Treatment of Facial Dog Bite Injuries in Children:
A Retrospective Study
By Jiad N. Mcheik, Pierre Vergnes, and Jean M. Bondonny
Bordeaux, France
Purpose: The authors assess their approach to immediate
surgical repair with general anesthesia of facial dog bites in
children over a 10-year period in their pediatric department.
Methods: The authors reviewed a series of 100 children (59
boys, 41 girls) who required immediate surgical intervention
during the first hours after admission between 1985 and
1995. Strict disinfection was always used to preclude the risk
of rabies, and parenteral antibiotherapy was used to avoid
aero-anaerobic infections.
Results: A total of 68% of children were below 5 years of age.
The most frequent injury was to the midface. Associated
injuries or death were not observed. One case of postopera-
T HE EXCELLENT RELATIONSHIP between hu-
man and dog sometimes is deteriorated by bites.
When the face is involved, their seriousness is increased
by the high risk of cosmetic and functional sequelae.
Most victims are under 5 years old. The frequency of dog
bites decreases with age.
MATERIALS AND METHODS
We reviewed 100 children (59 boys, 41 girls) treated between 1985
and 1995 representing 143 bites. There were 68 patients younger than 5
years, 25 patients between 5 and 10 years, and 7 patients between 10
and 15 years old.
Initial examination aimed to detect associated lesions such as
neurological (extradural hematoma, craniocerebral), ophthalmic (or-
bital), orthopedic (cervical spine), and thoracoabdominal wounds.
Search for bone injuries was systematic. Because of the legal implica-
tions, accurate photos were taken. The site, nature, and size of wounds
were noted. We distinguished 3 stages according to seriousness: stage 1,
simple wound without lacerations or muscular injury; stage 2, multiple
injury with tissular lacerations and muscular injury (Fig 1); stage 3,
substance loss (Fig 2).
Preoperative Treatment
On admission, emergency first aid was performed. After cleansing the
wounds with saline solution, a polyvidone iodine (Betadine) dressing
was used because of its antirabies effect. Moreover, antalgic therapy and
antibiotherapy by parenteral administration (aero-anaerobic spectrum)
were started. Our protocol consists of an association of betalactamin
From the Service de Chirurgie Pédiatrique, Hôpital des Enfants,
Centre Hospitalo-Universitaire de Bordeaux, Bordeaux, France.
Address reprint requests to Dr Jiad N. Mcheik, MD, 9 Allée des
conviviales. Res. Les fontaniles, appt. 104. 33700 Merignac, France.
Copyright 娀 2000 by W.B. Saunders Company
0022-3468/00/3504-0010$03.00/0
580
tive wound infection was noted. Four surgical revisions were
performed because of unsightly scars, but in most children
the scar had attenuated 1 year after injury.
Conclusions: The aim of immediate surgical repair is to
obtain a satisfactory cosmetic result and to avoid infections.
Better cosmetic results (4 cases of scar revisions) with a
minimal risk of wound infections (1 cheek wound infection)
are obtained.
J Pediatr Surg 35:580-583. Copyright 娀 2000 by W.B. Saun-
ders Company.
INDEX WORDS: Dog bites, face, immediate surgical repair.
and metronidazole: 50 to 100 mg/kg/d of amoxicillin (Clamoxyl) and 30
mg/kg/d of metronidazole (Flagyl) by intravenous administration. This
treatment was continued throughout hospitalization (5 days).
Surgical Repair
The delay between admission to the emergency unit and surgical
repair ranged from 1 to 10 hours. In the operating unit, strict disinfection
was performed with general anesthesia including an association of 2
antiseptics: Betadine and hydrogen peroxide. This disinfection was
followed by rinsing with saline solution. Because injury to the facial
nerve might be present, surgical repair was performed. If the parotid
lobe was damaged, closure was performed because of the possible
presence of salivary fistula, which regresses spontaneously after a few
weeks. Any lesion to the Stenon canal was repaired systematically. The
integrity of the lachrymal tracts was explored systematically by
catheters if the site of the wound was inside the canthal region.
Systematic cleansing with antiseptics allowed sutures in several
planes. Resorbed thread 5-0 and 6-0 was used for subcutaneous sutures,
whereas 6-0 monofilament nylon thread was used for cutaneous sutures.
Because a ‘‘U’’ flap always tends to retract, we used the small flap
(possible suture with substance loss) or excised the oblique peripheral
edges to make them perpendicular to the skin ready for closure. Any
skin substance loss was sutured directly or left open for controlled
healing. Strict disinfection allowed immediate reconstructive surgery; a
rotation flap with inferior pedicle was performed for a substance loss of
1 cm on the helix of the ear in one case. In another, a free skin graft was
performed for the same lesion. Three cases of substance loss in the
superior lip required plastic repair with rotation flap. One case of
substance loss in the left orbital region was repaired with a ‘‘Z’’ flap.
