COLUMBIA LIBRARIES OFFSITE HEALTH SCIENCES STANDARD HX00035882 (Lolumbia WiniUvmv^ ^ in tlje €itv of i^eto ^orfe^^H ^cj^ool of Bental anti 0tal burger? r § if SURGERY OF DEFORMITIES OF THE FACE INCLUDING CLEFT PALATE BY JOHN B. ROBERTS, A. M., M. D. PROFESSOR OP SURGERY IN THE PHILADELPHIA POLYCLINIC, SURGEON TO THE METHODIST hospital; FORMERLY ASSISTANT EYE AND EAR SURGEON TO THE CHILDREN'S HOS- PITAL, AND DEMONSTRATOR OF ANATOMY IN THE PHILADELPHIA DENTAL COLLEGE. ILLUSTRATED WITH 273 FIGURES NEW YORK WILLIAM WOOD AND COMPANY MDCCCCXII 2 7 Copyright, 1912 By WILLIAM WOOD & COMPANY Printed by The Maple Press York, Pa. TO M. E. R. MY COUNSELOR IN THE AFFAIRS OF LIFE Digitized by the Internet Archive in 2010 with funding from Columbia University Libraries http://www.archive.org/details/surgeryofdeformiOOrobe PREFACE The appointment to deliver the Miitter Lectures of the College of Physicians of Philadelphia for 1900 induced me to give increased attention to the operative correction of facial deformities. This sub- ject had long interested me, and seemed an appropriate topic for the lectureship established by Thomas D. Mutter, the Philadelphia teacher, who had played such an important part in the early history of plastic surgery. Further study has shown me an ever widening field for this depart- ment of surgical endeavor, and given rise to a consequent surprise that so many sorely afflicted persons fail to realize the present possibilities of relief. Nature seems willing to aid the operator's efforts in an as- tonishing degree, if he use skill and exercise patience in showing her the way to exert her reparative forces. J. B. R. 313 South 17th St., Philadelphia. March I, 1912. CONTENTS. CHAPTER I. Page The Development of Plastic Surgery 1 CHzlPTER IL A Survey of the Anatomy of the Face 9 CHAPTER in. Char.\cteristics of Surgery of the Face 29 CH.APTER IV. The Principles of Plastic Surgery of the Face 34 CH.APTER V. Gunpowder and Local Discolorations, Tattooing 44 CHAPTER VI. Fistules, Fissures, Encephalocele, Atrophy and Hypertrophy .... 55 CHAPTER VII. Disfiguring Skin Diseases Requiring Surgical Tre.\tment 69 CHAPTER VIII. Deformities of the Mouth and Lips 85 CHAPTER IX. Harelip and Other Facial Clefts 99 CHAPTER X. Cleft Pa L.\TE 112 CHAPTER XI. Cheiloplastic Operations not Connected avith Harelip and Cleft Pal.\te 141 CHAPTER XII. Deformities of the External Ear 153 CHAPTER XIII. Deforjiities of the Nose 169 CHAPTER XIV. Rhinoplasty 195 CHAPTER XV. Deformities of the Eye-lids and Eye-ball 215 vii SURGE EY or DEFORMITIES OF THE FACE, INCLUDING CLEFT PALATE CHAPTER I. THE DEVELOPMENT OF PLASTIC SURGERY. Until the revival of plastic operations upon the face about a hundred years ago, reconstructions of lost areas of tissue and readjustments of textural relations by operation had been practically unknown, to the scientific world, for a couple of centuries. The rhinoplastic and cheiloplastic methods and successes of Tagiiacozzi at Bologna, detailed in his work^ published in 1597, and the methods used for centuries in India for restoring mutilations of the nose had been forgotten or were disbelieved. The revival, as it may be called, of plastic surgery had its beginning in the middle of the eighteenth century when Rosenstein^ and Dubois and Boyer^ wrote discussing the possibility of restoring lost structures by plastic methods. It was not until the second decade of the nineteenth century that the successful operations and lucid writings of Carpue in England and C. Graefe in Germany aroused the attention of surgeons to the possibil- ities of this kind of work. These writers proved the possibility of operative reconstructions previously denied, and, by their historical researches, showed that operators in India, Sicily and Italy had been wont in previous centuries to make new noses and lips from the skin of the forehead, arm or buttock for the relief of facial disfigurement due to punitive mutilation. It is interesting to the English speaking nations to known that Lucas, an Englishman, learned frontal rhino- plasty from Indian operators and practised it successfully before the time of Carpue's book, and that, in England, Lynn in 1803 attempted though unsuccessfully to make a new nose for a patient. ' De Curtorum Chirurgia per Institionem. Venet, 1597. ^ De Chirurgicae Curtorum possibilitate. Upsal, 1742. ^ Dissert. Qusest., An curtse Nares ex brachio reficiendse? Paris, 1742. 1 2 SURGERY OF DEFORMITIES OF THE FACE The professional mind was directed to reconstructive surgery originally, almost exclusively because unfortunates with mutilated noses desired relief. It is said that in early times operations of a plastic character were done to conceal the condition of those who had been circumcised. It was rhinoplastic operations, however, that gave birth to a knowledge of the physiological possibilities of reparative surgery. In India, noses were and are yet frequently cut off as a punishment. Keegan states,^ that in that country women are frequently mutilated by husbands merely suspicious of the virtue of their wives ; and he gives a table of a very large number of rhinoplastic operations done within a limited time in the various sections of the country. It is interesting to repeat the story, which has often been told, of the retribution visited by an Indian potentate, the King of Ghoorka, upon a conquered city. Its name was changed to signify ''The City of Cut Noses," because he cut off the noses of all the inhabitants, except the infants and those who played wind instruments. Similar punishments, though on a less extended scale, were not unusual at one time in Europe. It is not impossible that the revival of plastic surgery at the end of the eighteenth and the beginning of the nineteenth century was due in some degree at least to non-medical literature. The interest of the general public naturally centered in the accounts, scarcely believed even by physicians, of the making of new noses, which were said to be constructed from the forehead, from tissues of slaves, or from parts of the body of the patient distant from the face. The vulgar allusion to Tagliacozzi's nose restorations, made in the latter part of the seventeenth century in Hadibras, shows that the learned Butler was familiar with the asserted skill of the illustrious Italian surgeon of the preceding century; but it was John Ferriar, litterateur, as well as doctor of medicine, who forcibly called public attention to Tagliacozzi's work in his ''Illustrations of Sterne with other Essays and Verses," published in 1798. Dr. Ferriar, who died in 1815, would have read with joy Carpue's account, published in 1816, of two successful