In dog bite cases it is essential to objectively assess the extent of scarring, outline a treatment protocol and predict future disfigurement in dog bite victims. These parameters are necessary in determining long term expenses and medical costs.
Incidence of Dog Bite Injuries
Approximately 77.5 million dogs are owned as pets in the United States.  Best estimates indicate about 4.5 million Americans are bitten annually.  Many of these dog bites result in litigation and will require expert medical testimony. While the majority of dog bites go unreported, dog bite injuries account for approximately 1000 emergency department (ED) visits a day. In 2008, 316,000 ED visits were reported, 9500 of which required hospitalization.  Statistically, this represents 103.9 ED visits and 3.1 hospital admission per 100,000 population.
Children at High Risk
Children under 18 years of age are particularly vulnerable, accounting for 38 % of dog bite related ED visits.  In fact, the highest rate of dog bite related ED visits were in children in the 5-10 year old group at 199.3 per 100,000 population followed by 175.0 per 100,000 in the less than 5 y.o group. 
Breeds of Dogs More Prone to Violence
Dog bites tend to occur in rural areas more commonly than urban areas by a ratio of 4:1.  Dog bite related ED visits were highest in the Midwest and Northeast and lowest in the West. Bites by family pets account for 27 % of the injuries.  Specific breeds are more prone to violence. The “molosser” breeds (named from the ancient Greek King Molossus of Epirus who used these solid, muscular dogs with pendant ears as guard dogs) include pit bulls, curs, rotweilers, mastiffs, sharpeis, boxers and their mixes.  While the molosser breeds only encompass 9.2% of the total dog population, they are responsible for 81% of the attacks that induce bodily harm and 72% of the attacks resulting in fatalities. 
Scope of Injuries
One percent of all ED admissions are related to human or animal bites. Breakdown in terms of anatomical regions are as follows: cervicofacial 36%; lower extremity 31 %; upper extremity 19 % ; chest 14 %. . Children under 18 y.o. are particularly susceptible to head and neck injuries. In fact, 78% of dog bites in children involve the head and neck, while only 10% affect that area in adults.  In most instances, the child playfully attempts to pet the dog. Because the size similarity between the dog and the child is more comparable than in the adult, the child’s face is an easy “target” for the dog’s aggression. Most susceptible are the lips, nose, eyelids and cheek. Injuries may be avulsive or “tearing”, puncture from penetration of the dog’s teeth, or crushing from the inordinate force of the clamping of the dog’s jaws (450 pound/ sq inch). Injuries may range from minor scratches to total avulsion of the lip, nose or eyelids with substantial loss of tissue or even death. Important deeper structures such as the facial nerve, parotid duct, eyelid tear ducts, and facial bones may also be involved. Puncture wounds and devitalized crushed tissue are more prone to infection, the most common organisms being Streptococcus, Staph Aureus, Pseudomonas, Pasteurela, E. Coli as well as the more insidious anaerobic varieties.  Systemic conditions such as infective arthritis, osteomyelitis, or septicemia may also complicate deeper dog bite injuries.
Over half of children who have experienced violent dog attacks will experience Posttraumatic Stress Disorder (PTSD) within 2-9 months.  Symptoms are characterized by excessive anxiety, sleep disorders, withdrawal, impaired school performance, diminished creativity, and startle responses.  Research using the PTSD Reaction Index, Child Dissociative Checklist and Child Behavior Checklist confirms the PTSD behavior in children following these adverse life threatening events.  Shame and guilt on the parents’ part are often woven into the family dynamics.
Following reconstructive surgery, a “re-mirroring” process occurs in the facially disfigured patient. Linda Gunsberg PhD and I have written a chapter entitled “Psychological Effects of Facial Disfigurement” in my plastic surgery textbook Aesthetic Facial Restoration (Lipincott-Raven, 1998).  This chapter is based on detailed interviews with eight facial restorative patients. In summary, patients need to re-establish the positive feedback (“mirroring”) that ordinarily occurs from maternal and family interaction during infancy. This mirroring process culminates in a positive “self-image” by the age of 24-36 months. That positive self-image is virtually destroyed by a devastating, disfiguring facial injury. Affirmative self-esteem can only be restored by the re-mirroring process that arises from the reassurance of the surgeon, family, and peers following reconstructive surgery. Re-mirroring reestablishes the continuity with the old psychological self as the physical traits of the repaired face are integrated with his or her self-identity and body image. This process often requires extensive psychotherapy over a sustained period of time.