Verification of Vaccination
Because humans may be contaminated directly by rabies, and the
incubation period is long (40 days), treatment or vaccination against
rabies must be set up. There are 3 possible scenarii in France. (1) If the
dog is vaccinated, the child is not systematically vaccinated, but the dog
must go into quarantine for 15 days. (2) If the dog has disappeared, then
the child must be vaccinated. (3) If the dog is not vaccinated, it must go
Journal of Pediatric Surgery, Vol 35, No 4 (April), 2000: pp 580-583
FACIAL DOG BITE INJURIES
Fig 1. Dog bite of the lip with muscular lesion (stage 2).
into quarantine for 15 days: if the animal show signs of rabies,
vaccination and serum are administered to the child, and the dog is
killed. Its brain is sent then to the Pasteur Institute for microscopic
examination. If the dog shows no signs of rabies, the child is not
systematically vaccinated.
Regarding tetanus immunization, this was systematically tested in all
children and given if necessary. All children were hospitalized for 5
days and were given intravenous antibiotics. Sutures were removed on
day 7. All cases were reviewed at short- and long-term consultations.
Evolution and quality of definitive scars were controlled until puberty.
Fig 2. Substance loss of the ear after dog bite (stage 3).
581
RESULTS
The distribution of severity of dog bites was as
follows: stage 1, 84 wounds (59% of cases); stage 2, 50
wounds (35% of cases); and stage 3, 9 wounds (6% of
cases).
Anatomic Region Involved
The midface was the most commonly involved with
the following distribution (Fig 3): Cheek, 35 wounds
(24.3%); Lip, 25 wounds (18.5%); Orbit, 24 wounds
(16.4%); Forehead, 21 wounds (15%); Chin, 11 wounds
(7.8%); Nose, 10 wounds (7.3%); Ear, 9 wounds (6.4%);
and Scalp, 6 wounds (4.3%).
Mortality Rate and Associated Lesions
No case of associated lesions or mortality were ob-
served. No case of rabies in children or dogs occurred.
Cases were reviewed at months 1, 3, and 12.
Short-Term Follow-Up
Extensive edema occurred in 4 cases but without
hyperthermia or infections. The edema had regressed a
few days later. In 5 cases an isolated erythematous scar
was observed during hospitalization and persisted until
month 3 in 3 cases. In 2 cases, there was a hyperthermic
peak at 40°C the first day, with a return to normal 24
hours later. All these children showed signs of infection
of the upper airway. In 4 other cases, there was hyperther-
mia at 38°C during hospitalization with a return to
normal just before discharge. There was one cheek
wound infection, but recovery was complete after 8 days.
Long-Term Follow-Up
After 3 months, there was an inflammatory aspect of
the scars in 4 cheek wounds. In these cases, Jonctum
ointment or compressive treatment with silicone gel was
given to reduce scars. The final result could be evaluated
only 1 year later. After 1 year, good cosmetic results were
mostly obtained. Almost all scars were reduced (Figs 4
Fig 3. Distribution of wounds according to anatomic site.
582
Fig 4. Aspect of cheek scar 1 year after surgical repair.
and 5). In 2 cases there was an inflammatory aspect of the
cheek 1 year later. These scars were still evolving and
required surveillance and continued treatment (Jonctum,
silicone gel). In 4 cases, a slight broadening of the scars
was noted. In 2 cases there was a dyschromic scar, which
did not require surgical revision. However, 4 scars with
considerable broadening did require surgical revision (3
cheek wounds and 1 alopecic scalp scar). In all cases
results were successful.
DISCUSSION
Dog bites are an important health care problem and a
common cause of trauma to the face in children. In the
United States the occurrence of dog bites is estimated to
range from 300 to 700 bites per 100,000 people per year,
and 30% of these concern children.1 In France, there are 9
million dogs, and 30% of families possess one.2
Age of Children
The multicentric study of Brogan et al3 included 40
children hospitalized with acute dog bites between 1985
and 1994. Most children were boys (60%), mean age was
4 years old, and mean hospital stay was 6 days, with 12
Fig 5. Aspect of ear scar 1 year after surgical repair.
MCHEIK, VERGNES, AND BONDONNY
children (30%) requiring hospitalization in the intensive
care unit for 2 days. In our study, there was the same male
predominance (59%), with a peak occurring in children
under 5 years (68%). Young children do not understand
dogs as well as adults, and it is perhaps because they have
their head and neck on the same level as dogs that there is
a high rate of dog bites in this age group.
Anatomic Region Involved
In the series of 116 children hospitalized for dog bite
injuries between 1960 and 1969 and reported by Richard
et al,4 80% showed multiple injuries with 52% of head
and neck injuries. In our study, cheek and lip wounds
represented 24.3% and 18.5%, respectively. Again, the
central part of the face is highly involved in these data.
