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Resident Manual of Trauma to the Face, Head, and Neck

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Chapter 9: Soft Tissue Injuries of the Face, Head, and Neck

wound can then be irrigated and loosely closed with one or two dermal

sutures after instillation of antibiotic ointment, preferably mupirocin,

within its depth.

Tissue flaps and associated wounds should be minimally debrided and

copiously irrigated. Surrounding tissue may be slightly elevated to

facilitate dermal closure with rather loosely placed 4-0 or 5-0 chromic

catgut suture (or polyglactin suture if some tension exists). Loosely

placed epidermal sutures of 6-0 polypropylene or 5-0 fast-absorbing

catgut (in children) then complete the repair.

1. Animal Bites

a. Dog and Cat Bites

Dog bites are most common. They yield puncture wounds, and more

commonly, lacerations. Infected dog and cat bites are likely to be

populated by

Pasteurella multocida, Staphylococcus aureus,

and

Streptococcus viridans.

Cat bites are exceedingly more likely than dog

bites to become infected (80 percent versus <5 percent).

b. Rabies Virus Transmission

Animal bites pose the risk of rabies virus transmission. If rabies is a

possibility, the patient should receive a first dose of immune globulin on

the day of the injury, followed by the vaccine at days 0, 3, 7, 14, and 28.

Because povidone-iodine is a known virocidal and can eliminate 90

percent of the rabies risk, the wound should be irrigated and cleansed

with this agent as well.

2. Human Bites

Human bites are less common than animal bites. Human bites are less

likely to penetrate deeply into facial tissue than animal bites, owing to

the length and shape of the anterior human teeth.

a. Primary Closure and Open Packing

Primary closure is selected only in the most favorable of wounds.

Human bites deemed not safe for primary closure may be packed open

with frequent dressing changes and application of topical antimicrobi-

als, then closed in a delayed fashion 2–4 days after wounding (if clean)

or left to heal by second intention. The latter will likely require subse-

quent scar revision.

b. Broad-Spectrum Antibiotics

A polymicrobial population, including anaerobic and aerobic organisms,

contaminates most human bites. Thus, it is common to utilize broad-

spectrum antibiotics with excellent anaerobic and microaerophilic

efficacy.