Background: Throat packs are commonly used in oral surgeries to prevent accidental aspiration or ingestion. However, a forgotten throat pack can be the cause of serious postoperative complications.Although plenty of recording and warning methods have been applied, such incidents are still reported from time to time. Lack of striking marks or communication within the team is the main cause of a forgotten throat pack, and extubation before checking the number of gauzes will likely cause the throat pack to remain in the body. After literature review, quite a few related cases and precaution are available for searching, yet there is no standardized process for the use of throat pack in orthognathic surgery at present.Case Description: This article reported a case in which the throat pack was lost and retrieved relying on the good teamwork and imaging methods. The patient was a 26-year-old female undergoing bimaxillary surgery for skeletal Class III malocclusion. The throat pack was missing after wound closure. Under the guidance of maxillofacial computed tomography (CT), the throat pack was found in her right nasopharynx, the patient was extubated and recovered uneventfully.Conclusions: This paper reviewed the use of throat packs and its iatrogenic complications, summarized the experience based on this case and earlier literature, and formulated a standardized process for using a throat pack in orthognathic surgery.