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

Guillermo Alvarez-Sanchez; Ignacio Lugo-Beltran

Journal of Plastic, Breast & Reconstructive Surgery·Informes quirúrgicos de acceso abierto revisados por paresRevisado por pares · Acceso abierto

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

Informe de caso

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

Guillermo Alvarez-Sanchez¹, Ignacio Lugo-Beltran¹

¹Plastic and Reconstructive Surgery Division of Microsurgery, Hospital Angeles Metropolitano, Cuauhtémoc, Mexico

Publicado 2 de abril de 2025210 vistas4 min de lectura

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Resumen

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 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. Patient examination 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. Pre-operative considerations 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 clos

Puntos clave de aprendizaje

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

Patient 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

Examination

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.

Pre-operative considerations

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

Paso 1 — Before photo - Arrival at the ER

Paso 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