Been a minute since I’ve given an update! A lot has happened in life since the last time I posted. We moved to the PNW and had to do sooo much to make this happen. Had to fix up the house, fix up and sell the RV, find a place and then move all our stuff up there! I can not believe I have had the energy to do all of this. And I have started back at work, and although I feel behind and a lot of work is hitting at once, it has been really good for me to feel like I am getting back to life and making progress.

I’ve had to take a break sometimes from thinking about my health (one of the reasons I haven’t been posting as often). It’s just been such a weird journey, I still have a lot of anger from all the years wasted on long treatments. I really wish I could have had this surgery sooner especially before my pain, breathing and ability to chew had gotten so bad. Was reading the other day about pain pathways and how difficult it can be to unseat them once they’ve set ( https://www.health.harvard.edu/blog/chronic-pain-the-invisible-disability-2017042811360 ). Now that I am working again and nerves have continued to wake up in my face, I have had some pain return especially to my sternocleidomastoid muscle, which was really painful before surgery too. I don’t really feel a lot in the joint area but that area is still fairly numb. I am trying new things with more natural pain management and just trying the best with the cards I’ve been dealt, and still really thankful that I am not in as much pain.

My posterior open bite is still open too, I was expecting to be done with my orthodontic treatment this month but need another refinement set. Not being able to bite down on my back teeth has gotten pretty annoying/ causes some of the pain.

Deviated Septum

My septum deviated within the first hour sometime after my jaw surgery (possibly from intubation removal, a 6.5 mm tube was used to try and avoid deviations like this), and my nose doctor believes it is also broken as well. Most likely “bend beyond repair”, so I will probably need an autologous rib graft but he doesn’t know for sure until he opens up my nose. I really hope he can use my existing septal cartilage, but “expect the worst and you aren’t disappointed” is what I joke with my family about. I am really thankful that there is a solution to this, my septum feels unstable/ the base is off the vomer bone and leaning into one nostril and just feels very awful on top of the issues with breathing that I have been experiencing.

I got 5 opinions from different ENT/Plastics doctors before deciding what to do. Let me tell you, I’ve learned from my jaw!! Never go with the first treatment option you are offered, always get second opinions! I have learned that noses are also intricate, and there is a 10-15% revision rate of work. Concerning but I’ve tried to yet again find one of the best doctors for this procedure, who also has a lot of experience working with maxillofacial surgery septum deviations.

It will be about a 4-5 hour surgery which was shocking to me (my full jaw surgery was 5 1/2 hours) and I’ll have a cast on my nose for about a week. First 3 days are the most pain then everything starts to subside. Apparently my nose will be really big for awhile and you don’t see your “final” nose for like 2 years or more!! Swelling is some serious bidness.

I also get to go straight home after and don’t have to be an inpatient (but wish I could be on some IV antibiotics for awhile to avoid infection, again like a 2-3% chance of this with open septoplasties).

Eating

I have continued to explore new and more challenging foods, it is difficult still with my open bite or maybe I just need to get used to the joints more? It is hard to explain, my back teeth also hurt from the Invisalign so I think this is a big part. Last week I was able to eat some harder bacon which was difficult (but worth it), and a few days ago I was able to eat a tender filet mignon. I still need to cut my food into pretty small bites and take my time with chewing. For some reason I think I was just expecting perfection with my bite and chewing after all these treatments and surgeries. I know my jaw will probably be a problem for the rest of my life, hopefully I can keep future surgeries at bay (or better yet, I hope I can keep these joints for the rest of my life! Again, not setting the expectation because expectation = disappointment sometimes)

Other Updates

First bite syndrome has mostly gone away for me, but not until recently. Grapes usually set it off I have no idea what’s up with that.

Most of the swelling is gone from my face now, but I do have some that is hanging out around my mid face I think near my nose (but not my nose itself).

Overall still very happy I found TJR as a treatment option, despite some of the set back I feel like I am making good strides and I am determined to live a good and happy life! Thank you to all who have given me such huge support during the last few years ❤ I will continue to post updates as I have them and hope this blog can stay up for decades to track my progress after treatment.

TJR Further Specifics

7 months post op | Swelling and Feeling :

1. Swelling
   • Midface has some residual swelling
2. Feeling–
   1. Bottom lip 100% back
   2. Palate 70% in front, Middle I can feel about 70%. Worries me a little that feeling hasn’t really made a ton of progress here. Front teeth are numb too.
   3. Below eyes 100%
   1. Skin over joints 80%
   2. Chin 100%, actually hyper-sensitized

Invisalign

I’m wishing I would have done braces now tbh. The invisalign created an instant open bite when I put the trays in at 4 weeks post op, and that feels terrible knowing that I had le fort relapse when my roots are so blunted anyways

The invisalign made sense, because I needed it anyways for SFOT and I already had the attachments and believed it was gentler on the teeth. I still think it can be gentler. It was also mentally better for me to cope over the last 2 years than to have visible braces for a 3rd time in my life. If my bite meets up and I lose no teeth I’ll probably go back to saying invisaline is amazing, it’s a very up and down journey!

Healing is not linear (thanks to Lindsey T. for sending me this photo during recovery, it has been my phone background to keep me thinking realistically!).

I always think I can make these posts shorter when I first set out writing, but that doesn’t always work out for me. The reader’s digest version of this post:

1. Last few weeks gaining muscle strength back and eating more difficult foods, better swallowing, getting used to how the joints feel.
2. Septum could not be fixed. Will have to have another surgery to repair this
3. TADS (screws in my mouth/gums) removed!
4. Got new invisalign trays and rubber band treatment instructions to close the posterior open bite
5. Have had some more pain in the 11th week/ a flare up now that nerves are more awake. Feeling good again now and thankful the flareup passed/ wasn’t too bad.
6. Mouth opening is now 35 mm, I will try to see if I can get to 38mm-40mm. (My family’s mouth openings are anywhere from 50-65mm for reference)
7. First bite syndrome since first week, not a huge deal to me and probably will go away?
8. I really love burgers and sandwiches 🥪🍔

---

The past few weeks have had their ups and downs, but I still have not had any major complications that have scared me, only minor ones. As I write this now, I actually had a huge stomach ache from how much I was able to eat at lunch 🍔, which is crazy to think about given where I was 11 weeks ago and the years and months leading up to needing this surgery. I’m so thankful for where I am at now, and that the hardest weeks of recovery are behind me. I will probably need to replace the joints a few more times in my life, and those recoveries will not be as difficult as this one (I only have to do the upper jaw surgery and genioplasty once for function). I am also thankful that I am getting back to normal life more quickly than I anticipated for myself!