cases of rhinoplasty in London; but he died knowing at any rate that he had earnestly called the attention of literary Eng- land to the importance of Tagliacozzi's original observations. Ferriar endeavors to show how Sterne derived the numerous allusions to the nose in Tristram Shandy from previous writers, classic and pro- fane, and says, " There is a writer who deserved a higher place in Mr. Shandy's library than any of those whom Sterne has ventured to ' Rhinoplastic Operations. London, 1900. THE DEVELOPMENT OF PLASTIC SURGERY 3 mention; and he was the more entitled to notice, because his fame has been unjustly and unaccountably eclipsed." He then devotes about a dozen pages to quotations from, and abstracts of, Taglia- cozzi's book, "De Curtorum Chirurgia." His enthusiasm is so great that he describes in considerable detail the operation of rhinoplasty as practised by the Bolognese surgeon, and compares that operators's physiological deductions with those of John Hunter. Hunter had died only five years before the publication of the "Illustrations of Sterne" ; and his experiments on grafting tissues were evidently known to Farriar. The latter lays much stress upon the fact that in Tagliacozzi's time the arteries were supposed to be full of air and that the circulation of the blood was unknown to him. Hence, the Italian investigator's views on the method of, union of living parts are in his estimation exceedingly interesting and remark- ably accurate. About the time of Ferriar's description of brachial rhinoplasty two other non-medical publications appeared in Englan^%-hich aroused public interest. They were the "Gentleman's Magazine^'^' of 1794 and Pennant's Views of Hindostan, published about the same' time. They gave accounts of the construction of new noses from the forehead per- formed in India to relieve the horrid facial disfigurements so common in that country. The "Madras Gazette" published in Indi^ called the attention of the English public to the same subject at about this time. An almost universal disbelief in the availability of plastic operations delayed the progress of this branch of surgery in a very marked degree. Jobert says that Hiester denied even the possibility of rhinoplasty. In Holmes' "System of Surgery" plastic operations for the removal of deformities clue to burns were discouraged by Coote. Prince, one of the most earnest advocates in America of reparative surgery, said, "It is even now (1867) in its infancy and is to grow into maturity by a better knowledge of general and local therapeutics applicable to the healing of wounds and to better conceptions of mechanical execution." This doubt of the professional mind is a little difficult to understand, when it is remembered that there was a considerable amount of litera- ture showing the possibility of the adhesion of parts entirely separated from the body, if they were reapplied and sutured within a reasonable time. Balfour wrote in 1814 an earnest article in the "Edinburgh Medical and Surgical Journal" asserting the possibility of the adhesion of completely severed fingers. He reported a case in which one-half of the index finger which had been completely cut off was reapplied after an interval of five minutes and became completely united to the 4 SURGERY OF DEFORMITIES OF THE FACE hand. Zeis a little later made a collection from surgical literature of many cases in which similar accidents had been followed by union of the severed organs. Probably the most interesting series is that of Hoffacker who in 1828 described sixteen cases of noses, lips, and chins, sliced off in duels at Heidelberg, which had united after reparation. One of the cases reported by him was remarkable because the ampu- tated organ had to be rescued from a dog who had seized it; yet union occurred after its replacement. The belief in India that cut-off noses could be successfully replaced is said by Velpeau to have caused those, thus mutilating criminals or enemies, to throw the amputated nose into the fire. In 1823 Biinger in Marburg operated upon a woman who had lost her nose from lupus. He found it impossible to get tissue from the face and therefore cut a portion of skin from the thigh and was so fortunate as to obtain union. At a later period Warren, of Boston, was success- ful in restoring small breaches of surface by portions of skin cut entirely free from their surroundings. These reports and the stories that continued to come from the British surgeons in India finally convinced European operators that the restoration of distorted features and useless limbs had been a aegiected department of surgery. The German and French writers became very enthusiastic in practising and urging a resort to plastic measures. American surgeons, largely through Mutter's influence, followed in their steps. Roux thought that there was almost nothing impossible in the restoration of the face. He said that in plastic sur- gery very many and signal services had been rendered in improving the appearance of the human face, integrity of which was of so much importance for the exercise of the senses and for " the needs and amen- ities of social life." Jobert was so carried away with enthusiasm that he said the prog- ress of plastic surgery would in the future be considered " one of the most beautiful conquests of the surgery of the nineteenth century." He adds " The artist should be above all things the savant who know^s all the laws of vital reaction, the physician who foresees every cause of accident, and who knows how to act under all conditions which present themselves." This opinion of the necessity of deftness in the operator, who essays plastic restorations, is also indicated in the words with which Phillips describes the instruments used by Dieffenbach, which were so small that they "looked as if intended for making lace rather than working with large portions of living tissue." It is not necessary for us at this time to go into a discussion of the various names which were given by these writers to that Avhich we now THE DEVELOPMENT OF PLASTIC SURGERY 5 call plastic or reparative surgery. The term plastic surgery, was, I believe, first suggested by Zeis, and it has displaced to a great extent autoplasty, anaplasty and other suggested terms. Delpech, Dieffenbach, Labat, Blandin, Serre, von Ammon, Jobert and Zeis continued, during the first half of the nineteenth century, the work of popularizing plastic surgery and extending its domain. Zeis's ''Manual of Plastic Surgery," pubhshed in Berlin in 1838,' is a systematic and scholarly treatise on the subject. It collected and made available for study most of that which had been previously written. About this time the method of employing skin without a pedicle for making the new nose was also adopted in a limited number of cases. The tissue was usually taken from the buttock of the patient himself and applied to the freshened edges of the nasal stump. Biin- ger appears to have been the only European operator who was success- ful in the use of this method.