nasal packing

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Severe hemorrhage noted at downfracture Bleeding would slow with pressure packing but would restart once pack was removed; vessel unable to be located to clip Surgery terminated and Avitene (Alcon, Fort Worth, TX) and Oxycel (Becton and Dickinson Co, Rochelle Park, NJ) were packed in the Rt pterygomaxillary region 1,500-2,000 Vessel severed during osteotomy cuts; sinus mL;3 U packed initially; following downfracture the vessel was identified and hemoclip placed 2,000 mL; Extensive bleeding from the Rt 4U pterygomaxillary region following the downfracture. This area was packed and the maxilla was repositioned, which slowed the bleeding. The pack was replaced with Surgicel and the surgery was aborted 7 U intraMarked hemorrhage from pterygomaxillary operaregions bilaterally at downfracture tively; 3 ? if scar tissue from previous surgery had U postinvolved pterygoid plexus or maxillary operaarteries tively Although bleeding was controlled intraoperatively by coagulation and pressure packs, the patient had intermittent minor hemorrhages over the next 5 d

Abbreviations: VME, vertical maxillary excess; BSRO, bilateral sagittal ramus osteotomies; V, venous; A, arterial; Lt, left; Rt, right; U, unit.

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568 ences can, or should, be drawn regarding the incidence of this complication from the cases reported to us. We do not feel it is a true reflection of the magnitude of this problem as there were undoubtedly many additional cases that the surgeons involved opted not to report. We would, however, concur with Freihofer's experience that significant postoperative hemorrhage following maxillary osteotomies is a rare complication and occurs in less than 1% of cases. 12 A series of illustrative case histories reported to us from the questionnaire will be presented to demonstrate the difficulties encountered in these situations. Only the best-documented cases are included in Tables 1 and 2. Cases in Table 1 marked with an asterisk are those discussed in the case histories. Case 1 An 18-year-old woman with vertical maxillary excess and mandibular retrognathia was treated with a Le Fort I osteotomy with intrusion. The estimated blood loss at surgery was 850 mL. The patient had a postoperative hemorrhage from the right nares 6 days postoperatively. An anterior-posterior nasal balloon was placed which stopped the initial bleeding, but the patient continued to experience minor nasal bleeds four to six times a day, which were always brought under control within 5 minutes. Coagulation screening tests were negative. Eight days postoperatively the patient was transfused with 4 units of fresh-frozen plasma, 3 units of red blood cells (RBC), and 4 units of platelets. The surgical site was reexplored. Upon initial downfracturing there was no active bleeding, but when a normal blood pressure was reestablished major arterial bleeding was noted in the right posterior pterygornaxillary region. No specific vessel capable of ligation could be identified. The area was cauterized, Surgicel (Johnson & Johnson, New Brunswick, NJ) was placed over the area, and iodoform gauze was packed against the bleeding site while the maxilla was still in the downfractured position. The pack was exited through the left nares. There were no further bleeding episodes.

Case 2 A 16-year-old boy with vertical maxillary excess and mandibular retrognathia was treated with a Le Fort I osteotomy with intrusion, bilateral sagittal mandibular ramus osteotomies, and an advancement genioplasty. Nine days postoperatively the patient experienced acute left epistaxis. The patient was immmediately hospitalized. His hematocrit was 26% on admission and he was transfused with 3 units of RBC and I unit of fresh-frozen plasma. Bilateral anterior and posterior nasal packs were placed three times during the next 4 days, and an additional 5 units of RBC and 2 units of fresh-frozen plasma were given. Oozing continued behind the patient's packs as monitored by nasogastric drainage and oral bleeding. On the 13th postoperative day the patient experienced acute oral bleeding. Maxillomandibular fixation was removed in the intensive care unit (ICU), and the patient was taken immediately to the operating room where the maxilla was redownfractured. The left descending palatine artery was noted to be the source of bleeding, and

HEMORRHAGE-LE FORT I OSTEOTOMIES

vascular clips were applied to this vessel. Surgicel was placed over the vessel and the left antrum was packed with iodoform gauze. The patient was transfused with 5 units of packed RBC and 2 units of fresh-frozen plasma at this time, and an additional 4 units of packed RBC and I of fresh-frozen plasma were given over the next 10 days. The patient had no further episodes of bleeding.

