Abstract
Background: The face is fundamental to human appearance as well as functionality. It may be challenging for patients with facial injuries to eat, talk, and interact with others. One prevalent form of trauma that the man experiences is bite injuries. Animals have a natural tendency to bite. However, people are also on the line.
Aim: The goal of the current study was to offer a comprehensive overview of facial bite injuries sustained by canines and humans, including presentation, anatomical location, management, and outcomes.
Results: Total number of cases was 32 over a period of ten years. Age range was 2- 70 years. There were 22 males and 10 females, giving a male to female ratio of approximately 2:1. Lip is the most commonly involved site (13 cases) followed by cheek (9 cases) and nose (6 cases). Dog bites mostly (10 cases) cause lacerated injury and all the human bites (13 cases) caused avulsion type injury. In 24 cases single stage reconstruction was possible and in 8 cases staged reconstruction was required.
Conclusion: Victims of bite injuries experience both psychological and cosmetic aftereffects. Their family also experience severe mental strain as a result of the victims’ disfigurement. A positive outcome can be obtained with appropriate wound debridement, antibiotic treatment, primary closure, or reconstruction in cases of canine or human bites to the face. The risk of infection is reduced with antibiotics, tetanus prophylaxis, and anti-rabies prophylaxis.
Introduction
Bite injuries by humans and animals are a serious global health concern.1 The incidence and type of injuries caused by animal and human bites vary depending on the area, degree of industrialization and cultural elements.2 Dog bites are the most frequent mammalian bites treated in emergency rooms in affluent nations, followed by cat bites and human bites.3 Few studies have been conducted on the incidence of dog bites worldwide, but the evidence that they cause tens of millions of injuries every year is compelling.4 Because they are smaller in stature, younger children are more likely to get bitten in the face. After the upper and lower limbs, the face is the third most common region to sustain a dog bite. The most affected areas of the face are the lips and nose.5 There are instances when people act viciously in a fit of wrath, even biting their own people. Arguments between family members or between neighbors are among the primary causes of human bites.6
The victims of facial bite injuries suffer severe physical, psychological, and emotional anguish. Whether complete or partial, ear loss carries many social stigmas, and the sufferer hides the impairment in public settings. The function of the mouth sphincter may be compromised by abnormalities in the lower lip. People with nose deformities find it extremely difficult to socialize because of their obviously noticeable flaw. Reconstruction is required when individuals have soft tissue anomalies as a result of bite injuries in order to prevent psychological issues. The goal of the current investigation is to clarify the presentation and management of bite injuries to the face.
Materials and Methods
This prospective observational study was conducted in the Department of Plastic and Reconstructive Surgery, Cumilla Medical College, Cumilla and in private setup in Cumilla between 1 January 2013 to 31 December 2022. All patients presenting with history of animal or human bites to face were included in the study. Detailed history from the patients was obtained, thorough clinical examinations were done, and necessary investigations were advised. The general principles of contaminated wound management were followed in all cases. Thorough wound wash was given using Povidone-iodine solution, hydrogen peroxide, and saline. Injection Cefotaxime 1 g intravenous (IV) daily, and injection Metronidazole 500 mg IV TDS for as long as the patients stayed in the hospital after which oral antibiotics were given for a total period of 7 days. All patients were given tetanus prophylaxis and patient with dog bite injuries received 5 dose anti Rabies vaccine given on 0, 3, 7, 14, 28 days. If patient was severely wounded and /or animal is rabid, Rabies Ig (human origin) 20 IU/Kg body weight was also given. In stable patients, primary single staged repair was done, or the first stage of staged reconstruction was done on the day of injury. Demographic data and data regarding the procedures, and complications were recorded in a data collection sheet. Cases were followed up after 1 and 2 weeks then monthly for at least 3 months after the final stage of reconstruction.
Results
From 1 January 2013 to 31 December 2022 a total of 32 cases of bite injuries to the face were managed, out of them 19 were dog bite and 13 were human bite cases. All dog bite cases were within 20 years of age and all human bite cases were above 21 years (Table 1). In dog bite, gender difference of victims was negligible. But, in human bite, males were the common victims (Table 2).
Table 1: Age incidence
Age in years Dog bite (cases) Human bite (cases)
< 10 10
11-20 9
21-30 5
31-40 7
˃ 41 1
Table 2: Sex incidence
Male Female
Dog bite 10 9
Human bite 12 1
Table 3: Literacy status
Dog bite Human bite
Preschool 4
Primary 15 3
Secondary 8
Graduate 2
According to bite site, lip (human bite), nose and cheek (dog bite) are commonest (Table 4). Dog bites mostly caused lacerated wound and human bites resulted in avulsion wounds (Table 5).
