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Dog bites of the face
DOG
By T. L.
BITES OF T H E F A C E BARCLAY,
M.B., F.R.C.S.(Ed.)
From the Mount Vernon Centre for Plastic Surgery THIRTY-ONE cases of dog bites of the face have been admitted to Mount Vernon Plastic Centre in the last two and a half years (I per cent. of all admissions). In these cases the damage was sufficiently severe to necessitate a general anmsthetic for repair of the wound. In addition, several cases with minor lacerations have been treated in the casualty department. TABLE
Type of Dog : Alsatian, 5 ; Mongrel, 5 ; Scotch Terrier, 3 ; Collie, 2 ; Bull Terrier, I ; Mastiff, I ; Airedale, I ; Labrador, I ; Fox Terrier, I ; Corgi, I ; N o t stated, IO. Site of Lesion.
Treatment.
Cases with T i s s u e L o s s - U p p e r lip, 12 .
Wedge excision, 7 ; local flaps, 3 ; postauricular Wolfe graft, I ; m u c o u s m e m b r a n e advancement, I. Wedge excision, 3Partial rhinoplasty, 2 ; post-auricular Wolfe graft, 2. Burying cartilage, subsequent reconstruction by local flaps, 2. Post-auricular flap, 2. Suture, I ; suture and D . G . , I.
L o w e r lip, 3 Nose, 4 Ear : U p p e r part, z . Ear : Lobule, 2 Cheek, z Cases w i t h o u t Tissue L o s s - L o w e r eyelid involving canaliculus, 2
Insertion o f ss wire in canaliculus and suture, 2. Suture of laceration, 2. Suture of laceration, x. Suture of laceration, I.
L o w e r lip, 2 U p p e r lip, I Nose, I .
Age of Patient : 2 to 5 years, 3 ; 5 to 14 years, 12 ; 15 to 72 years, 16. Sex of Patient : Male, I I (4 adult) ; Female, 2o (i2 adult).
DISCUSSION
I. Many of the cases have come from near at hand as the surrounding districts are mainly residential and the proportion of houses in which dogs are kept is higher than in more populous and industrial areas. 2. There did not appear to be much correlation between the size of the dog responsible for the bite and the extent of the damage sustained ; the two cases o f tissue loss of the cheek, both of which had extensive wounds and tissue loss, were caused by a Bull-mastiff and an Alsatian, but apart from these two cases the bigger dogs had not caused bigger wounds than the terriers and mongrels. In the majority of cases there was a definite reason for the dog bite, as in a small boy o f 2 years who sustained a bite of the ear " w h i l e trying to take the dog's bone away " and a woman of 34 who sustained a wound of the lower lip " when she 34
DOG
BITES
OF
THE
FACE
35
touched her dog unexpectedly." Unprovoked attacks were much less common, and indeed the unprovokedness was established in only two cases. 3- Contrary to what might be expected, sepsis was not experienced in any case, leading to the conclusion that primary repair should not be put off, at any rate when the case is seen early, because of this possibility. Primary healing was uneventful, for instance, in all four nasal injuries, two of which had partial forehead rhinoplasties and two post-auricular Wolfe grafts. 4. The bites of the upper lip call for further comment both from the point of a:tiology and treatment. All the upper-lip bites in this series presented a remarkably similar appearance, varying only in the breadth of the lip involved. The vermilion was missing from
FIG. I FIG. 2 FIG. 3 Fig. i.--Extensive kiss bite. Fig. 2.--Six months' result of Wolfe graft showing hypertrophic scarring. Fig. 3.--Butterfly flap gives good contour (after mucosal secondary adjustment) but scar is noticeable.
the mucocutaneous line to the free border, a distance of about I cm., and in addition there was always a strip of skin missing above the mucocutaneous line 2 to IO mm. in depth. The muscle was exposed but not usually damaged to any extent. It is probable that these bites are sustained when the lips are in one definite position, and that is the position assumed in kissing. When the lips are pouted with the upper lip protruding more than the lower lip it is easy to see that a superficial bite will result in exactly the tissue loss which these patients sustained. The one man in the series who sustained this type of bite admitted that he kissed his dog every morning and had been doing so when he was bitten, and since then the two women who have been admitted with this type of bite reluctantly confessed that they were kissing their dogs when asked this specific question. Further confirmation is perhaps to be added from the fact that twelve of the patients in the series with this type of bite were women or young children, who are perhaps more likely to kiss dogs, and the only man in the thirteen was the one referred to above who admitted kissing. Regarding treatment of these " kiss bites " the wound at first sight appears to be best treated by a free full-thickness skin graft, but experience shows that this is rarely satisfactory as the graft inevitably wrinkles and becomes hypertrophic (Figs. I and 2).
