Does immediate wound closure increase the risk of the infection in case of the dog
bite injury? Such controversial question always demands a deep probe into the problem.
According to one of the report of the World Health Organization (WHO), there are more
than 25 million dogs in the country with the annual incident of dog bite is around
1.75 million. The number is so big that it is quite common during the training period,
the surgical resident must have been encountered at least one case of dog bite wound,
if not many. There always lies a dilemma in the mind of many of us.
I encountered a case of dog bite in a 48-year-old male, under alcohol influence, where
more than 50% of upper lip involving the central part ([Figs. 1 ]
[Figs. 2 ]) was destroyed by a stray dog. There was always a state of dilemma in my mind that
how should I proceed? However, after going through the literature, We decided to go
for primary reconstruction using local flap after thoroughly cleaning the wound as
there was loss of tissue and injury was fresh. Exposure prophylaxis was given to the
local region. Anti-rabies immunoglobulin (20 IU/kg body weight) administered deeply
into the wound and antirabies vaccine (1 mL) was administered on days 0, 3, 7, 14,
and 28 intramuscularly into deltoid muscle. Intramuscular tetanus toxoid (0.5 mL)
and intravenous antibiotics were also administered. We managed to close the wound
with superiorly based nasolabial flap ([Fig. 3 ]). Patient was discharged after 5 days and the flap was healed well ([Figs. 4A ]
[B ]).
Fig. 1 Dog bite wound with significant tissue loss.
Fig. 2 Superiorly based nasolabial flap elevated.
Fig. 3 Flap inset.
Fig. 4 Follow-up image after 6 weeks.
A prospective clinical trial reported that there was no significant difference in
infection rates of animal bite wounds treated by primary closure compared with nonclosure,
except in those wounds occurring to the hands.[1 ] The wounds over the hands showed significantly higher infection rate than the rest
of the body region. The study also noted a delay in presentation of more than 10 hours
was associated with an increased risk of infection.[1 ]
Facial dog bite in addition to being an infectious emergency also poses cosmetic and
functional challenges. Therefore primary closure of the wound should be considered
in the first place as it promotes the primary healing when compared with the open
wound.[2 ] The authors conclude that the primary closure of the dog bite wound, especially
in a facial dog bite, should be considered particularly in an acute setting. For the
rest of the wounds after thorough cleaning and debridement, especially hands or extremity
wounds, decision should be taken depending on the time of presentation that whether
the surgeon should opt for a single-stage primary closure or two-stage procedure,
but an attempt toward the closure should be made in all cases.
In cases of crush injuries, complete avulsion or tissue loss where primary repair
is not possible, reconstruction should be considered. In superficial low-risk wounds,
especially in the region of the lip, primary repair may be considered. In deep wounds
or avulsion injuries, if attempt to reattach the avulsed parts is unfortunately fails,
a reconstruction using flaps should be considered. In cases of those wounds which
are presented late, debridement of infected or necrosed tissues often lead to the
substantial tissue loss which can be difficult to repair primarily but should be reconstructed
using other available options.
