Orthognathic Surgery in

t h e Offi c e S e t t i n g
Brian B. Farrell, DDS, MDa,b,*, Myron R. Tucker, DDSa,b,c,d

KEYWORDS
 Orthognathic surgery  Office-based outpatient surgery  Anesthesia  Recovery

KEY POINTS
 The delivery of surgical care provided by oral and maxillofacial surgeons is constantly challenged
through escalating health care costs and limited reimbursement from insurance plans.
 Outpatient orthognathic surgery has proved to be safe, efficient, and cost-effective.
 Office-based orthognathic surgery is centered on safe anesthetic techniques that enable rapid re-
covery with preemptive analgesia and expedient discharge.
 The delivery of care beyond the dentoalveolar level from the office environment provides autonomy
and efficiency for the surgeon.

HEALTH CARE LANDSCAPE The delivery of surgical services continues to

The delivery of care by an oral and maxillofacial
surgeon is becoming more challenging through
escalating health care costs and limited reimburse-
ment from insurance providers.1 Increased admin-
istrative efforts for individuals with dentofacial
deformities are required to progress from the
consultation establishing a treatment plan to
correction of the skeletal discrepancy in the oper-
ating room. Often the expectant denial returns after
initial preauthorization is submitted even though an
individual meets the objective and functional criteria
established within the policy (Fig. 1). Policies are
typically structured to include only the extremes of
the skeletal deformities and functional impairment
must be justified to overcome the stringent stance
on medical necessity. When successful in navi-
gating through the third-party bureaucracy and
receiving approval, the limited reimbursement for
the time, effort, and risk associated with the proce-
dure is often disappointing. The changing health
care landscape forces a surgical practice to be flex-
evolve as care traditionally performed in a hospital
environment is now achieved routinely in an outpa-
tient setting. Outpatient facilities can aid in control-
ling the perioperative costs associated with
orthognathic surgery. One further step is to
perform orthognathic surgery in an office-based
setting that can further increase the control over
all aspects of the surgical care, including anes-
thesia, fixation, and facility fees. Safe and efficient
orthognathic surgery completed in the office can
aid in controlling the persistent escalation of costs
that are evident with health care.
INSURANCE
Even though orthognathic surgery done to im-
prove function and aesthetics is a valuable service
provided by oral and maxillofacial surgeons, there
has been a significant decline in the volume of
cases performed each year. Orthognathic cases
are now being directed to centers, whether in an
academic or private practice setting, that routinely
oralmaxsurgery.theclinics.com

ible and adaptive to change to remain viable both perform the correction of dentofacial deformities.
professionally and economically. It is common for patients to travel long distances

a
Carolinas Center for Oral and Facial Surgery, 411 Billingsley Road, Suite 105, Charlotte, NC 28211, USA;
b
Department of Oral and Maxillofacial Surgery, Louisiana State University Health Science Center, New
Orleans, LA, USA; c Oral and Maxillofacial Surgery, Charlotte, NC, USA; d Isle of Palms, SC, USA
* Corresponding author. Carolinas Center for Oral and Facial Surgery, 411 Billingsley Road, Suite 105, Char-
lotte, NC 28211.
E-mail address: bfarrell@mycenters.com

Oral Maxillofacial Surg Clin N Am 26 (2014) 611–620

http://dx.doi.org/10.1016/j.coms.2014.08.009
1042-3699/14/$ – see front matter Ó 2014 Elsevier Inc. All rights reserved.
612 Farrell & Tucker

Fig. 1. (A) Typical letter denying approval of a preauthorization request for surgical services through an exclusion
in the policy. (B) The treatment plan calls for a segmental Le Fort and bilateral sagittal ramus osteotomy to
address an asymmetric class III skeletal open-bite malocclusion from maxillary hypoplasia with (C) transverse defi-
ciency, posterior vertical maxillary excess, and mandibular asymmetry.

