CHAPTER XXXIX

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THE FACE AND EXTERIOR OF THE NOSE AND MOUTH.

Monsters are born with almost complete absence of the face, which is called _aprosopia_. They have also been observed with double faces. Again a condition of congenital hypertrophy is known involving one or both sides. On the other hand congenital atrophy is also occasionally noted, affecting one or both sides. The former is likely to be of syphilitic origin (hereditary), in which case it will be accompanied by other indications such as corneal opacity, irregularity of teeth, or other evidences of its luetic origin.

Among the most interesting congenital defects are those connected with _imperfectly closed branchial fistulas_ and the various outgrowths therefrom. These may lead to fissures extending from the ear to the mouth. Fibrocartilaginous growths occur along the regions of the original branchial clefts, either as tags of skin upon the face or so-called _supernumerary auricles_ or auricular appendages. While these are covered with skin they usually contain a cartilaginous nucleus. They are most common in front of or on the tragus. They may be single, multiple, or symmetrical. They sometimes increase in size and at others remain stationary.

Fissures are seen more often upon the central portions of the face, especially in the nose or between it and the cheek. About the root of the nose and the orbit dermoids are somewhat common. They may be connected with fissures or fistulas, and extend upward and involve the dura.

Absence of the mouth is known as _astomia_, and of the lips as _acheilia_. These malformations are exceedingly rare. Atresia, or narrowing of the mouth, is more common. While the lips and mouth may be apparently well formed there may be imperfections. These conditions of narrowing call for division on each side and union of skin to mucous membrane. _Fistulas of the lip_ are extremely rare, but are found occasionally, especially opening upon the lower lip. Branchial fistulas opening upon the lips have also been observed.

A condition of arrest of development of one or both jaws leads to unnatural smallness of the mouth known as _microstoma_. The opposite condition, _macrostoma_, is produced usually by fissure of the cheek on one or both sides, extending upward and backward from the labial junction and due to incomplete closure of a branchial cleft. The most common congenital defect of the lip known as _hare-lip_ is a median fissure involving the upper lip. This occurs in all degrees, from a trifling notch at the vermilion border to a hideous defect, in which, through a wide cleft, projects a relatively overdeveloped intermaxillary bone, with a small downward projection of skin, known surgically as the philtrum. This defect may involve much more than the lip alone, for there may be failure to unite, along the median line between the lip and the uvula, of those portions of the superior maxillary which should develop symmetrically, and coalesce as they are formed from the rudimentary maxillary processes. Any portion, then, of the hard or soft tissues may show failure to unite in the middle line.

Hypertrophy of a lip is known as _macrocheilia_. It is not uncommon in strumous subjects. Another form is known as mucous ectropion. (See p. 373.)

The chin may be malformed in the direction either of atrophy or the reverse, as in the so-called double chin. A deviation forward, known as _galoche chin_, is also recognized. A peculiar malformation, consisting of the implantation of a supernumerary inferior maxilla by its own symphysis upon that of the subject, is known as _hypognathy_. Such a tumor will occasionally develop to considerable size, with cystic degeneration or other irregular changes.

Aside from the common forms of hare-lip most of the congenital defects that occur about the face are to be explained through incomplete closure of the branchial clefts or the development of dermoid cysts and tumors therefrom. Deviations rather than defects appear more commonly about the nose than anywhere else. They produce disfigurements known as pug-nose, saddle-nose, parrot-nose, etc. Again, double noses exist, each being more or less well formed. In such a case the surgeon should endeavor to remove a part of each and unite the remaining portions in one, unless one of them be placed away from the middle line, in which case it may be extirpated.

ACQUIRED MALFORMATIONS OF THE FACE.

These are usually the result either of mutilation or of some ulcerative morbid process. Injuries of the face, unless extremely carefully and promptly attended to, are commonly followed by scars, which may cause great disfigurement. This is invariably true of severe burns, which, by subsequent contraction, draw features badly out of shape, and sometimes close the mouth or pull the lower jaw down upon the neck and the chin upon the chest. Serious contused wounds are frequently accompanied by fracture of parts beneath, and should be treated as a compound fracture. Considerable portions of the facial mask are sometimes torn away, producing hideous appearances. By punctured wounds the maxillary sinus, orbit, or brain cavity may be perforated and foreign bodies carried in. A wound may be so placed as to sever Stenson’s duct. All of these injuries may be accompanied by serious brain disturbance, as the result of the contusion. Gunshot wounds will present either punctures or extensive lacerations, according to the proximity and the weapon. In no part of the body are gunpowder stains more observable or more deplored than upon the face. In order to prevent them each grain of powder must be picked out with a small spud or needle, after a careful scrubbing of the face. Every grain of gunpowder allowed to remain will produce a minute area of staining.

Injuries to the nose may require plastic reconstruction or the formation of a new nose by one of the rhinoplastic methods later described, or an artificial nose, carried by spectacles, may be worn. The cartilages of the nose are frequently dislocated, thus producing deformity, and the same result may follow fractures. As already indicated in the chapter on Fractures, prompt and complete replacement with support are usually sufficient to give a satisfactory result.