Case 3 A 23-year-old man with maxillary retrusion, mandibular prognathism, and apertognathia was treated with a Le Fort I osteotomy with advancement and posterior intrusion, and bilateral sagittal mandibular ramus osteotomies with setback. The patient lost approximately 1,000 mL of blood at operation and was transfused with I unit of autologous whole blood. On the 10th day postoperatively at 10 PM the patient experienced left epistaxis and bleeding into the pharynx. He was taken to the nearest hospital, where maxillomandibular fixation was released. The hemorrhage initially ceased spontaneously for I Vz hours but recommenced at midnight with a profuse left-sided anterior and posterior nasal hemorrhage. The patient was returned to the operating room. Anterior and posterior nasal packs were placed, but this failed to control the bleeding. The maxilla was then redownfractured resulting in profuse arterial hemorrhage from the left posterior sinus region. A large pressure pack provided temporary hemostasis. When it was removed after 20 minutes the bleeding recommenced from a large artery posteriorly in the left pterygomaxillary region. It was not possible to clamp the vessel. The region was packed again for 30 minutes. The hemorrhage began again when the pack was removed, and the source could not be located. The left external carotid artery was ligated in the neck, and the left maxillary sinus was packed with gauze which arrested the hemorrhage. The patient was transferred to the ICU. The nasal packs were removed on the second postoperative day. On the fourth postoperative day the patient was returned to the operating room where the maxilla and mandible were placed back into maxillomandibular fixation. On the 10th postoperative day the pack was removed from the left maxillary sinus in the operating room with the patient under intravenous sedation; there was no recurrence of any hemorrhage. The rest of the postoperative course was uneventful. During this hospitalization the patient was transfused a total of 10 units of whole blood, 8 units of packed RBC, 16units of platelets, and 12 units of fresh-frozen plasma.

Case 4 An 18-year-old man with mild maxillary retrusion and transverse constriction was treated with a Le Fort I osteotomy with advancement and transverse expansion. No significant hemorrhage was noted intraoperatively until following the transverse expansion via a midpalatal split, when brisk bleeding was noted from the right pterYgomaxillary region. This area was packed, leading to moderate control of the hemorrhage. When the pack was removed extremely heavy arterial bleeding was noted, probably from the right maxillary artery. The right pterygomaxillary region was packed with iodoform gauze, the patient was tranfused with 4 units of blood, and the remainder of the surgery was completed. The patient was then transferred to the ICU with his endotracheal tube in place. As the patient was hemodynamically stable, his

LANIGAN, HEY, AND WEST

packing was removed 12hours postoperatively. Six hours later the patient bled about 200 mL from his nose after coughing caused by the endotracheal tube. Three hours later the patient again coughed and experienced massive bleeding from his nose and all along his oral circurnvestibular incision. He was taken immediately to the operating room where the maxilla was redownfractured. Massive bleeding was again noted from the right pterygomaxillary region. No specific bleeding vessel could be isolated, and the bleeding could not be controlled by pressure packing and traction. The patient received an additional 6 units of blood as well as fresh-frozen plasma. When the hemorrhage could not be arrested after 2 hours it was decided to ligate the right external carotid artery and its branches, the superior thyroid, lingual, facial, posterior auricular, and superficial temporal arteries. The bleeding eventually slowed significantly following the ligations. The right pterygomaxillary space was again packed with iodoform gauze exited through the nose. The maxilla was refixed with intraosseous and suspension wires, but the patient was left out of maxillomandibular fixation. The patient was returned to the ICU for observation. The patient was kept in the hospital for a total of two weeks. No further bleeding occurred.

