Hello, everyone, and welcome to this webinar on a few tips you can use to close wounds. It's not gonna be something with lots of theory and where we can go very much in depth because this is a very short presentation, but hopefully, these few tips can help you on your daily practise if you don't know them already. And we'll end up having wounds to close all the time, and it can be more or less, easy.

This was a a recent tumour resection of mine where I might have get carried away a little bit and when you end up with a big wound to close like this can be a bit scary, but if you use the tips I'm, I'm going to give you now and you go a bit with a bit of method, you can end up, or get out of most of the situations. The first step I would like to talk about is the use of tower claps. So this is a very silly thing, but I see lots of people not necessarily use it.

When you, want to, basically mobilise skin or move skin about when you do skin flaps, when you close the wounds using your towel clamps, can be useful in two ways. The first one is, as you see here, we're doing a little flap, we're gonna talk about later in this talk. And to mobilise the skin with minimal trauma, you place your towel clamps once and for all, and you can then move your skin about, which you can use for lots of, .

Of types of flap, all the types of flaps really. So you can have proper instruments to, to, like, like skin hooks, if you're very, very fancy, but even I don't have that, whereas I do lots of reconstructive surgery, I just use the tower clamps like this to mobilise the skin, as you see on these different pictures. The tower clamps can also be very useful, to choose how you're going to approximate the skin, and this is a case I actually did yesterday.

It was not a very, very complicated case. We just removed a cutaneous tumour on this dog, but it was an area where we had a little bit of tension, not a lot. I didn't need to do any skin flaps or anything, but there was a bit of tension.

And as you can see here, we're going to use the towel clamps to actually choose the position of the skin where I have the least tension. And I'm, I'm, I can place the tower climb several times if I'm not happy. But basically using these will help me hold the skin in the position where I can find the least tension.

If you're on the leg, you're, you're able to, to move the leg once you've done that. You've not placed any sutures yet, and it helps you really find the best position for your, for your approximation. And then you can place subcutaneous sutures, which you see being done here, and you place them on both sides of each tower clamp that you've placed, and then you can remove the tower clamps and your wound is ready for final closure.

You may do a continuous subcutaneous suture if you want or not, depending on the situation, but basically, you have been able to position the skin exactly as you want it, and as it seemed to have the, the least tension. You'll also notice that I start my sutures with the deep aspect. So basically, when you have a vertical wound facing you, you start with the left, left side if you're right-handed, and do the right side afterwards, which means that your knot, will always be in depth, naturally, so you will have much less problems bearing your knots if you start with the deep aspect.

So we can replace the first tower clamp there and we're going to do the same thing for the second tower clamp. So again, it's a very small and silly wound. It just shows you, you know, small principles you can use on most of your wounds, and that can help you, very silly dip, but that can be useful on your daily practise, I hope.

I'm just going to replace another one there, starting with the deep aspect. Doing then superficial to deep. And being able to bury the note like this.

Another little tip is the use of releasing incisions, so that's a very silly thing to do as well, but that can be really helpful. And this is a case where we had to remove a sarcoma here on the, dorsal aspect of the hook of the dog, and the, the tumour resection aspect is not what we're interested in here. But we try to close this wound as much as possible and you don't want to put too much tension because the wound's going to reopen if you do, and you're going to have a, a tourniquet effect as well and your leg is going to swell a lot.

So once we have closed what we could use reasonable tension, we end up having a wound here, that is not going to close primarily and either we let that heal by second intention, but we have tendons being exposed there. If we want to close that one solution is to create a wound elsewhere. Like this, that's going to basically gape a little bit when you close the wound on the dorsal aspect.

But this wound, as you see, is just to get against tissues. You don't have any tendons exposed. This wound will heal more rapidly than the first one.

So sometimes creating a wound to close one that is more difficult to close is a solution, and that's what we call a releasing incision. And this we're going to let heal by second intention, but should heal. More rapidly because again more fleshy tissues are exposed, but also because we're not in an area of constant flexion and movement of the skin.

And this is another example where we use this. This was a dog with a, a sarcoma at the, on the palmar aspect here of the antebrachium, distal antebrachium, and we were going to destabilise this, so we did a pancarpal arthrodesis dorsally and you know that this creates already some tension on the skin there because we have very little. So once we had resected the tumour on also on the back of the, of the leg there, well, we had no way of closing this without tension.

And the one way we chose on this dog was just to create multiple staggered, releasing incision on all the, all around this wound to be able to close the primary wound. And these little wounds, are basically, you see that they're gaping open because of the tension, but they're going to heal much more rapidly, than, than the primary wound would have. And that's another, solution.

So you see here when the, the wound is completely healed, we see all these little staggered incisions are healed by second intentions, some of them still have a bit of scabbing, but that allowed to close the wound on the dorso on the palmar aspect, sorry. So that's a very silly thing also to do. Think of creating this releasing incisions when you want to focus and close primarily the wound of greater importance, so you think it's gonna be harder to heal, or that was not healing for a long time.

