Lip Biopsy — What to Expect

Gross photos warning ... pics are small, if you really want to see them close up, click on the pics.

For the last 9 months, I've had constant lower facial numbness and asymmetric swelling of my lips — it may be a sarcoidosis thing. So eventually my immunologist ordered a lip biopsy for me, for joy. Mainly to see if there is any need to increase my medication. It's worth mentioning that every nurse and doctor I mentioned the biopsy to shuddered.

I had the biopsy last week. The oral maxillofacial (OMF) surgeons did a professional job, and were nice guys, but they really didn't prepare me in any way for the recovery period. And any hospital information sheets I found online mentioned 'some discomfort' after the local anaesthetic has worn off. LIES!

So I thought it might help others if I document about what to expect during and after a salivary gland / lip biopsy.

Before

I had an initial appointment with the OMF team a few weeks before the procedure.

On the day of the procedure, I took 10 mg of diazepam — let's just say I was a tiny bit anxious about the whole thing. I started on prophylactic antibiotics, too, but that's unusual — this was because I'm on heavy immune suppression already, and have an artificial hip (which is always at risk from infections). It's not typical for most patients.

During

I was seated in a reclining 'dentist's chair' sort of thing, and given sunglasses to wear (to block out the bright light), and my body was covered by a sterile green sheet. Then I was given three injections of local anaesthetic, into the lower lip, inside, down near the gum — right, middle, and left. They stung a bit, and were a bit painful, but bearable. Then I was left in the chair for 10-15 minutes while the anaesthetic worked its magic.

The biopsy itself took about 15-20 minutes. One surgeon held my lower lip out, and the other carefully cut out 5 salivary glands. Then he put in a row if stitches, which was very neatly done (no cut ends of thread sticking out into my mouth, everything was tucked away nicely). The incision was about 1 cm long, vertical, near the front of my lip. It didn't bleed all that much, either. I kept my eyes closed most of the time, only so much one needs to see of such things, after all!

Immediately After

Very relieved it was over! My lower lip was extremely swollen, not surprisingly, and very very numb (damn good stuff, that local). I was told to avoid drinking anything hot while the local was still working, to avoid accidental burns. I also had an antiseptic mouth wash to use three times a day, to keep the area clean. Easy. Here's what it looked like, after the blood was mopped up.

After the Local Wore Off

HOLY FUCK

After about 3 hours, my dear friend, local anaesthetic, went away. It was not a pretty sight. Let's just mention stumbling downstairs to my children, weeping, unable to speak ... horrific pain. Really fucking awful. About a 9-10 on Allie's Pain Scale.

My son dashed out to buy me some Panadeine (we inexplicably had none in the house), and my daughter looked after me.

This was not 'some discomfort'. This was 'Kill me now, please' stuff. I don't know if the surgeon had cut some particularly important nerve, or if there's just so many damn nerves in the lips that it's inevitable, and I can't say whether my experience is typical or not. You may not have it as bad as this. But ... better to be prepared.

You will (probably) need heavy duty pain meds! You may need a script for something like Panadol Forte (ie something with a fair bit of codeine in it). At least lay in the strongest over-the-counter pain meds you can get. I react badly to opiates now, so it says a lot that the nasty side effects of opiates (the codeine in the Panadeine in this case) were preferable to the pain from the biopsy.

You also need an ice pack. The ice pack is your friend. Wrap it in a cloth. Don't leave it on your skin non-stop, otherwise you risk damaging the skin. 10 min on, 10 min off, that sort of deal.

I spent the rest of the day whimpering on the couch, doped on Panadeine, with an ice pack on my mouth, while my kids tried to distract me with Death in Paradise episodes ... I was able to sip a little milky tea through a straw, and a little soup. No talking, no eating, nothing that involved moving my lips at all. Intermittent weeping.

The Next Day

Could talk sorta kinda, in a mumbly way. Able to eat mushy things (applesauce, yoghurt etc) from a spoon, and tea through a straw. Still on pain medication every 4 hours. And I could tell the instant it wore off. Another not fun day, although not as bad as the previous day. Mostly curled up on the couch, watching TV, or knitting.

Lip looked like this now. Impressive bruise, huh?

The Next Next Day

Able to talk a bit more, and able to eat a little more, although still sticking to soft mushy things and sounding a bit drunk. The bruise started to 'fall through' to the front of my face. Still needing regular Panadol.