As I’ve been feeling better I have gotten back to a more normal life balance. Cleaning, paying bills, yard work, creativity, working some, multiple renovation projects, grocery shopping and making foods that I don’t always need to blend! I have not eaten a soup now in 3 weeks and honestly can’t stand the sight of smoothies, nutrition drinks or soups. My diet has been a lot of burgers lately haha.

Here is a quick run down of the past few weeks post op😄:

• 6th week
  • Cleared for hard chew diet! This doesn’t mean that everything is back to normal and I can eat all the things, but rather a slow progression to building back up mastication muscle strength, figuring out how to eat with the synthetic joints and learning your current limits (given the le fort healing sensitivity/pressure and teeth feeling achy among other things). After not using my chewing muscles post-op (and the strain on some/ lack of use on others pre-op) the muscles atrophy. I lack some permanent bite force due to some of the muscles being detached during surgery (part of the pterygoids, permanent atrophy) and the masseter muscles having to be cut through and reattached, which is the main reason for the limited mouth opening after surgery – have to work though the scar tissue and stretch.
  • The le fort area (upper jaw) of my surgery was (and is) still very numb and sensitive in my central face. I also was experiencing slight headaches more often when I chewed.
    • If you think jaw surgeries are interesting too: A well detailed video on the le fort 1 – 1 piece (there are 3 types of le forts and different “pieces” on each of them that can be done, most TJR patients have the le fort 1-3 piece or le fort 1-1 piece). The second part of the video, sagittal split osteotomy, I did not have done. I have these fixation plates as well but mine are much smaller (Dr. Sullivan told me he helped develop the plates that he uses in surgeries). Crazy to think the boney part of the maxilla is just free floating like this after the surgical cut! The cut line perforates the sinuses, a huge reason we are all so congested after this surgery for weeks and weeks.
    • https://www.youtube.com/watch?v=R6rw24p_nAA&list=PLAWfjJVQJtihBZMeLgooY-40TL9rC5rJn&index=2&t=9s
    • (Xray of my Le Fort 1 plates and screws and how small they are)
• 7th week
  • I was able to visit my orthodontist and open my mouth just wide enough for the iTero scanner for invisalign to start on my refinement trays and rubber bands. This is all in effort to close my posterior open bite (most people need orthodontic work after TJR surgeries). I had a 22-25mm mouth opening so I was shocked we could fit the camera in my mouth (they had to take off the head for scanning the back molars is all). And thank goodness for the days of impression taking being over…I sometimes feel like I am living history of the evolution of orthodontic work.
    • (If we had to take impressions, it would have been months until I had the mouth opening and felt comfortable enough to have that sort of suction against my palate, lower jaw and teeth.)
  • The posterior open bite has been the next most challenging obstacle for chewing besides lacking the muscular strength. It has been somewhat jarring to go from ~15 years of an anterior open bite to a posterior open bite almost overnight.
  • ✨GOT MY 6 TADS (temporary anchorage devices) OUT! ✨ My gums/ soft tissue had grown around the bottom one and the other ones were uncomfortable on top of everything else I was dealing with. So thankful those were able to be taken out 😭❤️. Thankfully I was under anesthesia for this. I’ve heard from someone else it wasn’t so bad getting them out without anesthesia, but I am always thankful to have the option to not remember my medical traumas lol.
  • We were not able to fix my deviated septum under anesthesia. Huge bummer as my nose is slightly crooked and my breathing is about 50/50 out of my left nostril. Healing during allergy season has not been kind to me either….
    • I am meeting with 3 different nose doctors to get second opinions on this, since it is a complex high deviation (said the first ENT I went to) it doesn’t seem as straight forward as I was hoping it was. These appointments are in June and July. And I just always want 3 second opinions (at least) on any medical decisions I make, given the history of my jaw and always going with the first treatment a doctor recommended without fact checking them/ confirming their opinion. Lots of disagreement in the medical community on treating TMJ issues/ many treatments aren’t even evidence based!!
      • More on TMJ evidence based treatment: “Evidence based clinical practice guidelines for the treatment of TMJs do not currently exist, despite the fact that treatment is common. Evidence about the safety and efficacy of these treatments is sparse; many of the research studies that have been conducted are insufficiently powered to produce solid conclusions, lack appropriate comparison or control groups, are missing standardized outcome measures, or focus on individual interventions without the context of holistic patient care.”^5,6
• 8th week
  • Had enough bite force to bite into a McDonald’s burger. Didn’t need to tear it into small pieces either like I did pre op. Honestly, highlight of my year👌 and the start of my undying love for burgers.
  • 
  • I think this was the week that my swallowing was starting to become more regular and predictable, thus why I felt comfortable enough eating a burger! I realize now that some of the swallowing difficulty (besides having to relearn) was with swelling and tongue movement. Weeks 8-11 mouth swelling went down quite a bit! I think after TJR and not having lateral side to side movements of my mandible anymore, I had to start using my tongue more to move food around. This is just my experience, every case is different.
  • Still doing popsicle sticks at least once a day in the mornings to widen my opening (gotta fit bigger burgers in!) – I am at around 30mm at this point! I also yawn a lot, I consider that stretching too haha.
• 9th week
  • I’m still continuing to do 2 sessions with my craniofacial PT a week and once a week with my myofunctional therapist. I still haven’t gone back to my chiropractor yet, who helped me the last 5 years with my cervical spine issues that have resulted from my jaw health/ he helped me to manage some of the pain.
  • Now that I am eating more normal foods often, I have felt more energetic.
  • I did a lot of yard work and realized just how weak I had become!
  • 8th-9th week speech feels completely back to normal
• 10th week
  • Got my refinement invisalign trays from my orthodontist. The rubber band treatment is surprisingly more painful than the other 2 times I have had it in my past. My roots are so short and I think everything is just inflamed.
  • 
  • Eating is getting easier. I can bite into/chew tortilla chips now and have had cheese and ritz crackers!!
  • I am having more low grade headaches than I did post op, which I think correlate to how much more I am eating/chewing and definitely the rubber bands are contributing.
  • Got another burger – look at that bite mark! My diet is consisting of mostly bad food but it has been nothing short of aaaamazing and I have loved every second of eating food without much of the pain! I bite into everything just for fun and relish every bite. I’ve been so hungry. I’ve actually had a couple of upset stomachs from eating too much!
  • I feel well enough now that I am starting to cut back on appointments and therapy that manage pain levels and exercises.
  • My bite opening is now at 35mm! Let’s see if we can get it to 40! 35-40mm is the average/general goal that Dr. Sullivan sees his patients get to after these surgeries.
• 11th week
  • Ate 3 sandwiches this week 🥪🥪🥪 (blended bacon and cut up into manageable bite sized pieces! Still a little too difficult to bite into).
  • Had more pain this week – unfortunately, old pain patterns returned in my neck and shoulders, though not to the extreme levels that they once were. As I am introducing more stress back into my life/ not resting as much, I am not entirely surprised. My facial nerves are also starting to wake up as time goes on, so I am more aware of pain now. Luckily it was just a 2-3 day flare up and I think wearing my rubber bands more often, sleeping wrong, chewing more and stress all contributed. This was also the week I decided that I was doing so well and didn’t personally need craniofacial PT anymore – figures!
  • Smile still feels tight, I am hoping it softens more in the coming weeks