Case 5 A 23-year-old woman with a class III bimaxillary protrusion and apertognathia was treated with Le Fort I osteotomy in multiple segments, bilateral intraoral vertical oblique mandibular ramus osteotomies, and an advancement genioplasty. The patient lost approximately 1,500 mL of blood during the surgery and was given 2 units of autologous blood. At 7 AM on the sixth postoperative day the patient awoke experiencing some bleeding from the right nostril, which stopped easily with pressure. At 5 PM the bleeding resumed. In a hospital emergency department, an ear, nose, and throat (ENT) consultant noted two areas of ulceration of the nasal mucosa on the right side which he felt were secondary to irritation from the nasoendotracheal tube. An anterior nasal pack was placed, which appeared to arrest the bleeding. The patient was admitted to the hospital. Her hemoglobin level was 10.2 g/dL and hematocrit was 33%. At 3:45 AM the following morning the patient began to bleed profusely from the right nose. A new, tighter anterior nasal pack was placed which again appeared to arrest the bleeding. Numerous large clots were suctioned from the nose, mouth, and pharynx. A repeated hemoglobin level was 8.9 g/dL, with a hematocrit of24%. The patient was transfused with 2 units of packed RBC. At 6:45 AM the patient started to bleed again. A commercially available tube that can provide anterior and posterior nasal packing was placed on the right side, with one balloon occluding the nasopharynx and the other applying pressure on the walls of the nose. The balloons were inflated under pressure with water. At 8:15 AM the patient began to bleed around the tube and the bleeding was stopped by adding more water to the balloons. The ENT consultant felt that this tube would have to be left in place for the next 5 to 7 days if it was to be effective. As the tube was very uncomfortable, this was considered an unacceptable option, especially as it was uncertain whether the tube had the bleeding under control. It was decided to transfer the patient to a hospital with a neuroradiologist trained in angiography and selective embolization. At 4:30 PM the patient was transferred

569 after she received 4 more units of packed RBC. The patient continued to have slow oozing from the right nose. Digital subtraction angiography was performed and a catheter was introduced into the right maxillary artery and directed to the site of the bleeding. The bleeding site was embolized with pellets of Gelfoam (Upjohn, Don Mills, Ontario, Canada) until the dye could no longer be seen leaking from the bleeding site on fluoroscopy. Five minutes later the tube was removed and no bleeding was observed from the right nasal airway. The tube was replaced with an anterior nasal pack. The next day the nasal pack was removed with no evidence of any oozing. Two days later the patient was placed back into maxillomandibular fixation, and the rest of her postoperative course was uneventful.

Discussion Major intraoperative hemorrhage can be due to a mechanical disruption of blood vessels or due to a. problem of hemostasis from inadequate platelet function or a coagulopathy (see Table 2). A generalized oozing throughout the operation is suggestive of problems with platelet function, especially if the patient has ingested aspirin recently. Patients should be advised preoperatively not to take aspirin, aspirin-containing cold medicines, etc, within the 2 weeks before their operation. Intraoperative venous hemorrhage can usually be managed by pressure packing, whereas arterial bleeding can usually be controlled by clamping the vessel and using electrocoagulation or hemoclips. At times, however, the bleeding vessel cannot be identified and clamped due to the sheer volume of blood, or because the vessel retracts to an inaccessible location. This bleeding may be controlled with pressure packing and topical hemostatic agents. On occasion, the surgeon may be forced to resort to additional treatment modalities such as anterior and posterior nasal packing, packing of the maxillary sinus, or ligation of the external carotid artery. Bleeding after Le Fort I osteotomies primarily takes the form of epistaxis, which can be anterior and/or posterior in nature. Patients should be advised of the possibility of postoperative hemorrhage before discharge from the hospital, and those who have been placed into maxillomandibular fixation should be instructed in the use of wire cutters. Rapid release of maxillomandibular fixation allows for clearing of intraoral, nasal, and pharyngeal clots which may be essential to maintain a patent airway and avoid aspiration. Patients should be cautioned to avoid heavy physical activity, either through work or exercise, for the first month postoperatively. The only case in our series in which the initial hemorrhage occurred longer than 2 weeks postoperatively was related to heavy exertion 5 weeks after surgery (case 18). Patients should also avoid raising their blood pressure via a Valsalva maneuver such as straining while passing a stool. Stool