for surgical management because their local oral
and maxillofacial surgeons have elected to elimi-
nate this from their scope. Participating as an in-
network provider with insurance companies
frequently requires acceptance of limited reim-
bursement, typically lower than one-fourth of es-
tablished fees. The poor rate of return combined
with the loss of productivity from the typical office
practice is the cause for the significant decline in
surgeon participation.2,3 When calculating the
time spent in consultation, work-up, surgical treat-
ment, and follow-up care it is not feasible to
manage orthognathic surgery cases if the reim-
bursement is less than that provided for routine
wisdom tooth removal. The decreasing comfort
level with orthognathic surgical procedures when
only performed sporadically is another reason
for surgeons removing the service from their
repertoires.
Surgeons who actively participate in the correc-
tion of dentofacial deformities may have the oppor-
tunity to negotiate a higher rate of reimbursement
with their third-party providers. Surgeons may
also have success in reducing costs by negotiating
a fixed fee from the hospital. This negotiation stems
from a review of previous cases in which the typical
supplies, operating room time, and hospital stay
can be calculated to establish fair market value.
These negotiations are not likely to generate reim-
bursement equivalent to that expected but can
make the delivery of orthognathic surgery more
inviting. An improved understanding on expected
billing incurred from hospitals and greater trans-
parency from insurance companies on coverage
would greatly assist both surgeons and patients
to make educated decisions on health care
expenditures.
Despite extensive administrative efforts there
are often situations in which there is no appre-
ciable reimbursement from an insurance com-
pany. Surgeons may hesitate to discuss
orthognathic fees with patients, even though
the fees may be equivalent to those anticipated
for cosmetic or implant procedures, because a
perception exists from a past history of insurance
support for orthognathic surgery procedures.
Many surgeons have altered their philosophies,
changing their orthognathic practices to parallel
that of a cosmetic office in which fees are
exempt from insurance constraints. The surgical
coordinator is essential to aid families in under-
standing issues with reimbursement, reduction
in coverage, and out-of-pocket expectations.
Despite the trend of decreasing reimbursement
by insurance companies and a greater financial
contribution required from patients, the value of
orthognathic surgery is not diminished.4 Patients
and families appreciative of the value of correct-
ing the malocclusion are more likely to pay for
services that are not reimbursed by the insurance