^ This forerunner of Krause's method of implanting flaps without pedicles shows the probability that asepsis was occasionally obtained accidentally by our surgical predecessors. In 1837 or 1838 there was published in the ''American Journal of Medical Sciences" an article on "Cases of Autoplastie," detailing operaT tions for cicatricial deformity of the mouth and for loss of^ the wing of the nose. The. author- and successful surgeon was a recent graduate, named Thomas D. Mutter, who was. destined to achieve fame in American surgery. In July, 1842, there appeared in the same periodical an article on "Cases of Deformity from Burns successfully treated by Plastic Operations" by the same Thomas. D. Mutter, who wrote a number of other papers about this time on allied topics. About the same time Joseph Pancoast of Philadelphia and J. Mason Warren of Boston published clinical reports of operations for the repair of nasal and other facial deformities by means of displaced integument. These three surgeons are therefore entitled to the credit of introducing reparative methods into American surgery. Mutter modestly mentions his own connection with the movement and truthfully says that Warren "was probably the first to introduce the successful application of plastic surgery in the United States."^ Post, Buck, Andrews and Prince took much interest in advocating in America this branch of operative surgery and devised additional methods of untilizing its principles. This brief historical review shows the potent influence that Mutter, exercised in the development of a most important department of '"Journal fUr Chir. und Augenheilkunde" (von Graefe und von Walther) iv, 569. ^ Introductory Lecture, Jefferson Medical College, 1842. 6 SURGERY OF DEFORMITIES OF THE FACE surgery; the benefits of which are to-day evident in the treatment of not only facial disfigurements, but gynecological, orthopedic and general surgical lesions. The important part played in the world's surgery by the plastic operations of Mutter and his colleagues in America is seen by reading the words of European writers. Sir William Fergusson in writing on cleft palate in 1864^ said: "In as far as I know, the greatest success recorded before my own views were made public was that achieved by Mutter of Philadelphia. In 1843 he had operated successfully nineteen out of twenty-one cases." Szymanowski, whose "Manual of Operative Surgery' ' is largely devoted to a systematic exposition of plastic methods in surgery, refers in his preface to the fact that in 1867 English authors were less acquainted than American surgeons with the progress of reparative surgical science. It is a little difficult at the present time to realize the great influence exerted by Mutter, Pancoast and Warren in a then comparatively undeveloped field. The frequent references in European literature of the time to Mutter's cases surprised me, when I first read them. It evidently was difficult for many to believe that displaced tissue would satisfactorily assume the functions expected of it in its new situation. It required ocular demonstrations at the hands of original and energetic men like Mutter to convince the incredulous. He himself says in his introductory lecture on "Recent Improvements in Surgery" that such operations had been ridiculed by Butler, Voltaire and Addison, and that "even now, notwithstanding the positive testimony of the first authorities in their favor, are supposed by many to be bare assertions, destitute of truth, and as useless as they are apochryphal." The Russian surgeon, Szymanowski, in 1867 made an elaborate attempt to sytematize the various operative procedures for the relief of deformities requiring plastic surgery. In his "Manual of Operative Surgery" he devotes many pages to illustrations showing the principles upon which the integuments can be satisfactorily displaced. His experiments on the cadaver aided him very much in the preparation of this portion of his book, which is a classic. A decided step in advance was made in 1871 by Reverdin,^ who proposed what is called skin grafting, or, better, epidermic grafting, for covering ulcers and granulating wounds. At about the same time Hanff also made the discovery that small particles of skin and epider- mis placed upon granulating surfaces would serve as centers of cicatri- 1 Lancet, June 25, 1864, p. 723. 2 Gaz. med. de Paris, 1873, 3 S, xxvi, 544, THE DEVELOPMENT OF PLASTIC SURGERY 7 zation. This method of skin grafting caused healing of ulcerated surfaces previously considered incurable. It also hastened the time of cicatrization in other ulcers by lessening the contraction due to the formation of a large amount of young fibrous tissue. It is now- well known that extensive areas of tissue will become covered with cicatricial skin without much contraction, if healing can be completed quickly and without the growth of much granulation tissue. Other steps in the progress of reparative surgery were the announce- ment by Thiersch^ in 1886 of his method oi transplanting large shavings of the upper layers of the skin. Some time previously Wolfe, the ophthalmic surgeon of Glasgow, had showed that moderate size pieces of skin could be transplanted without a pedicle with comparative certainty of union. His restoration of deformed eyehds was of great value in stimulating the study of plastic methods. Hiiter even went so far as to use hairy flaps after the Wolfe method for the repair of eyebrows. The osteoplastic operations of Oilier showed that even raw surfaces of bone would unite. Within later years the closing of a trephine opening in the skull by replacing the disk of bone, the substitution of a portion of fibula for a gap in the tibia, the splitting of a bone into two parts so as to make two distinct bones, and the nailing or suturing of bone flaps in new positions have resulted from Oilier' s experiments and widened the field of reconstructive surgery. Krause has so improved the use of grafts, or flaps of skin without pedicles, that it is even possible to amputate a limb and cover the structures with skin taken from other portions of the body or from the discarded leg or arm. Muscles are now sutured so as to substitute muscles torn away by accident, or paralyzed; and nerve trunks are transferred to new positions in order to assume new functions. A fatty tumor extir- pated from the thigh has been used by Czerny, it is said, to give a normal appearance to a mammary gland from which an undesirable tumor had previously been taken. Gluck succeeded experimentally in repairing a defect in the carotid artery by patching that vessel with a piece of the jugular vein." Ankylosed joints have been made permanently mobile by inserting flaps of fascia between the ends of their constituent bones. ^ Grafts from amputated limbs and cadavers have been emploved successfully; and Vanlair has even suggested, according to Gluck, ^ Verhand. der deutsch. Gesell. fiir Chirurgie, 1886, v. 17. 