Mortality
Sacks et al5 identified 109 dog bite–related fatalities in
the United States between 1989 and 1994, of which, 57%
concerned children under 10 years of age with 11 attacks
involving a sleeping infant. The most commonly reported
breeds were pit bulls, rottweilers, and German shepherds.
Nineteen dogs involved in fatal attacks had a prior history
of aggression. In our study, no death occurred.
Associated Lesions
Wiseman and Chochinov6 reported results of 57 pa-
tients over a 10-year period (1971 to 1981). Most patients
sustained puncture wounds and lacerations to the face
(77%). The investigators noted associated lesions, 4 of
which were severe. Our patients did not present associ-
ated lesions. However, it is essential to perform a clinical
examination of the cervical and abdominal regions of
children attacked by dogs.
Immediate Surgical Repair
The results of the current study support an attitude that
was considered dangerous for a long time, because of the
risk of rabies and infections. In the literature, the risk is
considered to be persistent despite surgical repair delayed
till day 7, and the rate of complications ranges from 1.5%
to 6% in some studies. Pinsolle et al2 published a series of
200 patients (368 dog bites) hospitalized between 1979
and 1980, of whom 73% were under 15 years of age.
Substance loss, nose amputation, partial amputation of
chin or cheek, and orbital laceration injury were observed
in 30, 7, 5, and 1 cases, respectively. The investigators
decided to delay repair. After a surgical exploration, a
dressing with hydrogen peroxide was applied daily, and
an antibiotherapy was started. Vaccination status was
then verified. Surgical repair was done between day 2 and
7 according to the seriousness and degree of the wound.
The rate of wound infections and unsightly scars was
FACIAL DOG BITE INJURIES
2.5% and 12.5%, respectively. No rabies or tetanus
infections were noted.
Some aspects of this attitude could be debated. For
example, explorations of dog bites on admission required
general anesthesias, as did repair some days later (2
anesthesias in 1 week). Immediate surgical repair avoids
2 anesthesias in a short period. Moreover, the rate of stage
II and III wounds (35% and 6%, respectively) means that
it would be necessary to change the dressing daily; this
would be very difficult in youngsters who require admin-
istration of high doses of antalgics. This disadvantage
could be avoided by immediate surgical repair. Moreover,
immediate repair often allows the surgeon to solve the
problem of cosmetic damage. Immediate repair must be
accompanied by strict disinfection with 2 antiseptics, and
cleansing is essential in our approach. Antibiotherapy by
intravenous administration for 5 days also is very impor-
tant. There was 1 case of wound infection that was cured
completely at day 8 without cosmetic damage after 18
months; our results confirm the efficacy of this treatment.
However, mean hospital stay and antibiotherapy are
identical in the 2 approaches. Our results are satisfactory,
and only 4 surgical revisions were performed for un-
sightly scars.
REFERENCES
1. Tuggle DW, Taylor DV, Stevens RJ: Dog bites in children. J
Pediatr Surg 28:912-914, 1993
2. Pinsolle J, Phan E, Coustal B: Les morsures de chien au niveau de
la face. Annales de Chirurgie Plastique Esthétique 38:452-456, 1993
3. Brogan TV, Bratton SL, Dowd MA: Severe dog bites in children.
Pediatr 96:947-950, 1995
4. Richard C, Schultz MD, William C: The treatment of dog bite
583
Preventive Procedures
Reducing the rate of dog bites implies better knowl-
edge of dogs and respect for some common sense rules,
both on the part of children and dog owners. Parents must
teach their children how a dog may behave, how to treat
animals with respect, and to be careful with an unknown
dog. Although children are the principal victims of dog
bites, the responsibility lies with the dog owners. They
are responsible for the dog, its education, and their child’s
education. It is absurd to lock up a big dog in a small flat.
A dog must be educated and know that it must not nip
even when playing. Its diet must be adapted, it must
receive sufficient physical exercise and be examined by a
veterinarian regularly. Moreover, infants or toddlers must
never be left alone with a dog.
Dog bite injuries to the face represent a frequent
surgical trauma. Such wounds threaten the vital organs
and cosmetic integrity. The aims of immediate surgical
repair is to obtain a satisfactory cosmetic result and to
avoid infections. It has allowed us to obtain better
cosmetic results, with a minimal risk of wound infec-
tions. The main difficulty is to prevent dog bites, and this
may be obtained only by educating the whole family.
injuries, especially those of the face. Plast Reconstr Surg 49:494-500,
1972
5. Sacks JJ, Lockwood R, Hornreich J: Fata dog attacks, 1989-1994.
Pediatr 97:891-895, 1996
6. Wiseman NE, Chochinov H: Major dog attack injuries in children.
J Pediatr Surg 18:533-536, 1983