Focusing on

At this point, I am just focused on,

• CHEWING: Continuing to chew more difficult food items, slowly. I’m still blending baked chicken and more difficult foods.
• INVISALIGN: Closing the posterior open bite, and rough estimate will have ~4 more months in invisalign and rubber bands – that’s not much!
• NOSE: Getting my nose looked at to correct the septum. I think it is smart to wait maybe a few more months for this (it would be best to wait a year for alllll my swelling to go down, but I don’t personally feel I can wait that long breathing like this).

I am not sure what can cause the posterior open bite… I think it is different for everyone and I have read before that the le fort can settle a little/ my teeth roots are so short that my teeth seem to move around pretty quickly too. I was not able to wear my invisalign trays for 4 weeks after surgery because I could not open my mouth wide enough to put in my trays. I know that this type of open bite has happened to other TJR people, so I don’t feel so alone. Just wish that I had more teeth root for stability! Which hopefully the SFOT surgery provided enough of last May 2021 with the bone grafting.

First bite syndrome

I also don’t think I have mentioned this yet, but since the first week after surgery I have experienced something called first bite syndrome¹ , another friend I talk to regularly has this as well. Sometimes when I bite into something (especially the first 2 meals of the day), I have this short lived pain near where my condyles used to be, very similar to the pain levels of a moderate brain freeze at its strongest lasting 3-5 seconds. It usually happens more strongly when I eat something really savory or sweet. “…result from damage to the sympathetic innervation of the parotid gland leading to parasympathetic overactivity”² I hope this goes away, reading more about it seems to suggest that it can calm down but takes time. Botox injections can also be administered, but mine is so mild I don’t think I would even do that. Something I will be asking my surgeon about next time I see him.

---

TJR Further Specifics

11 week post op | Swelling and Feeling :

1. Swelling
   • Intraoral swelling is down
   • Swelling around the area of my TJR is down more, under my eyes is still pretty puffy from the le fort. This is probably my area of greatest swelling
   • Chin swelling is massively down now
   • I am sleeping on my side comfortably now
2. Feeling–
   1. Bottom lip 95%, middle of lip is numb and lacks some sensation
   2. Palate 70% in front, 100% in back, middle seems to have lost more feeling somehow? Or more likely, that I can feel the rest more it feels more numb. Middle I can feel about 40% I would say.
   3. Below eyes 95%
   4. Cheeks 100%
   5. Skin over joints 70%
   6. Chin 70%

Invisalign

Per my last post about invisalign possibly contributing to posterior open bites³ (thanks to Micaela in the ICR group for pointing this out!) – I talked to my orthodontist about this. Thankfully he understands invisalign well (is currently the top provider in Arkansas⁴) and he said that this is usually not a problem that he has to correct. He said that often times the back teeth “erupt” to fill the distance. Another orthodontist online said that the front teeth can be tipped slightly too to close the back teeth. Overall, I am still very thankful for the invisalign. I had to have it anyways for the SFOT surgery to fully control my dental arches/ expand them with exactness. I really like not having braces as a 30 year old, I think mentally I would not have handled traditional braces well for a 4th time. I also feel like there are slighter/gentler adjustments to the invisalign. Remembering braces, the wire would be really strong the first few days, just a concern for me personally with my blunted teeth roots – I feel like Dr. Roblee does very small adjustments to each tray so that I don’t feel a lot of pain from them.

Lateral side to side motion

I know I got to keep more of my pterygoid muscles than others (since my resorption went on for 20 years or so, the muscles moved anatomically down my jaw bone to find attachment😳 so he didn’t need to cut out as much condyle on me – there was just not much left to cut out!) but I just do not have much lateral side to side movement. Maybe 1mm to the left and 1mm to the right, but I hate moving my jaw in that way now against the prosthesis. It just feels wrong! So I don’t even try and stretch it to gain more movement. I don’t feel like I need it anymore now that chewing has gotten easier just from practice.

Most surprising things to me at 11 weeks post op

• I am amazed that I feel as good as I do. Still getting back to normal, but I am definitely very functional now! Healing is a long game, and the biggest hurdles of my healing were in the first 6 weeks.
• I’m surprised by the weird feelings in my le fort and not being able to feel the middle of my palate. My upper teeth are still numb too, I tap on them and don’t feel anything/ have been whitening my teeth like crazy without the consequences.
• Yawning is slightly painful, esp on the left side that used to be my worst side. Part of the pain is stretching the masseter muscles.

Update vlog on progress, talking, exercises etc:

https://youtu.be/iaW7c0CSzKA

---

Links:

1. https://pubmed.ncbi.nlm.nih.gov/22573579/
2. https://medicine.uiowa.edu/iowaprotocols/first-bite-syndrome
3. https://orthodonticteaching.com/news/prevention-and-treatment-of-posterior-open-bite-with-clear-aligners#:~:text=Posterior%20open%20bite%20is%20often,or%20a%20lack%20of%20overjet.
4. https://robleeortho.com/invisalign/
5. http://tmj.org/wp-content/uploads/2020/12/NAM-Report-on-TMD.pdf
6. https://tmj.org/living-with-tmj/treatments/

In a nutshell – these last 2 weeks I have spent my time on increasing my mouth opening, enjoying my new soft chew diet 😄, working on proper swallowing and tongue placement with a orofacial myologist, getting better at speaking (starting to sound like my old self), lymphatic drainage massages from my craniofacial PT, considering what to do on my deviated septum and working on posture. There have been ups and downs and I constantly have to remind myself that I am still just 5 weeks post-op!