2 Verhand. d. Congres f. inn. Med., 1898, xvi, 384, 385. ^Ankylosis. Arthroplasty — Clinical and Experimental. By John B. Murphy, "Transactions American Surgical Association," xxii, p. 315. 8 SURGERY OF DEFORMITIES OF THE FACE that perhaps it is not impossible to take portions of organs at the moment of death, or possibly whole organs, and use them for the restoration of internal parts. The thyroid gland of the sheep has within recent years been implanted in the abdomen of man to act as a substitute for his diseased or extirpated thyroid gland. The ovary has been transplanted successfully from one animal to another and from one region to another region in the same animal; and is said to carry on its function so that pregnancy can occur. ^ This is an indication of the belief in some professional minds of the availability of such substitutive actions. Nicoladoni has recommended for the loss of the thumb, the grafting of a second toe upon the hand, and has done this operation. The successes of Payr, Hoepfner, Carrel, Garre, Guthrie Morestin and Lexer in experimental and clinical plastic operations have greatly widened this field of surgery. Arterial and venous suturing have become accepted procedures. Blood-vessels may be patched after injury. Masses of bone may be used to repair the osseous structures. Aseptic grafts may even be used with success after preservation in cold storage for a number of days; because the latent life is preserved.^ Gluck urges the introduction of foreign materials into the tissues to remain there permanently and act as substitutes for the normal structures. The use of a glass ball to represent the vitreous humor in an eviscerated eye, as proposed by Mules, has been employed by many surgeons with success. Paraffin moulded into shape, celluloid and> metal supports have been worn within the tissues of the nose and else-- where for many years without giving trouble, and substitutes of simi- lar materials have been placed in the scrotum to represent the testicles and relieve mental distress at the loss of these organs. It is possible that this "implantation-therapy" of Gluck is susceptible of far greater use and development than is yet realized. At the present time anesthesia permits our operative work to be prolonged; and our methods of restraining hemorrhage and preventing infection make the risk of operative treatment scarcely worthy of consideration. Under the opposite circumstances it must have taken men of great courage and mental force to have urged patients to under- go operations which were clearly procedures of convenience and not of necessity. ^ Surgery, Gynaecology and Obstetrics, July, 1911, p. 53, Deutsch Zeitsch. flir Chirurgie, 99. Bd. 1-2 Hft. ^Keen's Surgery, vol. v., p. 884. Archiv. fur klin. Chirurgie, 83. Bd. 2 Hft. CHAPTER II. A SURVEY OF THE ANATOMY OF THE FACE. In the present study, the face includes more than that which is called the face in a strict anatomical sense. The frontal and tem- poral regions of the cranium must be included. The disfigurements which are to be considered concern the ears and the forehead as well as that portion of the head usually called the face in anatomical treatises. The bones and soft tissues of the region, the surgery of which is to be discussed, need not be minutely described ; but a general view will be valuable. Good surgery of any region of the body is impossible without a knowledge of the bony landmarks and the mutual relations of the soft parts. The blood supply and the location of the important nerve trunks and ducts are topics of special interest. If the face is looked at from in front, it is bounded laterally above by the bulge of the parietal bones, behind the coronal suture, and by the anterior part of the squamous portion of the temporal bones. The. narrowest part of the forehead lies between the temporal crests or ridges, about half an inch above the external angular process. This is situated at the upper and outer part of the orbit. The lower part of the face, the shape of which is determined by the form of the mandible, or lower jaw, is bounded below by the upper portion of the throat and neck. This region also is of importance in the plastic surgery of the face, because the soft tissues of the throat and neck are often used in reconstructive operations about the mouth. In this hasty survey it will perhaps be sufficient to call attention to only a few of the most prominent anatomical features of the bony skeleton. Across the frontal bone and below the frontal eminences will be observed two transverse furrows, which are just above the super- ciliary ridges. Below these ridges are situated the supraorbital arches which form the upper margin of the eye sockets. They show at about one-half inch from their inner end the supraorbital notches, or foramina, through which pass the supraorbital nerve and vessels. The situation of this notch and the artery coming through it have an important bearing upon the position of the pedicle of the flap in frontal rhinoplasty. A well-known landmark is the glabella, the smooth surface in the middle line just above the depression made 9 10 SURGERY OF DEFORMITIES OF THE FACE by the junction of the frontal bone and the nasal bones. The mid- point of the suture between the frontal bone and the nasal bones is called the nasion. Very conspicuous are the two eye-sockets which, somewhat quad- rilateral in shape, have rounded margins of very compact bone. These margins are formed by the frontal, malar, and superior maxil- lary bones. The situation of the lachrymal gland underneath the upper and outer angle of the orbital margin should be recollected; and the groove for the lachrymal sac at the inner and lower angle must not be forgotten by the operating surgeon. The infraorbital foramen, through which pass the infraorbital nerve and vessels, lies about a quarter of an inch below the lower orbital margin, and almost vertically above the second bicuspid tooth. Ocasionally there are two openings here; probably because