provider. Patients must consider the long term
functional and esthetic value of orthognathic sur-
gery relative to more common expenditures
including cars, audiovisual equipment, home re-
modeling, and vacations.
Approval of the submitted claim by the insur-
ance provider implies that hospitalization, anes-
thesia services, and supplies are a covered
expense but the extent of coverage to surgeons
is based on policy language. The financial policy
for the Carolina Centers for Oral and Facial Sur-
gery (CCOFS) is that full payment of the estab-
lished surgical fee is required to schedule
surgery. CCOFS elects not to participate with
most major medical insurance companies but files
claims with all providers. A diligent pursuit on
behalf of patients (submission, appeals, peer to
peer) is completed, often with eventual reimburse-
ment of some portion of surgical fees returned
directly to the patients or their families.
HOSPITALIZATION CHARGES
The escalating costs associated with surgical ser-
vices are in contrast with individuals spending less
time within the facility. Despite orthognathic sur-
gery routinely being accomplished as an outpa-
tient (23-hour admission) the increased costs of
hospitalization are attributed to the perioperative
services. The increase in hospital fees has primar-
ily stemmed from larger perioperative charges,
including anesthesia, operating room time, surgi-
cal supplies (including rigid internal fixation), and
postanesthesia care.5,6 These perioperative areas
accounted for 50% of total hospital bills in 1985
but, by 1992, had escalated to 80%.7 Current re-
views of itemized local hospital bills show that
greater than 90% of the charges are associated
with the perioperative areas of anesthesia, surgical
supplies, and time in the operating room. Length of
Orthognathic Surgery in the Office 613
Table 1
Cost of fixation supplies to stabilize maxillary
and mandibular osteotomies calculated from
itemized bills from local hospital
Cost Total Hospital
Procedure ($) Number Cost ($) Billing ($)
BSSO with 50 6 300 1000
screw
fixation
BSSO with 375/50 2/8 1350 3500
plate
fixation
Le Fort 375/50 4/16 2300 7000
Abbreviation: BSSO, bilateral sagittal split osteotomy.
time in the operating room was billed indepen-
dently from anesthesia and supplies at a rate
ranging from $55 to $73 per minute.
The drastic inflation associated with surgical
services can be appreciated through a review of
the fixation required to stabilize bony osteotomies
(Table 1).
The surgical supplies within a hospital environ-
ment are frequently subject to a markup of more
than 300% and are correlated with negotiated
contracts with insurance companies. This markup
results in the fees submitted to the insurance com-
pany ranging from roughly $1000 for the isolated
screw fixation of a mandibular osteotomy to
more than $3500 attributed to the use of plates.
A review of itemized billing from a regional hospital
showed that charges for fixation of a Le Fort os-
teotomy (4 plates and 16 screws) totaled more
than $7000. Maintaining high-quality care with
appropriate fixation is essential but it is important
to understand the costs anticipated with the deliv-
ery of surgical services (Fig. 2).
Fig. 2. Operating room (OR) supply
charges show the dramatic increase in
cost of supplies. Costs from 2013 are
an average from multiple itemized
hospital charges collected from a
regional hospitals. The increased
health care charges are considerably
greater than that anticipated for
typical inflation. The initial increase
from 1985 to 1992 can be attributed
to advent of rigid fixation. (Adapted
from Lombardo GA, Karakourtis MH,
White RP Jr. The impact of clinical prac-
tice patterns on hospital charges for
orthognathic surgery. Int J Adult Or-
thodon Orthognath Surg 1994;9:251.)
614 Farrell & Tucker
OUTPATIENT SURGERY
Surgical specialties have begun to explore op-
tions to provide care in an outpatient setting in
an effort to curtail the escalation of charges. The
most common location for outpatient surgical ser-
vices remains within the hospital setting. Many
surgeons find that orthognathic surgery within a
hospital environment is the most feasible location
despite the escalated costs. Hospitals with estab-
lished insurance contracts and set fees may make
negotiating to reduce the cost of outpatient sur-
gery difficult. An increasing number of surgeons
have chosen to explore other ambulatory options,
including freestanding outpatient surgical cen-