I am constantly reminded that I had jaw surgery, either from my mouth that has a limited opening or the pressure or lack of sensations I feel within my mouth or around my face. I woke up this morning actually forgetting that I had had jaw surgery, until I got up and started moving around. But it was nice for awhile 😉. I constantly am needing to give myself grace for what feels like very slow progress at this stage post-op. But I also am very thankful for most of my past pain not being here – I would take the post-op discomforts to my worst days of pre-op pain any day for sure.

I have also been able to have some limited hang outs with family and some friends, so I have been happy that I am able to do this 4-5 weeks after surgery! Everyone understands I won’t be talking a whole bunch and it is nice to just be surrounded by loved ones. Thankfully it has been warm here too.

Soft chew diet!!

This is probably the biggest news I have!! March 18th I was cleared to a soft chew diet – but it wasn’t as quick and easy as the moment I was dreaming of. My mouth opening was still just 10mm on March 18th (due to the surgeon having to cut through the masseter muscles you have to work through that scar tissue and re-stretch that area on the muscle. I had to do the same thing on my bilateral fat graft diskectomy in 2016 – different muscles.) and the moment I placed food in my mouth it felt like I had a robot jaw. I couldn’t move side to side just up and down, one of the drawbacks of the prosthesis and losing part of my pterygoid muscles –these have to be cut out – they attach to the condyles so when the condyles are removed, the muscle can not be reattached to the prosthesis. In my case – I had had ~20 years of ICR, so my pterygoid muscles had actually moved DOWN my jaw over the years. I got to keep part of them! (The rest of the muscle is detached and atrophies over time). Which means I have a few mm of side to side movement. I don’t enjoy trying to move side to side though because of the resistant forces I feel from the prosthesis if I move more than that 2-3 mm, it doesn’t hurt, per say, but you feel the plastic fossa pulling against your skull on one side and the titanium on the mandible on the opposite side pulling. Same thing if I push my mandible forward I can do this about 1-2mm but it feels wrong. My facial muscles are also still in a state of spasm sometimes just post-op issues from everything being moved to a new location on my face and stretching out so many of the muscles that had been shortened over the last 10 years especially – so this makes makes them upset sometimes too. This is another reason you have to wear the rubber bands, in order to train your lower jaw on where to sit. It sounds strange but since I had a le fort (maxilla was moved up 6-8 mm I think and 5 mm forward) I don’t have a lot of feeling in my upper teeth or palate still! So the muscles kind of freak out a bit. I am also at the lowest weight that I have been at since I was 14 years old with my scoliosis surgery but I think I will be more able to gain weight now with all the pasta I am eating ☺️

Ok, without further ado, here was my awkward first “soft chew” bite (it was weird… but I had Anita Baker and my dad cheering me on). This was really difficult to do, the mechanics of chewing and swallowing with the new joints and throat/mouth space. So I was very proud of myself and thankfully it was just basically me and my dad at the restaurant.

https://youtu.be/y4STx2CONJs

Swallowing

Once I started my soft chew diet I started to have more swallowing and muscle issues. All feel mostly resolved now as I am writing this thankfully, but I had an orofacial myologist evaluate me on my 4th week post op. Wish I would have met with her before surgery…we are curious now if I had a backwards swallow which would have been slamming my condyles against the back of my fossa all these years. Paula knows her stuff and has worked with many TJR patients before – I am very thankful for her expertise! (I do facetime consults with her since we live in different states http://orofacialmyologist.org/paula-fabbie/ )

She taught me how to properly swallow, now that I had the correct mouth and throat space to not have to be “compensating” anymore. Old muscle memory dies hard, esp for me apparently. I have not talked to many others who had as much difficulty swallowing lasting weeks post-op. So we worked on swallowing and tongue placement the 4th week post-op. This is when I started to experience a lot of muscle spasms. The worst of it only happened 3-4 times, but it got so bad that I couldn’t swallow at all for hours at a time. And even if I was doing nothing it felt like my muscles were all fighting and pulling my mandible around in every direction possible, which it can not do anymore! I had to put my bands back on during the day time when this happened. Part of the problem was I had stopped taking the klonopin as I was feeling less pain – but coming off of it too quickly has it’s own problems, and I have been taking it for years now to manage the muscular pain. So I am tapering off of it, and my muscles have calmed down a lot. I have continued to practice my correct swallows and take the medicine and it has not bothered me much since!

Mouth Opening

I have been working with popsicle sticks to get my mouth opening larger. I am adding about a new popsicle stick every 2-3 days. In the beginning it is probably faster to get a larger mouth opening, but we are aiming for 35-40mm. Right now I can open 20mm. I imagine my fast progress might slow down as I approach 30mm. I have heard this takes months, and I practice opening as wide as I can at least 2-3 times daily. I also have other PT exercises I work on, myofunctional therapy (shared in my jaw vlog), and thumb exercises. I still have to go in 3 times a week for my thumb, and unfortunately might need another surgery for it . So that is disappointing. How many surgeries can you safely have in a one year time span? I feel like it is a job in and of itself remembering to do all of these exercises, research things still and go to all my appointments.

Energy Levels

For 4-5 weeks post-op I feel like I am doing pretty good! The 4th week I was still pretty tired but this week I have run lots of errands and been ok, but at night things start to get a little sore in my prosthetic joints (fossa and mandible area) and I feel more pressure behind my skull from the le fort. Allergy season doesn’t help. I still think I am sleeping better with a larger airway, so I still feel so much less fatigued than I used it. Even a friend commented that I was much more “here” recently. It is great to wake up feeling more refreshed and that it lasts through the whole day! I think some of my anxiety levels have even gotten better with proper sleep, however I am still very anxious about my jaw and my septum. Meal time is still anxiety provoking too – but overall I think I have improved, outside of normal post-op anxiety! Sometimes I have noticed that I become overwhelmed easily, but I think that is also understandable.

