A Case of Skeletal Mandibular Prognathism Treated by Orthognathic Surgery with Anorexia Nervosa

Orthognathic surgery is thought to have a great impact on aesthetic appearance and psychology, and there are also cases where mental illness appears after surgery. Anorexia nervosa is a mental disorder characterized by per-sistent caloric intake restriction and a strong fear of weight gain and becoming obese; treatments include behavioral therapy. We report on the safe perioperative management without worsening of anorexia nervosa successfully treated by behavioral therapy with orthognathic surgery. The case was a 32-year-old female. A clinical diag-nosis of skeletal mandibular prognathism as a chief complaint was made; we aimed to improve her occlusal position, and so decided to perform surgical orthodontic treatment. There was a history of cleft palate, anorexia nervosa, binge-eating/purging, and attention-deficit/ hyperactivity disorder. All treatment in a behavioral therapy program for psychosomatic medicine of another hospital was interrupted, and the body weight dropped to 20kg one year before the jaw corrective surgery. Aiming to increase weight for surgery a few months before surgery, she was hospitalized in another department of psychosomatic medicine. When her weight increased to 35kg and meals of up to 1,600kcal/day could be eaten, it was judged that surgery was possible. Body weight at the time of hospitalization was 34.5kg, and on the day after hospitalization, bilateral sagittal split ramus osteot-omy was performed under general anesthesia, and postoperative sedation was attempted with dexmedetomidine until the day after surgery. In addition, the bone frag-ment was fixed to a metal plate, and after arousal, only intermaxillary rubber towing was performed. During hospitalization, no restrictions were imposed on drinking of water and favorite foods except during the fasting and prohibition of drinking water due to general anesthesia, and they were consumed mainly when the patient was able to ingest. Nutrition started with a high nutrient fluid diet from the day after surgery. This was changed to whole porridge and soft meal on the second postoperative day, and she was able to ingest the whole amount at discharge. The weight at the time of discharge was 36.7kg, and overeating or self-induced vomiting was not observed during hospitalization. It was thought that close cooperation with psychosomatic physicians before surgery, and perioperative management for behavioral therapy led to good results.