Abstract
Importance
Upper lip avulsion after traumatic dog bite is a serious cause of facial disfigurement for which there is no consensus on management in the acute setting.
Objective
This review was prompted by a case at our institution and is intended to display the available evidence in the management of the patient after dog bite injury to the upper lip. Our main goals are to create a management algorithm using current evidence and to stimulate further clinical investigation to improve outcomes in patients with facial dog bite injuries.
Evidence Review
A review of English literature was performed using Pubmed/MEDLINE for case reports and case series of lip replantation using microvascular anastomosis. Additional review of hyperbaric oxygen therapy, medicinal leech therapy, lip reconstruction methods, and reapproximation was performed. Reference searches were performed for all retrieved articles.
Findings
Microvascular replantation is a successful method of acute management in dog bite injuries of the lip. Hyperbaric oxygen therapy and medicinal leech therapy improve outcomes. Immediate cross-lip flaps and immediate reapproximation are alternative techniques that can be performed in the acute setting, but further investigation is required.
Conclusions
The repair of the upper lip after a dog bite is a priority due to the functional and psychiatric sequelae associated with facial disfigurement. Microvascular replantation should be considered first-line. Immediate reapproximation without microvascular reanastomosis and immediate reconstruction may also be performed. A stepwise clinical algorithm may aid the surgeon in the acute management of dog bite trauma to the lip.
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Summary
A 30-year-old female presented to the Emory University Hospital Midtown emergency department with avulsion of the right upper lip from a dog bite. The avulsed tissue included white lip, vermillion border, and red lip but spared the columella and other nasal structures. No viable vessels were identified, and the avulsed tissue was reapproximated without reanastomosis of any vessels. Ultimately, the reapproximation failed and elective reconstruction was performed. This prompted an extensive review of the literature to generate a clinical guideline for the acute management of upper lip avulsion.
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Introduction
Disfiguring trauma can lead to significant psychological stress, particularly trauma resulting in facial disfigurement. Studies have shown individuals with facial disfigurement have lower satisfaction with life, poorer perceptions of body image, and higher rates of alcoholism and depression . Other causes of facial disfigurement can be equally distressing; surgical reconstruction for head and neck surgery has also been shown to be associated with depression . As a result, addressing the issue of facial disfigurement is a priority in the care of patients with facial trauma.
Management of avulsed soft tissue can be accomplished in many ways. Blood supply, integrity of the dermis, and the presence of specialized dermis, such as fingertip, nail beds, eyelids, eyebrows, sole of foot, vermillion of lip, and glans penis, in the wound are essential to the successful management of avulsed tissue . Avulsion of a lip segment can involve epidermis, dermis, underlying perioral facial musculature, and labial mucosa. According to Lehr and Fitts, there are five general methods of managing avulsed tissue: 1) debridement alone, 2) debridement and excision of the avulsed tissue with primary or secondary closure of the wound, 3) debridement and excision of the avulsed tissue with the use of the excised tissue as a free graft for the wound closure, 4) debridement and excision of the avulsed tissue and the use of a split- or full-thickness skin graft to close the wound, and 5) debridement and excision of the avulsed tissue with the use of a pedicle flap to close the wound .
Unfortunately, the literature does not address stepwise management of full-thickness upper lip avulsion in the acute setting, although an algorithm focusing on microvascular replantation has been proposed . This review is intended to compile and evaluate current evidence for the management of upper lip avulsion and to create a treatment algorithm to be used by clinicians to improve patient care.
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Introduction
Disfiguring trauma can lead to significant psychological stress, particularly trauma resulting in facial disfigurement. Studies have shown individuals with facial disfigurement have lower satisfaction with life, poorer perceptions of body image, and higher rates of alcoholism and depression . Other causes of facial disfigurement can be equally distressing; surgical reconstruction for head and neck surgery has also been shown to be associated with depression . As a result, addressing the issue of facial disfigurement is a priority in the care of patients with facial trauma.
