Successful replantation of an amputated nose after dog bite injury

Microsurgical Replantation of Completely Avulsed Nasal Segment

Complete avulsion of the nose is a devastating injury that may result in permanent disfigurement. Microvascular reattachment is technically difficult due to small size of the injured vessels, associated avulsion or crush injury, and relative inability to achieve venous anastomosis. This report describes a successful case of microsurgical replantation of the distal third of the nose in a 47-year-old patient after a dog bite injury with the use of a superficial temporal vein graft for arterial repair and leeching for venous outflow. The recovery was uneventful with total survival of the replant noted except for marginal skin necrosis, which healed by secondary intention. There was no need for any transfusion. The authors found that use of the superficial temporal vein for arterial revascularization was efficient and convenient as it was in the same surgical field, offering a favorable donor site scar in the preauricular sulcus. Microsurgical replantation should be attempted whenever feasible in cases of complete nose amputation.

Total Nose and Upper Lip Replantation: A Case Report and Literature Review

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The nose plays a critical role in olfaction, air filtration and humidification, and facial aesthetics. Most nasal amputations result from animal bites, human bites, and lacerations from glass. Successful replantation yields the best aesthetic and functional outcomes and is preferred compared with multistage nasal reconstruction. However, nasal replantation is technically challenging; establishing venous outflow can be particularly difficult. A 17-year-old male sustained a complete nose and upper lip amputation in a motor vehicle accident. The midface segment was emergently replanted. Two arteries (left dorsal nasal artery, left superior labial artery) and 1 vein (branch of the left supratrochlear artery) were anastomosed using microsurgical technique. A vein graft, systemic anticoagulation, and postoperative leeching were important adjuncts. Total operative time was 10 hours. Cold ischemia time was 2 hours and warm ischemia time was 1 hour. Two arteries were anastomosed to minimize the risk of ischemia of the nose and/or upper lip. Complete survival of the replanted segment was achieved. Eighteen months postoperatively, the patient has bilateral nasal patency, intact septal support, and an excellent aesthetic result. All efforts should be made to establish a venous anastomosis during nasal replantation to maximize functional and aesthetic outcomes. Partial necrosis is common following artery-only replantation, leading to tissue loss and contracture.

Microvascular replantation of a composite facial avulsion in a 24-month-old child after dog bite

Dog bite injuries are common sources of morbidity with an estimated incidence of 4.5 million bites per year with over 350,000 requiring treatment in the emergency room. Children under the age of 14 are most likely to be affected with a peak age of 5-9 years old. We report a case of a 24-month-old female who sustained a large composite facial avulsion injury from a pit bull dog bite. The avulsed tissue involved a substantial portion of the patient's mid-face, including the entire soft tissue of the nose, upper lip, part of the left cheek, and left oral commissure. Artery-only microvascular replantation was performed because no recipient vein could be identified from the facial defect. Medicinal leech therapy was used for eight days postoperatively to prevent venous congestion. The patient experienced significant blood loss due to leech therapy and required nearly 29 L of blood product replacement. At the last follow up of 8 months postoperatively, the patient was recovering well with significant improvement in function and cosmesis of the mid-face. This case describes a successful artery-only replantation of an avulsive bite injury to the face of a young child. Despite the technical difficulty of cases such as this one, microvascular replantation should be attempted because when successful it provides a superior cosmetic and functional result to other reconstructive techniques.

Supermicrosurgical replantation of a small amputated nasal tissue in a child

This study reports a case of an 8‐year‐old boy who suffered from a dog bite injury to the nose. The amputated nasal tissue measured approximately 1.0 × 1.5 cm and included part of the tip, alar, and soft triangle subunits. Both ends of an artery of less than 0.5 mm were found, and replantation was performed. Chemical leeching was performed postoperatively. At 5‐year follow‐up, a good aesthetic result was achieved.

Acute nasal reconstruction with forehead flap after dog bite

PURPOSE

This study aimed to describe immediate nasal reconstruction using a forehead flap after dog bite injuries.

BACKGROUND

Dog bites to the nose can avulse multiple aesthetic subunits, making primary repair difficult, inadvisable, or impossible. Microsurgical replantation and composite grafting of the nose have been reported, but this assumes the avulsed nasal segments are salvageable even after the animal's attack.

METHODS

We present 2 cases of dog bites to the nose with loss of multiple aesthetic subunits. The avulsed portions of the nose were not recovered. A search of the literature (OVID MEDLINE) was also performed, reviewing acute reconstruction of nasal defects after animal bites.