the vessels and nerve do not always come through the same foramen. The pyriform aperture of the nasal chambers, below and between the orbits, is in shape like an inverted ace of hearts. Its long axis is vertical and its margins, formed by the two nasal and two superior maxillary bones, has a rather sharp and easily broken edge. The prominent nasal spine below for the attachment of the columella is of some surgical importance. In the skeleton there is seen within the nasal aperture the anterior edge of the osseous nasal septum. It is made up of the vomer below and the nasal, or vertical, lamella of the ethmoid bone above. The nasal aperture is much contracted by the nasal cartilages, which form the basis of the projecting portion of the nose. A clear understanding of the cartilaginous attachments an4 of the influence of the bony and cartilaginous septum of the nose upon its shape are essential to successful plastic work upon this organ. Many very unsightly deformities of the face are due to inefficient treatment of nasal fractures. The anterior portion of the inferior turbinal bone is seen by looking into the anterior nostrils. The malar bone, which makes the prominence of the cheek and which behind is attached to the zygoma of the temporal bone, has a great deal to do with the shape of the face, as the configuration of the cheek depends greatly upon it. In its normal configuration it varies much in different races. This can be easily appreciated by comparing the face of the North American Indian with that of an individual of the yellow or the white race. The manner in which the malar bone assists in making the arch spanning the temporal fossa is the cause of the unseemly deformity, which arises when blows in this region crush in the arch. Elevation of the broken bone is an exceedingly simple operation, and yet is A SURVEY OF THE ANATOMY OF THE FACE 11 not always performed after the receipt of such injuries. The crush- ing of the anterior wall of the hollow upper jaw creates another de- formity of a similar kind, which is sometimes allowed to cause per- manent disfigurement by being unscientifically treated. The upper jaw is a bone of major importance in the construction of the face, for it takes part in forming the walls of the orbit, the nose and the mouth. Its alveolar arch must correspond with the same portion of the lower jaw in such a way that the upper teeth may lie in front of the lower teeth when the mouth is closed. The incisive portions of the two upper jaw bones are developed by special centers of ossification. They therefore have much to do with the deformities of the lower portion of the face and mouth. Harelip and cleft palate are the most conspicuous and commonly recognized congenital de- formities due to improper development of this portion of the facial skeleton. In some cases of double harelip there exists a projecting prominence of bone, because the premaxillary elements of the incisive region fail to unite with the rest of the upper jaw. A most conspicuous deformity is that in which the lower jaw with its teeth project in front of the upper jaw. This deformity is said to be due at times to a precocious ossification of the sutures between the body of the upper jaw and the incisive or intermaxillary portions. As a result, the upper jaw and the teeth belonging to it do not develop in a forward direction as much as they ought and the lower jaw consequently gains an undue prominence. It thus alters the shape of the lower segment of the face. The proper understanding of the cause of the deformity will prevent many children from becoming conspicuously uncomely. Mechanical appliances may be used by the dental surgeon to prevent the impending ugly alteration in the relation of the two jaws. The mandible, or lower jaw, gives form to the lower part of the face and to a certain extent the cheeks. It is one of the most important of the bony elements of the face and has an exceedingly great, direct and indirect, influence upon the appearance of the individual. The chin or mental process is often marked by a median notch, on each side of which is a blunt swelling or tubercle. From this ascends an oblique line to meet its fellow of the other side below the sockets of the incisor teeth. An external oblique line runs backward from the mental tubercle to the level of the last molar tooth. Above this line and below the second pre-molar, or biscuspid, tooth is the men- tal foramen through which passes the mental nerve and vessels. It is said that the lower jaw has a special tendency to become necrotic, because its arterial supply depends upon the integrity of the two mental 12 SURGERY OF DEFORMITIES OF THE FACE arteries. The other bones of the face are particularly well supplied with blood because of the large number of vessels running into them. The groove for the facial artery, found at the lower edge of the mandi- ble in front of the attachment of the massenter muscle, is a landmark of importance. Temporary pressure can be made upon the artery at this point to lessen the bleeding in operations upon the face. The angle between the body of the lower jaw and its ascending ramus varies greatly in different individuals and at different ages. It is very obtuse in infants and much nearer the right angle in adult males. The angle is more obtuse in women than in men. In the adult male it is about 122°. Changes in the angle of the jaw and the prominence of the chin, produced by the loss of the teeth and the ab- sorption of the alveolus in old age, give the characteristic appearance to the senile face. This; may be prevented by the early adoption of artificial dentures. Medical men as a rule pay too little attention to the influence of a proper development of the teeth upon the shape of the mouth, chin and the Lower face. While the facial angle, studied by Camper and others, has been a subject of interest to physicians as well as to artists, the influence of the teeth and jaws upon personal comeliness has been almost entirely overlooked in medical practice. Anchylosis of the temporo-maxillary joint, preventing. movement of the lower jaw, will, if occurring in childhood, lead to atrophy or want of proper development of the bone. As a result the patient, grows up with an immature chin which causes very conspicuous dis- figurement. Burns of the lower part of the face and of the neck will prevent proper mobility of the mandible and lead in growing children to a lengthening and bending downward of the front of the lower jaw bone. Persistent thumbsucking in young children, after the second dentition, causes deviation of the teeth, particularly of the upper jaw, and therefore an abnormal