36
BRITISH
JOURNAL
OF PLASTIC
SURGERY
It is possible to close the defect by skin advancement, by V-Y or " butterfly flaps " (Fig. 3), and mucous membrane adjustment, but this leaves a fairly noticeable scar and the mucous membrane usually needs a secondary adjustment later. It is also possible to advance the mucous membrane over the defect and
FIG. 4
FIG. 5
Fig. 4.--Typical kiss bite. Fig. 5 (result of Fig. 4).--Early result of advancing mucosa with small transposed skin flap leaves unacceptable notch and vermilion irregularRy.
FIG. 6
FIG. 7
Fig. 6.-Typical kiss bite. Fig. 7 (result of Fig. 6).--Three months' result showing good contour and minimal scarring following primary wedge excision and suture.
adjust the red margin secondarily, but this usually results in a notching of the lip (Figs. 4 and 5). The treatment which gives an immediate final repair with minimal scarfing is wedge excision of the defect, that is, the muscle underlying the defect is excised in an inverted " V " together with skin and mucous membrane towards the apex, and straight closure of the resulting defect, preferably with a Z-plasty on the vermilion border (Figs. 6, 7, 8, and 9)- This treatment is unjustified only
DOG
BITES
OF
THE
FACE
37
if the resulting upper lip would be too tight, this being the case in wounds of more than one-third of the total length of the lip. On these cases local flaps and conservation of tissue are probably best, accepting the fact that secondary adjustments will probably be necessary, although a wedge resection and immediate Abb~ flap might also be considered. The same treatment is applicable to wounds of the lower lip.
FIG. 8 Lateral kiss bite.
FIG. 9 Result of wedge excision.
SUMMARY An analysis is made of thirty-one cases of dog bites of the face which necessitated admission to hospital. Twenty-five of these had tissue loss and six bad lacerations without loss. It is thought that in the majority of cases the patients were more to blame than the dogs. Sepsis was no worse a problem in these cases than in other facial lacerations. Special attention is paid to bites of the upper lip which are thought to be due in most cases to damage while kissing the dog, and for which the best treatment is wedge excision of the affected area. I am grateful to M r Rainsford Mowlem for his help and advice, and to M r R. L. G. Dawson, Mr S. H. Harrison, and M r I. F. K. Muir for access to their cases ; and to Miss N. Walker for the photographs.
I C~
By T. L.
BITES OF T H E F A C E BARCLAY,
M.B., F.R.C.S.(Ed.)
From the Mount Vernon Centre for Plastic Surgery THIRTY-ONE cases of dog bites of the face have been admitted to Mount Vernon Plastic Centre in the last two and a half years (I per cent. of all admissions). In these cases the damage was sufficiently severe to necessitate a general anmsthetic for repair of the wound. In addition, several cases with minor lacerations have been treated in the casualty department. TABLE
Type of Dog : Alsatian, 5 ; Mongrel, 5 ; Scotch Terrier, 3 ; Collie, 2 ; Bull Terrier, I ; Mastiff, I ; Airedale, I ; Labrador, I ; Fox Terrier, I ; Corgi, I ; N o t stated, IO. Site of Lesion.
Treatment.
Cases with T i s s u e L o s s - U p p e r lip, 12 .
Wedge excision, 7 ; local flaps, 3 ; postauricular Wolfe graft, I ; m u c o u s m e m b r a n e advancement, I. Wedge excision, 3Partial rhinoplasty, 2 ; post-auricular Wolfe graft, 2. Burying cartilage, subsequent reconstruction by local flaps, 2. Post-auricular flap, 2. Suture, I ; suture and D . G . , I.
L o w e r lip, 3 Nose, 4 Ear : U p p e r part, z . Ear : Lobule, 2 Cheek, z Cases w i t h o u t Tissue L o s s - L o w e r eyelid involving canaliculus, 2
Insertion o f ss wire in canaliculus and suture, 2. Suture of laceration, 2. Suture of laceration, x. Suture of laceration, I.
L o w e r lip, 2 U p p e r lip, I Nose, I .
Age of Patient : 2 to 5 years, 3 ; 5 to 14 years, 12 ; 15 to 72 years, 16. Sex of Patient : Male, I I (4 adult) ; Female, 2o (i2 adult).
