Chin muscle repair after genioplasty

[ODog]

Alright this is a tricky topic and probably nobody will know anything about it but you never know...

So I had a DJS and genioplasty 7 months ago. Everything is good except I have this extreme lower lip stiffness/ frozen feeling that has persisted. I have numbness too, but surface sensation. The sensation has improved as time has gone on, the stiff feeling is exactly the same. The PROBLEM I have with this stiff feeling is mostly that it affects my speech and my lower lip feels like it lacks proper mobility. It both feels uncomfortable to talk and I sound more garbled than pre-op.

This is not in my head. I have had clients at work ask me at 6 months post op how my recovery is going, and when I say fine but my mouth is really stiff, they say, “I noticed.” So it’s an objective problem, not subjective or in my head.

The surgeons I consulted in Canada, including Cameniti, say that the tightness is from nerve damage; it’s from the nerve playing “tricks.”

However I connected with somebody online who has had similar issues as me and she recommended an Indian craniofacial surgeon who claims he can help. His Instagram page is here: https://instagram.com/drsunilrichardson?igshid=a1l97ihgqgt9

According to Richardson, he has been doing revision genioplastys for patients with these issues since 2002. He has sent me 2 surgery videos of such cases where the patients complained of speech issues post genioplasty and were cured after he revised. He claims he can offer me huge if not total relief.

I think he believes there are 2 main causes of this tightness in the lower lip and chin: fixated plate impinging on the muscle, which many of us know of, or accidental incarceration of the muscle complex of the chin, which is something I’ve never heard personally.

He has said to me, “mental nerve damage only causes numbness, not stiffness.”

After reviewing my scan, he said the screws wouldn’t be an issue with me because they are very small, but it’s more about how the segment was brought forward. He continued: “ Usually I see what’s called a incarceration of the muscle or the muscle complex when patients have such complaints. And it’s not visible on scans... but can be felt on examination.”

This means he would repair the damaged chin muscles. I have done a CBCT scan and will have the results sent to him Monday for further review.

The problem is, I’m not sure I feel comfortable getting a revision done in India. The surgeon seems very confident he can help me, and he’s the only one who’s even suggested some kind of solution other than “blah blah blah scar tissue” or whatever.

Does anyone know if any American or Canadian surgeons KNOW HOW or have experience with repairing a damaged chin muscle from genioplasty?

Because I’ve never heard of this issue EVER, and I’m sure none of you have either. But then why has Dr. Richardson been doing these revisions for almost 2 decades? Does he know something other surgeons do not?

[ODog]

FWIW it seems it’s the Orbicularis muscle just below the lower lip that is the origin of this stiff feeling (see attached picture), not the mentalis muscle.

I’m not sure who to believe: the surgeons who say it’s nerve damage or Dr. Richardson who’s says it’s an incarcerated muscle.

Evidence for the former is that the NERVES feed into the orbicularis muscle, so perhaps damaged nerves can indeed cause problems with the muscle itself including movement and sensation. Also, apparently there are cases of “stiffness” after wisdom teeth extraction, which would suggest that nerve damage CAN cause a stiff sensation.

Evidence for the latter is that there are so, so, so, so many cases of lower lip/ chin NUMBNESS post-BSSO/ genioplasty but no complaints of stiffness. The question then becomes, why is this problem so rare? Perhaps the nerve damage is SEVRE AND thus causes stiffness. Well, the person I connected with online doesn’t have severe numbness, but does have significant stiffness that has ruined her life. So that’s strange. Is it the type of nerve damage? Or is it additional muscle damage that gives rise to this feeling?

Hard to say when everyone gives you a different answer.

[GJ]

Did they rule out the hardware pinching the muscles and/or scar tissue around the hardware?

[kavan]

Did they rule out the hardware pinching the muscles and/or scar tissue around the hardware?

hmm...good question..could be that hardware pinching the muscle is same/similar as incarcerated muscle...muscle 'trapped' in the hardware?   .....just googled 'incarcerated muscle' and all I got was inmates in prison doing work outs.