relation of the upper and lower jaw bones. A lateral view of the region under consideration shows, in the upper portion, the anterior part of the curved temporal ridge, or crest, where it runs into the external angular process of the frontal bone. This bony prominence extends downward to join the corre- sponding process of the malar, or cheek, bone which bounds the tem- poral fossa in front. At right angles to the base of this anterior wall of the temporal fossa and extending backward is the zygomatic arch, made by contiguous processes of the malar and temporal bones. In front and above the temporal crest are seen the bulging frontal prominences which constitute the forehead. These frontal eminences A SURVEY OF THE ANATOMY OF THE FACE 13 are better marked in young persons and in women than in adult males. Beneath the frontal prominences is seen the shallow transverse furrow of the forehead. Beneath this are the superciliary ridges, forming the lower limit of the forehead, and the supraorbital arches which consti- tute the upper limits of the eye sockets. The superciliary ridges are directed obliquely upward and outward and are better marked in the adult, because the frontal sinuses, or air cavities, beneath them develop with the increasing age of the child. It is this increased prominence of the superciliary ridges, due to the frontal sinuses within, that makes the frontal eminences relatively smaller in the adult male than in women and children. The frontal sinus begins to develop at about seven years of age. The point where the temporal crest crosses the coronal suture is called the stephanion. The temporal fossa in which lies the tem- poral muscle, covered by the temporal fascia, is in many faces indi- cated by a marked depression. This is particularly the case in persons, who are lean. The emaciation of illness is often the cause of a great change in the face because of the absorption of fat in this fossa. A full appreciation of the construction of the zygomatic arch is necessary for the proper treatment of deformities in the temporal region. When the bones are covered by the temporal muscle and other soft tissues, the importance of maintaining a proper relation of the bony frame- work may be overlooked. Fractures here cause great deformity, which is easily overcome by elevating the broken bone so as to re- construct the normal curve of the arch. A study of the lower portion of the side of the face makes it at once evident that the lower jaw is the essential bony element. Upon the proper development of the teeth depends the shape of the lower jaw and therefore the configuration of the lower part of the face. This question has been discussed in the remarks made in regard to the appearance of the face from in front. The shape of the angle of the jaw and the manner in which the cheek is formed by the malar bone and ascending ramus of the jaw are apparent, when the face is examined on its lateral aspect. The deviations in the prominence of the nasal bones and the attached soft parts in front are usually observed much better when the face is studied from the side than from in front. The goniometer of Camper has been employed to measure the facial angle which varies greatly in the different races of man and in different types of the same race. There are certain of the soft tissues of the face which deserve special attention bj^ the surgeon operating in this region. The foramina for the exit of the terminal branches of the three divisions of 14 SURGERY OF DEFORMITIES OF THE FACE the fifth, or trifacial; nerve have passing through them the corre- sponding arteries and veins. The situation of these vessels is im- portant, because flaps should be cut so as to maintain when possible the integrity of these nerves and vessels. Injury of these nerves usually is not of grave importance because the lesion produces merely a paralysis of sensation, which may be only temporary. Division of the artery may in some cases lead to sloughing of an important part of the flap. This is not of very common occurrence, because of the rich anastomosis of vessels in the facial tissues. The supraorbital foramen is situated at about the juncture of the inner third with the middle third of the supraorbital arch. A line drawn from this point downward and slightly outward, so as to cross the space between the two bicuspid teeth in the upper and lower jaws, passes over the infraorbital and the mental foramina. The seventh, or facial, nerve, which is the motor nerve of the muscles of expression, makes its exit from the stylo-mastoid foramen, passes through the parotid gland, and breaks up into branches which radiate toward the temple, the eye, the cheek and the lower jaw. Its existence in this region should not be forgotten, because incisions made transverse to its branches are liable to divide it and cause permanent disfiguring paralysis of muscles. The manner in which its branches radiate from behind and beneath the lobe of the ear should be remem- bered. Immediately behind the posterior margin of the ascending ramus of the lower jaw is the external carotid artery, a structure to be carefully avoided when operating between the ear and jaw. The temporal artery, which is one of the terminal branches of the external carotid, extends upward between the root of the zygoma and the ear and then divides in the temporal region into an anterior and a posterior branch. These branches are easily seen under the skin of the forehead. The transverse facial artery, arising from the temporal, runs forward upon the cheek from in front of the auditory meatus toward the mouth. The facial artery, which is a branch of the external carotid in the neck, passes over the lower border of the jaw at the anterior margin of the masseter muscle. It runs obliquely upward to the angle of the mouth, passes along the side of the nose, and terminates at the inner canthus of the eye, where it is called the angular artery. From it arise the coronary arteries which supply the lips and are felt im- mediately under the mu€Ous membrane. The facial vein does not accompany the tortuous artery, but runs more directly from the inner angle of the eye to the front of the masseter muscle. The facial A SURVEY OF THE ANATOMY OF THE FACE 15 artery can be felt and compressed, where it crosses the border of the mandible, and also from within the mouth, where it lies under the mucous membrane near the corner of the mouth. A very important structure which must be avoided in incisions upon the face is the duct of the parotid gland. It is a firm white tube about the size of a goose quill. It runs parallel to and below the zygoma, on a line drawn from the base of