JOURNAL OF THE ROYAL SOCIETY OF MEDICINE Volume 91 Aug ust 1 998

Primary repair of dog bites to the face: 40 cases

M Javaid FRCS L Feldberg FRCS M Gipson FRCS

J R Soc Med 1998;91:414-416

SUMMARY
Dog bites to the face can be life-threatening if major infection occurs, and traditional management consists of
wound toilet and debridement, with repair only when the possibility of infection has been eliminated. Surgical
opinion is now swinging towards earlier repair. We have analysed retrospectively the outcome of 40 cases that,
irrespective of time delay between injury and presentation, underwent primary repair or reconstruction after wound
toilet, debridement and administration of prophylactic antibiotics.
The victims were 17 males and 23 females with ages ranging from 2 to 76 years (mean 25). Median delay between
the injury and presentation in the emergency department was 60 minutes (range 7 minutes to 5 days). All patients
received surgical treatment within 24 hours of admission, 18 being operated on within 6 hours. 31 had primary
repairs and 9 patients had reconstructive procedures with local skin flaps or skin grafts. Primary healing was
achieved in all but 2 patients, of whom one developed minor wound infection and one had necrosis of a composite
graft.
These results support the view that, for dog bites to the face, primary repair is the method of choice.

INTRODUCTION PATIENTS AND METHODS

Biting is a natural instinct of dogs. Most bites on the face are Case notes were obtained for the 40 patients with dog bites
inflicted by pet dogs and happen during playl. The typical to the face treated in the plastic surgery department from
victim is familiar with the dog, one way or another, and is a April 1994 to April 1997. We retrieved information on
child2'3. Bites of all kinds account for about 1% of outcome and on complications after primary repair or
emergency department visits4'5, and dog bites are 80-90% reconstruction.
of these6. In the USA domestic dog bites kill 10 to 20
people a year7'8. RESULTS
The most common complication of dog bites is
infection, due to contamination of the wound by Gram- 17 patients were male and 23 female, age range 2-76 years,
positive and Gram-negative microorganisms in the mean age 25 years. Most were children and young adults
saliva9'10. Because of the high potential for infection, (see Figure 1). 25 patients presented within 3 hours of
urgent attention is required, with administration of injury, 14 of them within the first hour. 4 patients arrived 3
antibiotics, thorough wound toilet and surgical debride-
ment. Delayed repair is the traditional approach, especially
for patients who present late5'11; however, for lacerations
of the face primary repair gives the best cosmetic and
functional results. Opinions differ on how to manage dog 10
bites to the face6'9, but many surgeons now favour primary
repair after surgical debridement and wound toilet, with I
a
antibiotic prophylaxis. This is the policy in our unit, and we z
z
5
report here experience with 40 cases seen in 3 years.

0
0-10 11-20

Department of Plastic Surgery, Whiston Hospital, Prescot, Merseyside, UK Age range in years
Correspondence to: Mr M Javaid, Department of Plastic Surgery, Figure 1 Patients' ages (mean age=25 years; range=2-76 years;
414 Addenbrooke's Hospital, Cambridge CB2 2QQ, UK n=40)
 JOURNAL OF THE ROYAL SOCIETY OF MEDICINE Volume 91 August 1 998

15 fl Table 1 Reconstructive procedures in patients with tissue loss

Procedure and part Site

10
.3 Advancement flap Lip 1
Debridement and split skin graft Nose 1
z
5 Debridement and post-auricular FTSG Nose 2
Debridement and rhomboid flap closure Chin 1
Debridement, mucosal advancement and FTSG Lip 2
0
<6h 6-12h 1324h >24h 5dayr NotSled Debridement and resuturing lost tissue as free graft Lip 1
Debridement and mucosal advancement Lip 1
Time interval from injury until surgical treatment
FTSG=Full thickness skin graft

Figure 2 Interval from arrival in emergency department to

surgical treatment (n=40)
hours after being bitten and 2 came with infected wounds as
late as 5 days after sustaining bites on the cheek and the
nose. These had been treated only with oral antibiotics by
the local general practitioner. The median delay between
injury and arrival in the emergency department was 60
minutes. Times from injury to surgical treatment are shown
in Figure 2. All patients were operated on within 24 hours
of admission 18 in under 6 hours, 9 within 6-12 hours
and 13 within 13-24 hours. Sites of injury are shown in
Figure 3: the lip was the commonest site (n = 15).
18 patients had partial thickness injuries and 22 full
thickness injuries, 9 of which communicated with the oral
cavity. Wound length was <2cm in 14, 2-4cm in 7, and
>4 cm in 3 (not recorded in 16 cases). None of the patients
had injury to facial nerve, parotid duct or facial bones.
All patients initially had a thorough wound toilet with
saline or Betadine and saline and surgical debridement of
crushed wound edges in simple wounds. Primary closure
was then attempted; in those with substantial tissue loss,
reconstruction was performed with local flap, mucosal
advancement, split skin graft or full thickness graft. In one
patient who had lost the upper lip, this was resutured as a
free composite graft. Hospital stays ranged from <1 to 6
days, most patients being discharged home the same or the
20
12
i
z
next day. After discharge patients were followed up in the
department's dressing clinic.
Operative procedures
32 patients were operated on under general anaesthesia and
8 patients under local. 31 had primary repair and 9 had
reconstructive procedures as shown in Table 1. Of the 2
patients who arrived late with infected wounds, one had his
cheek wound repaired after thorough toilet, the other
received a post-auricular graft on nose; both wounds healed
well without further infection.
Antibiotics
Patients received antibiotic prophylaxis with co-amoxiclav,
7 with co-amoxiclav plus metronidazole, and 7 with other
antibiotics (flucloxacillin, cefuroxime, ampicillin, erythro-
mycin). One patient had no antibiotic cover. In most cases
antibiotic prophylaxis was continued for 5-7 days.
Complications
2 patients had early postoperative complications. One
developed a minor wound infection after rhomboid flap
reconstruction of the chin, treated with further oral
co-amoxiclav. The patient who had resuturing of lip as a
free composite graft developed complete necrosis of the
grafted lip. It was further debrided and the defect was
covered with a full thickness skin graft which then healed.
On subsequent follow-up 5 patients proved to have
minor scar complications: one had a dog-ear deformity at

0'
Lip Nose Ear

Figure 3 Sites of injury (n=40)

Cheek Eyelid

Site of injury
Chin Forehead Mukiple
I the end of his scar about which he was unconcerned; 2 had
trap-dooring which needed further revision; and 2 had scar
hypertrophy which was treated with corticosteroid cream
and injections.

