Orthognathic surgery: doubts from patients with orofacial fissures regarding the immediate postoperative period

Objectives : to identify the main doubts regarding the immediate postoperative care of patients with orofacial clefts undergoing orthognathic surgery. Methods : cross-sectional, quantitative study, developed in a public and tertiary hospital, between November 2017 and May 2018. Data collection occurred through interviews during the preoperative nursing consultation. An instrument was used to describe doubts, which later were grouped according to the subject. Results : 48 patients participated. The doubts referred to sun exposure (56%), food/mastication (48%), the relationship between intermaxillary block-breathing-vomiting (48%), oral hygiene (31%), physical activity restriction (27%), nasopharyngeal cannula, removal of surgical stitches, hospitalization time and speech/communication (23%), bleeding, cryotherapy, facial massage, aesthetic and functional results, healing, edema/ecchymosis, postoperative pain, and changes in facial sensitivity (21%). Conclusions : the doubts were related to food, the period of convalescence, care for the surgical wound, postoperative complications, and medications. Descriptors: Orthognathic Surgery; Nursing; Postoperative Period; Cleft Lip; Cleft Palate. RESUMO Objetivos: identificar principais à cirurgia bloqueo intermaxilar-respiración-vómito (48%), higiene oral (31%), restricción de la actividad física (27%), cánula nasofaríngea, retirada de los puntos quirúrgicos, tiempo de internación y habla/comunicación (23%), hemorragia, crioterapia, masaje facial, resultados estéticos y funcionales, cicatrización, edema/equimosis, dolor postoperatorio y alteraciones en la sensibilidad facial (21%). Conclusiones: las dudas se relacionaron a la alimentación, período de convalecencia, cuidados con la herida operatoria, complicaciones postoperatorias y medicaciones. Postoperatorio; fracture, scar alteration, bleeding, exacerbated pain, soft tissue laceration, dental injury, and problems with fixation material (10-11)


INTRODUCTION
Orofacial clefts, better known as lip and/or palate, are prevalent among malformations affecting the face, whose incidence in Brazil is 1 in every 700 live births. Of multifactorial etiology, which includes genetic and environmental factors, they develop in the embryonic period and early fetal period, that is, between the 4th and 12th week of pregnancy. They can affect the lip, alveolar ridge, and palate alone or in association. Thus, the greater the anatomical impairment, the greater will be the functional, aesthetic, and psychosocial implications (1)(2) .
The rehabilitative process takes time: it begins in childhood and extends into adulthood, requiring multidisciplinary and interdisciplinary treatment. Although the benefits of primary surgeries performed in childhood are evident, they may result in a rigid and fibrosis labial belt in the region of the maxilla and cause damage to the bone growth of the face, including maxillary development, leading to dentofacial deformities such as dental malocclusion. The most common type of malocclusion found in patients with a cleft is the Angle Class III, requiring orthognathic surgery for its correction (3) .
In other words, orthognathic surgery aims to repair maxillomandibular and facial impairments. For patients with cleft lip and/or palate, it should be performed at the end of facial development, provided that the patient has undergone previous alveolar bone grafting surgery (4) .
The surgical procedure benefits include aesthetic and functional improvements, such as better breathing, mastication, hearing, and speech (5)(6)(7)(8) . Besides, there are benefits related to improvements in the perception of the quality of life (9) .
In this context, in the postoperative period, nursing interventions should focus on preventing surgical complications, monitoring sensitivity, motor skills, pain management, and anxiety control (3,12) .
Postoperative care includes diet changes, oral hygiene, alterations in physiognomy to overcome the onset of edema and bruising, the need to use intermaxillary blockade, pain monitoring, and difficulties related to verbal communication. In this situation, the nursing staff should teach or train patients and their caregivers to maintain care at home, whose quality will influence the therapeutic success. Thus, guidelines should start in the preoperative period and extend until the hospital discharge (12)(13) .
The nurse plays a fundamental role in training and clarification of doubts since resolving them reduces the insecurity of the patient and his family (12)(13)(14) .
Therefore, the question is: What are the main doubts concerning the immediate postoperative orthognathic surgery period in patients with cleft lip and/or palate?
Considering the increase in oral and maxillofacial surgeries, among them orthognathic, the decentralization of health services, as well as the scarcity of studies on this subject, especially those developed by nurses, this investigation is expected to provide elements to plan for the care of quality nursing, humanized and safe, focused on the real needs of the clientele.

OBJECTIVES
To identify the main doubts, concerning the immediate postoperative of orthognathic surgery, from patients with orofacial fissures.

Ethical Aspects
The research started after the Research Ethics Committee's approval involving human beings of the institution. The participants formalized their adhesion to this research by signing the Term of Free and Informed Consent, in compliance with Resolution 466/2012.