570 softeners should be used for orthognathic surgery patients who are constipated either from the lowfiber blended diet or from the narcotics prescribed for postoperative analgesia. The initial postoperative hemorrhage usually ceases spontaneously, allowing the patient to be transported to the hospital for definitive treatment. If maxillomandibular fixation has not been released by the time the patient is seen in the emergency department, it should be done immediately if arterial bleeding is suspected. If brisk active hemorrhage is occurring when the patient is first seen, large Foley catheters should be place bilaterally to serve as temporary posterior nasal packs. Commercial catheters are also available with balloons that can be blown up to provide anterior and posterior nasal packs. It may be advisable to consult an ENT surgeon at this stage to help in the placement of ideal nasal packs and to help in the patient's subsequent management. A tracheostomy should be considered if the airway is felt to be in jeopardy at any stage during the patient's subsequent treatment. The patient's general status should be quickly assessed, vital signs monitored, and intravenous fluids started as appropriate. Blood should be sent for a complete blood count, and for typing and crossmatch. Coagulation studies should be done if a coagulopathy is felt to be of possible etiologic significance. In the cases reported to us, however, the coagulation studies have generally been normal as the bleeding is usually secondary to a mechanical disruption of the blood vessels rather than a defect of coagulation. The nasal area should then be examined with a good light source, preferably a fiberoptic headlight. The nose should be gently suetioned with a Frazier suction tip, as this will often reveal the bleeding site and give an indication as to whether the bleeding is arterial or venous. After the initial assessment, a decision should be made as to the further management of the patient. If the bleeding is minor, it may be sufficient simply to place the patient on bedrest, mild sedation, and observation. If the bleeding fails to stop, or is recurrent in nature, it will require more definitive therapy. More vigorous bleeding will require at least anterior and usually also posterior nasal packing for 3 to 5 days. Venous hemorrhage and even arterial hemorrhage will often respond to this regimen. Patients with nasal packing are placed on bedrest and usually require supplemental oxygen by rnask'P due to possible systemic problems such as hypoxia or hypercapnea. Nasal packing can also lead to local problems, such as nasal septal mucosal excoriation, necrosis, or infection. 14 If the bleeding does not respond to anterior and posterior nasal packing, consideration could be

