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.