Management of avulsed soft tissue can be accomplished in many ways. Blood supply, integrity of the dermis, and the presence of specialized dermis, such as fingertip, nail beds, eyelids, eyebrows, sole of foot, vermillion of lip, and glans penis, in the wound are essential to the successful management of avulsed tissue . Avulsion of a lip segment can involve epidermis, dermis, underlying perioral facial musculature, and labial mucosa. According to Lehr and Fitts, there are five general methods of managing avulsed tissue: 1) debridement alone, 2) debridement and excision of the avulsed tissue with primary or secondary closure of the wound, 3) debridement and excision of the avulsed tissue with the use of the excised tissue as a free graft for the wound closure, 4) debridement and excision of the avulsed tissue and the use of a split- or full-thickness skin graft to close the wound, and 5) debridement and excision of the avulsed tissue with the use of a pedicle flap to close the wound .
Unfortunately, the literature does not address stepwise management of full-thickness upper lip avulsion in the acute setting, although an algorithm focusing on microvascular replantation has been proposed . This review is intended to compile and evaluate current evidence for the management of upper lip avulsion and to create a treatment algorithm to be used by clinicians to improve patient care.
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Methods
A review of English literature was performed using Pubmed/MEDLINE for case reports and case series of lip replantation using microvascular anastomosis. Keywords used include a combination of the following: “lip replantation,” “microvascular reanastomosis,” “lip reconstruction,” “immediate reconstruction of lip,” “lip injury,” “dog bite,” and “lip avulsion.” All cases were reviewed for patient demographic information, patient presentation, management, and follow-up. Cases that did not describe patient presentation or management were not included. Literature addressing lip reapproximation and immediate reconstruction was also reviewed.
Review of adjuvant therapy in the management of lip avulsion was performed. Keywords used include a combination of the following: “hyperbaric oxygen therapy,” “head and neck injury,” “medicinal leech therapy,” “venous congestion,” and “soft tissue avulsion.” The pathophysiological and therapeutic aspects of hyperbaric oxygen therapy were addressed in the review. We also reviewed literature on medicinal leech therapy using cases of microvascular anastomosis, independent cases, experimental series, and reviews. Reference searches were performed manually for all retrieved articles to expand the scope of the review and to ensure that all available data were assessed.
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Case Presentation
The patient is a 30-year-old Caucasian female who presented to the Emory University Hospital Midtown emergency department (ED) for evaluation of a facial dog bite. At approximately 12:00 am, the patient was playing with her dog when it jumped forward and bit her upper lip. The avulsed lip was quickly found by the patient’s husband and placed on ice. She presented to the ED at 1:20 am. The otolaryngology team on call for facial trauma was consulted to assist with management.
The full thickness of the right lateral upper lip and a portion of the right medial upper lip (cupid’s bow) were avulsed. The avulsed tissue included white lip, vermillion border, and red lip ( Fig. 1 ). The patient had paralysis of the area with pain noted. There was significant cosmetic deformity but minimal bleeding with no prominent blood vessels.
Given the significant cosmetic deformity, the team decided to reapproximate the avulsed lip. Verbal consent was obtained, and the wound was anesthetized locally with 15 mL of 1% lidocaine with epinephrine. The wound was then washed with three liters of bacitracin-infused normal saline. The avulsed tissue appeared in good condition and was washed as well. The composite graft was attached with deep monocryl interrupted sutures. Skin was closed with vertical mattress nylon sutures. The external lip was then closed with interrupted monocryl sutures. Intraoral lip lacerations were closed using running locked chromic sutures. The patient tolerated the procedure well without complications. The reapproximation was completed at 5:20 am. Time of ischemia was approximately 5 h. The patient was started on ampicillin/sulbactam for prophylaxis and admitted for further monitoring.