In 2012, over 27,000 patients underwent reconstructive surgery as a sequel of dog bite injuries according to the American Society of Plastic Surgeons.  Average cost of hospitalization is $18,200 per dog bite admission with an aggregate cost of $43.9 M annually.  Economic losses to dog bite victims account for $1-2 Billion annually.  Moreover, these figures do not factor in the intangible losses due to pain and suffering of the injured dog bite victim.
Early Medical/ Surgical Evaluation
Early evaluation is advantageous. Causal and temporal relationships, treatment parameters and medical expenses can be defined to both parties to accelerate resolution of the claim. Most dog bite injuries exceed the $1000 medical limit on most homeowner’s policies. Therefore, most victims are reliant on their own health insurance (often limited to in-network surgeons) or settlements from the dog owner’s personal liability sections of the homeowner’s policy. From an empathy standpoint, quick resolution of the legal issues can grant the victim the funds to speedily proceed with necessary reconstructive surgery.
Case example #1: A six year old child sustained multiple facial lacerations when attack by a Mastiff dog while visiting a friend’s home. Reportedly, the little girl was sitting on the sofa while her playmate was riding the back of the family pet. Unprovoked, the dog attack the girl, ripping away a substantial portion of the upper lip and deeply lacerating the nose and forehead. At the request of the plaintiff’s attorney, I evaluated the victim within 4 weeks of injury and substantiated the causality and extent of the wounds, laid out a comprehensive treatment protocol, estimated the expenses of the staged reconstruction, and opined on the significant residual scarring based on anatomical positioning and orientation of the respective scars. Settlement with the dog owner’s homeowners insurance was concluded within 3-4 months & the family had the resources to proceed with the definitive reconstruction.
Comprehensive Medical Evaluation
Comprehensive medical evaluation includes a thorough review of the past medical records and reconstruction of the events leading up to the dog bite incident including descriptions from the parents and witnesses regarding the type of dog, family pet or unknown dog, location, and circumstances of the attack. Specifics of the encounter may be critical to victim’s claim of owner negligence or dog owner’s claim of provocation.
Case example #2: A 32 y.o. fitness instructor was visiting her boyfriend’s home when the dog, a mix of Mastiff and Rottweiler, viciously attacked her without warning, biting her on the LT side of the face, below the eye, on the side of the nose and under the chin. I carefully elicited the history from the patient and the Emergency Department records and determined that she had been seeing her boyfriend for a year and a half & there was no prior indication at the time that she was about to be attacked by the dog. On the basis of my medical report and Video deposition, plaintiff’s counsel was able to rebut defense’s claim of provocation.
Emergency Room Records
Review of the emergency department record is critical in evaluating lag time to treatment, length of lacerations, depth of injuries, loss of tissue, injury to deep structures, and immediate treatment. Queries to the patient or parents regarding extent of cleansing, skill of the surgeon (resident or attending; ED or plastic surgeon), administration of antibiotics, and recommendations for aftercare are also very informative. Records of operative reports, follow up visits and rehabilitation are thoroughly reviewed for quality of treatment.
Impairment of Facial Dog Bites
During the medical evaluation, subjective findings related to impairment of physiologic activities of daily living are documented (chewing, fluid management, speech patterns, airway patency, smile symmetry, etc). Expressions of anxiety, fear of animals, recurrence of event nightmares, school performance, peer interaction, etc are elicited from the parents. Referral to a psychiatrist or mental health care professional is often recommended to assess responses to injury and coping mechanisms. Family therapy may be necessary to assuage feelings of guilt, shame or rejection.
Clinically, facial dog bite wound are graded according to the Lackman classification scale.  A Frenchay Dysarthric Assessment (Pro Ed Publishers, 2008) of facial expressions is performed by a PhD speech pathologist, if physiological function deficits are reported (see above paragraph). Peri-ocular injuries are assessed by a board certified opthalmologist. A quantitative analysis of each scar is documented including length, width, orientation, and impact on key facial structures. The Vancouver Scar Scale (VSS) is used to assess scar vascularity, height/thickness, pliability and pigmentation.  Differentiations are noted between normal scar maturation and pathological hypertrophic/ keloid scars. Pain and pruritis (itching) are recorded. High resolution studio photographs memorialize each of the scars. Video monitoring using Mirror Imaging software (Canfield Imaging Systems Inc, Fairfield NJ) is utilized in documenting aberrations in dynamic facial movements and to give the patient a “virtual preview” of surgical outcomes. All of these studies objectively quantify the extent of injury to the litigants and eschew subjective parameters of assessment.
