{'fraction_non_alphanumeric': 0.024734982332155476, 'fraction_numerical': 0.015017667844522967, 'mean_word_length': 4.81808838643371, 'pattern_counts': {'":': 0, '<': 2, '<?xml version=': 0, '>': 1, 'https://': 0, 'lorem ipsum': 0, 'www.': 0, 'xml': 0}, 'pii_count': 0, 'substrings_counts': 0, 'word_list_counts': {'cursed_substrings.json': 0, 'profanity_word_list.json': 0, 'sexual_word_list.json': 0, 'zh_pornsignals.json': 0}}
Dog bite injuries to the face: A narrative review of the literature

Abstract Objective Dog bite injuries remain a public health concern for two key reasons: the physical threat to health following attack and the infective sequelae a canine bite can incur. Facial bite injuries can result in significant emotional, psychological and physical trauma to victims involved. This narrative review elucidates the current presentation and management of dog bite injuries to the face. Data Sources and Methods A literature search was conducted electronically using the search terms “dog bite” and “face” and “management” using the National Library of Medicine (Pubmed) and the Cochrane Library. There were no time nor language restrictions. A total of 79 studies were initially retrieved using the search algorithm. After screening of the titles and abstracts, 9 full texts were retrieved, and a total of 7 studies included. Results The number of patients included in each study following a dog bite ranged from 40 to 223. The percentage of children included in each study (aged <18 years old) ranged from 27.5% to 100%. The majority of dog bite injuries to the face were managed by primary repair, ranging from 56.3% to 100%. Prophylactic antibiotics were used in most studies for dog bite injuries, ranging from 81% to 100%. The secondary infection rate following a dog bite ranged from 0 to 35%. Conclusion This review highlights that children are disproportionately affected by canine bite injuries to the face relative to adults. The dog involved in the attack is typically known to the victim, with the lips, the cheek and the nose representing the most common sites of facial injury. More units are managing such injuries with primary repair and prophylactic antibiotics. Reconstructive procedures most commonly involve a local or advancement flap, a full thickness skin graft or a split skin graft. These are typically performed by Plastic Surgery and Maxillofacial Surgery specialists.


INTRODUCTION
Animal bites remain a significant public health issue, with the number of these injuries increasing annually. Dog bites represent the most common mammalian bites treated in emergency departments, followed by cat bites and human bites. 1 In the United Kingdom, around 250 000 people who have been bitten by dogs seek medical treatment from minor injuries and emergency units per year. 2 Children are disproportionately affected by dog bites when compared to adults. 3 Younger children, in particular, have an increased likelihood of being bitten on the face, given their shorter stature and the disproportionate size of their head relative to their body. [4][5][6] There is a paucity of data on global estimates of dog bite incidence, however studies suggest that they account for tens of millions of injuries annually. 7 Dog bite fatality rates are higher in lowand middle-income countries than in high-income countries. This is believed to be attributed to the prevalence of rabies in many of these countries and a lack of post-exposure treatment and suitable access to health care. 7 Facial bite injuries result in significant emotional, psychological and physical trauma to victims involved. 8 The face is the third most commonly affected area from dog bites, following the upper and lower limbs. 9 Within the face, the nose and lips represent the most affected sites. 9 This narrative review aims to elucidate the current presentation and management of dog bite injuries to the face. Peerreviewed articles were identified using the National Library of Medicine (Pubmed) and the Cochrane Library using the search term "dog bite", "face" and "management." All information was sorted and analysed for suitability for inclusion and relevant articles were retained.

MATERIAL AND METHODS
A literature search was conducted electronically using the search terms "dog bite" and "face" and "management" using the Pubmed and the Cochrane Library. There were no time nor language restrictions.

Inclusion criteria
All studies reporting the management of dog bite injuries to the face with >1 patient reported.
All age groups.

Exclusion criteria
All review articles were excluded from this study ( Figure 1).

RESULTS
A total of seven studies were included for this narrative review. The number of patients included in each study following a dog bite ranged from 40 to 223 (Table 1, Table 2, Table 3).
In the studies reporting time from injury to presentation to a medical doctor, the majority of patients presented within 24 hours, ranging from 72.5% (Javaid et al. 10

DISCUSSION
Dog bite injuries remain a public health concern for two key reasons: the physical threat to health following attack and the infective sequelae a canine bite can incur. This is particularly pertinent due to the scale of the issue. Animal bite injuries account for 1%-2% of all Accident and Emergency presentations in the UK. 17 Around half of people will be bitten by an animal during their lifetime. And 90% of this is attributable to domestic animals. 18 One of the main injury sites is the head, particularly in children, which increases morbidity. 19 The most common complication of dog bites is infection,  All studies included in this review highlight the significant proportion of children (<18 years old) affected by dog bite injuries to the face. It is reported that children are the main victims of canine attacks, with regards to both morbidity and mortality. 14 Our study demonstrates that the dog involved in the attack is typically known to the victim, accounting for between 75% and 96% of cases. 12

CONFLICT OF INTEREST
There are no conflicts of interest to declare.