[ODog]

Did they rule out the hardware pinching the muscles and/or scar tissue around the hardware?

He took a look at my X-Ray and said the screws wouldn’t be an issue for me personally. Some people have large plates there, mine are tiny screws. Although if I do do the revision I can ask him to take them out anyway. He didn’t say anything about scar tissue around the hardware; I believe Zuniga in Dallas is the person to see about that? Apparently he has a special imaging technique to assess scar tissue.

If by “they” you mean my surgeon/ Caminetti, they didn’t really say much of anything. My surgeon said “you probably have a lot of scar tissue and need to massage it” but that’s bulls**t. This is not a scar tissue problem. Caminitti said “Removal of plates/ screws won’t do anything and that it’s a nerve issue.”

Richardson from India is the only one who’s even mentioned “incarceration of the muscle.” Which feels right to me, and he’s very confident. When I pressed him and said the Canadian surgeons all claim it’s nerve damage he seemed a little annoyed and said “I have been revising cases like this since 2002. I know what I am talking about.”

Personally, I don’t think any surgeon would speak so confidently about something they are unsure about. It’s not a big money surgery for him either, between 3-5000 USD.

[ODog]

hmm...good question..could be that hardware pinching the muscle is same/similar as incarcerated muscle...muscle 'trapped' in the hardware?   .....just googled 'incarcerated muscle' and all I got was inmates in prison doing work outs.

LOL oh boy.

[ODog]

Here’s my scan. You can see that the screws are small and according to my surgeon fixated directly to the bone, not over the muscle, so it’s probably not causing impingement. I don’t have any plates.

https://imgur.com/a/kbO8kWl

He wanted me to get a CBCT in order to see the full anatomy better. But regardless he did say the damage doesn’t come up on scans but “can be felt on examination.”

[kavan]

Alright this is a tricky topic and probably nobody will know anything about it but you never know...

So I had a DJS and genioplasty 7 months ago. Everything is good except I have this extreme lower lip stiffness/ frozen feeling that has persisted. I have numbness too, but surface sensation. The sensation has improved as time has gone on, the stiff feeling is exactly the same. The PROBLEM I have with this stiff feeling is mostly that it affects my speech and my lower lip feels like it lacks proper mobility. It both feels uncomfortable to talk and I sound more garbled than pre-op.

This is not in my head. I have had clients at work ask me at 6 months post op how my recovery is going, and when I say fine but my mouth is really stiff, they say, “I noticed.” So it’s an objective problem, not subjective or in my head.

The surgeons I consulted in Canada, including Cameniti, say that the tightness is from nerve damage; it’s from the nerve playing “tricks.”

However I connected with somebody online who has had similar issues as me and she recommended an Indian craniofacial surgeon who claims he can help. His Instagram page is here: https://instagram.com/drsunilrichardson?igshid=a1l97ihgqgt9

According to Richardson, he has been doing revision genioplastys for patients with these issues since 2002. He has sent me 2 surgery videos of such cases where the patients complained of speech issues post genioplasty and were cured after he revised. He claims he can offer me huge if not total relief.

I think he believes there are 2 main causes of this tightness in the lower lip and chin: fixated plate impinging on the muscle, which many of us know of, or accidental incarceration of the muscle complex of the chin, which is something I’ve never heard personally.

He has said to me, “mental nerve damage only causes numbness, not stiffness.”

After reviewing my scan, he said the screws wouldn’t be an issue with me because they are very small, but it’s more about how the segment was brought forward. He continued: “ Usually I see what’s called a incarceration of the muscle or the muscle complex when patients have such complaints. And it’s not visible on scans... but can be felt on examination.”

This means he would repair the damaged chin muscles. I have done a CBCT scan and will have the results sent to him Monday for further review.