Deviated Septum

I went to an ENT doctor to get a second opinion on my septum and he said it is a complex deviation (he also looked in my ears and asked “Can you hear me??” I was like “…umm, yes?” and he proceeded to pull out of both ears a massive blood clot! I couldn’t believe it. I could hear so much better after he extracted both. Gross!). The septum is impacted from my maxilla and is high and far back. I also had a previously deviated septum, which I didn’t believe until I saw the cut in my past CBCT scan. But now it is REALLY deviated. This doctor wants to reduce my enlarged turbinates, fix the septum and also have a board certified plastic surgeon in on the surgery to help make sure that the septum/ nose goes back to being completely straight afterwards. I talked with my surgeon about this, and after some consideration I am still going to have him try to reposition it next week. He says that it will not mess up any future ENT work on my nose – but if I could do anything to help me breathe better now it is worth it to me. The ENT doesn’t want to operate for another 3 months! Plus I need my TADs (screws in my mouth) removed – and I would reeeeeally like to be under anesthesia for that anyways. One has now been completely enveloped by my gums and tissues and is painful, while another one is fighting off being covered. I can not WAIT to get these things taken out.

It will also help my lips to meet, which I am also working on with the myofunctional therapist. Apparently this doesn’t always go back to normal and has to be worked on too since these muscles become shortened and trained in an open mouth position if you have a large open bite like I had before the surgery.

Posture

I thought that my body would right itself once I had this surgery – it did some, but I still have some residual forward head posture and very rounded shoulders from how my body was trying to compensate before in order to open the airway. The myofunctional therapist and physical therapist are helping me work on this right now, hoping to help ensure the stability of my new joints! I think I will go back to my group pilates class next month if I am cleared by my surgeon to help my posture and my scoliosis.

Prayer Requests🙏

Some people have asked how they can be praying for me,

1. Pray for the new muscular pain/tightness underneath my mandible to get better
2. Pray for continued healing and lack of complications from this surgery
3. Pray that my septum would go back into place during my operation next week so I can breathe better, and that there would be no le fort complications from this! Just my anxiety making me nervous on this last part.

---

TJR Further Specifics

4-5 week post op | Swelling and Feeling :

1. Swelling
   • I can’t tell if swelling is down. Still puffy in all the areas that were operated on!
   • I stopped sleeping with my wedge pillow the 5th week because of my scoliosis it was becoming uncomfortable/ I was sliding down at night. Instead I stacked 2 pillows for my head and have a thin pillow under my back.
   • I have been sleeping on my side more and waking up to more jaw pain in the mornings… hard for me to sleep on my back.
2. Feeling–
   1. Bottom lip 95%, middle of lip is numb and lacks some sensation
   2. Palate 60% in front, 80% in back. Nothing has changed here.
   3. Below eyes 70%
   4. Cheeks 90%
   5. Skin over joints 50%
   6. Chin 50%, yay progress!

I don’t know if I said this in a previous post or not, but my le fort stopped cracking I think the 3rd or 4th week so thank goodness! I still feel a lot of congestion/ pressure, but that seems like that is here to stay for awhile. I’m not really using my humidifier anymore.

Invisalign or Braces?

Some others have been noticing that I don’t have braces! We had to do a specific type of orthodontic movement in order to align my teeth correctly for my total joint replacement. My teeth roots were so blunted from my other 3 times in braces that we were worried I would lose teeth during this process/ my final occlusion would be less stable. So I did SFOT May 2021 (surgically facilitated orthodontic treatment/therapy) in order to move my teeth and it was best in my case to use invisalign to expand the arches and move the teeth.

I personally think invisalign is gentler on teeth roots with an orthodontist who uses invisalign often. Dr. Richard Roblee makes very small changes on me from tray to tray, so I feel confident that we are doing everything we can to keep my teeth. I still need ortho work post op as my teeth are not all hitting on the left side. Dr. Roblee told me to wear extra rubber bands on the left side TADs in order to try and intrude the right side teeth more. Hopefully my last intrusions ever 😭. 3rd time’s the charm. Not much left to intrude.

I was able to still fit in my last invisalign tray on the 4th week post op (with a 15 mm mouth opening, I had to use tweezers to pry it off as my fingers couldn’t fit in my mouth still! Still have to use the tweezers 5 weeks post-op) teeth had moved but I cut up my top and bottom invisalign tray further so that they would flex more to fit. I also shaved down part of my invisalign attachment with a drilled nail file 🤦‍♀️, my upper canine was hitting hard on it and causing my occlusion to be off even more and that tooth to be more loose from the contact. You do what you gotta do!

A note on invisalign vs. braces: Most surgeons will prefer the braces. They can fixate the dental and skeletal whereas with me my surgeon could only fixate my skeletal post op. The TADs also tend to get covered by gums and tissues and are more painful to take out after surgery.

***Edit: It has also come to my attention from talking with other ICR friends that clear aligners can sometimes cause a posterior open bite³, of which I am just realized I am struggling with on both my R and L sides. I placed my aligners in 15 days ago and now have noticed the right side opening up since then. I meet with my orthodontist next week to discuss!

Muscular Issues

I’ve experienced more muscular pain (new muscles than pre-op) in the red areas circled below.

I keep massaging them but I am surprised that these muscles didn’t hurt until 4-5 weeks later. Just part of surgery and having my jaw moved 22-24mm I guess. Also, just note, whatever your muscles are doing now might carry over into your post TJR jaw. I used to yawn towards the left, I guess because my left joint was more broken down, and I had this same muscle memory after surgery and have been working on equally strengthening both muscles and getting them even. So don’t be surprised if this happens to you!

Muscles and posture don’t always automatically reset! The surgery helps but this all takes time, I am coming to find.

ENT Visit

After your surgery – do yourself a favor and get your ears checked by an ENT. I had those huuuuuge blood clots in both of my ears that I was not aware of! The ENT pulled them both out, both were about 1.5-2 cm long and as wide as my ear canals 😓. I could hear so much better after this. My ear drums were fine thankfully 👍 He couldn’t see all the way down into the left ear canal as that one is still pretty swollen from surgery. The TMJs are crazy close to your ears.

https://youtu.be/XnEObPnFn9U

✌️

---

Links

1. https://www.craniorehab.com/average-jaw-mouth-opening#:~:text=In%20studies%2C%20MMO%20for%20adults,and%20women%20to%2045%2D55mm.
2. https://www.perioimplantadvisory.com/clinical-tips/surgical-techniques/article/16411515/surgically-facilitated-orthodontic-therapy-sfot-maximizing-case-outcome
3. https://orthodonticteaching.com/news/prevention-and-treatment-of-posterior-open-bite-with-clear-aligners?fbclid=IwAR3mEmouSFl-RFApC3Qv8zRK0Zi33PGnGziNtLjglz4bPzdB1IQvp3ndnVI#:~:text=Posterior%20open%20bite%20is%20often,or%20a%20lack%20of%20overjet

It feels like it has been an eternity since my surgery 21 days ago. I feel like I am in some sort of time warp, the days have gone by quickly but at the same time I feel like I should be further along. I often times have to be reminded by Rick and my family that my surgery was just 3 weeks ago (if I am getting down about the difficulty I have with eating, congestion from the le fort/septum still, weird feelings in my face, and a myriad of other things.)