Comprehensive treatment recommendations are included in the medical evaluation. Short term scar management may include a regimen of topical steroid creams, scar massage, and application of silicone sheeting. Long term solutions encompass innovative advances in scar revision surgery, laser technology, filler materials, tissue re-arrangement, post-operative scar management and camouflage make-up that can improve the appearance of disfiguring scars. Range of surgical options can be viewed on my website at http://www.facemakernyc.com/restorative-facial-surgery/dog-bites/
Assessment of Disfigurement
The detailed medical report should answer the questions of causality, short/long term disfigurement, and permanency of scarring with a “reasonable degree of certainty” and probability. Was there a causal and temporal relationship between the dog bite attack and the subsequent scarring? Has the maturation of the scars reached a “plateau”? If not, when? What are the surgical and non-surgical options? Which option will offer the patient the most optimal opportunity for improved appearance and function? What will be the extent of the permanent visible scarring with or without surgery? Can the scars be “erased” in their entirety? Is there a need for life-time cosmetic camouflage make-up? Is there evidence of permanent functional deficits? What is the effect of functional impairment on activities of daily living? Will physical therapy be necessary? What is the long term emotional impact of the dog bite attack on the patient and the family? Is there evidence of PTSD? Will the disfigured child or adult be subject to a lifetime of peer abuse, discomfort in social settings, and permanent loss of self-esteem? Will long term mental health counseling be necessary?
Estimate of Future Medical Expenses
The comprehensive medical report should include a detailed cost analysis of the anticipated medical/surgical costs. Each stage of the surgical reconstruction should be defined by procedure, location, and recovery time. Cost factors should include surgeon’s fee for each CPT code, anesthesia costs, hospital or outpatient surgery center fees. Allowances should be made for pre-surgical testing, medical clearance, lab work, splints, face masks, post-surgical rehabilitation, and other vendors. Estimates should be included for para-medical costs such as lifetime camouflage make-up, aesthetician services, medical tattooing, or microfollicular hair transplantation (for eyebrow or beard loss). Allocations for long term counseling should be deferred to the mental health provider. In the event that the patient does not elect to have surgical correction, allowances should be made for long term camouflage make-up. Precise estimates of these costs will give the litigants a matrix to remove the “mystery” of fair compensation and more clearly define long term medical/surgical expenses in realistic terms.
Case example #3: I evaluated previously mentioned above 32 y.o. fitness instructor for extent, size, location & orientation of her disfiguring facial scars. A surgical treatment plan with appropriate costs were presented to both plaintiff and defense counsel. The patient, however, declined to pursue surgical intervention. I opined that her facial scars would be “visible” during her entire lifetime and provisions should be made for non-invasive treatment modalities (chemical peels, filler, and laser) by a licensed cosmetician & lifetime camouflage make up for cover up.
I have presented a broad overview of the complexities in evaluating devastating dog bite injuries and assessing long term disfigurement and medical cost. I am hopeful that better understanding of the nuances of scar evaluation and scope of surgical intervention will assist attorneys and others involved in evaluating and litigating these cases.
About the Author
Dr. Elliott Rose, a board certified plastic and reconstructive surgeon is currently Associate Clinical Professor in the Division of Plastic and Reconstructive Surgery at The Mount Sinai Medical School and an attending surgeon at The Mount Sinai Medical Center. Dr. Rose’s international reputation in burn reconstruction, dog bite injuries and re-animation of the paralyzed face attracts patient from all over the world. He was voted by his peers as the Best Plastic Surgeon in New York City for “Corrective Facial Surgery” and is listed in the “New York Magazine Best Doctors” and “Castle Connolly America’s Top Doctors.”. Dr. Rose has also appeared on ABC’s “20/20” and “Good Morning America”, NBC’s “Today Show”, “Entertainment Tonight”, Fox News Network, as well as numerous local news segments in NYC. Dr. Rose is a member of numerous professional societies including the Aesthetic Society, the American Burn Association, and both the American and World Reconstructive Microsurgery Societies. He was on the international editorial board of the Journal of Reconstructive Microsurgery and is a frequent reviewer for the Journal of Plastic & Reconstructive Surgery. Dr. Rose is an invited Fellow of the prestigious American Association of Plastic Surgeons. In addition to his 40+ peer reviewed papers and over two dozen book chapters, Dr. Rose is author of a textbook entitled “Aesthetic Facial Restoration” that is considered the “landmark text on enhancing appearance and correcting functional impairment…..” (Lipincott-Raven Publishers, 1998). Dr. Rose uses his extensive clinical skills in objectively evaluating victims of burns, dog bites, facial trauma and providing expert testimony in future medical treatment/ prognosis/ medical costs.
Elliott H. Rose, MD acts as an expert witness in dog bite and other cases invlolved with cosmetic and plastic surgery. He can be reached at 212/639-1346 or firstname.lastname@example.org.
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