Your Questions

Q: Dr. Eppley, two years ago I had jaw advancement and sliding genioplasty surgery. Although my face symmetry has improved dramatically, this surgery has left me with lower lip incompetence. There is a 5mm to7mm gap between my top and lower lip when my lips are in resting phase, and although I have no evident mentalis strain when I force my lips to close, I would like to know if anything can be done to correct this lip incompetence. I have read that mentalis resuspension can work but I am not sure if this applies to me as I do not know the source of my lip incompetence (though I suspect it has to do with the mentalis muscle). Please see a before and after picture demonstrating the change in my lower face shape/size as well as my lower lip incompetence. 

A: Any lower lip repositioning  downward after any intraoral procedure that involves an incision inside the mouth at the chin area disrupts the mentalis muscle. Whether the muscle was adequately resuspended or not I would have no idea. But when the lower jaw is advanced combined with a sliding genioplasty, the amount of soft tissue to cover over the chin may simply have become ‘inadequate’ or stretched. This is reflected in the lower lip position which is affected by being pulled downward. Whether you can overcome the lower lip position by mentalis resuspension alone is suspect. That alone is unlikely to hold the lower lip upward and reduce the incompetence. This is a problem of tissue deficiency not just one of tissue malposition. The mentalis resuspension would have to be combined with other maneuvers to have chance of success. The addition of dermal-fat graft on top of the muscle suspension and a V-Y mucosal closure would be needed to end up seeing any improvement in your lip incompetence.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I have a problem with the mentalis “balling up” when I try to elevate my lip after having a genioplasty. Prior to the genioplasty I had an indentation (not really a cleft but a small ridge) in the lower middle of my chin, this since is gone and simply looks like a ball of tissue when I elevate my lip (at rest it looks okay). I did consult with a local surgeon over a year ago who then performed a mentalis resuspension. This showed some improvement but afterwords, due to still having the “balling” found out that he never fully released the mentalis and he’s recommending releasing the entire mentalis and resuspending again. I’ve been doing some research about mentalis resuspension. One technique goes intraorally to do a wide release of the mentalis but also makes a small incision under the chin until the mentalis is completely released. Once the mentalis is fully released it is suspended intraorally and then the chin pad is anchored rom below. Do you think this will work? My main objective is to reduce (or eliminate if possible) the balling effect, hopefully returning that nice indentation (which I feel is the main reason the area balls up) and hopefully reducing my lower teeth show (full competence would be nice however I’d be happy with a mere improvement). Please let me know if this is something that you perform and if it’s something you’d feel comfortable with.

A: As you know there are different variations and extent of mentalis muscle releases. Depending upon how much the mentalis muscle is released will determine how much it can be resuspended. The mentalis muscle has its origin on the bone in the incisive fossa of the incisor teeth superiorly and inserts inferiorly into the skin of the chin. (not really the bone on the bottom of the chin) It is the insertion point of the muscle that actually contracts and pulls the skin upward. Thus when you are talking about a balling up of the muscle when you elevate your lower lip, that suggests that the problem may be exactly the opposite of what you think. I would question with your history if releasing the whole insertion of the mentalis muscle from below is really going to correct this balling up issue. Rather that anatomically suggests that the balled up area of muscle may represent the fact that the insertion point of the muscle in that area has been lost. However given that it is very difficult to re-establish a long-standing disinsertion point of the mentalis muscle (chronic scarred muscle contracture) the only real effective option may in fact be complete mentalis muscle insertion release. This does require a submental incision to really fully release it properly. Once fully released then it would have to be resuspended intraorally.

That is a long answer to say that this full mentalis muscle release and resuspension would be the only hope of eliminating this balling up issue even though it is ‘anatomically incorrect’ when you look at how the muscle moves and its origin and insertion points. That most certainly could be done under a sedation and local anesthesia approach like before.

Dr. Barry Eppley

Indianapolis, Indiana