ters. Oral and maxillofacial surgeons may elect
to complete major surgery within their offices, in
the environment with which they are most familiar.
For many surgeons, orthognathic surgery per-
formed in the office can be intimidating and may
seem like a daunting task initially when contem-
plating moving beyond routine dentoalveolar
procedures.
The delivery of surgical care in an office environ-
ment must be at a level equal to or superior to that
offered within the hospital environment. Surgeons
may think that they deliver better surgical care in
the office because patients are to be discharged
either home or to an overnight facility in an expe-
dited manner. The performance of orthognathic
surgery in an office setting with anticipated
discharge hours later heightens the requirement
for meticulous surgical techniques.
Surgical intervention completed in a hospital
environment involves reliance on the nursing staff
to handle the expectant postoperative challenges,
such as controlling pain, managing secretions, oral
intake, and bleeding.
OFFICE OPERATING SUITE
Substantial cost can be anticipated with the
development of an office operatory whether new
construction or modification of existing space to
handle the anticipated demands. The financial
obligations to establish a facility adequate for
the delivery of major surgical services include
initial construction, maintenance, surgical instru-
mentation (including backups), and agency
accreditation process. An auxiliary generator is
needed to ensure that reserve power supply is
available should there be a power outage. Anes-
thesia equipment essential for orthognathic sur-
gery should be space efficient, have state-of-
the-art monitoring capabilities, and possesses
battery backup. The use of inhalational general
anesthesia necessitates breathing circuits, filters,
assorted-size masks, airways and emergency
equipment for difficult intubation. The recovery
area following outpatient orthognathic surgery
should be equipped with necessary monitoring
and suction, and have sufficient room for escorts.
The operating room and recovery within an oral
and maxillofacial surgery office is generally staf-
fed by nurses, surgical technicians, and dental
assistants.
An office surgical suite must be of adequate
size and configuration to accommodate the surgi-
cal and anesthesia teams, similar to a typical
operating room environment. The surgical suite
does not have to be very elaborate, as shown
by the initial surgical suite for CCOFS, which
was a space of just 20.8 m2 (224 square feet),
measuring 4.3  4.9 m (14  16 feet). Most surgi-
cal intervention in the practice over the past
decade has been accomplished in a room
measuring 6.4  4.9 m (21  16 feet) that had suf-
ficient space to allow the necessary equipment
(tables, surgical lamps, anesthesia cart, and so
forth), with space available to easily transport pa-
tients to the recovery room. New office construc-
tion provided an opportunity to expand the
surgical theater to 44.6 m2 (480 square feet),
providing ample room for the delivery of surgical
care. In addition to orthognathic surgery, arthro-
scopic temporomandibular joint intervention,
complex reconstruction cases obtaining anterior
iliac crest grafts, and cosmetic procedures have
been readily completed within the office environ-
ment (Fig. 3).
Surgical facilities that have received accredita-
tion from the Accreditation Association for
Ambulatory Health Care (AAAHC) or Joint Com-
mission (JACHO) have met established stan-
dards governing patient rights, quality of care,
quality management, and facilities. A certificate
of need regulating health care construction is
required to obtain government approval of free-
standing outpatient surgical facilities. In the
past, only facilities that received approval as a
Medicare provider were eligible for facility reim-
bursement from third-party providers. A greater
understanding of the safety, efficiency, and cost
savings provided in an office environment has al-
lowed the stance of many insurance companies
to evolve. Insurance carriers are now recognizing
facilities other than hospitals and federally
approved facilities for reimbursement. Compen-
sation for facility fees has been received from
third-party providers to offices that are ac-
credited by AAAHC or JACHO and that perform
major surgical services. The collections from fa-
cility fees are subsequently applied to overheads,
maintenance, supplies, and staff salaries.
 Orthognathic Surgery in the Office 615