the lobe of the ear to a point midway between the ala of the nose and the angle of the mouth. About the middle of this line, it dips suddenly inward around the front of the masseter muscle, and penetrates the fat and the buccinator muscle to enter the mouth opposite the second molar tooth of the upper j aw. The parotid gland, filling the irregular space between the mastoid process and the auricle behind and the ramus of the jaw in front, should be remembered. Incisions into it, however, usually do little harm unless the duct of Stenson, already mentioned, or one of its larger branches is injured. A salivary fistula is then likely to be produced. The eyebrows and eyelids are important structures because in- cisions or wounds may make conspicuous blemishes, unless carefully repaired by suturing. The size of the palpebral fissure has a great influence in making the eyes look large or small. The eyeballs vary very little in size, but a narrow fissure, as in the Chinese race, makes the eye seem very small. The lachrj^mal puncta, which are seen as two little black dots on the edge of each lid near the inner angle of the eye, lie close to the ball so as to catch the tears which wash the surface of the eye. Any eversion of this portion of the eyelid due to cicatricial contraction will cause a continual overflow of tears. The surgeon's incisions must be made so as to avoid the production of this everted condition. Care must also be taken to avoid wounding the lachrymal sac at the inner angle of the eye lying underneath the tendo oculi. The attachments of the nasal and aural cartilages and their general shape should be familiar to operators. The varieties in shape of the nose and ear are very great and will often require surgical interference for their modification. It is not unusual to find the details in the shape of the auricle different on the two sides. This variation is not very important, because both ears are not apt to be critically observed at the same time. A study of the soft parts of the lips and the mouth shows that there is great variation here also. The mobiHty of the lips is extreme, though there is a certain amount of fixedness in the middle line. The orbicular muscle of the mouth forms the bulk of the lips. It may 16 SURGERY OF DEFORMITIES OF THE FACE be subjected to many operative procedures without the occurrence of much deformity, provided that the relation between the Hps them- selves and between them and the other features is maintained. A want of balance due to operation or injury may make a very conspic- uous deformity which a restoration of the relative proportions will overcome. Surgeons and medical men in general have very little conception of the importance of the teeth in the physical conformation of the face and the expression of the individual. Many persons suffer a very great, though unnecessary uncomeliness, because the teeth have been allowed to assume irregular positions. As a result of this, not only the soft parts of the mouth, but even the bony framework of Fig. 1. — The head of infancy. (Bell.) the lower face is permanently changed A relative over-development of the upper jaw gives an expression similar to that of an imbecile. On the other hand, an over-development of the lower jaw forward produces the prognathous condition which makes the face assume a canine look. These alterations only are mentioned here, so as to call attention to the necessity of early regulation of dental irregu- larities, which produce all degrees of change in the physiognomy. The face of the infant is small in comparison with the rest of the head; but the development of the accessory sinuses of the nose and of the jaws in the adult alter the relation. The cranium of a baby is five or six times as large as tbgs^face. The cranium and face of the adult woman retain to a certain extent an appearance of immaturity and show less marked prominences and ridges, than in the man. It A SURVEY OF THE ANATOMY OF THE FACE 17 is proportionally smaller than the male face and has narrower and less prominent jaws. The development, as the infant grows, of the superciliary ridges and frontal sinuses in the lower part of the frontal bone makes the frontal eminences less conspicuous; and therefore the forehead as- sumes a more receding character. The face at birth, in addition to being relatively small, is short in comparison to its breath, and lacks the prominence of the adult face. The region about the eyes is better developed than the middle and lower portions. The floor of the orbits at their outer sides is situated not much above the bottom of the Fig. la. — The head of the aged. Senile changes in the mandible. (Bell.) nasal chambers; the jaws show little alveolar process, because the teeth have not been erupted; the body of the lower jaw is not devel- oped and its rami are very oblique; the chin is small, and the temporal ridge and fossa and the zygomatic arch are inconspicuous. Bell believed that the fulness, roundness and chubbiness of the infant's face are due to the circumstance that the soft parts are ex- pected to meet the requirements to which they are to be subjected by the increased size of the bony framework of the face in later years. As the child grows, the bones of the face, especially the jaws, increase at a proportionately more rapid rate than those of the cranium; and the face is less round than in the baby. The superciliary ridges, 18 SURGERY OF DEFORMITIES OF THE FACE moreover, begin to appear as the frontal sinuses are developed and finally become a prominent characteristic of the face of the adult. At the time of the first dentition the lower part of the face in- creases in relative size, the chin becomes more prominent, the jaws become deeper and lengthen, the rami of the lower jaw become more vertical, and the zygomatic arch begins to give its characteristic ap- pearance to the side of the face. The later dental changes and the adolescent growth of the accessory sinuses of the nose induce still more marked alterations in the facial outlines, especially if the ventilation of the nose and nasopharynx is not obstructed. The angle of the inferior maxilla recedes and becomes prominent, and the square chin Fig. 2. — ^Facial angle of Caucasian skull, ab and dc are lines enclosing angle. 