Q: Dr. Eppley, Just wanted to follow-up with you regarding my Mentalis Muscle Resuspension Surgery. I wanted to makes sure I understood what you told me during our consultation. You made the following points:
1) That my chin and lower lip sag are “fixable”.
2) Based on my chin x-ray, you said that the screws were placed
way too low to fix my issue. You would place screws much higher
between tooth roots
3) Also you would dissect a much larger area (under and around
the chin) to get enough lose skin to pull up and overcorrect issue as
there will be some sagging after surgery
4) And during the operation you would be able to place my head in
an upright position so you can confirm that my lower lips are way
above my bottom teeth before you attach the anchor then after
attachment confirm it has been raised high enough.
5) Lastly you recommended a V-Y lower lip mucosal
What kind of results have you had with similar situation as mine? Do you usually have good luck?
A: Correction of a sagging chin and lower lip is challenging and the best results come when every available technique is done for it. The entire chin tissues must be mobilized and the anchorage point for the muscle must be high with a screw(s) placed between the tooth roots. While this can lift sagging chin tissues, it does not always guarantee that the lower lip will end up elevated. Raising the lower lip is very difficult to sustain and that is why I usually perform a soft tissue elevation/roll out of the lower lip as well. Reattaching the mentalis muscle higher is no guarantee that it will push up the lower lip. It may seem that way when one pushes the chin tissue up on the outside with their fingers but it does not work that way in surgery.
My experience has been with these techniques that everyone gets improvement but it is the lower lip position that can remain the most incomplete part of the repair.
Dr. Barr Eppley
Q: Dr. Eppley, I am in desperate need of finding the right person to help me with mentalis resuspension. I had two previous chin/genioplasty surgeries at least a year ago and my biggest fear is not being able to close my lips together without strain or headaches. The first surgery was a chin implant under the skin, the second surgery was done by an different surgeon who did a removal of the implant and performed a genioplasty of about 8 millimeters of my bony chin moved forward intraorally. The last surgery was done to correct the ptosis or wrinkling of the chin by the same surgeon a year later by putting in a button chin implant. The result was horrible and was removed a couple of months later and me not being able to close my mouth without strain was the after effect. I’m so depressed…I have thousands of photos where you can tell I’m trying to close my mouth or trying to make it not noticeable that I can’t function like a normal person anymore. I regret the surgeries trying to reach perfection and now I lost the ability to just do a simple thing of closing the mouth without strain. I have been turned down by surgeon’s either because they don’t see a problem or don’t think it’s anything that can be done. Please give me options. So far your the only one I hear about that has enough knowledge in this area.
The photo’s here are examples of myself trying to take nice picture’s but as you can see every photo my lips are open. That is the best I can do as far as closing my mouth without really forcing myself but when I do the last picture describes it…it’s tight as if I’m sucking on a sucker and it’s very uncomfortable.
A: Thank you for providing the pictures and a detailed explanation of your chin surgery history. What you have is some lower lip retraction, tightness and chin dimpling. These problems can not be corrected by a mentalis resuspension as you really don’t have a muscle displacement issue. Your chin tissues are scarred and do not have the flexibility that they once had after several surgeries. I do not see that invasive surgery will provide any significant relief and may likely even make it worse or at least no better for the effort. My suggestion is that of fat injections using PRP. The tissues need to be softened/scar reduction and to try and get some suppleness back into them. This can be combined with V-Y mucosal advancement of the lower lip. This approach is my opinion has a better chance of improvement than trying to release and reposition the scarred mentalis muscle.
Dr. Barry Eppley
Q: Dr. Eppley, I have a question about mentalis resuspension. Can you explain what is the procedure you perform and what is the percentage rate of success. I have heard that this procedure will never restore the lip position back to normal (prior to when the injury occurred). I also heard that most of the time the lower lip descends back to its malposition (as though the mentalis resuspension never occurred) within the first couple of months after the mentalis resuspension procedure.