DISCUSSION
I. Many of the cases have come from near at hand as the surrounding districts are mainly residential and the proportion of houses in which dogs are kept is higher than in more populous and industrial areas. 2. There did not appear to be much correlation between the size of the dog responsible for the bite and the extent of the damage sustained ; the two cases o f tissue loss of the cheek, both of which had extensive wounds and tissue loss, were caused by a Bull-mastiff and an Alsatian, but apart from these two cases the bigger dogs had not caused bigger wounds than the terriers and mongrels. In the majority of cases there was a definite reason for the dog bite, as in a small boy o f 2 years who sustained a bite of the ear " w h i l e trying to take the dog's bone away " and a woman of 34 who sustained a wound of the lower lip " when she 34
DOG
BITES
OF
THE
FACE
35
touched her dog unexpectedly." Unprovoked attacks were much less common, and indeed the unprovokedness was established in only two cases. 3- Contrary to what might be expected, sepsis was not experienced in any case, leading to the conclusion that primary repair should not be put off, at any rate when the case is seen early, because of this possibility. Primary healing was uneventful, for instance, in all four nasal injuries, two of which had partial forehead rhinoplasties and two post-auricular Wolfe grafts. 4. The bites of the upper lip call for further comment both from the point of a:tiology and treatment. All the upper-lip bites in this series presented a remarkably similar appearance, varying only in the breadth of the lip involved. The vermilion was missing from
FIG. I FIG. 2 FIG. 3 Fig. i.--Extensive kiss bite. Fig. 2.--Six months' result of Wolfe graft showing hypertrophic scarring. Fig. 3.--Butterfly flap gives good contour (after mucosal secondary adjustment) but scar is noticeable.
the mucocutaneous line to the free border, a distance of about I cm., and in addition there was always a strip of skin missing above the mucocutaneous line 2 to IO mm. in depth. The muscle was exposed but not usually damaged to any extent. It is probable that these bites are sustained when the lips are in one definite position, and that is the position assumed in kissing. When the lips are pouted with the upper lip protruding more than the lower lip it is easy to see that a superficial bite will result in exactly the tissue loss which these patients sustained. The one man in the series who sustained this type of bite admitted that he kissed his dog every morning and had been doing so when he was bitten, and since then the two women who have been admitted with this type of bite reluctantly confessed that they were kissing their dogs when asked this specific question. Further confirmation is perhaps to be added from the fact that twelve of the patients in the series with this type of bite were women or young children, who are perhaps more likely to kiss dogs, and the only man in the thirteen was the one referred to above who admitted kissing. Regarding treatment of these " kiss bites " the wound at first sight appears to be best treated by a free full-thickness skin graft, but experience shows that this is rarely satisfactory as the graft inevitably wrinkles and becomes hypertrophic (Figs. I and 2).
36
BRITISH
JOURNAL
OF PLASTIC
SURGERY
It is possible to close the defect by skin advancement, by V-Y or " butterfly flaps " (Fig. 3), and mucous membrane adjustment, but this leaves a fairly noticeable scar and the mucous membrane usually needs a secondary adjustment later. It is also possible to advance the mucous membrane over the defect and
FIG. 4
FIG. 5
Fig. 4.--Typical kiss bite. Fig. 5 (result of Fig. 4).--Early result of advancing mucosa with small transposed skin flap leaves unacceptable notch and vermilion irregularRy.
FIG. 6
FIG. 7
Fig. 6.-Typical kiss bite. Fig. 7 (result of Fig. 6).--Three months' result showing good contour and minimal scarring following primary wedge excision and suture.
adjust the red margin secondarily, but this usually results in a notching of the lip (Figs. 4 and 5). The treatment which gives an immediate final repair with minimal scarfing is wedge excision of the defect, that is, the muscle underlying the defect is excised in an inverted " V " together with skin and mucous membrane towards the apex, and straight closure of the resulting defect, preferably with a Z-plasty on the vermilion border (Figs. 6, 7, 8, and 9)- This treatment is unjustified only
DOG
BITES
OF
THE
FACE
37
if the resulting upper lip would be too tight, this being the case in wounds of more than one-third of the total length of the lip. On these cases local flaps and conservation of tissue are probably best, accepting the fact that secondary adjustments will probably be necessary, although a wedge resection and immediate Abb~ flap might also be considered. The same treatment is applicable to wounds of the lower lip.
FIG. 8 Lateral kiss bite.
FIG. 9 Result of wedge excision.
SUMMARY An analysis is made of thirty-one cases of dog bites of the face which necessitated admission to hospital. Twenty-five of these had tissue loss and six bad lacerations without loss. It is thought that in the majority of cases the patients were more to blame than the dogs. Sepsis was no worse a problem in these cases than in other facial lacerations. Special attention is paid to bites of the upper lip which are thought to be due in most cases to damage while kissing the dog, and for which the best treatment is wedge excision of the affected area. I am grateful to M r Rainsford Mowlem for his help and advice, and to M r R. L. G. Dawson, Mr S. H. Harrison, and M r I. F. K. Muir for access to their cases ; and to Miss N. Walker for the photographs.
I C~