Six Days After the Biopsy

Each day, naturally, things got a bit better. The bruise is a lot less now. I can talk normally, but wouldn't want to talk for too long. My lower lip still feels lumpy and aches constantly.  I'm not needing pain meds any more. Still using the antiseptic mouth wash.

If I tried to eat anything thick (like a bite from a hamburger), it would still hurt a fair bit. Still being careful about chewing. Can't rest my chin on a pillow, for instance, as that hurts  too much. I think the dissolving stitches might be starting to dissolve.

This is how things look now — inner bruise has mostly moved to being an external bruise below my lips :

Two Weeks Afterwards the Biopsy

It. Still. Hurts.

The wound is healing well, and the bruising is all gone. Stitches are starting to dissolve. But it still feels like there's something caught between my lip and gum (which, of course, there is). And it aches constantly. Eating still hurts a bit. And if I talk too much, it hurts more. I can't comfortably rest my chin on anything. And bumping my lip on anything hurts a lot. Getting there, but s l o w l y.

Three Weeks After

It still hurts around the biopsy site, and the surrounding lip area, but the more 'widespread' pain has eased off. Current theory is the surgeon damaged a nerve. They also took out a fair bit of muscle tissue, which makes recovery more painful. Even still, this level of pain post-op is unusual. My immunologist suggested Lignocaine Gel (available in pharmacies without a script) and it's pretty fabulous stuff. Why did no-one mention this stuff to me before??!

Biopsy was all clear, too, no sign of sarc. So we don't know what's causing the swelling, and it's likely it is still the sarc causing it (Melkersson-Rosenthal Syndrome), but they didn't manage to get the right area with granulomas in it ...  dammit. A null result doesn't rule out the MRS.

Four Weeks Later

Was still in pain, so I went back to see the oral surgeon. They removed the undissolved stitches (a horrifically painful procedure, despite local anaesthetic). The theory is that I was reacting badly to the suture material, or my immune system wasn't reacting properly to the suture material (I'm on immune suppressants), so it was just being constantly irritated by the sutures, but my body wasn't able to dissolve them. No sign of nerve damage, thankfully. 

Within a few hours of removal, the whole area started to feel better, and a day later there's almost no pain! Bliss! So this theory seems to be right. 

Moral of the whole sorry tale : if you're in bad, ongoing pain around the biopsy site, go back to the surgeon, much sooner than I did. 

I hope that this might help you, if you have to have one of these horrible things too. Pain meds and ice packs are your friends. Get Lignocaine Gel. Don't expect to do too much for a couple of days afterwards, apart from feeling sorry for yourself. Stock up on mushy foods, custard, jelly, applesauce, yoghurt, ice cream, soup, and so on. It is possible to get inflammation and reactions to the various suture materials. Hopefully you won't be anywhere near as badly affected as I was.

And if the hospital tells you there may be 'some discomfort', laugh in its face, bitterly.

Another moving experience

Apologies for disappearing for quite some time ... we decided to start looking for a new place to rent in late February, and things moved unexpectedly quickly!

So — after several horrendous weeks of which we shall not speak — we are back in Weston Creek.  Very happy to be back in the area, and on a quiet suburban street. Ten years of living on main roads has been wearing. We're much closer to Mt Stromlo, and our other main destinations (largely doctors and the hospital).

Our new place has a downstairs area for the kids (one of our main reasons for moving, to find a place with a more separate living space for them, seeing as they're not able to afford to live independently yet). It comes complete with a full bar (including — bizarrely — cash drawer, sink, and three drinks fridges), wood-burning stove, small bathroom, and several rooms, and internal access to a big garage (glass workshop). 

Upstairs is for Hubby and me — four bedrooms (Hubby has his own study for the first time), kitchen with a gas stove and saucepan drawers (where have you been all my life?!), good sunny living areas, and two porchy / balcony thingies. With views!

The garden is leafy and lovely to be in (unlike our last place), and there is a paved area under cover for entertaining, too. The pups are adapting to the new surroundings, and we're all gradually settling in. The question of 'Where is ...' is less frequently answered with 'In a box somewhere!' so I guess that's progress!

We've not unpacked at least half of our boxes, and are loving the simpler minimalist feel of the upstairs section (kids' area is another matter!). So I still want to sort and declutter the rest of our stuff, and only store a bare minimum.

I calculated that this is the 27th home I've lived in. And the house in Gordon was the longest, at just over 6 years! No moss on this stone! But I am rather over the whole 'moving house' thing ... don't want to do this too many more times.