HEMORRHAGE-LE FORT I OSTEOTOMIES

given first to reexploration of the operative site or to angiography and subsequent embolization. If the postoperative hemorrhage occurs early in the postoperative phase it may be most appropriate to reexplore the surgical site. Angiography and embolization may be preferable to reoperation even at this stage, however, if there is likely to be gross distortion and displacement of tissues secondary to postoperative edema and hematoma formation, or if there are problems with a hemorrhagic diathesis following repeated blood transfusions. 14 If the bleeding occurs later in the postoperative course, especially if recurrent in nature or if bone grafting and rigid internal fixation have been used and reoperation would disrupt the healing process, angiography and subsequent embolization may be the best choice. In some cases this may mean that the patient has to be transferred to a center with an experienced neuroradiologist trained in this technique. If the patient is actively bleeding, angiography not only helps to locate the site of hemorrhage, but also can determine if the contralateral arterial tree is contributing to the problem. Angiograms will also rule out whether a ruptured pseudoaneurysm of the maxillary artery or one of its terminal branches, especially the sphenopalatine artery, could be the cause of the problem.v" At reoperation, depending on the findings on angiography or on surgical exploration, vascular clips may be applied to suspected vessels or they can be electrocoagulated. Even with the maxilla downfractured, however, it can be extremely difficult in this relatively inaccessible area to find all the branches of the maxillary artery or its collaterals that could perpetuate postoperative bleeding.v'" Due to the sheer volume of bleeding, it may be difficult to gain an unimpaired view of the area to ascertain the specific vessel responsible for the hemorrhage. If one opts to try to ligate the terminal branches of the maxillary artery, the relationship of one vessel to another can become confused. A branch can easily be overlooked or, if an abnormal bifurcation occurs, such as an early division of the sphenopalatine artery, an important vessel may not be ligated. 16 , 17 Arterial ligation can therefore occasionally fail even when the suspected vessels have presumably been well identified and adequately ligated.!" If one is unable to isolate and clip the specific source of hemorrhage, especially ifit is from the pterygornaxillary region, then this area can be packed with a topical resorbable hemostatic agent such as Surgicel or a collagen sponge such as Instat (Johnson & Johnson, New Brunswick, NJ) or Helistat (Marion Laboratories, Kansas City, MO). It may be useful, on occasion, to place Tissel (lmmuno Canada, Toronto, Ontario, Canada), a fibrin sealant, on the collagen

LANIGAN, HEY, AND WEST

sponge. Packing of the maxillary antrum has also occasionally been used to control extensive and persistent bleeding from the posterior antral walls following maxillary osteotomies. I A ribbon gauze pack impregnated with Whitehead's varnish or 5% iodoform in petroleum jelly can be left in place for 7 to 10 days and then removed. A transantral approach has been used for the control of epistaxis,17-19 and identification of the maxillary artery and its terminal branches, the posterior nasal, sphenopalatine, and descending palatine arteries, is usually possible through this approach. These three branches of the maxillary artery must be isolated and arterial clips placed if direct, retrograde, and anastomotic flow to the nose is to be minimized. Anastomoses occur, however, between branches of the external and internal carotid arteries that can perpetuate nasal bleeding despiteligation of the maxillary artery. 17 Although transantral ligation of the maxillary artery and its branches appears to be a useful treatment for epistaxis, it is an impractical approach for cases of bleeding following maxillary osteotomies because it is difficult to locate the maxillary artery and its branches due to a blood-filled antrum and altered anatomy. I Complications reported from transantral ligation of the maxillary artery include blindness and ophthalmoplegia.P:" The pterygopalatine fossa is filled with loose fibroadipose tissue and there is free communication between this space and the orbit via the infraorbital groove and foramen. Above the inferior orbital fissure is the superior orbital fissure, and the optic foramen is even further superior and medial. Postoperative edema following transantral ligation can transmit pressure to the superior orbital fissure via the inferior orbital fissure, leading to the superior orbital fissure syndrome and ophthalmoplegia." Blindness with total ophthalmoplegia occurs as a result of the orbital apex syndrome where both the superior orbital fissure and the optic canal contents are affected, the former from edema and the latter by expanding hematoma." Angiography with embolization of the distal branches of the maxillary artery has proved a useful technique in the management of hemorrhage following maxillofacial trauma and orthognathic surgery.2,14,15.22 Hemmig et af reported a case of hemorrhage from a ruptured pseudoaneurysm of the sphenopalatine artery following a Le Fort I osteotomy that was successfully embolized with a 3-mm Gianturco coil (Cook, Bloomington, IN). Solomons and Blumgart15 reported a case of severe late-onset epistaxis following a Le Fort I osteotomy secondary to a false aneurysm of the maxillary artery that was successfully embolized with a large Gelform pledget followed by a 3-mm Gianturco coil. Angiog-