Deviations of the nose, and especially cosmetic defects which result from injuries or disease, producing the so-called saddle-nose, when not extreme, may often be remedied by the injection of paraffin, the patient being either under cocaine or general anesthesia.

Burns, injuries, and serious ulcerations about the cheeks and lips produce conspicuous disfigurement (perhaps none more so than a serious form of cancrum oris) with a considerable loss of substance. In this way may be produced an acquired microstoma, or adhesion of cheek to jaw, which is known as _syncheilia_. More superficial lesions may produce ectropion or eversion of the lips, or acquired macrostoma. Cretins, idiots, and patients with facial paralysis acquire gradually a chronic swelling of the lower lip with drooling of saliva. The lip may enlarge to such an extent as to ulcerate as the result of exposure. _Frostbite_ also produces serious deformity by ulceration of the skin. When a puncture of the cheek occurs at the opening of Stenson’s duct, _i. e._, opposite the second upper molar tooth, there may occur a salivary fistula. In a recent clean wound the duct ends may be stitched together. In old wounds Souchon recommends to introduce catgut into the distal end, and then by pressure on the parotid to discover the proximal end and stitch it with the catgut in the divided portion; or the wound may be enlarged and the proximal end turned into the mouth and there retained.

Considerable emphysema may follow contusions of the face, especially those causing fracture of the nose. In this way a face may be so distended as to produce almost a caricature of its former appearance; this, however, will subside within a few hours.

By virtue of its extreme vascularity wounds and injuries of the face heal with a surprising degree of promptitude and certainty. This affords the reason for the satisfactory results of extensive plastic operations. For the same reason secondary hemorrhages may easily occur and additional precautions should be taken. Exact hemostasis, before closure of wounds, will afford protection as against this event. Wound edges should be neatly trimmed and _subcutaneous sutures_ may often be used to advantage to minimize the resulting scars. A lesson “how not to do it” may be learned from the faces of German university students who have indulged in the common but senseless sport of duelling, and who are said to rub salt and alum into their cuts in order to make the scars as conspicuous as possible.

NEUROSES AND CONSEQUENCES OF INJURIES OF NERVES OF THE FACE.

Anesthesia of parts supplied by the trifacial necessarily follows division of its various portions. It may also occur as the result of a deep-seated or central lesion. In course of time more or less sensibility will return, apparently due to an anastomotic process. _Facial paralysis_, so-called Bell’s palsy, may be of central origin, or be due to the effects of a “cold” following exposure, apparently with inflammation of and an exudate around the trunk of the facial nerve as it passes through its bony canal in the temporal bone. It is also the result of a division of the nerve trunk either outside of the bone or in the bony canal, where it is occasionally wounded in operations upon the mastoid or in removal of the parotid for malignant tumor. _Facial neuralgia_ is an affection of one or more of the branches of the fifth nerve, and, when assuming a spasmodic and intermittent type, is often spoken of as _tic douloureux_. Its exciting cause may be a carious tooth, even though it give no pain, while other causes are lesions in the neighborhood, such as callus, foreign bodies, tumors, bone disease, and the like. Its special treatment has already been indicated in the chapter dealing with the Cranial Nerves. Many of these cases of neuralgia gradually diminish the patient’s strength.

ULCERATIVE AND GANGRENOUS LESIONS OF THE FACE.

The serious ulcerative lesions of the face are usually due to _tuberculosis_, _syphilis_, or _malignant disease_. In all of these conditions there will be enlargement of the neighboring lymphatics. This is true also of the lesions of _actinomycosis_, which should not be forgotten as a possible cause. The free border of the lips is occasionally ulcerated in patients with pulmonary tuberculosis. Otherwise tuberculous lesions are uncommon upon the lower lip, while in the upper lip they show a tendency to invade and spread. Syphilitic ulcers may be either primary chancres, which are most common on the lower lip, or the results of mucous patches, or other secondary or tertiary lesions. Of the cancerous ulcerations, which tend always to break down and spread, without any tendency to healing in the centre, _epithelioma_ is the most common form. It is a frequent disease in men, occurring much oftener on the lower than upon the upper lip. In women it is exceedingly rare at this point. The difference is explained by the liability to constant irritation incurred by those who smoke pipes or are particularly careless about their teeth. Of epithelioma there are, as is well known, various types, including the so-called rodent ulcer, which, however, is less frequent here. The location of the lesion subjects it to constant irritation, as well as maceration from the moisture of the mouth. Such a growth may be superficial and raw, or it may be covered by scale or crust. It will nearly always have an indurated and raised periphery. A papillary form, with non-indurated edges, is also known, as well as a diffuse form, where several minute lesions seem to coalesce, with elevation of the central portion. This is perhaps the most malignant of all, as it has no well-defined boundaries. In nearly every well-marked case involvement of the submaxillary lymphatics can be detected. All of these cancers of the lip and face should be removed, with plastic re-arrangement of the parts. Growths of this kind seen early, before much tissue is involved, can be removed with permanent success. Error is made on the side of not doing sufficient rather than doing too much. (See