Case 15: Closure of a complex defect after a dog bite wound of the middle third of the face

Keywords: Cheek reconstruction, face, cheek, forearm, free flap, Neurorrhaphy, radial forearm flap

Authors: Dr. Guillermo Alvarez-Sanchez, MD; Ignacio Lugo-Beltran, MD, Chief, Dr. Haro-Cruz Jorge Said, MD. Institution: Plastic and Reconstructive Surgery Division of Microsurgery, Hospital Angeles Metropolitano, Cuauhtémoc, Mexico.

Abstract

A 52 year old female who presents to the emergency room after receiving a dog bite in her right face, the defect is managed with a free radial forearm flap.

Patient medical history

52 year old female, without past medical history, presented to the emergency room, referring she was attacked by her dog at her house, suffering a bite on her right cheek, with bleeding and loss of skin

Surgical cheek wound with sutures and blue medical tool.
Patient post-facial surgery with stitches and bandages.

Before and After

1

Before photo – Arrival at the ER

Facial asymmetry, with a complex wound on the right cheek, with skin loss, a defect approximately 10 x 9 cm, irregular borders, with muscle exposure, visualizing blood vessels and section of the buccal and zygomatic terminal nerve branches, active mild bleeding. Intact parotid gland and Stensen duct. Laceration of the zygomatic ligament. Difficulty mobilizing of the zygomatic and buccal branches muscle groups.

Facial asymmetry, with a complex wound on the right cheek, with skin loss, a defect approximately 10 x 9 cm, irregular borders, with muscle exposure, visualizing blood vessels and section of the buccal and zygomatic terminal nerve branches, active mild bleeding. Intact parotid gland and Stensen duct. Laceration of the zygomatic ligament. Difficulty mobilizing of the zygomatic and buccal branches muscle groups.

Given the circumstance of tissue loss, active bleeding and section of the nerve branches, also being a contaminated wound, we decided to go to the operating room immediately

Due to tissue loss dimensions, we planned a radial free flap for tissue coverage

2

Debridement and assessing damages

we cleansed, remodeled the irregular borders and closed the irregular wounds to bring together the uneven flaps, to make a more regular and “rounded” shaped defect. The nerve endings, proximal and distal, were identified and referred.

We performed a debridement of both proximal and distal ends of the nerve branches and then, neurorrhaphy of the facial nerve zygomatic and buccal branches was performed with nylon 9-0, we added fibrin glue to cover the neurorraphies.
The department of epidemiology did an Intralesional administration of immunoglobulin

3

Determining tissue loss

Once the defect was established, it was measured (8 x 7 cm) and the planning of a fasciocutaneous radial forearm free flap according to the defect was made.

The radial artery was the axis of the flap for the markings and design of the cutaneous island (9 x 9 cm)

Given the defect dimensions and thickness needed to close the defect, we chose the radial free flap, with thinning of the flap for a better cosmetic result.
A right cervical incision was performed; blunt dissection until the facial artery and vein, jugular were located and referred.
Tunnelization from the defect to the cervical incision was made via blunt dissection.
4

Harvesting of the radial forearm free flap

Harvesting of the radial forearm free flap was performed
Placing of the flap on the cheek defect with radial vessels in a longitudinal direction to the facial vessels. The radial vessels were passed through the tunnelization to the facial artery and jugular vein.
Terminoterminal anastomosis of the radial artery to the facial artery was performed with interrupted sutures with nylon 9-0

Terminoterminal anastomosis of the radial vein to the external jugular vein was performed with interrupted sutures with nylon 9-0

5

Closing the donor site

Once the radial free flap was harvested, closure of the donor site was performed with a fenestrated partial thickness skin graft

6

Closure of the defect with the free flap

Person with facial surgery stitches and bandages.
7

Day 3 post-OP

–

Woman with facial surgery scars from side view.
8

Follow-up 2 weeks

–

Woman with facial asymmetry in front and side views.
9

Follow-up 8 months

–

Pearls

Suturing the fascia to the dermis of the cutaneous island flap helps to prevent shearing damage of the flap
Performing a direct Allen’s test to make sure adequate blood flow to the hand is paramount
Frequent irrigation with heparin solution is key when performing the anastomosis to prevent blood clotting of the lumens.

Pitfalls

Radial hand and/or thumb ischemia due to insufficient collateral hand circulation, preoperative evaluation is vital to avoid this rare but feared complication
Delayed wound healing, over 6 weeks, as well as tendon exposure are common complications
Nerve injury at the donor site, with as many as 46% of patients presenting some degree of dorsoradial numbness

Post-operative plan

Remodeling and liposuction of the flap
Correction of ectropion with a planned tarsal strip and contralateral blepharoplasty for symmetrization

References

Contents

Case 15: Closure of a complex defect after a dog bite wound of the middle third of the face