First Free Anterolateral Thigh Flap for Facial Reconstruction Following Bear Mauling in Bhutan

Approximately 70% of Bhutan is forested, providing habitat for the Himalayan black bear. A farmer who was mauled by a bear experienced significant tissue loss affecting his left forehead, eyebrow, upper and lower eyelids, and cheek. Immediate management included wound irrigation, antibiotic prophylaxis, and soft-tissue reconstruction using an anterolateral thigh fasciocutaneous flap for coverage. Flap reconstruction facilitated ocular salvage, with retention of excellent visual acuity and a cosmetically acceptable, functional facial outcome. The flap also provided protection and function of the parotid duct, temporomandibular joint, and the oral and nasal cavities. This case highlights the value of a multidisciplinary team approach from ophthalmology, ear, nose, and throat, and plastic and reconstructive surgery in the management of severe composite facial defects. The recent establishment of plastic and reconstructive surgical services in Bhutan allowed for timely microsurgical intervention that would not have been possible in earlier years, demonstrating a significant advancement in local reconstructive capacity and patient outcomes.