Design, period, and place of study
This study is a descriptive, cross-sectional, quantitative design study guided by STROBE, conducted in a public, tertiary hospital, with reference in care for patients with craniofacial anomalies and related syndromes in the countryside of the state of São Paulo, Brazil. The hospital has 91 beds; the service is interdisciplinary and humanized, and the unit contemplated in this study was the hospitalization unit.

Population, criteria of inclusion, and definition of sample
The population consisted of patients in the preoperative period of orthognathic surgery. They included patients aged 18 years or older who underwent exclusively orthognathic surgery. The study excluded patients with communication deficits that made data collection impossible.
The sample consisted of 48 participants, considering the monthly average of surgeries (eight) and the stipulated time for data collection (six months).

Study Protocol
Data collection occurred during the preoperative nursing consultation, specifically by the researchers. Aspects related to the patient's preparation for the surgical procedure were addressed, including checking the fasting start time, as well as its maintenance, the general condition of the patient, complications presented in the last 24 hours, previous pathologies, use of medication, need for medical evaluation, expectations about the surgical procedure and significant doubts related to the postoperative period.
For data collection, researchers used a structured interview. Initially, participants received information about the surgical procedure, which included indication, mean time of surgery, and aspects related to anesthesia. Subsequently, researchers asked them about their doubts and wrote it in a form prepared for that purpose.
The interviews took place in a private room, individually, and lasted an average of 20 minutes. The study characterized participants according to variables, such as gender, age, education, socioeconomic classification (15) , marital status, and the number of children.
The researchers conducted the data collection between November 2017 and May 2018.

Analysis of results and statistics
We chose to group the doubts by subject to facilitate the presentation of the results. This grouping was established by similarity. After identifying the doubts, they were grouped according to the subject they addressed: for example, those related to food included the type of food, consistency, temperature, among others.
The results were tabulated in an Excel spreadsheet (2015 version) and submitted to descriptive statistical analysis, including the mean, standard deviation, relative and absolute frequencies.
After identifying the doubts, researchers formed groups according to the similarity of subjects, including food, care for the surgical wound, post-operative complications, period of convalescence, and medications. There was a predominance of the theme "period of convalescence, " which included the variables sun exposure, physical effort, time away from activities, time of hospitalization, aesthetic, and functional results (56%; n = 27) ( Table 3).

