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Facial Reconstructive Surgery

Plastic Surgeons Helping Tiny Dog Bite Victims

Cosmetic Surgery Staff Report
Medically Reviewed by Dolores Kent, M.D.

Back in 1995, Paul S. Nassif was a newly-minted M.D. in surgical training at University of New Mexico School of Medicine when he encountered a case that would change his life.

(Currently, Dr. Nassif is a board-certified facial plastic surgeon who specializes in rhinoplasty and revision rhinoplasty in Beverly Hills.)

"I was undergoing training in head and neck surgery then and worked as a resident in the university emergency department," Dr. Nassif told "One day, a boy about four years old was playing in his backyard when two Rottweilers came into his yard and savagely attacked him, horribly injuring his face and scalp."

National Dog Bite Awareness Week
(Photo Credit: Anton Ferreira)

8 Reconstructive Procedures

The damage was so severe that the lad needed eight separate reconstructive procedures in which the young Dr. Nassif assisted. He also noticed that children were often the most rewarding to be around because they were usually pleasant. For instance, the young dog attack patient was almost always in high spirits, despite his injuries.

Adds Dr. Nassif: "The other thing I learned is that few, if any, plastic surgeons that have seen these attacks keep any type dog in their homes if they also have young children.

"...four million dog bites happen yearly in the United States, with about 75 percent being children under 10."

"I helped highly trained surgeons make that boy's face functional again and decided right then and there that I would become a plastic surgeon specializing in surgery of the face and head," Dr. Nassif says.

The thing that drew Dr. Nassif into plastic surgery -- a terrible dog attack on a child -- still occurs with such alarming frequency that special days of commemoration, National Dog Bite Awareness Week, have been set aside to warn caretakers of the terrible tragedies that can result when dogs and tots are left unsupervised. This year, the observance is from May 18th to the 24th.

Display of Teeth

"Even placid dogs that have been in the family for years will attack a toddler or small child because the animal and the youngster are on the same eye level," says Bonnie Beaver, D.V.M., a professor at Texas A&M University and former president of the American Veterinary Medical Association (AVMA).

"It happens because the child is laughing and smiling, happy to see a doggy," Dr. Beaver says. "But the dog interprets a display of teeth as aggression and attacks first."

Consequently, most injuries to children are around the mouth.

While training at the Mayo Clinic in Rochester, Minnesota, Darshan Shah, M.D., a plastic surgeon with offices in Malibu and Bakersfield, California, once assisted with a study of children bitten by dogs. The study was performed because dog bites near the Mayo Clinic were happening about once daily.

2 to 5 Surgical Sessions

"Our study showed that children aged two to five were 75 percent of the victims and were bitten somewhere around the child's mouth," Dr. Shah says. "Average length of hospitalization was four days while each child required two to five surgical sessions to repair the damage."

"This story is not uncommon," says American Society of Plastic Surgeons (ASPS) President James Wells, M.D. "Seventy percent of all dog bites involve the family pet biting somebody on the dog owner's property."

According to the ASPS, dog bites on children often result in severe lacerations, infections, or scarring. It requires the special training of a plastic surgeon to rearrange skin and tissue and reduce scars, a procedure that takes place over time and many sessions. (See photos below.)

"We found the breeds most often attacking include pit bulls, Rotweilers, German Shepherds, Dobermans, Chows, and Huskies," says Dr. Shah.

Facial Reconstructive Surgery Before and After Photos
Two-year-old dog bite victim just after treatment by a plastic surgeon and the
same child at six years of age after three more scar reduction procedures.
(Ben Lee, M.D. photo)

Adds Jason Diamond, M.D., a board-certified Beverly Hills plastic surgeon who specializes in facial plastic surgery: "Every family who has a child bitten by a dog says the dog has always been sweet and never caused a problem in the past.

"In most cases, remediation of scars is often done with a laser that softens the child's facial scars over time," he says.

"From where I sit, parents are playing Russian roulette if they allow a child to be unsupervised around any type of dog."

One of the most horrific child dog bite cases on record happened in 1999 when the family dog, an American Staffordshire, attacked a two-year-old Oklahoma child and bit away all the facial flesh from just under the child's eyes to his throat.

At first, doctors thought the child would die from blood loss within minutes because the child's nose, eyelids and cheeks were gone. But the tot survived and was flown to Dallas, where a team of eight surgeons and seven anesthesiologists at Children's Medical Center labored 39 hours straight to replace and rebuild the child's face.

Free Flaps

"For instance, we took muscle from the boy's stomach to replace the missing facial flesh," says Jay Burns, M.D., the plastic surgeon who lead the team.

The team used a procedure known as free flaps to rebuild the boy's face.

Here's how it works: Surgeons remove a section of healthy tissue from the patient and transplant it to another location. But the work is excruciatingly demanding because the surgeons must also reconnect small nerves and blood vessels. Moreover, if one of the five flaps fail, all wither and die.

"…parents are playing Russian roulette if they allow a child to be unsupervised around any type of dog."

According to Dr. Burns, the hardest part of the surgery was replacing the lining of the child's mouth. The lad still does not have lips, which are exceedingly difficult to recreate.

A face-licking dog is cute but dangerous.
(SBX photo)

"Until that time, the record for performing free flap surgery was three," says Dr. Burns, an assistant professor at Texas A&M University and in private practice in Dallas. "We used five flaps on the child because we had no other choice."

The boy is now 10 and fully functional, although doctors say anybody can clearly see something is amiss with his face. He wears a plastic nose although surgeons plan on creating one of flesh for him.

"Other dangerous situations occur when a dog with a history of no bites whatever is put in close contact with a youngster," says Dr. Beaver. "Then, if the dog has never seen a child, the creature views the tot as a strange, foreign thing to be feared. If the child takes off running, the dog's pursuit instinct takes over and tragedy ensues."

AVMA figures reveal that about four million dog bites happen yearly in the United States with about 75 percent being children under 10.

Minor danger signals include a dog pacing back and forth, emitting a low growl, whining or staring intently at a child.

A dog posturing to attack usually stiffens, leans forward and stares while the hair on its back stands erect. Dog experts say anybody being threatened by a dog should:

Stay calm
Canines can sense nervousness and fear.
Slowly back away
Go to a safe distance while keeping the dog in sight.
Never turn your back
Also, don't look a threatening dog directly in the eye.

Given proper supervision and the knowledge that things can quickly go wrong, every child should have two things: a dog, and a mother willing to let him have one.

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