A: I am not sure where you have been getting your information about mentalis resuspension and under what circumstances or techniques that it is performed. There is a difference between uplifting the chin tissues from an injury vs attempting to alter a naturally low/genetic chin ptosis. Soft tissue sag of the chin has a higher success rate when its origin is that of an injury. The best mentalis resuspension technique uses suture anchors that can adequately lift and maintain the position of the muscle until they heal to the bone. The success of mentalis suspension is also enhanced by a concomitant V-Y mucosal lengthening procedure done at the same time which is helpful for improving the horizontal position of the lower lip. These are some general concepts and I would have know more about your particular chin problem to know how they may apply.
Dr. Barry Eppley
Q: Dr. Eppley, I have chin ptosis after the removal of a large chin implant. So what needs to be primarily done should be a mentalis resuspension. I am considering sliding genioplasty despite the risks of bone osteotomy, longer surgery time, and longer recovery time, only if it helps the result of the mentalis resuspension procedure. If genioplasty would have any negative effect or no effect on the mentalis resuspension procedure (i.e. more bleeding, swelling, more complications than the resuspension procedure alone), I would not want to have it done.
My question is, first of all, regarding [mentalis resuspension alone] vs. [mentalis resuspension + sliding genioplasty], would there be any difference in the result concerning the ptotic chin and lower lip disturbance? If there should be no actual difference, then I probably wouldn’t want the sliding genioplasty done due to longer recovery time and more risks. But, if the genioplasty should give any positive effect, I should consider it be done along with the mentalis resuspension procedure.
Secondly, my implant insertion and removal were both done by intraoral approach. Should the mentalis resuspension procedure be performed by intraoral approach again?
Lastly, you have mentioned the disruption of the attachments of labiomental sulcus as the cause of lower lip eversion disturbance. By the “attachments of labiomental sulcus”, do you mean the mentalis muscle attachment to the bone? Or is there any other muscle involved in this area? Does labiomental sulcus muscle repair simply mean resuspension of the mentalis muscle? Are there any other muscles that should be repaired to fix the attachments of labiomental sulcus?
A: The mentalis muscle suspension is infinitely improved by the concomitant sliding genioplasty as this procedure addresses one anatomic element that intraoral suspension does not…excess skin and subcutaneous tissues. Bone-occupying volume expansion with muscle tightening addresses all the issues of the ptotic chin problem.
The intraoral approach has disrupted the superior attachements of the muscle and, if only the mentalis muscle resuspension was going to be done, then you would do an intraoral approach for repair.
Labiomental sulcus disruption means the complete loss of superior mentalis muscle attachments. That is addressed in the intraoral mentalis muscle suspension procedure through the use of bone anchors.
Dr. Barry Eppley
Q: Dr. Eppley, I had a chin implant removed and my chin muscle sags now. Because the initial surgery was fraught with infections and complications, my chin muscle was cut into four more times after the first surgery. Doctors tell me now, 4 years later, that the chances that I could have my chin muscle reattached higher, where it used to be, is slim. Since there is very little of anything left to sew into, I’ve been told that they could try and drill screws near the nerves of my bottom teeth and try to attach something that way, but this is unlikely. Is there a surgeon out there who has dealt with this same issue successfully? I am desperate to get my face back. There must be some way to reattach my chin muscle!! Help, please!
A: Reattachment of the mentalis muscle is very possible. The key is to have a stable method and non-injurious place to attach the muscle/scar. This is best done with micro-suture anchors that are designed to be very small (1.5mms) and can be placed over (in between) the roots of the lower anterior incisor teeth. I have found this technique to be successful, regardless of how many times the mentalis muscle has been re-entered.
Despite re-attaching the mentalis muscle, complete improvement of the sagging chin pad may not still be obtained. The implant may have created some extra chin tissues through expansion that a combined submental tuck-up may be needed as well to get a tight redraping of all of the soft tissues over the convex chin bone. Whether this approach to you revisional chin surgery is needed would require photogtraphs and an examination to determine.