The problem is, I’m not sure I feel comfortable getting a revision done in India. The surgeon seems very confident he can help me, and he’s the only one who’s even suggested some kind of solution other than “blah blah blah scar tissue” or whatever.

Does anyone know if any American or Canadian surgeons KNOW HOW or have experience with repairing a damaged chin muscle from genioplasty?

Because I’ve never heard of this issue EVER, and I’m sure none of you have either. But then why has Dr. Richardson been doing these revisions for almost 2 decades? Does he know something other surgeons do not?

India has history of highly advanced civilization. I believe they were the ones who did one of the first rhinoplasties and also came up with the forehead flap to replace nose tissue lost when someone had their nose cut off. The also have history of what's called here 'alternative medicine' and a lot of maxfax papers are written by doctors in India. North America (US and Canada) don't arise from advanced civilizations. So, if you have funds to travel there, why not. Besides, they have a lot of Indian food there.

[ODog]

India has history of highly advanced civilization. I believe they were the ones who did one of the first rhinoplasties and also came up with the forehead flap to replace nose tissue lost when someone had their nose cut off. The also have history of what's called here 'alternative medicine' and a lot of maxfax papers are written by doctors in India. North America (US and Canada) don't arise from advanced civilizations. So, if you have funds to travel there, why not. Besides, they have a lot of Indian food there.

I may have no choice so I’m not saying I WOULDN’T go, but it is at the other end of the earth. I‘ve never even been to Europe. I’d ideally prefer a NA surgeon, ya know? Not sure why, feel safer maybe. Not that I doubt this surgeons competence; quite the contrary actually. Seems like he does jaw surgeries plus a whole bunch of complex craniofacial surgeries, which most jaw surgeons do not do.

It’s not really a money issue. It would be the same price or more in the US save for maybe $1000 on the flight cost.

I guess the reason I’m asking if that before I commit to this surgery in India I would like a surgeon here to AT LEAST confirm that this type of revision could be beneficial to me. I’m just wondering why no Canadian surgeon would even think of this problem in terms of it being of “muscle damage” etiology. I mean if they dont even think of it in those terms, there’s no way they can fix it either.

[kavan]

I may have no choice so I’m not saying I WOULDN’T go, but it is at the other end of the earth. I‘ve never even been to Europe. I’d ideally prefer a NA surgeon, ya know? Not sure why, feel safer maybe. Not that I doubt this surgeons competence; quite the contrary actually. Seems like he does jaw surgeries plus a whole bunch of complex craniofacial surgeries, which most jaw surgeons do not do.

It’s not really a money issue. It would be the same price or more in the US save for maybe $1000 on the flight cost.

I guess the reason I’m asking if that before I commit to this surgery in India I would like a surgeon here to AT LEAST confirm that this type of revision could be beneficial to me. I’m just wondering why no Canadian surgeon would even think of this problem in terms of it being of “muscle damage” etiology. I mean if they dont even think of it in those terms, there’s no way they can fix it either.

maybe there is another name for it. maybe 'incarceration' refers to a SUTURE locking the muscle up.

[ODog]

maybe there is another name for it. maybe 'incarceration' refers to a SUTURE locking the muscle up.

That’s very true. It could be the suture, and that’s what Richardson means by “incarceration.”

However I looked over his conversation with the person I connected with online and he said this:

“Yes the issue is with the muscle being incarcerated with the implant (plates & screws) or the bone cut.”

So incarceration could ALSO be from the cut alone.

Referring to her case (she had large plates and screws fixated) he said: “The plates and screws will need to be removed. And the muscles that are getting pulled and stretched need to be fixed.”

I’m curious how he fixes an incarcerated muscle. Sure if it’s caused by the plates then removal and re-stitching might solve the problem. But if it’s due to what he said above, the “bone cut,” which appears to be the case for ME, I wonder how he would fix the muscles ? 

Because he doesn’t elaborate beyond that WRT the “how-to” for obvious reasons and which I respect.

[kavan]

That’s very true. It could be the suture, and that’s what Richardson means by “incarceration.”

