This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/).
Facial skin wounds are common problems seen and treated by emergency centers around the world. Among all wounds, cat and dog bites are frequently seen. Human bite injuries are both deceptive and difficult in their presentation and management. The injuries have a disfiguration effect with possible psychological impact on the patient.
The aim of this paper is to compare experience with human bites of the face in our surgical unit, with other similar trials in term of reasons for the circumstances of injuries, age, and sex of the patients, site of injury, pan-time between consultation and treatment, incidence of infection and surgical management.
Data in terms of age, gender distribution, circumstances of injury, location of injuries, evolution of surgical management and complications were recorded.
We report here a series of 10 cases of human bite wounds to the face, admitted to our department, and treated with different reconstruction procedures.
Keywords: Human bites, Face wounds, Management, Antibiotic prophylaxisThe reconstructive techniques are usually varied but the ultimate goals of treatment are to achieve healing, function and aesthetics.
The restorative management and medical treatment remain a problem and controversial issue for the medical practitioner.
Traumatic facial injuries raise serious challenges in terms of reconstructive opportunities and surgical management results. The etiology of facial injuries includes human bite as human interpersonal violence. Bite wounds are always considered to be complex injuries contaminated with polymicrobial agents. The reconstructive techniques are usually varied but the ultimate goals of treatment are to achieve healing, function, and aesthetics.
The management of human bites is very complex due to the various factors surrounding it. The cases described in the literature remain limited, and the conduct to adopt are controversial; so we highlight our experience in the management of these particular cases and compare it with what is described in the literature.
The study was performed on Ten patients (03 women and 07 men) treated in the emergency and aesthetic unity of maxilla-facial department.
It was a descriptive and retrospective study over a period of two years from January 2018 to January 2020, in the Emergency and Maxillofacial Surgery Department of the University Hospital Center of Casablanca.
The entire series had an identical indication for consultation, i.e. Interpersonal violence.
Patients who consulted for a facial injuries caused by a human bite that was surgically treated were included in the study.
The exclusion-criteria were, injuries caused by animals bites, and those that were not surgically treated.
The parameters studied were epidemiological (Age and Gender, Socioeconomic level and, geographical location, and circumstances of injuries); clinical (injury site, and Anti-tetanus vaccination coverage study of the patient); and therapeutic (management surgical-step, medico-surgical procedure, and evolution).
Patient characteristics, technical considerations and results concerning their evolution with the procedure are reported in Table 1 .
Patient characteristics and results.
| Patient | Age (yrs) | Gender | Socioeconomic level | circumstances | Injury site | Surgical procedure | Evolution |
|---|---|---|---|---|---|---|---|
| 1 | 45 | Male | Low | Alcohol fight | Auricle(pinna) amputation | Suture in one plan | Lost to follow-up |
| 2 | 35 | Male | Low | Conjugal abuse | Nose tip and alar wing | Forehead flap | Good |
| 3 | 25 | Female | Low | Neighbor violence | Auricle(pinna) | Suture in one plan | Necrosis |
| 4 | 20 | Female | Medium | Conjugal abuse | Nose tip | Nasolabial flap | Good |
| 5 | 26 | Male | Low | Alcohol fight | Nose tip and alar wing | Forehead flap | Good |
| 6 | 50 | Male | Medium | Alcohol fight | Cheek | Suture in two planes | Good |
| 7 | 42 | Male | Medium | Alcohol fight | Cheek | Suture in three planes | Infection |
| 8 | 28 | Male | Low | Conjugal abuse | Centro-facial (lower lip) total | Karapandzic flap | Good |
| 9 | 39 | Male | Medium | Neighbor violence | Auricle(pinna) | Suture in one plan | necrosis |
| 10 | 18 | Female | Low | Neighbor violence | Centro-facial (low lip) partial | Suture in three planes | Good |
During the study period between January 2018 and January 2020, ten facial human bite injuries were treated in the emergency and Maxillofacial Surgery Department.
In this population, data of 10 surgically treated cases were collected.
Three of the participants were women and seven were men. The average age of the 10 patients enrolled in the study was 32.8 years, leading to a sex ratio of 2.3 (range, 18–50 years).
60% of the patients had a low socioeconomic level coming from rural areas. We define the socio-economic status by individual indicators: education, profession and income.
The injuries were all caused by interpersonal violence; due to the fights under alcohol effect ( Table 1 ) Alcohol use at the time of the incident was documented (50%). the biters were wife or husband in three cases of whom one had psychiatric disorders (hysteric crisis). None of the perpetrators could be tested for any blood-borne diseases. ( Fig. 1 )
human bite injuries in a different facial site.
The clinical presentation of the treated injuries has been recorded in Table I . Anti-tetanus vaccination coverage was 100% more than period of 10 years. Early presentation and antibiotic prophylaxis administration reduces the risk of infection.
The treatment time was on average 24 h. Different surgical procedures were used to repair injuries. Six patients were treated under local anesthesia by one-step surgery (sutures).
In the other four cases (40%), the treatment was provided under general anesthesia with hospitalization for the implementation of frontal (two cases) and Karapandzic or nasolabial flaps (two-step surgery).
The follow-up fluctuated from seven days to six months. There were two cases of major surgical complications (necrosis). Slight infection was common during the first week postoperatively. The outcome was good in 6 cases (60%).
The human bite injury is a deceptive wound. The potential for infective, functional, and aesthetic complications calls for rapid treatment in an appropriate setting. Human bite wounds are generally associated with male predominance and late-night-alcohol-fuelled aggression [1,2]. This association was in line with our data (7 men versus 3 women).
The incidence of human bites is unknown [3] because most bites are associated with potentially embarrassing social circumstances such as quarrels or bad sexual behavior, which explains the high frequency of under-reporting [3,4].
Some high-risk contexts have been highlighted, such as an increased incidence in institutionalized patients (psychiatric history and poor impulse control), those likely to be bitten as a result of the occupational risk (law enforcement, institution staff) and more commonly in the context of late-night, alcohol-fuelled aggression [[5], [6], [7]]. The actual directives call for the management of these injuries in the same way as any contaminated surgical wound.
Delayed arrival (>24 h) at the emergency department was also reported to be a factor associated with increased risk of infection. Both findings are consistent with previous studies [8].
It is essential to achieve satisfactory aesthetics, restoration of functions, and restoring normal anatomic relationship of the defaced facial subunit. Therefore, repair of the avulsed subunits of the face is based on the use of local flaps abutting or adjacent to the facial defect in small defects [9]. The advantages are good color, texture, and thickness match.
The use of the simple wedge-shaped closure was employed when less than a third of the lip was missing; this is also a guide for ala and pinna avulsion. In some of our patients, the evolutions were good with high level of satisfaction even when there was perceived tension of the wound ( Fig. 2 ). A frontal flap was used in two cases for nose repair ( Fig. 3 ). With the loss of ala, we found the nasolabial flap a better option. The defects presented were not massive enough to use composite flaps. The case of ear amputation was lost to follow-up.
