Completing the Picture: The Impact of Multimodal Analgesia on Post-Operative Outcomes in Cleft-Related Orthognathic Surgery

Background and purpose: Suprazygomatic Maxillary Nerve Blocks (SMB) have demonstrated efficacy in reducing post-operative pain and narcotic use in orthognathic surgery. This study evaluates the impact of a multimodal analgesic approach, combining Enhanced Recovery After Surgery (ERAS) with SMB (ERAS/SMB), in patients undergoing Le Fort I (LF1) alone or with Bilateral Sagittal Split Osteotomy (LF1/BSSO). Methods: From June 2019 to June 2024, patients with cleft lip and/or palate undergoing LF1 and LF1/BSSO treated with ERAS/SMB were prospectively evaluated and compared to historical controls. Primary outcomes included post-operative narcotic use (morphine milligram equivalents per kilogram per day; MME/kg/d), pain scores, and length of stay (LOS). Results: For LF1 (n = 95; 75 ERAS/SMB, 20 Control), ERAS/SMB significantly reduced narcotic use (0.078 vs 0.386 MME/kg/d, P < 0.0001), pain scores on POD1 (1.444 vs 5.077, P < 0.0001), POD2 (1.638 vs 4.694, P < 0.0001), and POD3 (0.682 vs 5.008, P < 0.0001), and LOS (1.96 vs 3.23 days, P < 0.0001). LF1/BSSO patients (n = 68; 50 ERAS/SMB, 18 Control) experienced a similar reduction in narcotic use (0.123 vs 0.492 MME/kg/d, P < 0.0004), with a trend toward lower pain scores and a shorter LOS by 13 hours. Notably, pain control was most profound during the first 24 hours, attributing to SMB efficacy. Conclusion: Multimodal ERAS/SMB therapy significantly improves outcomes in cleft-related orthognathic surgery, reducing narcotic dependence, pain, and LOS. These findings underscore the importance of integrating advanced pain management strategies to optimize recovery.