However I looked over his conversation with the person I connected with online and he said this:

“Yes the issue is with the muscle being incarcerated with the implant (plates & screws) or the bone cut.”

So incarceration could ALSO be from the cut alone.

Referring to her case (she had large plates and screws fixated) he said: “The plates and screws will need to be removed. And the muscles that are getting pulled and stretched need to be fixed.”

I’m curious how he fixes an incarcerated muscle. Sure if it’s caused by the plates then removal and re-stitching might solve the problem. But if it’s due to what he said above, the “bone cut,” which appears to be the case for ME, I wonder how he would fix the muscles ? 

Because he doesn’t elaborate beyond that WRT the “how-to” for obvious reasons and which I respect.

Ok, the muscle is imprisoned by something. It could be stuck between the bone cut...then 'sandwiched muscles'...so maybe he pulls out the meat between the bread.

[PloskoPlus]

I don’t know, man. I had the same stiffness on right side of my UPPER lip and have most surface sensation. I just think it was nerve trauma that my fat surgeon inflicted on me, which was simply too great to recover from and the stiff feeling is simply how it manifested itself. I mean some people have weird like touching the lip feels like touching the chin - the nerves recovered in a weird way. Get your dentist to inject anaesthetic. If your stiff feeling gets worse, it’s probably the nerve.

[GJ]

Here’s my scan. You can see that the screws are small and according to my surgeon fixated directly to the bone, not over the muscle, so it’s probably not causing impingement. I don’t have any plates.

Yeah it's usually those butterfly plates that cause issues. Regarding scar tissue, he should just be able to look at the lower lip to get an idea of what's looming below...you can even look yourself. Is there a lot of scar tissue (white, weird looking) inside your lower lip? Scar tissue can cause the symptoms you're describing, so I'd rule that out before considering anything else.

[DRIVVEN]

FWIW it seems it’s the Orbicularis muscle just below the lower lip that is the origin of this stiff feeling (see attached picture), not the mentalis muscle.

I’m not sure who to believe: the surgeons who say it’s nerve damage or Dr. Richardson who’s says it’s an incarcerated muscle.

Evidence for the former is that the NERVES feed into the orbicularis muscle, so perhaps damaged nerves can indeed cause problems with the muscle itself including movement and sensation. Also, apparently there are cases of “stiffness” after wisdom teeth extraction, which would suggest that nerve damage CAN cause a stiff sensation.

Evidence for the latter is that there are so, so, so, so many cases of lower lip/ chin NUMBNESS post-BSSO/ genioplasty but no complaints of stiffness. The question then becomes, why is this problem so rare? Perhaps the nerve damage is SEVRE AND thus causes stiffness. Well, the person I connected with online doesn’t have severe numbness, but does have significant stiffness that has ruined her life. So that’s strange. Is it the type of nerve damage? Or is it additional muscle damage that gives rise to this feeling?

Hard to say when everyone gives you a different answer.

I think this is more common than you think.  I have talked to several people with this problem. Before getting any procedure or revision in the area, I suggest getting an MRN, its an MRI of the nerves.  It can show nerve entrapment and muscle problems. I had this done, and the images are nothing short of amazing.  Also, there is EMG muscle testing where they can test facial muscles—they do this in stroke patients. I totally believe that the surgeon can diagnose muscle entrapment as it feels totally different than normal tissue, but i would want a nerve and muscle assessment if possible.  Since the facial nerves in the area innervate those muscles, I would want to know if part of it is due to nerve damage. An MRN would also show scar tissue—remember in additional to the external scar tissue, there could be INTERNAL scar tissue surrounding that area. John Zuninga in Dallas is one of the few  in the country that does this imaging and he also does nerve testing (including the block described by PloskoPlus) Having this information would give you a better idea if muscle repair would help. The link below involves the shoulder but it described the imaging.

https://www.sciencedirect.com/science/article/pii/S0378603X16300171