LETTERS TO THE EDITOR J Oral Maxillofac Surg 72:846-847, 2014
NEUROPATHIC PAIN AFTER MANDIBULAR RAMUS SAGITTAL SPLIT OSTEOTOMY
cial attention should be given to those patients most likely at risk of NPP, as noted above. A prompt diagnosis and timely treatment are essential to achieving the maximum therapeutic benefit for the patients with a nerve injury.
To the Editor:—The report by Marchiori et al1 regarding neuropathic pain (NPP) after sagittal split ramus osteotomy of the mandible (SSRO) should serve as a cautionary tale for those surgeons who perform orthognathic surgery. Patients who undergo these elective operations are generally (but not always) ‘ youthful, in good general health, and highly expectant of a result that renders them more facially attractive and functionally improved.’’2 A complication such as NPP that arises after SSRO can be devastating to the uninformed or unprepared patient. Marchiori et al1 reported 7 cases of NPP among 1,671 patients in their study, for an incidence of 0.42%. However, their data might be inaccurate, because theirs was a retrospective study, and all necessary information might not have been recorded contemporaneously and be available for retrospective review in each patient’s record. Additionally, they failed to report how many, if any, other patients had sustained permanent nerve injuries, but had not developed NPP. Other studies, including our own,2,3 have found the incidence of NPP among those patients who sustained peripheral trigeminal nerve injuries after SSRO to be about 5%, a much greater incidence than that reported by Marchiori et al.1 NPP in our patients was found to be associated with either inferior alveolar nerve (IAN) or lingual nerve (LN) injury. The patient most likely to develop NPP as a major chronic complaint after SSRO was the patient in whom the nerve injury repair was delayed for longer than 12 months, who was older than 45 years, and whose procedure involved compression or partial severance of the IAN or complete discontinuity of the LN with a proximal stump neuroma.2 Patients with chronic illnesses that compromise the healing process or place the patient at risk of developing peripheral neuropathy (eg, diabetes mellitus) or with pre-existing chronic pain from any cause (eg, low back pain, post-thoracotomy syndrome) are also known to be at greater risk of developing NPP after an operation. Gregg4 has previously reported on surgical intervention to address pain after peripheral trigeminal nerve injuries. He identified 4 distinct pain subtypes: anesthesia dolorosa (AD), sympatheticmediated pain (SMP), hyperalgesia (HA), and hyperpathia (HP). Surgical repair of the injured nerve produced pain reduction in 60.5% of the patients with HA and 58.3% of those with HP. In contrast, only 20.0% of the SMP patients and 14.6% of the AD patients gained any pain relief. The duration of pain before surgery had ranged from 4 weeks to 12 years (mean 9 months). Early surgical intervention is more likely to be successful for various reasons.5 In conclusion, we would emphasize that preoperative counseling of patients who are undergoing SSRO should include a discussion of the risk of nerve injury and sensory dysfunction (both loss of sensation and chronic pain). Spe-
ROGER A. MEYER, DDS, MS, MD Greensboro, GA SHAHROKH C. BAGHERI, DMD, MD, FICD Marietta, GA
References 1. Marchiori EC, Barber JS, Williams WB, et al: Neuropathic pain following sagittal split ramus osteotomy of the mandible: Prevalence, risk factors, and clinical course. J Oral Maxillofac Surgery 71:2115, 2013 2. Bagheri SC, Meyer RA, Khan HA, et al: Microsurgical repair of the peripheral trigeminal nerve after mandibular sagittal split ramus osteotomy. J Oral Maxillofac Surg 68:2770, 2010 3. Jaaskelainen SK, Teerijoki-Oksa T, Virtanen A, et al: Sensory regeneration following intraoperatively verified trigeminal nerve injury. Neurology 62:1951, 2004 4. Gregg JM: Studies of traumatic neuralgia in the maxillofacial region: Symptom complexes and response to microsurgery. J Oral Maxillofac Surg 48:135, 1990 5. Meyer RA: Studies of traumatic neuralgia in the maxillofacial region: Symptom complexes and response to microsurgery (discussion). J Oral Maxillofac Surg 48:141, 1990
http://dx.doi.org/10.1016/j.joms.2014.01.018
MODIFICATION OF THE LATERAL CRURAL SUSPENSION FLAP To the Editor:—I have recently modified the lateral crural suspension flap (LCSF), as described by Bohluli et al,1 when used to stabilize the nasolabial angle and suspend the nasal tip. In the original description, 2 flaps are prepared on the lateral crural cartilages that start medially at the beginning of the dome, with a 3-mm width, and extend laterally as cephalic trim. Next, these 2 flaps are sutured to the septum and aligned with the lateral surfaces. The lower lateral cartilage has been described as a tripod2 divided into 3 segments: medial, intermediate, and lateral crura. The intermediate crura will overlap the caudal edge of the septum and constitute the domes and rest within the nasal tip.3 Modification of the length of the tripod’s legs and support can affect the nasal shape, structure, appearance and function.2,4
Letters to the Editor must be in reference to a specific article or editorial that has been published by the Journal. Letters must be submitted within 6 weeks of the article’s print publication or, for an online-only article, within 8 weeks of the date it first appeared online. Letters must be submitted electronically via the Elsevier Editorial System at http://ees.elsevier.com/ joms. Letters are subject to editing and those exceeding 500 words may be shortened or not accepted due to length. One photograph may accompany the letter if it is essential to understanding the subject. Letters should not duplicate similar material or material published elsewhere. There is no guarantee that any letter will be published. Prepublication proofs will not be provided. Submitting a Letter to the Editor constitutes the author’s permission for its publication in any issue or edition of the journal, in any form or medium.
