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Guillermo Alvarez-Sanchez, Ignacio Lugo-Beltran. Case 15: Closure of a complex defect after a dog bite wound of the middle third of the face. Journal of Plastic, Breast & Reconstructive Surgery. 2025.
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Guillermo Alvarez-Sanchez1, Ignacio Lugo-Beltran1
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
BeforeAfter52 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
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
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.
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
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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)
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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
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Once the radial free flap was harvested, closure of the donor site was performed with a fenestrated partial thickness skin graft
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