Over the course of her inpatient stay, daily assessment for tissue survival and infection was performed. Xeroform gauze was placed over the wound daily, and her pain was controlled with oxycodone/acetominophen. On post-op day three, dark blood was noted on needle-prick suggesting venous congestion. The patient began hyperbaric oxygen (HBO) therapy on post-op day four. She was discharged to home on amoxicillin/clavulanate on post-op day ten. At the time of discharge, the wound did not show signs of infection or frank failure, but there was eschar formation without sloughing of skin.
As an outpatient, she continued HBO therapy for a total of twenty courses. On post-op day twenty-one, the patient saw the facial plastics and reconstructive surgeon in clinic. Physical exam continued to show eschar formation with pink granulation tissue at the edges. Inner mucosal tears were healing well. The patient’s anxiety was still significant, and, therefore, conservative therapy without debridement was recommended. On post-op day thirty-two, the eschar had expanded and contracted, and it was determined that the reapproximated tissue had failed. Minimal debridement was then performed. Five days later, repeat debridement of overlying dead tissue of the white upper lip was performed. Hypertrophic scarring was again noted, and Kenalog injection and massage routines were initiated in preparation for revision reconstruction.
At six weeks post-op, the patient underwent revision reconstruction of the defect with a rhomboid flap ( Fig. 2 ).
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Discussion
Reconstruction of a facial defect after trauma is critical to improving the aesthetic outcome and patient quality of life. The shock of facial trauma to the patient is significant, and immediate reapproximation may assuage the patient’s anxiety. In the case of traumatic upper lip injury, the clinician should exercise judgment to tailor care to each patient while simultaneously following an appropriate treatment protocol. First and foremost, the patient should be assessed for life-threatening injury. This should be followed by a comprehensive history and physical, the details of which are beyond the scope of this review. As well, it is important to evaluate for characteristics that can lead to complication, such as the quality of the tissue edges and risk of infection.
In the examination of the lip, focus should be given to the edges of the avulsed tissue and the presence of viable blood vessels. Careful inspection for presence of these vessels is a crucial part in the decision-making process. Dog bites often cause crush injury to tissue, leading to maceration of the edges. This can compromise apposition of tissue edges during replantation and may worsen cosmesis.
In addition, macerated, uneven edges create a nidus for bacterial proliferation and increase the chance of infection. Infection is a complication of dog bites, and the concern that the wound may become infected can sway the surgeon from immediate reconstruction or replantation of tissue. However, many studies show a low incidence of infection after dog bite injuries to the face. Maimaris et al. showed that dog bite wounds of the face, without the use of prophylactic antibiotics, are no more likely to become infected when closed immediately by primary closure than when left open . Another study performed without prophylactic antibiotics showed a wound infection rate of 1.4% . A prospective series by Zook et al. and retrospective chart review by Wu et al., both looking at reconstruction using prophylactic antibiotics, showed even lower wound infection rates of 0.5% and 0.0%, respectively . Careful inspection of the avulsed tissue and the recipient tissue bed can aid the surgeon in assessing the probability of infection. Maceration may increase the risk of infection, and delicate and appropriate debridement may curtail this risk.
After initial evaluation, the physician must decide how to best reconstruct the lip. There are many ways to reconstruct a defect measuring 30%–60% of the horizontal length of the lip. Lip replantation should be considered first line and should be performed if there are viable vessels present. Replantation gives the patient an increased chance of regaining function and sensation while preserving cosmesis. If vessels are not present, primary reapproximation of full-thickness avulsion of the lip can be attempted; however, success is rare and unpredictable. Emergent cross-lip flap reconstruction can be done instead to avoid unnecessary intervention and prevent additional anxiety. Cross-lip flaps are commonly used in the delayed treatment of upper lip defects and have the added benefit of having similar texture, complexion, thickness, and muscular activity to that of the reconstructed site . The following sections present evidence for the different management options for upper lip avulsion from a dog bite in the acute setting. In addition, we propose a stepwise algorithm to be used when addressing this specific type of injury ( Fig. 3 ).