846
NEUROPATHIC PAIN AFTER MANDIBULAR RAMUS SAGITTAL SPLIT OSTEOTOMY
cial attention should be given to those patients most likely at risk of NPP, as noted above. A prompt diagnosis and timely treatment are essential to achieving the maximum therapeutic benefit for the patients with a nerve injury.
To the Editor:—The report by Marchiori et al1 regarding neuropathic pain (NPP) after sagittal split ramus osteotomy of the mandible (SSRO) should serve as a cautionary tale for those surgeons who perform orthognathic surgery. Patients who undergo these elective operations are generally (but not always) ‘ youthful, in good general health, and highly expectant of a result that renders them more facially attractive and functionally improved.’’2 A complication such as NPP that arises after SSRO can be devastating to the uninformed or unprepared patient. Marchiori et al1 reported 7 cases of NPP among 1,671 patients in their study, for an incidence of 0.42%. However, their data might be inaccurate, because theirs was a retrospective study, and all necessary information might not have been recorded contemporaneously and be available for retrospective review in each patient’s record. Additionally, they failed to report how many, if any, other patients had sustained permanent nerve injuries, but had not developed NPP. Other studies, including our own,2,3 have found the incidence of NPP among those patients who sustained peripheral trigeminal nerve injuries after SSRO to be about 5%, a much greater incidence than that reported by Marchiori et al.1 NPP in our patients was found to be associated with either inferior alveolar nerve (IAN) or lingual nerve (LN) injury. The patient most likely to develop NPP as a major chronic complaint after SSRO was the patient in whom the nerve injury repair was delayed for longer than 12 months, who was older than 45 years, and whose procedure involved compression or partial severance of the IAN or complete discontinuity of the LN with a proximal stump neuroma.2 Patients with chronic illnesses that compromise the healing process or place the patient at risk of developing peripheral neuropathy (eg, diabetes mellitus) or with pre-existing chronic pain from any cause (eg, low back pain, post-thoracotomy syndrome) are also known to be at greater risk of developing NPP after an operation. Gregg4 has previously reported on surgical intervention to address pain after peripheral trigeminal nerve injuries. He identified 4 distinct pain subtypes: anesthesia dolorosa (AD), sympatheticmediated pain (SMP), hyperalgesia (HA), and hyperpathia (HP). Surgical repair of the injured nerve produced pain reduction in 60.5% of the patients with HA and 58.3% of those with HP. In contrast, only 20.0% of the SMP patients and 14.6% of the AD patients gained any pain relief. The duration of pain before surgery had ranged from 4 weeks to 12 years (mean 9 months). Early surgical intervention is more likely to be successful for various reasons.5 In conclusion, we would emphasize that preoperative counseling of patients who are undergoing SSRO should include a discussion of the risk of nerve injury and sensory dysfunction (both loss of sensation and chronic pain). Spe-
ROGER A. MEYER, DDS, MS, MD Greensboro, GA SHAHROKH C. BAGHERI, DMD, MD, FICD Marietta, GA
References 1. Marchiori EC, Barber JS, Williams WB, et al: Neuropathic pain following sagittal split ramus osteotomy of the mandible: Prevalence, risk factors, and clinical course. J Oral Maxillofac Surgery 71:2115, 2013 2. Bagheri SC, Meyer RA, Khan HA, et al: Microsurgical repair of the peripheral trigeminal nerve after mandibular sagittal split ramus osteotomy. J Oral Maxillofac Surg 68:2770, 2010 3. Jaaskelainen SK, Teerijoki-Oksa T, Virtanen A, et al: Sensory regeneration following intraoperatively verified trigeminal nerve injury. Neurology 62:1951, 2004 4. Gregg JM: Studies of traumatic neuralgia in the maxillofacial region: Symptom complexes and response to microsurgery. J Oral Maxillofac Surg 48:135, 1990 5. Meyer RA: Studies of traumatic neuralgia in the maxillofacial region: Symptom complexes and response to microsurgery (discussion). J Oral Maxillofac Surg 48:141, 1990
http://dx.doi.org/10.1016/j.joms.2014.01.018
MODIFICATION OF THE LATERAL CRURAL SUSPENSION FLAP To the Editor:—I have recently modified the lateral crural suspension flap (LCSF), as described by Bohluli et al,1 when used to stabilize the nasolabial angle and suspend the nasal tip. In the original description, 2 flaps are prepared on the lateral crural cartilages that start medially at the beginning of the dome, with a 3-mm width, and extend laterally as cephalic trim. Next, these 2 flaps are sutured to the septum and aligned with the lateral surfaces. The lower lateral cartilage has been described as a tripod2 divided into 3 segments: medial, intermediate, and lateral crura. The intermediate crura will overlap the caudal edge of the septum and constitute the domes and rest within the nasal tip.3 Modification of the length of the tripod’s legs and support can affect the nasal shape, structure, appearance and function.2,4
Letters to the Editor must be in reference to a specific article or editorial that has been published by the Journal. Letters must be submitted within 6 weeks of the article’s print publication or, for an online-only article, within 8 weeks of the date it first appeared online. Letters must be submitted electronically via the Elsevier Editorial System at http://ees.elsevier.com/ joms. Letters are subject to editing and those exceeding 500 words may be shortened or not accepted due to length. One photograph may accompany the letter if it is essential to understanding the subject. Letters should not duplicate similar material or material published elsewhere. There is no guarantee that any letter will be published. Prepublication proofs will not be provided. Submitting a Letter to the Editor constitutes the author’s permission for its publication in any issue or edition of the journal, in any form or medium.
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