DISCUSSION
Dogs' teeth are not very sharp but can exert sufficient
pressure to perforate light sheet metalll. Young children 415
 IJOURNAL OF THE ROYAL SOCIETY OF MEDICINE
are most prone to severe dog bites involving face, head and
neck area12'13 because they are small, defenceless, and often
fearless. In our study lips were the commonest site probably
because of incidents while kissing or playing with the
animals. Fortunately, because of excellent blood supply,
facial wounds become infected less often than other
areas7'13. The bacteria in dog saliva include Staphylococcus
aureus, streptococci, Pasteurella multocida and anaerobes;
and, when a bite communicates with the oral cavity, one
must also consider the flora of human saliva5. Co-amoxiclav
is used in our department because of its activity against
many of these5'11. In patients presenting late with infected
wounds, the intravenous route is recommended5. We
found oral co-amoxiclav equally effective and less
expensive.
In our series 9 patients had full thickness lacerations of
lips communicating with the oral cavity and 12 patients
sustained multiple lacerations. All were repaired primarily
and healed without any infection and satisfactory cosmetic
results. Jones and Shires in 197914 and Weber in 199115
advocated delayed rather than primary repair of all facial
dog bites because of the high risk of infection. Goldstein5 in
1991 and Lewisl1 in 1995 suggested that wounds seen more
than 24 hours after the bite should be left open. Many
surgeons now believe that primary repair gives the best
functional and aesthetic results12' 6. Our initial management
includes copious irrigation with 150 mL saline via a syringe
with a 19-gauge needle, to reduce the bacterial count6'11.
Irrigation with antibiotic or iodine solution is no more
effective and may increase tissue irritation5. Careful
debridement of devitalized tissue is essential6 17,18. With
these precautions, primary repair of dog bites to the face
carries no greater hazard than delayed repair6. Our
infection rate of 2.5% is low compared with Palmer's
14.7% in the UK19 and similar to the 1.6% reported by
Zook in the USA20.
416
Volume 91 August 1 998
REFERENCES
I Karlson TA. The incidence of facial injuries from dog bites. JAMA
1984;251:3265-7
2 Brogan TV, Bratton SL, Dowd MD, Hegenbarth MA. Severe dog bites
in children. Pediatrics 1995;96:947-50
3 Sacks JJ, Lockwood R, Homreich J, Sattin RW. Fatal dog attacks,
1989-1994. Pediatrics 1996;97:891-5
4 Goldstein EJC. Infectious complications and therapy of bite wounds. J
Am Pediatr Med Assoc 1989;79:486-91
5 GoldsteinEJC. Bitewoundsandinfection. ClinInfectDis l992;14:633-40
6 Callahan M. Dog bite wounds. JAMA 1980;244:2327-8
7 Ruskin JD, Laney TJ, Wendt SV, Markin RS. Treatment of
mammalian bite wounds of the maxillofacial region. J Oral Maxillofac
Surg 1993;51:174-6
8 Sacks Jj, Sattin RW, Bonzo SE. Dog bite-related fatalities from 1979
through 1988. JAMA 1989;262:1489-92
9 Griego RD, Rosen T, Oringo IF, Wolf JE. Dog, cat, and human bites:
a review. J Am Acad Dermatol 1995;33:1019-29
10 Dire DJ. Emergency management of dog and cat bite wounds. Emerg
Med Clin N Am 1992;10:719-36
11 Lewis KT, Stiles M. Management of cat and dog bites. Am Fam Physician
1995;52:479-85
12 Lackmann GM, Draff W, Isselstein G, Tollner U. Surgical treatment of
facial dog bite injuries in children. J Cranio-Maxillo Fac Surg 1992;20:81-6
13 Guy RJ, Zook EG. Successful treatment of acute head and neck dog
bite wounds without antibiotics. Ann Plast Surg 1986;17:45-8
14 Jones RC, Shire GT. Bites and stings of animals and insects. In:
Schwartz SI, Shire GT, Spencer FC, Sorter EH, eds. Principles of
Surgery. New York: McGraw-Hill, 1979:232-42
15 Weber DJ, Hansen AR. Infections resulting from animal bites. Infect
Dis Clin N Am 1991;5:663-80
16 Slonim CB. Dog bite induced canalicular lacerations: a review of 17
cases. Ophthal Plast Reconst Surg 1996;12:218-22 4
17 Dinman S, Jarosz DA. Managing serious dog bite injuries in children.
Pediatric Nursing 1996;22:413-17
18 Dire DJ, Hogan DE, Waker JSD. Prophylactic oral antibiotics for low-
risk dog bite wounds. Pediatr Emerg Care 1992;8:194-9
19 Palmer J, Rees M. Dog bites of the face: a 15 year review. BrJ Plast
Surg 1983;36:315-8
20 Zook EG, Miller M, Van Beek AL, Wavak P. Successful treatment
protocol for canine fang injuries. J Trauma 1980;20:243-7