Puppeh Casserole

A few months ago, the bods who make MyDog clearly changed their recipes, and both my pups suddenly decided to stop eating it. Unless they had a doggy conspiracy going. Yeah, it could have been that too ...

Anyway, we tried them on other tinned food, to no avail. They have Royal Canin dry food, so they weren't starving, but they weren't getting a good dinner.

So I started to cook Puppeh Casserole. (FOR puppehs, for them, goodness, what do you take me for?!)

And they love it! In fact, Petal loves it SO much that she's put on a bit too much weight. Chunky puppeh. Ooops. So we're giving her smaller meals now.

It's cheaper, and it's better for them. Even their vet was impressed — home-cooked food + the good quality dry food (for special nutrients that dogs need) is an excellent diet regime for pups. Having chihuahuas makes this very economical, too, as they only eat ¼ to ½ a cup each a day. One batch makes enough for roughly two weeks of meals for two chihuahuas.

(It also makes a rather good sandwich filling, especially the chicken one, once puréed!)

Puppeh Casserole

Two variations: Beef + Liver, and Chicken

Ingredients

This is a 'hand wavy' recipe:

Some meat:

~1–2 kg of meat  (a whole chook, chicken thighs, casserole beef, cheap mince, whatever — avoid meat with lots of tiny bones in it, though, like chicken necks)

Some diced liver, if you want to make beef + liver (but don't add too much, as heaps of liver is not good for dogs — 1 med small liver, chopped up, is plenty). I love my dogs so much that I will actually cook liver for them. This is saying a lot.

Some veggies:

Choose several / more than several of the following dog-safe veggies. You want roughly a quarter to a third of your casserole to be veg.

• Peeled potatoes (the skins contain chemicals harmful to dogs)
• Peeled pumpkin
• Sweet potato
• Peas
• Green Beans
• Carrots
• Zucchini
• Small quantities of broccoli / cauliflower, if they don't cause digestive upsets for your dog

Some other stuff:

A handful or two of brown rice or barley
A bit of water, around 1 cup
A few herbs (oregano, thyme etc) if you're feeling creative
Some ground pepper (my dogs like spicy food!)
A little garlic is okay

Please avoid : onions, mushrooms, tomatoes, nutmeg. (I use the cute app Om nom? to check for food safety for dogs.)

You may like to cook this on the stove top in a very large saucepan (which I usually do for the beef + liver one), or a slow cooker (which I usually use for the chicken one).

Method

Veggies ready to go

1. Roughly chop your veggies. I didn't peel the potatoes here, oops, but I usually do.

2. You may like to brown the meat slightly in the pan first, but it's not vital. Add the veggies, and other ingredients. When using a slow cooker, I put the veggies in first, and just sit the meat on top of them. If you're using liver, you might want to add it to the saucepan later on in the cooking process, as it goes a bit hard and rubbery if you overcook it.

Beef + Liver ready to go on the stove

3. Set it to cook for several hours, with a lid on. On the stove, you'll want to cook it on the lowest heat. I usually cook the chicken casserole for about 4 hours in the slow cooker, and the beef + liver one for about 2–3 hours on the stove.

Chicken Casserole in the slow cooker

4. Allow the casserole to cool a bit, so it's warm but not hot. Don't let it sit overnight in the fridge before deboning, everything solidifies and it makes bone removal very difficult. Ask me how I know  :p

5. If you've got bones in there, remove them. It works quite well doing this by hand, wearing rubber gloves (which protect you from the heat as well as the eeeeeeew liver). plus it makes you look like a surgeon. A very sick and amateur surgeon.

6. Use a stick blender or food processor to 'lightly' purée the casserole to the desired amount. I have to make sure the veggies are fairly well mashed otherwise one of my dogs (Petal), not naming any names (Petal) will flick every single one out with her delicate little tongue. But your dog may like it chunky. A potato masher works well for a 'rougher' texture.

Beef + Liver Casserole after cooking

Beef + Liver Casserole after puréeing

7. Now for portions. I use a silicone muffin tray to freeze the portions — it is brilliant, because I can just pop them out once they're frozen. It's that easy. I do half as smaller portions for little Miss Chunky, and larger portions for Griff (who is twice her size). I store them in ziplock bags and boxes in the freezer.

8. Each meal time, you just defrost a portion (1 or 2 minutes in the microwave, or you could defrost in the fridge overnight, or in a tiny saucepan), make sure it's warm for them (not too hot to burn their tongues), and then let the nomming begin!

Griff approves!