RESULTS

Acute forehead flaps were used as part of a first-stage operation to reconstruct the nasal defects. Second- and third-stage operations were performed to thin and divide the flap, respectively. Although the defects involved the full thickness of the nose, only the skin and nasal lining were acutely reconstructed. Acute cartilage grafts were not used due to concern of wound contamination; however, some resultant collapse of the nasal vestibule was noted and selectively addressed with subsequent cartilage grafting.

DISCUSSION

Dog bites to the face can create immediately disfiguring injuries that may initially seem devastating. Nonetheless, soft tissue damage often can be primarily repaired, leading to roughly linear scars that can be revised later. However, nasal injuries from dog bites can be more challenging if multiple subunits are irreparably lost. Acute forehead flap reconstruction after dog bite-concomitant with initial debridement-is a reliable method of reconstruction. It remains to be seen whether acute cartilage grafts would be useful during the first-stage reconstructive operation for better long-term outcomes.

Partial salvage of avulsed tissue after dog bite

Injuries to the nose can be severe from both a functional and cosmetic perspective. After suffering a dog bite to the central part of the face, an 18-year old woman underwent replantation of the avulsed tissue with the help of microsurgical arterial anastomosis. A venous anastomosis was impossible and venous congestion was treated with leech therapy. Subsequent skin necrosis occurred after a few days and the replantation was revised, revealing healthy tissue immediately below. The defect was covered with a full-thickness skin graft. At follow-up review eight months later, the functional and cosmetic result was satisfactory. To our knowledge, this is one of few cases where an injury of this severity healed with a cosmetically acceptable result.

Long-term outcomes of microsurgical nasal replantation: review of the literature and illustrated 10-year follow-up of a pediatric case with full sensory recovery

We present a case of successful artery only total nose replantation in an 18-month-old child, with 10 years of follow-up and full sensory recovery despite no nerve repair. The common absence of veins for anastomosis does not prevent successful replant, as demonstrated with the use of Hirudo medicinalis use in this unique case. We comprehensively review the literature of this rare and complex injury and advocate microsurgical replantation where possible over other methods of nasal reconstruction.

Successful delayed nose replantation following a dogbite: arterial and venous microanastomosis using interpositional vein grafts

The nose is one of the most important aesthetic units of the face. Following traumatic amputation, although technically very challenging, replantation is undoubtedly the procedure of choice. We present the first successful replantation of a partially amputated nose subjected to an ischaemic time of over 12 h. The injury was sustained following a dog-bite and inter-positional vein grafts were used to re-establish both arterial and venous blood flow.

Microsurgical replantation and postoperative leech treatment of a large severed nasal segment

The survival of a microsurgically replanted segment of nose in a 41-year-old woman was facilitated by the assistance of the medicinal leech Hirudo medicinalis. An arterial microanastomosis was made to a severed partial segment of nose with no possibility of recreating a venous anastomosis. The resulting venous congestion was treated with nine days of treatment with a medical leech until venous neovascularisation had been achieved. At follow-up six months after discharge there was a well-heeled nasal segment and a satisfying functional - as well as cosmetic - result.

Artery only microanastomosis in nose replantation: a report of two cases

The nose is a central, prominent unit of the face. The surgical approach to complete nasal amputations is challenging and an experienced microsurgical team should always attempt microvascular replantation. This one-stage procedure could result in a superior clinical outcome compared to delayed reconstructive procedures. Two successful microvascular replantations of the distal half of the nose were performed. Both amputations were the result of two completely different aetiologies (sharp guillotine-like vs. avulsion trauma). However, we were not able to re-establish the venous drainage, which was managed through medicinal leeching. Both replantations resulted in an aesthetically pleasing result and no additional surgery was needed. A microsurgical replantation attempt should always be attempted in nasal amputations and the inability to perform venous anastomosis should not preclude the replant attempt.

Successful re-plantation of an amputated nasal segment by supermicrosurgery: a case report and review of the literature

The nose is a critical aesthetic subunit of the face, but because of the difficulties in anastomosis of the small-sized arteries and veins, several cases of nasal replantation have been reported. Using supermicrosurgical techniques, we successfully replanted a patient's nasal segment which had been amputated by a falling sharp metal pipe. The result was excellent both aesthetically and functionally, and the patient was very satisfied. The nose is located at the centre of face and is thus important aesthetically. The nose also has functions in olfaction, respiration, humidification, filtration, temperature regulation and phonation. However, the nose protrudes from the face and is readily injured by trauma, and in injured cases, reconstruction of the nose is essential. Recently, with the development of microsurgery, microsurgical replantation of the amputated nose has been reported.(1-11) We performed successful replantation of the nasal alar and tip that were completely amputated and smaller in size than previous reports, using a supermicrosurgical technique.