Fig. 3. Evolution of office operating rooms used for delivery of orthognathic and major surgery at Carolinas Cen-
ter for Oral and Facial Surgery. The initial suite (A) was a subtle modification of an existing operatory, whereas
subsequent construction provided more space for anesthesia and operating room equipment (B, C).

COSTS increased with inflation. The cost escalation is

attributed to the increased cost of doing business
The cost of basic supplies required for delivery of and is experienced in every oral and maxillofacial
orthognathic surgery within the office has been surgeon’s overheads.
quantified. The supplies encompass disposable In addition to supplies, staffing costs associated
items (gowns, drapes, gloves, blades, suture, with the operating room, the staffing costs (surgi-
and so forth), possible graft materials, and fixation cal technician and circulator), and recovery room
that are used during each procedure. The total (dental assistant) were also calculated. Facility
costs for orthognathic procedures performed in fee charges include the aforementioned costs
the authors’ outpatient surgical setting are listed (supplies, fixation, staffing) in addition to facility
in Table 2. and equipment maintenance (Fig. 4).
Evaluation of those costs currently incurred The costs incurred for the completion of an iso-
(2014) for orthognathic surgery is expectantly lated mandible, isolated maxilla, and double-jaw
surgery have been compared with itemized bills
Table 2 obtained from patients undergoing similar surgical
Cost of supplies to deliver orthognathic care within the hospital. The delivery of orthog-
surgery in the office (CCOFS) nathic surgery in the office is routinely approxi-
mately one-half to one-third of that anticipated in
Year BSSO Le Fort BSSO/Le Fort the hospital (Fig. 5).
2004 580 1590 1760–1970a
2008 1000 2000 2300–2800a ANESTHESIA
2011 1400–1800a 2200 3500–4400a
The prevailing trend in health care has been the
a
Range attributed to variability in fixation methods. shift of surgical specialties to ambulatory facilities
616 Farrell & Tucker
with the hospital setting reserved for more medi-
cally compromised individuals and cases of higher
complexity. Anesthesia has followed suit through
the use of techniques and agents that allow
decreased recovery periods and a more practical
discharge. Orthognathic surgery in the office
setting is grounded in the delivery of safe and effi-
cient anesthesia. A key principle is controlling the
length of surgery and the associated anesthetic
duration. Studies have documented the relation-
ship between increased anesthesia time and the
need for a longer postoperative recovery.8,9 Initial
orthognathic procedures in the authors’ facility
were focused on completion of the surgical
correction within a time limit of 90 to 120 minutes.
The early opinion was procedures suited for the of-
fice setting, which were uncomplicated ramus and
Le Fort osteotomies. Continued exposure with
major office surgery and associated anesthesia
provided more comfort, lengthening the amount
of time designated for surgical intervention. Expe-
rience and subsequent confidence has allowed an
Fig. 4. Cost of supplies, staffing, and
facility fees for completion of surgery
within an office environment (CCOFS).
expansion of the cases that are deemed satisfac-
tory for an office setting, including simultaneous
wisdom tooth removal, segmental osteotomies,
addressing the cartilaginous septum and inferior
turbinates with superior repositioning, combined
bilateral sagittal split osteotomy (BSSO) and gen-
ioplasties, combined Le Forts and genioplasties,
and in very select cases double-jaw surgery.
The anesthetic delivery for major office surgery
moves beyond the typical surgeon anesthetist
model used for dentoalveolar applications. A mo-
bile medical anesthesiologist, certified registered
nurse anesthetist, or dental anesthesiologist is
routinely called on for the delivery of anesthesia
involving intubation. An anesthetic technique with
rapid induction, simple maintenance providing hy-
potensive anesthesia, and expeditious emergence
are essential to ensure patient comfort, safety, and
recovery. This principle is at the forefront of outpa-
tient surgery when discharge from the facility is ex-
pected just hours after the procedure. The thought
of performing orthognathic surgery in an office
Fig. 5. The costs anticipated with the
delivery of orthognathic surgery
within an office setting compared
with similar intervention in a local
hospital environment (2013).