Table 4: Region of bite
Dog bite Human bite Total (cases)
Lip 6 7 13
Nose 3 3 6
Cheek 8 1 9
Ear 1 2 3
Chin 1 1
Table 5: Injury patterns
Dog bite Human bite
Lacerated injury 10
Avulsion 6 13
Deep puncture 3
Most cases were managed by single stage reconstruction surgery except for 4 cases of lip injury and 4 cases of nose injury which had undergone staged reconstruction (Table 6). Methods of reconstruction are shown in Table 7. Complications were uncommon (Table 8).
Table 6: Timing of reconstruction
reconstruction reconstruction
Lip 9 4
Nose 2 4
Cheek 9 –
Ear 3 –
Chin 1
Table 7: Methods of reconstruction
Ear
Bipedicle flap 1
PA Flap 1
Primary closure 1
Lip
Abbe lip switch 5
Primary closure 8
Nose
Forehead flap 4
Primary closure 2
PA Flap = postauricular flap
Table 8: Complications
Ear
Wound infection 1
Flap edema 1
Lip
Microstomia 1
Discussion
One prevalent form of trauma that man experiences is bite wounds. Animals have a natural tendency to bite. However, people can also be dangerous. Dog bites are frequent and can harm people of all ages, including small children and the elderly. Typically, injuries occur in many body parts, such as the head and face. The victim’s age group determines which body part is most impacted. Children are mainly affected in the head region, whilst adult sufferers are more affected in the limbs and torso.7 We discovered in this study that all dog bite injury victims are between the ages of 2 to 11. Smaller children are especially vulnerable to dog bite injuries in the craniofacial region due to their low stature, propensity to crawl/play on the ground, exploratory behavior, children playing with dogs or teasing. This study shows that men are more often affected by bite injuries in general. Dog bites are more common in male child (10 cases); human bites are also common in adult men (12 cases). This is in line with the results from a previous study.8
Approximately 15 patients with dog bite injuries were enrolled in primary school, but only 8 patients with human bite injuries had finished secondary education. This is consistent with the findings of an earlier investigation.9 The cheek accounted for around 8% of dog bite injuries, whereas the lip accounted for approximately 6% of cases. The lips accounted for 40% of all biting injuries in humans (13 cases). This result differs from a prior study where the ear accounted for almost 67% of all injured sites.9
Ages 21 to 40, which are considered economically productive, accounted for the majority of patients with bite injuries from humans. The bulk of those bitten in Harrison’s study were young men, with 44% of the males being between the ages of 16 and 25. The ratio of men to women was 3:1.10
Human bite injuries are often linked to violent behavior conducts linked to property abuse, child abuse, sexual offenses, and sometimes alcohol and other drug usage in domestic violence.1 According to our current study, hostility was present in over 70% of human bite cases where the victim knew where the bite originated.
Animal and human bite injuries to the face can cause serious morbidity from structural problems, infectious complications that impair function, and psychological stress from cosmetic difficulties. Avulsion injuries are the main cause of the bad reputation that human bite wounds have earned. Animal bites are not more dangerous than bites from humans. Infection is the most frequent side effect of dog bites, which is caused by salivary bacteria that can contaminate wounds with both Gram-positive and Gram-negative bacteria.11 Abscesses, tenosynovitis, septic arthritis, osteomyelitis, tetanus, and sepsis are examples of infectious consequences. Injuries ranging from lesions limited to superficial tissues, with or without tissue loss, to severe vascular and nerve injury, as well as face and cranial bone fractures, are examples of structural complications. Cut, crush, avulsion, abrasion, and deep puncture are the different types of biting injuries. Following dog bite injuries, there are clear psychological effects such as distress, anxiety, and sadness.12
Human bite wounds can be treated using the general guidelines of contaminated wound management, which include complete wound irrigation and/or wound debridement.
According to a study, 10–20% of bite wounds, including 5–25% of canine bites and 20–25% of human bites, develop an infection.13 As a result, for bite wounds, the majority of doctors advise prompt preventive antibiotic treatment. It is imperative to receive vaccinations against rabies and tetanus.