1. Audi- tory meatus; 2, nasal spine; 3, frontal emi- nence. (Camper.) Fig. 3. — Facial angle of negro, ab and ac enclose angle at 2. (Camper.) and well developed jaws succeed the rounded and plump face of the child. In old age the teeth are lost, the alveolar processes of the jaws disappear, the angle between the axes of the body and ramus of the lower jaw increases, and the face becomes correspondingly shorter, resembling the face of infancy. The body of the lower jaw has a larger arch than its alveolar border. Hence, as the alveolus is ab- sorbed the jaw is drawn upward, bringing the chin, now markedly prominent, nearer to the nose, the lips fall in and the mouth becomes too small for the tongue. These characteristics of old age may be developed in those persons who are not extremely old when the teeth are lost prematurely from any cause. The human face taken as a whole has varying characteristics in the different races of man and in different individuals of the same It may be broad or narrow, long or short, oval or round, large race. or small, receding or prominent. Some persons have faces which A SURVEY OF THE ANATOMY OF THE FACE 19 are peculiarly concave or dish-shaped in the center, though a promi- nent central contour is more common. The degree to which the lower part of the face is thrust forward has much influence upon the whole appearance of the individual. A protruding face is called prognathous, the non-protruding face orthognathous, and a broad face eurygnathous. The Caucasian face is orthognathous and often prominent mesially and centrally, while the African and Mongolian races are prognathous. The last are characterized by faces which are broad and centrally depressed as well as prognathous. Fig. 4. — Face of African negro. {Bell.) Fig. .5. — Head of antique statue. (Bell.) The relative size of the face to the cranium or rest of the head is indicated by the facial angle. This angle is ascertained by drawing a horizontal line from the anterior nasal spine to the auditory meatus and dropping a second line from the glabella, the smooth portion of the frontal bone above the fronto-nasal suture, to the alveolar process of the upper j aw. The angle between these lines at the anterior nasal spine is the facial angle of Camper. In the Caucasian this angle averages about 80°, in the Mongolian about 75°, in the African about 65°. In the lower animals of man's class the facial angle is much less; and the proportionate size of the face is so great compared with the decreasing brain cavity that the face is almost entireh^ in advance of the cranium. The facial angle of the gorilla is about 31°. The facial angle of man 20 SURGERY OF DEFORMITIES OF THE FACE is never a right angle, but the ancient sculptors made it so in their representation of mythological beings, to whom they desired to give the appearance of unusual intellectual development. Beneath the skin of the face lie the sheets of muscular tissue, which give expression to the countenance. They have one end at- tached to the bones of the face, which with the exception of the lower jaw are stationary, and the other end inserted into the under surface of the skin. Contraction of such muscular fibers causes the more movable end and its attached skin to approach the fixed end. This shortening of the fibers rucks the skin up into folds, with intervening wrinkles, which are at right angles to the direction of the muscular pull. In subjects whose skin is thin and flexible the muscular contraction causes many and delicate wrinkles to appear. When the skin is thick and stiff by nature, or as the result of disease, such as myxedema, a slight action of the muscles of expression will produce no visible wrinkling of the surface. The more active muscular contraction Fig. 6. — Facial angle of monkey, shown by lines ab and dc. (Camper.) ..i> Fig. 7. — Facial angle of Apollo. Angle shown between lines ab and 3c crossing near 2. {Camper.) required in this case to give evidence of its occurrence will cause few and thick wrinkles. The delicate shades, variety and beauty of facial expression are absent under such circumstances. The muscles of expression are difficult of dissection, because they are small, of loose texture, and somewhat pale in color, and from the fact that the removal of the skin dissects away the tissue into which the muscle is inserted. A SURVEY OF THE ANATOMY OF THE FACE 21 There are two muscular landmarks on the front of the face — about the eyes and around the mouth. Encircling each orbit is the orbicular muscle of the eyelids. Each of these arises at the inner side from the nasal process of the upper jaw, the tendon of the eye-lids, and the frontal bone. It is a sphincter muscle and encircles the orbit, its fibers being inserted on the outer side of the orbit into the external tarsal ligament and the malar bone. The orbicular muscle of the eyelids by its central fibei's closes the eyelids. The elliptical fibers running around its outer margin draw the brow down, and the lower Fig. 8. Fig. 9. Fig. 8. — Diagram sho\\ing Knes in forehead due to contraction of frontal part of occipito-frontal muscle. These furrows give expression of attention to the face. (Duval.) Fig. 9. — The emotion of attention and astonishment expressed by contraction of frontal muscles. (Duval.) eyelid up, thus wrinkling its edges and forcibly closing the eyes. It produces at the outer side of the eye the radiating wrinkles which in old age, when the skin is inelastic and the underlying fat has been absorbed, become very conspicuous and are called "crow's-feet." A similar orbicular or sphincter muscle, called the orbicular of the mouth, surrounds that opening and constitutes the muscular mass of the lips. It differs from the circular muscle of the eyelids in having its fixed attachments in the middle line above and below, instead of at its outer and inner ends. Its attachment to the upper jaw below the nose and to the lower jaw in the middle line permit the lips to be puckered in whistling. There are two naso-labial muscular slips, which connect the upper lip to the septum of the nose. The}' have an interval between them which makes the well-known depression in the 22 SURGERY OF DEFORMITIES OF THE FACE skin just below the columella. These are accessory fibers of the orbicular muscle. Many of the muscles of expression are inserted into or blend with the fibers of the orbicular of the mouth, and by acting upon it make great changes in the expression of the face. The so-called occipito-frontal muscle is really two muscles: — a posterior attached to one end of the fascia covering the top of the cranium, and an anterior or frontal portion, inserted in a similar manner into the front part of that fascia. The frontal portion arises Translferse facial art. TEMPORAL iMSsrj*. ^jTron taZ art. PrffAM/DALIS NA.Sf /Angular art^ Lateral I nasf art. coMPnsssoR /VAfi/S- Tjvasaln. Auricula temporal . _ . /Superficial , jr^-^f, temporalart W\/ Tempf branches y/l Cervico- facial / V'\ div-ision , '^ Us Su.73ramaxillari/j^ hran-c/i -^■ Submental ■