Over the past 10 years, dog bite related admissions in all age groups have risen, with children under the age of 10 being most commonly afflicted. A year long audit at our plastic surgery units in Liverpool have revealed that there are three times the number of admissions in children than in adults with, on average, a child a day being attacked in Merseyside. While the vast majority of these injuries are not life threatening they can still have a devastating impact, with many children requiring surgery and most suffering permanent scarring. 90% of dog bite admissions were a result of a family or friend’s pet, with recent work finding that most injuries in children were caused by untrained puppies [1]. All the commonly owned breeds were represented to some extent in our study, supporting the view that no child should be left alone with any dog regardless of breed, even if it is familiar, as it is this group that are most vulnerable.

Plastic surgeons are usually the sub specialty referred to if surgery is necessary, especially given the distribution of injuries and availability of on-call services. We are fortunate to be equipped with the full armamentarium likely to be required to address the wide range of injuries seen, from effective debridement to maximise wound healing to the more complex procedures. In adults, the most commonly affected body area is the upper limb, with tendon and nerve repairs often required. The most commonly injured area in the paediatric group is the head and neck region, with lip, nose, ear or cheek injuries requiring careful reconstruction with understanding of aesthetic subunits principles. In our year long audit, the procedures required ranged from simple skin laceration repair to a free latissimus dorsi flap for scalp reconstruction. Although reconstructive techniques in dog bites are characterised more by a wide range than novelty, it should be noted that the first composite tissue allotransplantation to the face was performed in 2005 by plastic surgeons in France, after a dog bite, albeit arising from unusual circumstances.

Children in particular remain at risk as UK legislation does not protect this high risk group by merely outlawing four breeds of dogs (The Dangerous Dogs Act of 1991 outlawed American Pit Bull Terriers, the Japanese Tosa, the Brazilian Fila, and the Dogo Argentino) of which only one, the American Pit Bull, features as a common biter in our recent audits, the rest being represented by the full range of commonly owned dogs with no bias towards size.  As the incidence of these injuries can be expected to remain high, dog bites therefore remain a public health concern and present significant child protection issues, placing pressure on the medical system, usually the plastic surgery team, to intervene. For example, it has been necessary for our team to discuss methods of risk management with families, including separation of a pet dog from the home environment, or to involve the police to safeguard the patients which we are treating. The RSPCA have called for changes to current legislation and increased enforcement to deal with dangerous owners as well as dangerous dogs, a view with which we support. Legislation has unfortunately remained unchanged, and we welcome improvements to the system which may limit the escalation of this problem.

Competing interests: We declare that that we have read and understood the BMJ Group policy on declaration of interests and we have no relevant interests to declare.

Christian Duncan is a plastic surgeon and lead clinician of the craniofacial unit at Alder Hey Children’s Hospital. He is also a member of the British Association of Plastic, Reconstructive, and Aesthetic Surgeons (BAPRAS). He qualified in Ireland, completed plastic surgery training in the West Midlands, and has spent the last 10 years developing children’s plastic surgery services in Liverpool. His main interests include all aspects of paediatric craniofacial surgery, service development, and development of outcome measures in plastic and craniofacial surgery. He grew up with dogs and likes them.

Rakhee Chawla is a ST6 plastic surgery trainee. She has completed a period of research and some of her training in the West Midlands and is now completing her training within the Merseyside region.

References:

[1] Kasbekar A, Garfit H, Duncan C, Mehta B, Davies K, Narasimhan G, Donne A. Dog bites to the head and neck in children; an increasing problem in the UK. An observational study over a decade. Clinical Otolaryngology 2013; 38 (3) 259-262