Primary reconstruction of major human bite wounds of the face

Hyena bite: A rare intriguing mode of maxillofacial injury, its management, risks involved, scenarios to avoid

The striped hyena (Hyaena hyaena) is a rarely spotted carnivore in India listed as Near Threatened (red list) by International Union for Conservation of Nature (IUCN) in 2014. Hyena is considered as scavenger but also executes rare opportunistic attacks on humans. In India, reported cases of hyena attack on humans are very rare, because of remote locations of these attacks majority of which go unreported to higher medical centres. This article describes about the circumstances and management of Hyena inflicted maxillofacial injury in North India, which is as per our knowledge first scientifically documented maxillofacial injury caused by Hyena in Indian subcontinent.

Animal Inflicted Maxillofacial Injuries: Treatment Modalities and Our Experience

INTRODUCTION

Animal inflicted injuries to the face and neck are becoming much more common as people lavish affection on pets. Injuries caused by animal attacks to the face can cause complex injuries to soft and hard tissues, presented as perforations, lacerations, crushes, avulsion or fractures. An uncountable number of bacteria and virus can be found in such injuries, with a potential pathological effect to humans, regarding infections. Although the infection rate is low due to excellent blood supply to face, the injuries have disfiguring effect with possible psychological repercussion to the patients. The treatment of animal inflicted injuries must address the soft tissue defect, neurovascular injuries, and bone injuries as well as prevention of post treatment infection. Primary wound repair is the treatment of choice for most clinically uninfected bite wound where as delayed closure should be reserved for wounds at high risk of infection or already infected wounds and tissue defect may require local flap or micro-vascular re-implantations.

MATERIAL AND METHODS

In this article, we have elicited up to date considerations regarding the management of animal inflicted injuries to the face based on literature search and exemplified by multiple case reports.

CONCLUSION

For bite injuries on face, immediate primary wound repair after meticulous wound debridement and irrigation with sufficient volume added by antibiotic prophylaxis gives good cosmetic results with minimum risk of infection. Depending upon type of attack and age of victims, psychiatric or social counseling may also be required.

Management of human bite injury of the upper and lower eyelids: a rare case report

Human bite injury to the eyelid is extremely rare and poses a significant challenge in surgical reconstruction. We report an extremely rare case of human bite injury to the eyelid in a 43-year-old male with approximately 60% full thickness loss of the upper eyelid and 80% to 90% full thickness loss of the lower eyelid and its successful reconstruction using the local advancement cheek flap.

Presentation and management of human lip bites at a Kenyan center: a case series

PURPOSE

To describe the pattern of presentation and management of human lip bites.

PATIENTS AND METHODS

Data on patients who presented with human lip bites between 2005 and 2007 were recorded.

RESULTS

There were 6 men and 4 women whose ages ranged from 25 to 60 years with varying degrees of lip loss that occurred in different circumstances. Reconstruction using local flaps was carried out in various stages to achieve satisfactory esthetic and functional outcomes.

CONCLUSIONS

Human lip bites can be repaired at any time of presentation using local flaps with acceptable results. Wound infection is not a major issue following these injuries.

Management of facial bite wounds

Bite wounds are especially prone to infectious complications, both local and systemic. In bite wounds to the face, such complications can create more difficulties than the initial tissue damage itself for the task of restoring an esthetic appearance. Management should aim to neutralize this potential for infection and provide an infection-free environment for wound healing. Wound cleansing followed by primary closure is the treatment of choice, and the use of prophylactic antibiotics may further decrease the risk of infection. Delay in presentation beyond 24 hours is not necessarily a contraindication to immediate repair, but excessive crushing of the tissues or extensive edema usually dictates a more conservative approach, such as delayed closure.

Human bite injuries in the oro-facial region at the Muhimbili National Hospital, Tanzania

Background

Human bites in the maxillofacial region compromise function and aesthetics, resulting in social and psychological effects. There is paucity of information regarding human bite injuries in Tanzania. The aim of the study was to assess the occurrence, treatment modalities and prognosis of human bite injuries in the oro-facial region at the Muhimbili National Hospital Dar es Salaam, Tanzania.

Methods

In a prospective study the details of patients with human bite injuries in the oro-facial region who attended at the Department of Oral and Maxillofacial Surgery of the Muhimbili National Hospital between January 2001 and December 2005 were recorded. Data included information on age, sex, site, duration of the injury at the time of reporting to hospital, reasons, details of treatment offered and outcome after treatment.

Results

A total of 33 patients, 13 males and 20 females aged between 12 and 49 years with human bite injuries in the oro-facial region were treated. Thirty patients presented with clean uninfected wounds while 3 had infected wounds. The most (45.5%) frequently affected site was the lower lip. Treatment offered included thorough surgical cleansing with adequate surgical debridement and primary suturing. Tetanus prophylaxis and a course of broad-spectrum antibiotics were given to all the patients. In 90% of the 30 patients who were treated by suturing, the healing was uneventful with only 10% experiencing wound infection or necrosis. Three patients who presented with wounds that had signs of infection were treated by surgical cleansing with debridement, antibiotics and daily dressing followed by delayed primary suturing.

Conclusion

Most of the human bite injuries in the oro-facial region were due to social conflicts. Although generally considered to be dirty or contaminated they could be successfully treated by surgical cleansing and primary suture with a favourable outcome. Management of such injuries often need multidisciplinary approach.