571

raphy is therefore very helpful in delineating abnormal anatomy such as anomalous vessels, false aneurysms, or arteriovenous malformations, as well as the development of collateral blood flow to the nasal area from other sources. This information is unlikely to be ascertained by surgical reexploration alone. Angiography is useful in localizing the site of hemorrhage only when the patient is actively bleeding, but embolization can be carried out even when hemorrhage is not occuring. If the bleeding point is visualized angiographically, selective occlusion of the supplying vessel may be all that is required, but when the actual bleeding site is not visible more extensive embolization is necessary.23 A catheter is passed under fluoroscopic control from the femoral artery to the arotic arch, into the common carotid, into the external carotid, and then selectively into the maxillary artery and the superficial temporal arteries. Serial angiograms are then obtained. Tadwalkar et al 24 reported that angiography is useful in demonstrating the extravasation of blood during epistaxis if the patient is bleeding at a rate of more than 0.5 mLlmin. This rate is based on the work of Nusbaum and Baurrr" with regard to gastrointestinal bleeding sites. Rosnagle et al 16 described three patients who bled during arteriography, but who showed no radiographic evidence of the site of active hemorrhage. These patients were felt to be bleeding at a rate insufficient to stain during the injection, so patients may have to be actively bleeding at a rate considerably greater than 0.5 mLlmin to demonstrate a bleeding point in epistaxis. The authors also speculated that the dye could have been shunted into collateral vesels and thereby did not reach the bleeding points in sufficient concentration. The inability to localize bleeding points also occurs whenever the opacification does not exceed the lower limits of contrast resolution of the applied imaging system. Schilstra and Marsman!" suggest that digital subtraction angiography may be able to detect more minor bleeding because it outperforms conventional film techniques for low-contrast objects and thus allows smaller amounts of extravasated contrast medium to be detected. Its instant subtraction facility also eliminates the difficulties in localizing a bleeding point due to superimposition of the facial bones. The efficiency of the imaging of digital subtraction angiography as compared with conventional angiography also results in a shortened examination time and a faster assessment of anatomoses, reflux, and the effect of injected emboli. 14 Embolization is done with small pieces of Gelfoam which are gently delivered through the cathe-

572 ter into the maxillary artery and its terminal branches. If active bleeding is occurring during embolization there will be preferential flow of the Gelfoam emboli to the traumatized area due to the faster decline in blood pressure at the bleeding site. Particles of small size are used to allow them to exert their effect as distally as possible so that persistent hemorrhage from collateral channels that open up following embolization is less likely. The procedure is considered complete when blockage of flow into the distal branches of the maxillary artery is noted on fluoroscopic examination. If bleeding continues after all the branches of the maxillary artery have been occluded by embolization, then perpetuation of the bleeding from potential collateral pathways from the facial and ethmoid arteries, or anastomoses from branches of the maxillary artery from the other side, should be suspected. 14 The major precaution with this technique is to prevent reflux of emboli down the external carotid artery since entry of emboli into the internal carotid artery system could lead to cerebral embolization and stroke. Other side effects of embolization procedures in the facial region are transient local numbness, facial pain, fever, and edema. 14 •23 Two cases of bilateral facial nerve paralysis of several months' duration following arterial embolization for epistaxis have been reported.i" Lanigan et al 27 reported a case in which embolization to control postoperative hemorrhage following a maxillary osteotomy contributed to the development of aseptic necrosis of the maxilla. Kingsley and O'Connor'? felt that local complications were more likely to develop when more extensive embolization was performed due to tortuosity of the external carotid artery vessels, which makes supra-selective catheterization impossible. Ligation of the external carotid artery has also been used successfully to control postoperative hemorrhage following Le Fort I osteotomies. 1 If unilateral ligation is unsuccessful in arresting bleeding the procedure can be done bilaterally. The use of this procedure for the control of epistaxis has been criticized'" because ligation of the maxillary artery is more in keeping with the surgical principle of controlling the source of hemorrhage as close to the bleeding point as possible, Collateral arterial supply to the maxillary artery distal to the point of external carotid artery ligation, or across the midline, can allow bleeding to continue even after the ligation procedure. If ligation of the external carotid artery fails to control the hemorrhage it will probably be impossible to perform subsequent angiography and embolization unless the external carotid artery can be directly punctured to introduce a catheter distal to the ligation point.