may be daunting for many surgeons and alarming
when contemplating early discharge with an inex-
perienced caregiver.10 Preoperative preparedness
is of the utmost importance when performing
either routine or complex oral and maxillofacial
procedures within an office setting.11 Prepared-
ness of the surgeons, anesthetists, equipment,
and facilities is essential. Patients undergoing
complex surgery within the office mirror those suit-
able for anesthetic techniques provided through
the surgeon anesthetist model (American Society
of Anesthesiologists I or II with a satisfactory
airway status).
Expectant anxiety for the approaching surgery,
anesthesia, and recovery by both patients and
families are often addressed with a tour of the fa-
cility when returning for thorough preoperative in-
structions before the surgery. Patient anxiety can
also be quickly addressed with masked induction
via an inhalational agent shortly after entering the
operating room. Sevoflurane is the typical inhala-
tional agent for mask induction because it pos-
sesses a nonpungent odor to limit bronchial
irritation and subsequent coughing. A favorable
low blood-gas solubility allows both rapid onset
and reversal, which is ideal for outpatient
settings.
Narcotics are used concomitantly with inhala-
tional agents for maintenance of general anes-
thesia and hypotensive anesthesia. Fentanyl is
the primary narcotic administered in ambulatory
surgery for anesthesia and pain control. Fentanyl
is economical and a rapid onset is advantageous
but with a short duration of action intermittent bo-
luses are required, which can be cumulative. The
additive effect in longer procedures can be
Fig. 6. Recovery area for CCOFS facility.
Orthognathic Surgery in the Office 617
responsible for delayed emergence, which is
counterintuitive to the expedient discharge that is
necessary with office surgery. Remifentanil is an
alternative to fentanyl that is administered via an
infusion (0.1–0.2 mg/kg/min) and possesses a brief
half-life (3.65 minutes), accounting for rapid recov-
ery.12 Rapid recovery is independent of the dura-
tion of infusion secondary to metabolism through
plasma and tissue esterases. Remifentanil is
excellent for hypotensive anesthesia but second-
ary to the rapid reversal does not provide postop-
erative analgesia. Patients require adjunctive
analgesia in recovery, typically in the form of fenta-
nyl or Demerol to supplement the Marcaine infiltra-
tion at the conclusion of the surgery. A higher cost
can be anticipated with the use of remifentanil; this
is estimated at approximately $80 for an orthog-
nathic procedure lasting 90 minutes.
The inhalational agent and narcotic infusion are
discontinued as closure of the soft tissue com-
mences. Stomach contents are evacuated via an
in-and-out orogastric tube and intravenous anti-
emetic medication is given at the conclusion of
the procedure in an effort to combat the chal-
lenges of nausea and vomiting. The rapid reversal
of the medications allows extubation criteria to be
met only minutes following removal of the drapes.
Care continues after extubation within the oper-
ating room, similar to that delivered in the posta-
nesthesia care unit, with close monitoring of
vitals and pain control by the anesthesia provider.
The step-down to recovery frequently occurs
expeditiously through swift emergence from the
anesthetic. The transfer from operating room to re-
covery can be accomplished via a wheelchair and
support of several assistants (Fig. 6).
618 Farrell & Tucker
RECOVERY
Recovery after orthognathic surgery is one of the
most critical aspects of delivering care within the
office environment. Ensuring that patients are off
to a solid start is vital when discharge is anticipated
shortly after complex care. Recovery can be staffed
by a dental assistant or nurse experienced in the
management of individuals emerging from anes-
thesia and the numbness and ooze associated
with dentoalveolar surgery. Ensuring that escorts
(parents/spouse/friend) can assume patient care
responsibilities is a key aspect of recovery
following orthognathic surgery whether it is early af-
ter surgery in an office setting or after an overnight
hospital admission. Caregiver participation in the
recovery area is critical to aid in overcoming early
postoperative concerns after discharge. Participa-
tion of the accompanying chaperone is initiated
early in recovery after the individual is subjectively
and clinically stable. The escorts gain valuable
experience observing the assistant provide sup-
portive care involving oral intake, oral and nasal
secretions, dressings, and ice placement (Fig. 7).
Questions that arise from the initial early expo-
sure to postoperative patients are addressed to
assist the caregiver in becoming more comfortable
with the necessary attention. A transition occurs
as the escort assumes the role of primary care-
giver with the nurse/assistant remaining close for
questions and additional support. The experience
of participating in the recovery area is valuable and
is referenced after isolation from the health care
professionals. The valuable hands-on experience
received while accompanied by the surgical
and anesthesia team cannot be underestimated
because office-based orthognathic surgery is
Fig. 7. Caregiver participation in re-
covery provides valuable hands-on
experience to maintain supportive
care and helps to address concerns
when patients are discharged.
contingent on competent postoperative care pro-
vided by family or friends. Patients who are stable
and feeling comfortable about discharge, com-
bined with caregivers who are content with their
roles, allow patients to be transported from the fa-
cility (Boxes 1 and 2).
A prolonged recovery or inexperienced care-
givers who are unprepared to aid in management
of the patients after discharge force several op-
tions to be considered. Discharged patients may
return to the office for additional management, in-
struction, and reassurance with release once the
patients and/or escorts are subjectively improved.
An increased volume of calls is anticipated within
the initial 48 to 72 hours if the caregiver is inexpe-
rienced. Detailed preparation is required with both
patients and anticipated primary caregivers before
the surgery to ensure that there is a solid
understanding of the responsibilities associated
with early postoperative care. Patients can be
Box 1
Potential problems with postoperative
outpatient care of surgical patients
 Patients not ready to leave
 Caregiver (parent/spouse) is inexperienced
and emotionally attached
 Transport from facility required
 Nausea and vomiting
 Managing secretions and bleeding
 Fluid management
 Ability to medicate patient diminished
 Higher volume of calls in the first 48 hours