Facial bite wounds: management update

Bite wounds are frequently located on the face; injuries inflicted by dogs are most common, especially in children. Bacteriology of infected dog and cat bite wounds includes Pasteurella multocida, Staphylococcus aureus, viridans streptococci, Capnocytophaga canimorsus, and oral anaerobes. Infected human bites yield a similar spectrum of bacteria except for Pasteurellae and C. canimorsus; instead human bites are frequently complicated by Eikenella corrodens. Antibiotic therapy against these bacteria is indicated both for infected bite wounds and fresh wounds considered at risk for infection. Amoxicillin-clavulanate (and other combinations of extended-spectrum penicillins with beta-lactamase inhibitors) and moxifloxacin offer the best in vitro coverage of the pathogenic flora. Initial wound management consisting in irrigation and debridement is at least equally important with antibiotics for prevention of infection. The need for prophylaxis against systemic infectious complications, particularly tetanus, should also be evaluated. Primary surgical repair is the treatment of choice for most clinically uninfected facial bite wounds, whereas delayed closure should be reserved for certain high risk or already infected wounds. Avulsive injuries with significant tissue loss represent the most difficult cases for definitive management and are also those most likely to require hospitalization.

Early repair of avulsive facial wounds secondary to trauma using interpolation flaps

PURPOSE

This article describes the use of various local interpolation flaps for the reconstruction of facial defects resulting from trauma.

PATIENTS AND METHODS

Fifteen interpolation flaps were used to restore missing tissue of 14 patients who sustained trauma. Two of the procedures were performed as a single stage, whereas 13 flaps required a separate surgery to "take down" the pedicle. All flap procedures were performed within 72 hours from the time of trauma. Four types of interpolation flaps were used.

RESULTS

All flaps healed without evidence of infection, dehiscence, or necrosis. Two patients required secondary treatment 6 months after the flap procedure.

CONCLUSION

Various local interpolation flaps provide a reliable and aesthetic treatment option for early repair of soft tissue defects secondary to trauma.

Management of a Lower Lip Avulsion Injury Due to a Human Bite

The present case report illustrates the management of an avulsion involving two-thirds of the lower lip. An unsuccessful attempt at microsurgical replantation led to a trial of composite tissue engraftment. Ultimately, the tissue sloughed, and after minimal debridement, the defect was treated by direct approximation of mucosa, muscle and skin. The treatment decisions made in caring for this injury show the challenge of microsurgical tissue replantation, the unpredictability of the composite graft and the benefit of having enough tissue to consider direct tissue approximation. Clearly, lips are worth every attempt at preservation, given their functional, cosmetic and psychological importance.

Management of animal bite injuries of the face: experience with 94 patients

PURPOSE

Because of the large number of bacteria in the oral cavity, animal bite wounds are generally contaminated, and their treatment is difficult because of the risk of infection, especially in extensive injuries. This report describes the management of a large series of patients and recommends treatment guidelines on the basis of the results.

PATIENTS AND METHODS

Ninety-four animal bite wounds on the face and head were analyzed according to the type of animal, location and extent of the soft tissue wound, duration and type of surgical treatment, occurrence of infections and their pathogen spectrum, as well as the choice of antibiotic therapy.

RESULTS

Dogs caused 91% of the bite wounds. Infections developed in 4 of 53 patients who underwent primary wound closure with minor edge excision and prophylactic administration of oral penicillin. Without antibiotic administration, 2 of 15 patients had infections, which were treated on an outpatient basis. Of 26 patients with initially delayed treatment, 18 showed clinical inflammatory symptoms with a wide spectrum of pathogens (Escherichia coli, Streptococcus, Enterococcus, Staphylococcus epidermidis, and Proteus) on presentation.

CONCLUSION

Extensive animal bite wounds on the face, even with soft tissue defects, should be treated according to the criteria of a esthetic reconstructive facial surgery. In view of the low infection rate, routine antibiotic prophylaxis is not justified.

A study of primary closure of human bite injuries to the face

PURPOSE

This study evaluated the management of human bite injuries to the face during the period from May 1995 to April 1996.

PATIENTS AND METHODS

Data on 30 patients presenting with human bite injuries during this period were collected on specially designed forms. The information was pooled and analyzed. A standardized surgical treatment consisting of thorough debridement of the wound followed by primary closure either by direct suturing, a local flap, or skin grafting on the day of presentation was used. Most of the cases were treated under local anesthesia. Patients were prescribed tetanus prophylaxis and a course of antibiotics for 1 week. Suture removal was done 1 week postoperatively except for the skin grafts, which were uncovered at 10 days postoperation.

RESULTS

There were 21 males and 9 females ranging in age between 17 and 55 years, with a mean age of 31.8 years. Sixty-six percent of the bites involved the lips. The duration of injury before presentation ranged from 1 to 4 days. In 27 of the cases (90%), wound healing was complete at the time of suture removal.

CONCLUSION

The results indicate that immediate closure of human bite injuries is safe, even with old injuries.

Replantation of amputated facial tissues with microvascular anastomosis

A challenge to the microsurgeon is perfecting the technique of replantation of small pieces of facial tissue, mainly because of the extremely small size of the arteries as well as a lack of suitable veins for drainage. In the past 4 years, we have had seven cases of facial amputations, which included one scalp, two nasal tips, two ears, one lower lip, and one eyebrow. All of these patients were replanted/revascularized by microvascular anastomosis. Only two of the cases had suitable veins for anastomosis. Alternative techniques used for improving venous outflow were arterio-venous fistula, chemical leeches, and pin pricks. Four of the cases were completely successful, two cases had partial loss of the replant, and one case failed due to absence of venous drainage. In facial amputation, an aggressive microsurgical attempt will result in more tissue surviving and a better cosmetic outcome than in any other reconstructive procedures.