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Rosenberg et al 29 investigated the effect of ligation of the external carotid artery and its major branches on blood flow from the maxillary artery in baboons. They found that ligation of the external carotid artery close to the carotid bifurcation, both below and above the origin of the lingual and facial arteries, reduced maxillary artery blood flow by only 40% and 73%, respectively. Collateral blood supply still had the potential to maintain a rate of blood flow in the maxillary artery large enough to perpetuate postoperative hemorrhage. Ligation of the external carotid artery above the origin of the lingual and facial arteries, combined with ligation of the posterior auricular-occipital arterial trunk, reduced maxillary artery blood flow by 99.2%. They therefore felt that maxillary artery hemorrhage in humans might be most effectively controlled by ligation of the external carotid artery in the retromandibular fossa distal to the origin of the posterior auricular artery, in conjunction with ligation of the superficial temporal artery at the root of the zygoma proximal to the origin of the transverse facial artery. This study also pointed out, however, the significant contribution that retrograde blood flow from a severed distal segment of the maxillary artery could make to a postoperative hemorrhage. Retrograde blood flow from the sectioned distal segment is approximately 25% of that from the proximal segment, so that blood loss from the severed distal portion of the maxillary artery could still be a significant clinical problem. Hopefully, this could be dealt with by pressure packing. Lownie et al30 reported a case in which the ligation technique suggested by Rosenberg et al 29 was used successfully to arrest hemorrhage from the maxillary artery after a handgun injury. Summary From examining the cases that were reported to us in our questionnaire on major vascular complications following orthognathic surgery, it can be noted that postoperative hemorrhage continues to be a rare but significant complication following maxillary osteotomies. The vast majority of these patients experienced their first bleeding episode within the first 2 weeks following surgery, but in one case the first hemorrhage did not Occur until 5 weeks postoperatively. Most of the cases were recurrent in nature, and they often did not respond to the first treatment used. Successful treatment modalities used to arrest the hemorrhages included anterior and posterior nasal packing, packing of the maxillary antrum, reoperation with clipping or electrocoagulation of bleeding vessels or the use of topical hemostatic agents in the pterygomaxillary re-

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gion, external carotid artery ligation, selective embolization of the maxillary artery and its terminal branches, or any combination of these. The methods used to arrest hemorrhage, however, could possibly decrease blood supply to the maxilla and contribute to the development of later aseptic necrosis, particularly in cases of multisegmental Le Fort I osteotomies.

12. 13. 14. 15. 16.

Acknowledgment We would like to express our sincere appreciation to the many surgeons who took the time, not only to respond to our initial questionnaire, but also to our subsequent requests for further information.

17.

References

19.