Dr. Barry Eppley
Q: Dr. Eppley, about six months ago I had a medpor chin implant inserted through an intraoral incision and secured with screws. Unfortunately, the wings were too large and malpositioned. I had a revision one month ago in which the implant was removed, trimmed and re-inserted. Now the implant is the right shape and size, but my lower lip feels shorter and tighter. The top halves of my lower teeth show with the lip at rest, and I can barely raise it enough to cover them. When raised, the lip is lower in the center than at the sides. After the original surgery I had the same problem but not as bad, and the lip eventually went back to normal. This time the lip seems worse, and I’m worried it might stay this way. My Dr. said getting the medpor implant out was “very difficult” and it took twice as long as he expected. The implant actually broke when he took it out and he added 2 extra screws to hold it together when he re-inserted it. My chin and lower lip where very swollen for two weeks afterward and the center of the lip is still slightly numb. I’m worried I might have a problem with my mentalis muscle. Does my lip issue sound like something that will go back to normal on its own or like something that will require correction? Thanks for any advice.
A: In your history you have said the key words…intraoral incision. When using this approach for chin augmentation, the superior bone attachments of the mentalis muscle are cut and have to be resutured at the end of the procedure. Besides the numbness,, it is common to have some lower lip tightening and little tethering until the tissues heal and relax again. Going through the muscle twice, particularly in a more extensive revisional procedure, traumatizes and scars the muscle again…making symptoms of tethering and lower lip retraction more significant. It is too early to tell whether this problem is temporary or permanent. If it has not significantly improved by three months after surgery then I would recommend a mentalis muscle v-y lengthening and resuspension procedure.
Dr. Barry Eppley
Q: I had a sliding genioplasty just one month ago in January 2011. It was advanced 8mm and I feel it was too much. I do not like how my chin looks. It is not a natural look. I also lost almost 2/3 of my lower lip which make the chin even bigger. It really has changed me a lot. I was wondering what can be done to recover the fullness of my lip. I am even considering a reverse genioplasty to bring it back to 5mm even though the cephalometric analysis says that I am short 9 mms. How long should I wait for a revision and any further interventions?
A: Now that you are roughly 6 weeks out from your initial chin surgery, most (but not all) of the swelling should have subsided. While there is some final swelling and stiffness of the chin that needs to go away in the next few months, that will only change the chin projection by maybe 1 to 1.5mms. Therefore if you feel the chin is too strong at this point, then it is and your decision to set it back some more is reasonable. A change from 8mm to 5mm is reasonable since it takes at 2 to 3mms to really see any difference. The time to make that change is NOW. The bone is not yet healed and it is a relatively easy plate and screw exchange to do the revision.
When you say you have lost ‘2/3s of my lower lip’, I am assuming you mean that you have a drooping lower lip otherwise known as lip incompetence or sag. Unlike chin swelling where time will make some of it go away, time will not lift up a sagging lower lip. This is a function of the mentalis muscle position/resuspension on the chin bone. To imrpove that situation, the muscle need to be lifted up higher in the bone and secured. This will help the lower lip get back to a more normal position. The sooner this is done the better as muscle scarring is occurring. So again, NOW is the time to revisit this with your surgeon and have these discussions.
Reversing/revising the effects of a sliding genioplasty are best done early before complete bone and soft tissue healing has occurred.
Dr. Barry Eppley
Q:I am looking at having a revision surgery on my chin for what I believe is a partial non-attachment of the soft tissue to the hydroxyapatite implant. Some of my chin hang independently from the rest and looks aged. My surgery was two years ago. I am contacting you because I see you have specific knowledge of the intricacies of chin surgery. Could you give me some information about what I should do now and whether you have dealt with this problem before?
A: Thank you for your inquiry. Before I can answer your questions specifically, let me get some details as to your chin surgery from two years ago. You refer to having a hydroxyapatite implant placed. Since there are no off-the-shelf hydroxypatite implants of which I am aware, I assume that this was an intraoperatively carved one that was done from a block of material. Furthermore, I am assuming that it was placed intraorally (through the mouth) as opposed to under the chin through the skin.
Your description of your concern’s sounds like what is known as a ‘witch’s chin deformity’, otherwise known as soft tissue chin ptosis. There is where the chin soft tissues sag off of the end of the bone/implant. Because any type of chin implant augmentation must detach the muscles, there is that risk after surgery although it almost exclusively occurs from an intraoral approach.
Please send me some photos of your chin and provide answers to my questions, then I will be able to confirm this diagnosis. I have seen this numerous times and the appropriate correction (implant notwithstanding) in most cases is a mentalis muscle resuspension procedure.
Dr. Barry Eppley