In 21 of the patients in our study, primary closure was completed. For the remaining 11 cases, reconstructive surgeries were required; these typically involved a local or advanced flap. Additionally, our analysis shows that two-stage surgical procedures were necessary in 8 cases (Figure 1).
Figure: A case of dog bite (A) on admission, (B) after 1st stage surgery, (C) after 2nd stage reconstruction.
Patients’ self-esteem increased with primary repair of their facial abnormalities, which also resulted in shorter hospital stays and lower costs. Thirteen participants in this study suffered biting injuries that resulted in lip deformities. Five of them had a partial upper lip deformity involving the right lateral subunit. Lower lip defects affected eight people. Tissue loss in five patients was less than 30%. The vermillion was always a part of the tissue defect in every instance. Avulsion-related central defect in the upper lip repaired using an ABBE Lip switch flap from the lower lip. Eight patients had wedge excision of the defect and three-layer closure for primary repair.
Figure: A case of human bite (A) on admission, (B) after cartilage graft from ear, (C) forehead flap, (D) after 3 months of reconstruction.
A forehead flap combined with a cartilage graft was utilized to restore nasal deformities (Figure 2). Bipedicle flap reconstruction of lost ear lobules. primary closure for the healing of a cheek avulsion.
Conclusion
Injuries from bites are not unusual. Children are most commonly bitten by dogs, and the face is the most commonly affected area. Victims may experience psychological and artistic fallout from this. Additionally, the degree of disfigurement causes their families to experience severe anxiety. The fundamentals of careful wound care are the same as those for infected wounds. A positive outcome can be obtained with appropriate wound debridement, antibiotic treatment, primary closure, or reconstruction in cases of canine or human bites to the face. Prophylactic use of antibiotics, tetanus, and anti-rabies vaccines reduces the chance of infection.
Author of this article
Dr. Mirza Mohammad Tyabul Islam, Associate Professor and Head, Department of Plastic and Reconstructive Surgery, Comilla Medical College, Comilla.
References
1. Aziz H, Rhee P, Pandit V, Tang A, Gries L, Joseph B. The current concepts in management of animal (dog, cat, snake, scorpion) and human bite wounds. J Trauma Acute Care Surg. 2015 Mar;78(3):641–48. http://dx.doi.org/10.1097/TA.0000000000000531.
2. Rothe K, Tsokos M, Handrick W. Animal and Human Bite Wounds. Dtsch Arztebl Int. 2015 Jun;112(25):433–42.
3. Edens MA, Michel JA, Jones N. Mammalian Bites In The Emergency Department: Recommendations For Wound Closure, Antibiotics, And Postexposure Prophylaxis. Emerg Med Pract. 2016;18:1‐20.
4. World Health Organization. Animal Bites. https://www.who.int/newsroom/fact-sheets/detail/animal-bites. Accessed on 10/04/2020.
5. Chhabra S, Chhabra N, Gaba S. Maxillofacial injuries due to animal bites. J Maxillofac Oral Surg. 2015;14:142‐53.
6. Lindsey D, Christopher M, Hollenbach J, Boyd, J. Lindsey, W. Natural course of the human bite wound: Incidence of infection and complications in 434 bites and 803 lacerations in the same group of patients. J Trauma 1987;27:45-48.
7. Macedo JL, Rosa SC, Queiroz MN, Gomes TG. Reconstruction of face and scalp after dog bites in children. Rev Col Bras Cir. 2016;43:452‐57.
8.Simone Ehrhard, Mirjam Keller, Linda Morgenstern, Martin Müller. Presentation and treatment of animal and human bite injuries at a Swiss tertiary emergency department: a cross-sectional study. Swiss Med Wkly. 2023;153:40093.
9. Kumar PS, Bai SL, Anandan H. A Study of Human Bite Injuries to the Face. Int J Sci Stud 2017;5(3):243-47.
10. Wienert P, Heiss J, Rinecker H, Sing, A. A human bite. Lancet 1999;354:572.
11. Griego RD, Rosen T, Orengo IF, Wolf JE. Dog, cat, and human bites: a review. J Am Acad Dermatol. 1995;33:1019‐29.
12. De Keuster T, Lamoureux J, Kahn A. Epidemiology of dog bites: a Belgian experience of canine behaviour and public health concerns.
Vet J. 2006;172:482‐87.
13. Rothe K, Tsokos M, Handrick W. Animal and Human Bite Wounds. Dtsch Arztebl Int. 2015 Jun;112(25):433–42.