Box 2
Overcoming problems when immediate
postoperative care is completed at home
 Thorough review of supportive care antici-
pated during preoperative appointment
Preoperative and postoperative instruction
booklet for reference
 Limit time of surgery
 Anesthetic techniques that facilitate rapid
recovery
 Preemptive analgesics
 Preemptive antiemetics
 Adequate time in recovery
 Caregiver participation in recovery area
Hands-on experience
Becoming comfortable with supportive
care
Providing oral intake
Moving patient
discharged to home accompanied by a home
health nurse who can continue supportive man-
agement and permit a longer acclimation period
for caregivers who may initially be uncomfortable
with these responsibilities. In addition to the phys-
ical management there is significant benefit from
the emotional and mental support offered during
recovery, because nurses may pass on experience
and reassurance regarding the patient’s current
state and expected progress.
Additional options for management of postoper-
ative patients may involve the transfer of patients
to a facility designated for an overnight stay. The
transfer to the hospital is generally not an issue if
surgeons are members of the hospital staff and
Orthognathic Surgery in the Office 619
actively participate in coverage for on-call respon-
sibilities. The fees encountered from an overnight
hospital admission for management of routine
postoperative needs is usually reasonable in the
absence of the typical surgical charges (anes-
thesia, fixation, supplies). The national average
for hospital admission following a surgical proce-
dure from an ambulatory surgical center is approx-
imately 1.1%.13 CCOFS has had 3 admissions to
an overnight facility since delivery of orthognathic
surgery was initiated in the office in 2002 (n 5
675). The admissions were not medical or surgical
in nature but were subjective concerns and unrest
expressed by the patients or families that war-
ranted additional supportive care. All patients
were subsequently discharged after a short over-
night stay with no sequelae. Admission to an over-
night facility after office-based orthognathic
surgery through CCOFS (0.01%) is less than the
national standard for ambulatory surgical centers.
AUTONOMY
The advantages of completing complex office sur-
gery extend beyond reducing costs because au-
tonomy is enhanced through control of all aspects
of care, including schedule, staffing, and materials.
Efficiency for surgeons is greatly improved be-
cause the day is spent in their typical environment
with the ability not only to manage the surgical pa-
tients but also to complete administrative tasks,
including dictations, insurance appeals, or return-
ing phone calls and emails. The productivity of sur-
geons is maintained by being present in the office
with an opportunity to continue care for past and
future patients. The familiarity with the office and
the rapport established with the staff throughout
their multiple visits can help reduce the expectant
anxiety for both patients and families at the time
of surgical intervention (Figs. 8 and 9).
Fig. 8. CCOFS noted a substantial in-
crease in the amount of surgery per-
formed in the office environment,
peaking in 2008. The initial trend has
reversed and has been attributed to
improved insurance approval
providing coverage for hospital ser-
vices. The surgical cases delivered in
the office setting were frequently indi-
viduals with little if any third party
support that would otherwise be un-
able to undergo corrective surgery if
a cost effective alternative was not
available. Thirty eight surgical cases
were delivered in the office setting
over the summer of 2014.
620 Farrell & Tucker
Fig. 9. (A, B) The CCOFS case log for the last decade (n 5 2967) shows that approximately 25% of the orthog-
nathic surgery procedures have been delivered in the office environment.
SUMMARY
Orthognathic surgery should remain a funda-
mental part of an oral and maxillofacial surgeon’s
practice. The delivery of orthognathic surgical
care is becoming more challenging based on
escalating health care costs and limited
reimbursement from insurance providers. Orthog-
nathic surgery within an outpatient environment,
including an office-based setting, can greatly
reduce costs and improve autonomy with mainte-
nance of high-quality care. Office-based correc-
tive surgery is centered on an anesthetic
technique with rapid recovery and expedient
discharge. Caregiver participation with recovery
is essential to instill confidence to aid in managing
early postoperative concerns after discharge. The
delivery of orthognathic surgery in an office setting
is safe, efficient, and cost-effective, and has aided
in preserving the scope and volume of cases,
which is constantly being affected by health care
changes and insurance companies.
REFERENCES
1. Farrell BB, Tucker MR. Safe, efficient and cost-
effective orthognathic surgery in the outpatient
setting. J Oral Maxillofac Surg 2009;67(10):2064–71.
2. Zins JE, Bruno J, Moereira-Gonzales A, et al. Or-
thognathic surgery: is there a future? Plast Reconstr
Surg 2005;115:1442.
3. Zins JE, Morrison CM, Gonzalez AM, et al. Follow
up: orthognathic surgery: is there a future? Plast Re-
constr Surg 2008;122:555.
4. Athanasiou AE, Melsen B, Eriksen J. Concerns,
motivation and experience of orthognathic surgery
patients: a retrospective study of 152 patients. Int
J Adult Orthodon Orthognath Surg 1989;4:47.
5. Dolan P, White RP Jr, Tulloch JF. An analysis of hos-
pital charges for orthognathic surgery. Int J Adult Or-
thodon Orthognath Surg 1987;1:9.
6. Lombardo GA, Karakourtis MH, White RP Jr. The
impact of clinical practice patterns on hospital
charges for orthognathic surgery. Int J Adult Ortho-
don Orthognath Surg 1994;9:251.
7. Dolan P, White RP Jr. Community hospital charges
for orthognathic surgery. Int J Adult Orthodon Or-
thognath Surg 1996;11:253.
8. Knoff SB, Van Sickels JR, Holmgreen WC. Outpa-
tient orthognathic surgery: criteria and a review of
cases. J Oral Maxillofac Surg 1991;49:117.
9. Lupoir JP, Van Sickels JR, Holgreen WC. Outpatient
orthognathic surgery: review of 205 cases. J Oral
Maxillofac Surg 1997;55:558–63.
10. Sexton J. Comment on orthognathic surgery in a sur-
gical day care setting. J Oral Maxillofac Surg 1991;
49:917.
11. Cangemi CF. Administration of general anesthesia
for outpatient orthognathic surgical procedures.
J Oral Maxillofac Surg 2011;69(3):798–807.
12. Song D, White PF. Remifentanil as an adjuvant dur-
ing desflurane anesthesia facilitates early recovery
after ambulatory surgery. J Clin Anesth 1997;11(5):
364–7.
13. ASC Quality Collaboration. ASC quality measures:
implementation guide. Version 2.0. Ambulatory Sur-
gery Center. January 32, 2014. Available at: http://
www.ascquality.org/.