Microvascular replantation of a composite facial avulsion in a 24‐month‐old child after dog bite

Abstract

Dog bite injuries are common sources of morbidity with an estimated incidence of 4.5 million bites per year with over 350,000 requiring treatment in the emergency room. Children under the age of 14 are most likely to be affected with a peak age of 5-9 years old. We report a case of a 24-month-old female who sustained a large composite facial avulsion injury from a pit bull dog bite. The avulsed tissue involved a substantial portion of the patient's mid-face, including the entire soft tissue of the nose, upper lip, part of the left cheek, and left oral commissure. Artery-only microvascular replantation was performed because no recipient vein could be identified from the facial defect. Medicinal leech therapy was used for eight days postoperatively to prevent venous congestion. The patient experienced significant blood loss due to leech therapy and required nearly 29 L of blood product replacement. At the last follow up of 8 months postoperatively, the patient was recovering well with significant improvement in function and cosmesis of the mid-face. This case describes a successful artery-only replantation of an avulsive bite injury to the face of a young child. Despite the technical difficulty of cases such as this one, microvascular replantation should be attempted because when successful it provides a superior cosmetic and functional result to other reconstructive techniques.

Surgical Management of Animal and Human Maxillofacial Bites: A Comprehensive Review

“…14,65,69 In the event of tissue avulsion, replantation must be considered as the first option. 7,15,23,64,66,70,74 Not only aesthetic complaints but also functional problems are very often encountered. 73 When cartilages such as nose and ear are affected, another cartilage can serve to allow further reconstruction.…”

“…73 Immediate flaps and microvascular anastomosis are successful methods to prevent further necrosis. 64,70,73 More successful outcomes are associated with arterial and venous anastomosis. 7,43,64,66 Reconstructive flaps, scar revision and grafts may be required in a significant number of cases.…”

Mordeduras de perro en edad pediátrica: una revisión actualizada sobre la población más afectada por este fenómeno y su manejo en Costa Rica

“…Es de especial importancia, además, preguntar sobre el estado inmune del paciente, ya sea que presente alguna inmunodeficiencia adquirida o congénita, lo que ayudará en el proceso de determinar la necesidad de tratamientos adicionales (12,13). Al realizar la exploración física, es imprescindible examinar al paciente en búsqueda de datos como: la ubicación de las heridas sobre el paciente, las características (herida punzante o laceración, tamaño o extensión, profundidad), saber si la herida atraviesa varias o todas las capas de la zona afectada, la involucración de articulaciones, presencia de cuerpos extraños, y presencia de zonas fluctuantes que puedan indicar abscesos o infecciones de tejidos blandos; además, siempre es importante analizar la posibilidad de daño a estructuras funcionales como nervios, vasos importantes, o el sistema músculoesquelético, que puedan implicar un manejo más complejo (14,15). Al estar frente a mordeduras de perro en general, pero en especial en extremidades, es beneficioso documentar a profundidad el estado neurovascular distal a la herida, ya que existe la posibilidad de daño en estas estructuras al recibir este mecanismo de trauma (9,10,16).…”

Cultured Skin Autograft in Subtotal Pediatric Scalp Avulsion

“…Case studies report frequent causes of scalp avulsion including dog bites, motor vehicle accidents, heavy machinery, and assaults. [1][2][3][4] The incidence of dog bites has been extensively studied at the national, state, and local levels; researchers have found that boys aged 6 to 12 years who are bitten by a pit bull disproportionately experience lacerations requiring surgical intervention. [5][6][7][8][9][10][11][12][13][14][15][16][17] Microsurgical replantation of an avulsed scalp remains the criterion standard but may not always be feasible.…”

“…Reconstruction of pediatric scalp avulsion secondary to injury or defect presents a technical challenge. Case studies report frequent causes of scalp avulsion including dog bites, motor vehicle accidents, heavy machinery, and assaults 1–4 . The incidence of dog bites has been extensively studied at the national, state, and local levels; researchers have found that boys aged 6 to 12 years who are bitten by a pit bull disproportionately experience lacerations requiring surgical intervention 5–17 …”