Rick and I went to the movies tonight to celebrate 3 weeks post op/ much needed date night. We saw the Batman movie, and it felt nice to feel good and actually feel up to doing some eye makeup!! And feeling “social” without the environment being too overly stimulating/ needing to talk to people.

I will say, I have stayed pretty positive throughout this whole thing, way more than I thought I would… partially because the anxiety leading up to the surgery was over and that was such a relief. It was just DONE. Then I saw a lot of progress the first 1.5 weeks. And now I feel like I have kind of plateaued in my progress. Some of my friends who had this surgery within 2 weeks of me say the same thing. I haven’t seen any real big changes in anything and my brain is still ahead of my body, leading to some frustrating and difficult moments for me.

My brain wants to go meet friends but my body has low energy and weird heart rate things happen to me/ exhaustion from the meds and my body healing.

My brain wants to work on the RV or retake cello lessons, but manual labor and using my left thumb (injured) are difficult for me. I just bend over and I feel like my face is going to break from the muscular pulling/ pressure and I get dizzy.

My brain wants to go on walks but my body can only get so far and the cold air HURTS like nothing else. Once the masseter muscles start chattering it is very painful. Ricky had to put his jacket around my face just 3/4 of the way down our block and we scurried home. The dogs are mad that they aren’t going on walks, so their judgement doesn’t help either 😉. If you are reading this right now and are having a summer TJR surgery, that is better!!

My brain wants anything tasty at all, like even just a blended sand-which or blended meat again, but my body is still struggling to swallow pureed smoothies and soups + my maxilla is still fusing to the skull so no chewing is allowed. I am also starting to feel nauseous from the liquid foods and just long for something more solid. I hope my surgeon clears me for scrambled eggs or something next week when I see him. I started crying today from watching someone eat a hot dog, it just smelled so good. Hard to even watch people eating on TV! I usually lose about 6-10 lbs with any jaw/ mouth surgeries I have had, so I have lost about 7 lbs now and am trying my best to keep my weight up. But it’s difficult – my body just doesn’t get hungry a lot anymore, which is maybe an odd thing to hear but it’s been this way for about the last year or two of my ICR issues. It’s like I have trained myself to be this way. Eating is just so unenjoyable and the fear of pain I have associated with food probably still has a large foot in the door with me (it is still hurting now to eat but that is from stretching my limited mouth opening if I am trying to fit a spoon in my mouth. Also add in the fear of choking due to my swallowing issues and we have a real complex mental and physical situation going on here. I don’t feel dramatic at all anymore in saying this, this is real and this is hard.) Swallowing has gotten better slowly at least.

I also do miss my ability to move my jaw side to side. With the joint prosthesis, I can only move up and down. I used to move my jaw laterally to release muscle tension, and it feels like I still need to do this but am unable too. It is so strange to lose this ability. But in light of all that I get back (sleeping better, less future chronic pain, less headaches, ability to functionally eat) it is a small and worthy price to pay. But I just miss it now in the moment.

Also, look at these oxygen readings for the month of March! I can breathe, I can breathe!

Dealing with some anger and difficult emotions

Throughout this week dealing with my own frustrating healing process and talking with others online in my situation, I’m emotional about how there are TMJ exclusions on many insurances and feel a deep sadness for my friends who are struggling to get coverage and struggling with other comorbidities associated with their TJR or TMJs. Just lots of struggle and pain, and most of us are really young and already just beaten down by life it feels like/ many I feel lose hope. This is a pretty good summary video by the TMJ Association of some of the issues we face, or this article as well https://www.ncbi.nlm.nih.gov/books/NBK558001/ . I do wish this video were exaggerating the complications and pain levels but from my own experience and countless other stories I’ve heard, it’s really not 😢.

https://www.youtube.com/watch?v=yVii-b68lPo

I was actually looking at CH Ministries the other day (a group share insurance program, because I am so tired of dealing with regular insurance which tends to think any jaw issues are only cosmetic or not really needed for health. Nothing gets me more angry these days.) So then I come across this on CH Ministries guidelines,

It’s just such a slap in the face to all of us who have been through so much. I would much rather have gone through so many other illnesses that insurance covers than go through the last 15 years of my life again of mixed TMJ treatments, medicines, and surgeries to end up worse off than ever with a bilateral total joint replacements in my jaw now – which may or may not be covered by insurance. Yet a hip, shoulder or knee replacement would most likely be covered and not questioned. I still do not know how much my insurance will pay for my procedure and that is frightening. They approved it, but often times with TMJ issues they do this to then code bundle and low ball you, and the fact that they “approved” it makes some other appeal options out of my reach actually. It’s really messed up and they are pretty tricky. They did this to me on my last jaw surgery.

I’ve also struggled to use my thumb this week (got out of my splint for it last week), which I fractured and tore a ligament in over Christmas and needed surgery on. Even with going to physical therapy 3 times a week, I am just not getting my movement back in the knuckle of my thumb, so I have been disappointed with this outcome as well. I just feel like I keep breaking. With these emotions, plus thinking of my friends plus thinking of my own issues I’m struggling with I just had some very overwhelming days this week. I was driving and crying after one of my doctors appointments and just pulled up to some random church to go inside and pray and express to God how difficult this has all been. I don’t feel the need to be in a church to pray but I just needed to be there for some reason that day and have some quiet so I could think. I know He cares for me but many times I just feel radio silence. I thought about a framed photo of a little bird that my late grandmother had hanging in her bathroom. It had Matthew 6:26 on it, which says,

“Look at the birds of the air; they do not sow or reap or store away in barns, and yet your heavenly Father feeds them. Are you not much more valuable than they?”

