Acid Attack

[SavageGlow]

>>Our patient (H.C.C.) is an otherwise healthy 16-year-old female from a small, underdeveloped town in Liberia. H.C.C. was uneducated, and she worked selling concessions at a local market. She was the victim of an intentional acid attack by a known male acquaintance, disgruntled by her refusal to accept his marriage proposal. H.C.C.'s injuries were multiple and severe, and we have little information regarding the initial date of her acute burn treatment. Her case was referred to our institution, and she was ultimately seen in April 2016.

>>H.C.C.'s initial complaints were mostly related to her vision and her excessive tearing. On presentation, she had obvious cicatricial ectropion of bilateral upper and lower eyelids, with purulent exposure keratitis of her left eye and resultant visual loss ( Fig. 1 ). There was complete effacement of her supratarsal folds bilaterally, near-complete obliteration of her brow lines, and perioral contractures affecting her bilateral nasolabial folds and commissures. She had a flexion contracture of her neck that effaced her cervicomental angle and precluded adequate chin extension.

>>The most urgent treatment began with a focus on eyesight preservation. We requested immediate ophthalmologic consultation for eyesight preservation and possible corneal transplantation. In a multidisciplinary fashion, we then put forth a surgical plan in conjunction with our ophthalmology colleagues. Accordingly, we released her bilateral upper lid cicatricial ectropion first to provide an immediate improvement in globe coverage ( Fig. 2 ). Her eyelid skin was largely present, but it was scarred to her forehead. Our release, therefore, was initiated superior to her brow line in a supraorbicularis plane. We extended our initial dissection caudally to provide adequate lid coverage of her cornea but not enough to disrupt her levators. Because she was being seen commensurately with ophthalmology and would need repeated eye exams, we were unable to rely on traditional bolster dressings, as they would make repeated ophthalmologic exams difficult. We therefore placed Integra bilayer matrix wound dressing over her forehead releases to minimize bulky dressings and to optimize her chances of ultimate graft take ( Fig. 2 ). We performed Z-plasties to her nasolabial regions to relieve tension on her lower lids. Three weeks later, she underwent autografting of her bilateral forehead release sites, corneal gluing with protective lens placement, and additional tissue rearrangement in her neck for tension release.

>>The following month, H.C.C. underwent an urgent corneal transplant, and we were able to coordinate additional steps in her facial reconstruction. Due to the limited time we would have her in our care, we began treating her mature burn scar contractures with fractional, ablative CO 2 laser (Ultrapulse, Lumenis, Yokneam, Israel).

>>Over the next few months and five additional procedures, we undertook a series of staged reconstructive operations to restore form and function to H.C.C.'s face. Because she demonstrated areas of residual contractures, we released and grafted her left oral commissure and cheek and her right upper lid ( Fig. 2 ). Through a combination of release and grafting (to lower lid, cheek, and oral commissure), local tissue rearrangement (Z-plasties to neck, nasolabial folds), and laser treatments to her burn scars and skin grafts, we were able to provide her with improved globe protection, improved oral competence, and a more cosmetically appealing facial appearance ( Fig. 3 ).

[ride]

Photo 5 is nightmare fuel. Actually, the thought of living in Liberia is nightmare fuel.

[kellyhound]

Hope he gets life or stoned.

[shadowstein]

Maybe countries with high rates of acid attack should do a Hammurabi and sentence the perps to have a sulphuric facial cleanse of their own