I. Lanigan D, West R: Management of postoperative hemorrhage following the Le Fort I maxillary osteotomy. J Oral Maxillofac Surg 42:367, 1984 2. Hemmig S, Johnson R, Ferraro N: Management of a ruptured pseudoaneurysm of the sphenopalatine artery following a Le Fort I osteotomy. JOral Maxillofac Surg 45:533, 1987 3. Turvey T, Fonseca R: The anatomy of the internal maxillary artery in the pterygopalatine fossa: Its relationship to maxillary surgery. J Oral Surg 38:92, 1980 4. Herring S, Rowlatt U, Pruzansky S: Anatomical abnormalities in mandibulofacial dysostosis. Am J Med Genet 3:225, 1979 5. Reaume C, MacNichol B: Complications encountered during Le Fort I osteotomy in a patient with mandibulofacial dysostosis. J Oral Maxillofac Surg 46:1003, 1988 6. Robinson P, Hendy C: Pterygoid plate fractures caused by the Le Fort I osteotomy. Br J Oral Maxillofac Surg 24:198, 1986 7. Hiranuma Y, Yamamoto Y, Lizuka T: Strain distribution during separation of the pterygomaxillarysuture by osteotomes. J Craniomaxillofac Surg 16:13, 1988 8. Timble LD, Tideman H, Stoelinga P: A modification of the pterygoid plate separation in low-level maxillary osteotomies. J Oral Maxillofac Surg 41:544, 1983 9. Epker B, Fish L: Dentofacial Deformities, Integrated Orthodontic and Surgical Correction, vol I. St Louis, MO, Mosby, 1986, p 308 10. Precious D, Ricard D: Modifications de l'osteotomie de Le Fort I. Rev Stomatol Chir Maxillofac 89:288, 1988 II. Precious D, Clinton R: Role of infection in hemorrhage fol-

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lowing orthognathic surgery. Presented at CAOMS 35th annual convention, April 30, 1988(abstr) Freihofer HP: Latitude and limitation of midface movements. Br J Oral Maxillofac Surg 22:393, 1984 Murakam W, Davidson T, Marshall C: Fatal epistaxis in craniofacial trauma. J Trauma 23:57, 1983 Schilstra S, Marsman J: Embolization for traumatic epistaxis. JCraniomaxillofac Surg 15:28, 1987 Solomons N, Blumgart R: Severe late-onset epistaxis following Le Fort I osteotomy: Angiographic localization and embolizaton. J Largngol Otol 102:260, 1988 Rosnagle R, Allen W, Kier E, et al: Use of selective arteriography in the treatment of epistaxis. Arch Otolaryngol 106:137, 1980 Pearson B, MacKenzie R, Goodman W: The anatomical basis of transantralligation of the maxillary artery in severe epistaxis. Laryngoscope 79:969, 1969 McDonald T, Pearson B: Follow up on maxillary artery ligation for epistaxis. Arch Otolaryngol 106:635, 1980 Montgomery W, Katz R, Gable J: Anatomy and surgery of the pterygomaxillary fossa. Ann Otol Rhinol Laryngol 79:606, 1970 . Johnson L, Parkin J: Blindness and total ophthalmoplegia. A complication of transantralligation of the internal maxillary artery for epistaxis. Arch OtolaryngoII02:501, 1976 Beall J, Scholl P, Jafek B: Total ophthalmoplegia after internal maxillary artery ligation. Arch Otolaryngolll1 :696, 1985 Stein R. Kerber C: Therapeutic arterial embolization for post-traumatic hemorrahge. J Oral Surg 39:439, 1981 Kingsley D, O'Connor A: Embolization in otolaryngology. J Laryngol Otol 96:439, 1982 Tadwalkar V, Santos V, Polisar I: Angiography in the treatment of severe epistaxis. Ear Nose Throat J 64:60, 1985 Nusbaum M, Baum S: Radiographic demonstration of unknown sites of gastrointestinal bleeding. Surg Forum 14:374, 1963 Metson R, Hanson D: Bilateral facial nerve paralysis following arterial embolization for epistaxis. Otolaryngol Head Neck Surg 91:299, 1983 Lanigan D, Hey J, West R: Aseptic necrosis following maxillary osteotomies: Report of 36 cases. J Oral Maxillofac Surg 48:142, 1990 Hunter K, Gibson R: Arterial ligation for severe epistaxis. J Laryngol OtoI83:1099, 1969 Rosenberg I, Austin J, Wright P, et al: The effect of experimentalligation of the external carotid artery and its major branches on hemorrhage from the maxillary artery. Int J Oral Surg 11:251, 1982 Lownie J, Shakenovsky B, Berezowski B, et al: Haemorrhage from the maxillary artery. A case report. South Afr Med J 71:781, 1987