DISCUSSION
In this study, the average age of the participants was 24 years, hence young. Most were single, without children, and had completed high school. Orthognathic surgery should be performed at the end of bone growth, which usually occurs in late adolescence. However, in patients with cleft lip and/or palate, it is necessary to perform the alveolar bone grafting and previous orthodontic treatment (16) .
As for the gender, the prevalence of women was evident, although there has been a predominance of this surgical procedure with cleft lip in male patients (1,17) .
About the socioeconomic classification, the low class was predominant. It is noteworthy that orthognathic surgery is a high-cost procedure. Thus, populations in need seek public    10 21 Medications (antibiotic therapy, analgesics, and antiinflammatory) 10 21 To be continued institutions that offer the procedure for free, such as the hospital in which this research was conducted, which is managed entirely with public resources (15,18) . The grouping of doubts by similarity resulted in themes: food, care for the surgical wound, postoperative complications, period of convalescence, and medications. A similar result was observed in another investigation whose objective was to know patients' and caregivers' doubts about another orofacial surgery (18) .
According to the institution's protocol where the study was conducted, it is recommended that, after hospital discharge, the patient avoids intense physical exercise and stay away from work for 60 days to prevent possible complications. It is also recommended to avoid sun exposure for at least 30 days and to use sunscreen.
In general, the patients remain hospitalized for 48 hours, although it is possible to discharge them within 12 hours (19) . Therefore, it must be taken into consideration the patient's clinical stability, food acceptance, and ability to change the elastic bands (20) .
Another aspect associated with limited mouth opening refers to communication problems, especially considering the verbalization of words. Thus, some strategies must be incorporated, such as written communication. The presence of a companion also favors communication (13,18) .
Another doubt referred to the aesthetic and functional benefits of the surgery, which, although desired immediately, are evidenced in the medium and long term (4) . They include improved respiratory capacity, mastication, speech quality, and facial harmony, in addition to psycho-emotional aspects, such as self-esteem and better perception of the quality of life (5,(8)(9) .
As for the topic "food, " the doubts were related to the type of food, consistency, temperature, and period of time. In fact, with orthognathic surgery, it is necessary to modify the consistency of the diet, i.e., it is recommended that the patient eat foods of liquid and cold consistency for 30 days because the opening of mouth and mastication are impaired (19,21) .
Food should be cooked and beaten in a blender. It can be mixed with juices, milk, water, or broths, remembering the importance of providing balanced meals since the patient's nutritional status is related to the healing process and contributes to reverse the catabolic metabolism resulting from the surgery, favoring recovery. After this period, the patient will be able to ingest pasty foods, such as purees. For those whose food acceptance is insufficient, it is indicated the use of supplements (21)(22) .
It is a known fact that trauma and/or surgical stress generate a hypermetabolic state, causing an increased need for energy and protein. So, it becomes essential to monitor food acceptance because poor nutrition predisposes to postoperative complications (22) .
About "postoperative complications," doubts included the association between intermaxillary blockade with elastic bands and breathing and vomiting, the use of a nasopharyngeal cannula, bleeding, cryotherapy, facial massage, edema/ecchymosis, postoperative pain, and changes in facial sensitivity.
Intermaxillary blockade with elastic bands is commonly used in the postoperative period, whose function is to exert traction force on the teeth helping in the correct dental positioning, and the elastic bands should be positioned on the hooks of the fixed appliance and changed daily and properly. The use of these elastic bands brings concerns to patients since they limit the mouth opening, with repercussions on masticating, feeding, breathing, and the risk of asphyxia, in cases of vomiting, for example (19) .
In fact, in the postoperative period, nausea and vomiting are among the most frequent and also undesirable symptoms because of the risk of asphyxia. In patients undergoing orthognathic, vomiting is usually related to the blood swallowed during the surgical procedure and anesthetic procedure. Thus, sometimes it is necessary to maintain fasting in the first hours of postoperative (23) . It is necessary to guide patients and their families about the elastic bands' insertion and their removal to minimize these effects. Other measures can be implemented, such as raising the headboard and the administration of antiemetics.
The institution where this study was conducted uses the nasopharyngeal cannula routinely to aim at airway permeability, introducing it into both nostrils shortly after extubation and maintaining it for the first 24 hours.
Bleeding after orthognathic surgery is rare, and compression with gauze or cold compresses is effective for treatment in lowintensity bleedings (24) . However, signs and symptoms of bleeding should be systematically monitored, especially in the immediate postoperative period (23) .
As far as cryotherapy is concerned, it is recommended in the postoperative period for the treatment of pain, edema, and inflammation because it promotes slowness of painful impulses that are conducted to the brain, minimizing muscle spasm, decreasing the activity of inflammatory enzymes, and promoting vasoconstriction, in addition to preventing bleeding and bruising. Massage, cryotherapy, and facial lymphatic drainage contribute to reducing edema, which is accentuated in the first days after surgery (19,25) .
The pain is related to the surgical act itself and several factors, such as contraction of peripheral soft tissues and surrounding muscle stiffness (26) . Its control improves respiratory function, promotes hemodynamic stability, inhibits hormonal and metabolic reactions, and decreases hospitalization time (27) . Assessing facial sensitivity in the postoperative period, especially in the chin, lower lip, and cheek should also be emphasized, as there may be an injury in the lower alveolar nerve during the surgical procedure (28) .
It is noteworthy that intubation and surgical technique cause oral wounds with consequent edema of the associated structures, causing pain and/or discomfort and may compromise the frequency and quality of oral hygiene. Therefore, the dentist should provide oversight to whom teaches and supervises oral hygiene. It is also indicated that water-based mouthwash (19) , such as 0.12% chlorhexidine, is associated with brushing four to six times a day (29) . Oral hygiene is the main factor in the prevention of surgical site infection in orofacial surgeries and should be performed with a brush and toothpaste, as usual, minimally after meals (18) .
There is no need to remove the stitches used to suture the incision because they are absorbable (29) . Healing is a complex process and is influenced by several factors, varying from individual to individual. Knowing this, it is important that after the surgical intervention, the patient performs all the recommended instructions, including vigilance of the healing process and monitoring postoperative complications (19,25) .
Another topic was about the medications used. Opioids are used to treat pain in the immediate postoperative period, while traditional analgesics are used in the mediate period (26) . However, the administration of non-steroidal anti-inflammatory drugs is also frequently employed, depending on the patient's pain threshold. In addition to those medications, there are also used dexamethasone, which has the purpose of reducing orofacial edema caused by surgical intervention, and droperidol, which presents satisfactory effect in the prevention of nausea and vomiting (30) .
Also, to minimize the infection of the surgical site, besides adopting an aseptic surgical technique, it is necessary to administer prophylactic antibiotics. Cefazolin has proved to be effective, being the drug of choice (31) . The implementation of surveillance and follow-up after hospital discharge is a way to minimize the incidence of surgical site infections and other complications (32) .

Study Limitations
The study in a single center and with a specific population limits the generalization of the results.

Contributions to the field of Nursing
This investigation's benefits are evident and include nursing care focused on the real needs of the patients, which should begin in the preoperative phase by providing guidance and strengthening the decision-making process. Correctly oriented patients feel better prepared for the surgical procedure, present better coping with the difficulties experienced in the postoperative period, besides acquiring knowledge about care.

CONCLUSIONS
The doubts were related to food, period of convalescence, care for the surgical wound, postoperative complications, and medications. Based on them, it was possible to plan and implement a nursing assistance aimed at the real needs of patients, promoting self-care, and favoring postoperative rehabilitation.