Orthognathic Surgery Operative Note (Le Fort/BSSO/Genioplasty)

(Meta-instructions: Include only sections and subsections for procedures actually performed. For Surgical Plan and Movements, include only operated anatomic sites. If a value matches the plan, document "as planned" rather than repeating numbers. Omit the Findings section if there were no notable findings. For EBL, Specimens, Drains, and Implants, omit lines where there is nothing to report unless "none" is explicitly dictated. Never infer procedures performed, laterality, fixation details, movement values, occlusion verification findings, EBL, or complications; these must come from the dictation. If implant identifiers are not dictated, state that identifiers are recorded in the implant log.)

Date of Procedure: [Date]

Patient Name: [Patient full name]

MRN: [Medical record number]

DOB: [Date of birth]

Facility: [Facility name]

Operating Room: [OR number/name]

Primary Surgeon: [Surgeon name, credentials]

Assistant(s): [Assistant name(s) and role(s)]

Anesthesia Type: [General endotracheal anesthesia - nasal ETT / oral ETT / other]

Preoperative Diagnosis: [Diagnosis using coding-friendly terminology]

Postoperative Diagnosis: [Diagnosis; update if different from preoperative]

Procedure(s) Performed:

• [Le Fort I maxillary osteotomy - 1-piece / 2-piece / 3-piece] (Include interdental osteotomy locations if segmental.)
• [Bilateral sagittal split osteotomy (mandible)]
• [Sliding genioplasty]
• [Additional procedures] (List each distinctly with laterality where applicable.)

Indication(s): [Brief statement of skeletal deformity and functional rationale]

Wound Classification: [Clean / Clean-contaminated / Contaminated / Dirty-infected]

Surgical Plan and Movements

Planning Method: [Virtual surgical planning (VSP) / Traditional model surgery] (Include software/vendor if stated.)

Splints/Guides Used: [Intermediate splint / Final splint / Cutting guides / Custom plates] (List all used.)

(Document planned versus achieved movements in millimeters. Provide side-specific values for asymmetric corrections or cant adjustments. Include only operated sites.)

Maxilla (Le Fort I)

(Include only if Le Fort I performed.)

• Configuration: [1-piece / 2-piece / 3-piece; interdental osteotomy locations if segmental]
• A-P: Planned [advancement / setback: X mm]; Achieved [X mm / as planned]
• Vertical: Planned [impaction / downgraft: X mm; R/L values if asymmetric]; Achieved [values / as planned]
• Transverse: Planned [expansion / constriction: X mm]; Achieved [values / as planned] (Include only if segmental.)
• Midline correction: Planned [X mm to R/L]; Achieved [values / as planned]
• Cant correction: Planned [X mm or degrees]; Achieved [values / as planned]

Mandible (BSSO)

(Include only if BSSO performed.)

• A-P: Planned [advancement / setback: X mm; R/L values if asymmetric]; Achieved [values / as planned]
• Midline correction: Planned [X mm to R/L]; Achieved [values / as planned]

Genioplasty

(Include only if performed.)

• A-P: Planned [advancement / setback: X mm]; Achieved [values / as planned]
• Vertical: Planned [reduction / lengthening: X mm]; Achieved [values / as planned]
• Midline shift: Planned [X mm to R/L]; Achieved [values / as planned]

Variance from Plan: [Explanation if achieved differs from planned] (Include reason and corrective action. Omit if none.)

Verification Method: [Seated to splint / External reference measurements / Intraoperative imaging] (Include if numeric values were not directly measured.)

Description of Procedure

Setup

[Patient positioning, table and head position, eye protection]

[Airway management including ETT route and throat pack if placed]

[Prep and drape]

[Local anesthetic infiltration: agent, concentration, vasoconstrictor, sites] (Include if used.)

Maxilla (Le Fort I)

(Include only if Le Fort I performed.)

• Incision and exposure: [Incision type/location; subperiosteal elevation; structures exposed]
• Osteotomy and down-fracture: [Technique; pterygomaxillary dysjunction; down-fracture; nasal septum and lateral nasal wall management]
• Segmental osteotomies: [Number of segments; interdental locations; palatal integrity; mobilization] (Include only if performed.)
• Bone grafting: [Material/source; location(s)] (Include only if performed.)
• Positioning: [Maxilla positioned to intermediate splint; MMF method]
• Fixation: [Plate/screw configuration at piriform rims and/or ZM buttresses; number, type, locations]
• Soft tissue adjuncts: [Alar base cinch / V-Y closure] (Include if performed.)
• Closure: [Irrigation; hemostasis; closure technique; suture materials]

Mandible (BSSO)

(Include only if BSSO performed.)

• Approach and exposure: [Incisions; subperiosteal elevation; neurovascular protection]
• Osteotomy and split: [Sagittal split technique; split pattern; management of unfavorable split if applicable]
• Positioning: [Mandible positioned to final splint; MMF method]
• Condylar seating: [Method to assess/ensure condylar position]
• Fixation: [Bicortical screws and/or plates; configuration and locations]
• Occlusion verification: [Findings after fixation and MMF release: intercuspation, midlines, transverse relationships]
• Closure: [Irrigation; hemostasis; closure technique; suture materials]

Genioplasty

(Include only if performed.)

• Approach: [Intraoral / submental; soft tissue handling; mental nerve protection]
• Osteotomy and mobilization: [Technique; segment mobilization; movement achieved]
• Fixation: [Plates/screws; configuration and locations]
• Grafting: [Material; location] (Include only if performed.)
• Closure: [Mentalis reapproximation; soft tissue closure; suture materials]

Final Checks

• Irrigation and hemostasis: [Performed; hemostatic agents if used]
• Throat pack: [Removal confirmed] (Must document removal if placed; safety-critical item.)
• Final occlusion check: [In splint / out of splint; elastics placed; occlusal findings]
• Counts: [Sponge/sharps/instrument counts correct / discrepancy and resolution]
• Intraoperative imaging: [Modality and findings] (Include only if performed.)

Findings

[Clinically meaningful intraoperative findings affecting the procedure or postoperative care] (Omit this section if no notable findings beyond expected anatomy.)

EBL, Specimens, Drains, Implants

EBL: [Numeric value] mL

Specimens: [Description and destination] (Omit if none.)

Drains: [Type and location] (Omit if none.)

Implants: [Summary of fixation by site; UDI/lot/serial recorded in implant log per institutional workflow]

Complications

[None / Complication(s) and management] (Include unfavorable split, nerve or tooth injury, bleeding requiring intervention, hardware issues, count discrepancy, or deviation from plan with reason and corrective action.)

Postoperative Disposition

• Extubation and destination: [Extubated in OR / Remained intubated] to [PACU / Floor / ICU]
• Airway plan: [Jaw fixation status; elastic/wire type; wire cutters/scissors at bedside if rigid fixation; OSA/airway precautions]
• Diet: [NPO / Clear liquids / Full liquids / Other]
• Splint/Elastic instructions: [Splint in place / removed; elastic configuration and duration]