Perioperative pulmonary edema is a rare complication of maxillofacial surgery. However, this potentially fatal complication may arise during any maxillofacial surgery. Negative pressure pulmonary edema can be caused by upper airway obstruction after operation. When this phenomenon arises, if not treated properly, it progresses rapidly causing fatal outcomes. Because orthognathic surgery is performed mostly on healthy and young patients, surgeons and anesthesiologists might neglect the possibility of such complications. Therefore, we must always take into consideration the possibility of negative pressure pulmonary edema. Careful observation of the patient; accurate knowledge; and active, quick, and noninvasive safe measures are required to treat this malady when it does occur. We report a case of negative pressure pulmonary edema after orthognathic surgery and its successful treatment.

The surgery-first approach indicates that the orthognathic surgery precedes the orthodontic treatment, whereas the orthodontics-first approach indicates that the orthodontic treatment precedes the orthognathic surgery. The conventional approach is an orthodontics-first approach. The purposes of this article are to introduce the concept of the surgery-first approach and to report the guidelines for orthodontic management and model surgery without presurgical orthodontic decompensation. The surgery-first approach treats facial esthetics first and then occlusion, whereas the conventional approach treats occlusion first and then facial esthetics. The surgery-first approach uses osteotomy to solve both skeletal problems and dental compensation, and a \"transitional\" occlusion is set up postoperatively. Orthodontics in the surgery-first approach is a postoperatively adjunctive treatment to transfigure the transitional occlusion into the solid final occlusion. The advantages of the surgery-first approach are that 1) the patient\'s chief complaint, dental function, and facial esthetics are achieved and improved in the beginning of the treatment; 2) the entire treatment period is shortened to 1 to 1.5 years or fewer depending on the complexity of orthodontic treatment; and 3) the phenomenon of postoperatively accelerated orthodontic tooth movement reduces the difficulty and treatment time of orthodontic management in the surgery-first approach.