Other Updates this past week

Swallowing

• My swallowing has maybe improved some? It still feels freaking weird. I’m swallowing a lot of air and my mother-in-love told me this is what newborns do a lot, which I thought was funny 😂 I am kind of a newborn trying to figure out how to eat and talk haha. I’m getting some feeling back in the back of my palate which I think helps me to tell where my tongue is, where a pill is in my mouth, or where a bulk of pureed mess is so I can move it to the back of my throat. The front of the palate is still very numb.
• I have linked up with a myofunctional therapist at the recommendation of one of my other TJR friends, and thankfully this therapist is with 👏  it 👏 . Much like all the other amazing doctors and therapists that have taken a long time to add to my health team. And she has worked with many TJR patients to improve swallowing, tongue placement, speaking and lip placement post-op of these very intricate surgeries. I was worried to go to someone in Dallas like a feeding or speech therapist because I am just so tired of wasting time and money on appointments and doctors that do not understand this condition. And that is totally fine, I know what I have is weird and rare – but I have also had a horrible experience through the medical system and that is very valid. So when you find these kinds of therapists and doctors, you get really excited.

Physical therapy

• We are just doing some lymphatic drainage for now since I am just 3 weeks post op. Helps to just move swelling and other things out from the surgical area, and just feels nice ☺️. And I love my PT so it is always nice to just catch up with her as well.

Le Fort cracking noises

• Best part of this week – on Wednesday I noticed I had no cracking for the first time!!! I think when I swallow it still suctions up and down a little bit, but not near as much as it was doing before. I started really getting serious about taking,
  • Vit D₃
  • Calcium
  • Vit C
  • Tons of protein
  • Vit K
  • Collagen powder
• And I think this has all helped my body to really start healing that fracture. I was so freaked out about this beforehand, a few people were saying the cracking lasted months for them – so I wouldn’t be surprised if it came back but so far so good 🙌
• I am working on a separate article now on my supplement research, I’m hoping to have sort of a TJR Resources section on my blog soon to talk about topics that I have learned about throughout my journey, such as items to have prepared, questions I asked surgeons, mental health, and topics to discuss with caregivers. The ICR facebook group has a lot of this as well in the hub❤️ https://www.facebook.com/groups/IdiopathicCondylarResorption/permalink/1410214152644481

Infection Scare

I write this in the sense that I know I tend to be an “alarmist” sometimes. I look at the small risks and become really afraid of them. I am the 5% of bad TMJ disorders⁵ and probably even a smaller subset than that and I was the 10% group of my diskectomy that failed (according to a percentage Dr. Piper gave me, unsure what this number is if a research study were to be done). I’ve also gotten infections after my scoliosis surgery in 2007 and after my palate expander was placed in Nov 2020. So, I might be an alarmist, but I feel justified in it sometimes!

• Sooo I ended up getting a really bad acne breakout on my back, which I don’t like even writing about this but I’m uploading pictures of my mouth every day so whatever – like really bad breakout that was starting to spread to my face. So I just curiously looked up “surgery and acne” links, and literally the first two articles I found were on the link between P. acne and prosthesis infection (Chances of getting a TJR infection are 1-4.5% – more so 2.5% being the average, depending on the article you read^1,2,3, would require a re-operation and a brand new joint ordered, probably a 6 month wait! It was my greatest fear going into this surgery – that or just aseptic loosening without reason). So I messaged my surgeon like “Here are these articles, I’m just freaking out right? Lol?” And he said “Let’s put you on doxycycline and spironolactone to get this under control”. So I got kind of freaked out and also went to an acne care specialist for extractions (wish I wouldn’t have done the extractions now, some of them bled, which leads to my next bullet point below), a chemical peel and bluelight therapy along with a dermatologist to see what was going on. She thinks (and one of my other friends figured it out too) that it was the steroid pack that caused this acne party, which makes sense because it also messed up my cycle. So at least we know where it came from!
• And luckily P. acne is more of an intraoperative concern than it is postoperatively (so it is good to try and get your skin around your face cleared up a few months before surgery I think). It could be introduced via the incision rather than a late stage blood transfer of P.acne, which is also suggested in the article at the bottom of this post, otherwise I don’t know why my surgeon would have called in doxycycline and spironalactone to get it under control instead of something like rifampin⁴.

Pain Levels

• Past pain patterns: My old pain patterns are STILL not presenting themselves!! I am so happy about this!!!!!! I figured out now that I am on the other side of this, that my MANDIBLE was pressing hard on all my neck muscles, it was so far back on my neck from losing the 75% of my condyles on both side over the last 20 years. It was probably causing most of my radiating pain in the final years. Joint pain was starting to get worse as well, but it wasn’t as “searing” as it was in 2016 before my fat graft diskectomies.

• Surgical Pain patterns: It really just depends on many variables – If I have multiple appointments that day/ have moved a lot
  – How I slept
  – How much I have talked, eaten or moved
• Generally I am still taking half a norco, 1-2 klonopin, 1/2-1 trazodone at night and an ibuprofen to manage my pain during the day. I still have not gotten the new pain medicine from my pain management doctor (insurance hold up, not surprised).
• I would say I still have some boney pain wherever the prosthesis is screwed into my skull or mandible, and “phantom” joint pain if you will, my face just feels tight and kind of sore all over, my teeth still hurt when they touch sometimes and I have shooting pain twice a day in one tooth 😬, temporalis muscles and scalp are still sore but only notice if I touch them, sinus pressure and congestion is still bad from the deviated septum and just the le fort itself.
• At night everything just kind of hurts, muscles, bones, then I kind of “Reset” with sleep but wake up a little uncomfortable too and take ibuprofen/ norco/ or klonopin right when I wake up.

Occlusion:

• I have noticed more and more than the right side of my bite meets but not the left. I will definitely need some work once I can get my mouth opening up to 30mm is the goal, I am hoping for a more normal 38-40mm if I can. Normal jaws can usually open 40-45mm if I remember correctly. (right now I can only open 10mm, enough to squeeze a pill or force a baby toothbrush in). I try and open my mouth and let the lower jaw hang to try and stretch out these muscles, I still have not been given any exercises officially though. Maybe next appointment with my surgeon we will discuss this

• Have a zoom appointment with my orthodontist next week as well where I plan to talk to him about the concerns on my bite and my concerns over the scanning device they use in their office, I had trouble fitting it in my mouth even when I could open wider. I worry that it might have trouble fitting into my mouth. I would NEVER want them to force it as I always have to be gentle on the joints, they run the risk of popping out of the socket although rare, would require surgery to pop it back in or most likely a new joint would have to be ordered. I really hope that Stryker/TMJ Concepts waiting list goes from 6 months to 3 months real quick!

Posture

• I have now been told by various people and a doctor that I need to be doing some posture exercises, given that my neck was craned forward for years in order to open the airway, apparently this doesn’t always go back to normal. So will take some work. I am barred from T1-T12 as well so I have no natural curve in my thoractic spine anymore.
• With how overwhelmed I feel about everything else, I am going to go for progress over ✨perfection✨ on this one. That might just be my new motto.

TJR Further Specifics

3 week post op | Swelling and Feeling :

1. Swelling
   • Swelling is down a little more – kind of show in my vlog below my puffy areas
   • Genio area and cheeks are most swollen

https://youtu.be/XVRgQOm0vvw

1. Feeling– in % of what I can feel (ex: 99% have the feeling back in my lips) – also this is very arbitrary and everyone’s anatomy and surgical cuts are different. I’ve heard feeling comes back even years later sometimes,
   1. Top lip 100%
   2. Bottom lip 90%
   3. Palate 60% in front, 80% in back
   1. Below eyes 60%
   2. Cheeks 85%
   3. Skin over joints 50%
   4. Chin 30%

https://youtu.be/4_-tlIduzYU

---

Citations:

1. “Avoiding and managing temporomandibular joint total joint replacement surgical site infections”, https://pubmed.ncbi.nlm.nih.gov/22883323/#:~:text=The%20infection%20incidence%20within%202,2%20weeks%20to%2012%20years.
2. “The occurrence rate is less than 2 % with greater risk for patients on immuno-supressant medications such rheumatoid patients or others with connective tissue/autoimmune diseases”, https://drlarrywolford.com/tmj-temporomandibular-joint-disorders/total-temporomandibular-joint-tmj-replacement-2/
3. “Alloplastic reconstruction of the temporomandibular joint”, https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5750826/
4. “Propionibacterium acnes: from Commensal to Opportunistic Biofilm-Associated Implant Pathogen”, https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4135900/
5. Individual and Societal Burden of TMDs ( really great article!!) , https://www.ncbi.nlm.nih.gov/books/NBK558001/

Today it has officially been 2 weeks since my surgery, but it feels like it has been 2 months. So much has been packed into the past 2 weeks.

We drove back home late on Wednesday night and got the dogs back, so that was a nice treat to come home to (thanks to my awesome in-laws, sister and parents for baby sitting!). They still recognized me which was good 😉.

Coming home

Being home now, it has kind of set in what a long recovery this will be. I feel like I was making great strides and the fact that I wasn’t in bed all day with pain just made me so happy. I think my brain is getting ahead of itself wanting to get back to the “normal” I have so longed for, meeting friends, eating without difficulty in restaurants and at home, enjoying talking and laughing without the pain in muscles, back teeth and joints. But my body really did just go through a major trauma from this surgery so it feels weak and wants to lay on the couch all day and continues to have facial pain from the surgical movements. Wish my body were up to speed with my brain🧠. Going to do one thing a day, like seeing my pain doctor today, is probably all I can manage for a while as it took some energy to muster. But I drove myself the 20 min there, talked to my doctor and drove back home so I was proud. And I think it will take small steps like this to get back to life faster – so I plan to push my body more in the weeks to come to go on walks, stretch my stiff face, practice opening and closing my mouth to get a larger opening, etc. It just feels all very overwhelming in this moment.

My pain doctor wants to put me on a new medication to manage the surgical, teeth and muscular pain that I have, and will probably continue to have, as nerves wake up and my body heals itself. My teeth still hurt when they touch, so I tend to keep those apart too. It is just a new face/ skull with new sensations but I accept it as my own and give myself grace and love through this time in my life of healing ❤️ as I have done before with my other jaw surgeries.

Mental resolve with these kinds of medical issues that effect how you eat, socialize, breathe and laugh is as much a physical game as it is a mental game. I’ve told my husband before this almost feels like a “social” disease because it completely impacts how you are able to interact and build relationships with others. I am so thankful for the medicine that has helped me manage for so long, but ultimately it was a bandaid beginning to fall off. It is easy to get really down about all of this and the amount of time that it has gone on while I remained hopeful on other treatments. Sometimes a good cry is needed. Yet ultimately, it is necessary to pull yourself up, keep going and keep hoping. This is the life I have been given and I will live it to the best of my ability. I am thankful to live in 2022 where I have options to deal with my ICR and was able to receive this surgery, I have had a successful surgery so far with little complications and I am showing signs for continued healing and a good prognosis 🦾.

Right now my complications are,

1. A deviated septum that I can hopefully get fixed by May (requires another surgery). It is making my left sinus congested and causing ear pain from the congestion. I really hope I don’t develop a sinus infection as I don’t know if that could negatively effect the Le Fort. I stay on top of my sudafed and afrin.
2. Cracking sounds in my 1 piece Le Fort as I swallow 😖. Not really a “complication” but more of the healing process, but I can only find 2-3 other patients online currently who had this happen to them too. My maxilla was cut away from my skull and repositioned, needing to fuse back to the top of my skull. So this tells me it is not fusing in the area with cracking. I talked to one patient long ago that had non-fibrous union (her le fort never fused), so I know it is a concern. But my surgeon said mine should resolve. So I try not to worry but it is so unnerving to swallow…on top of it already being really difficult to swallow correctly.

So if you can pray for the 2 complications above, that would be great! And for continued healing, bite opening progress and for my anxiety levels through this whole process to stay low.

Thank you all for the continued encouragement, support and messages! My families and Rick are taking good care of me ❤️

https://youtu.be/vCRD-AcZjXw

---

For those considering TJR

 (or just want to keep reading)

2 week post op | Swelling and Feeling :

1. Swelling
   • Same from what I wrote a week ago – face near joints and under eyes and cheeks are still swollen and puffy but going down, most swollen part is around the genio area.
   • Bruising is all gone now

1. Feeling– in % of what I can feel (ex: 99% have the feeling back in my lips) – also this is very arbitrary and everyone’s anatomy and surgical cuts are different. I’ve heard feeling comes back even years later sometimes,
   1. Top lip 99%
   2. Bottom lip 90%
   3. Palate 60%
   4. L of tongue 100%
   5. Below eyes 50%
   6. Cheeks 85%
   7. Skin over joints 40%
   8. Chin 15%

https://youtu.be/na4ub0t6yr0