Closing closing a chronic wound, creating one or two or several fresh wounds around is a good way of dealing with a chronic wound. The third tip is the use of far near the suture pattern. So this is one of the most useful, suture patterns you can use if you have moderate tension.

And the idea behind it is, when, when you do a simple suture like this, schematize here, on this wound. If you're close to the wound edges, you will have a, a really neater position of your skin because you're very close. You control very well the position.

But unfortunately, you place a lot of tension on a very small amount of tissue, and that will have a tendency to cut through the tissues. You've all had that sutures that will actually, it's not the suture giving up, it's just the, the, the, the tissues actually giving up because they're less resistant than the suture and it cuts through. So to avoid this, the solution is to take much bigger suture bites.

So you take much more tissue, the tension is equivalent but will be spread over a lot more tissues and the tissues will bear the tension better. It's much less likely to cut through. The problem is if you're very, very far from, from your wound edges, you have no control on your position.

You're, you're way too far. So a way to to to combine this to have a good tension holding, but also keep a good position is to use a suture patterns such as the far near near far. So it's called like this because you introduce your needle first on 0.1 here, far away from the wound.

You don't need to go deep, you can stay pretty superficial, it doesn't matter. But you will exit close to the woods so near, you do far, exit near. And near again and exit far on the last one.

And that is the same movement as you would do a cruciate pattern, except that it's symmetrical and will take a lot, a lot of tension. So these two points will actually bear the tension, and these two points will make sure that everything stays close together. So what does it look like when you do this on a, on a patient, you introduce your needle far from the wound, but you see we're not, we're not, it's not very far, it's not a very, very extreme far far, but you see that we're not necessarily deep.

We're going to stay at the same depth on the other side, but closer to the wound we exit. And we enter close to the wound, same depth, and this time we exit further from the wound on this, on this side. And you bring that together, so it makes a very dissymmetric.

It's nothing different than a cruciate in a way, but you see it's symmetrical. So this is the near near and this is the far and the far, and this will make it a a suture that will take a lot of tension. While still having a need a position.

And this is the same on the wound we've just seen before, where we introduce our needle far away from the wound edges. We're going to now exit close to the wound. Enter close to the wound again.

And exit far. And you'll see when we actually tension this this knot. When we tighten this, you see that the tension is taken by the two.

You see how these two points are actually taking on the tension and the wounds remains approximated because of the neonia element. That's a a very silly tip, but believe me, this pattern I use all the time when I have a little bit of tension. Obviously, you don't have to, to do that in, in several steps.

You can also do everything in one go. You just basically place a suture that is dissymmetrical on one side on one go, dissymmetrical on the other, so you don't have to do 4 steps, obviously. It was just to demonstrate, you can do that more quickly, like this.

It's the same thing when you tighten your future. You see that the tension is really taken from these tissues. It brings everything together and will limit the tension on the wound, and there's a lot of tissues taking this tension on.

And the, the, the beauty of this is because it's just a cruciate pattern in a way that's the symmetrical. You can really be progressive in how much tension you take on. Obviously afaifa uses more sutures.

Suture material than just a normal cruciate, so you don't want to do it all the time, but on the wound, typically the tension will be on the middle here on this wound on the stifle, and you see that we've started doing normal cruciates because there's no tension there. And as the tension is deemed to be a bit greater and greater, we do far near and near far that are wider and wider, and then we go again, progressively smaller to be back to normal crusads, and that really. Makes the most distributed attention relief that we can have with a movement that's very natural, very easy to do and very quick to do, and so this is a, a, a, a really good tip to know in my opinion.

You see, we've done the same here, where the tension, you see where the tension we thought was maximal, which is very often in the middle of the road. Another little, tip is a progressive closure. So that can be very useful in some cases.

This is a, a, a case of woundy since there, so this was not, ready to be closed primarily, and we just wanted to, to deal with that with a, a, a minimal amount of revision closure to have to do. And what progressive closure is, is placing a very loose continuous suture across the wound. That we're not gonna tighten completely, we're going to leave it very, very loose on the, on the day we place it, and what we're going to do is use, fishing shots like this, we'll see how that, that works that you can buy any new fishing shop really.

And the next time we see the dog, and that could be 345 days down the line, the, the skin will have relaxed a little bit, and we will be able to, to pull a little bit on the suture we've placed before, which is going to progressively close the wound, and we pull on that until we have reasonable tension, gaining a little bit on the closure. And to hold the suture together so that the suture does not recoil back, we place fishing shots there on the suture. So that it that it prevents the suture.

You see the, the, what we've gained in the future by pulling a little bit on it. The wound is more close now, and the fishing shots we placed typically several there, will prevent the suture from going back and will hold the, the, the wound a bit more close. And the following time, we do the same, just pull a bit more, and, and put more fishing shots.

The very convenient aspect of that as well is it's easy to place something like a foam dressing underneath, you slip it underneath the, the continuous suture you've placed, and that holds the, the, the dressing together, protecting the wound. And you may or may not place a a dressing on that. And the kind of funny story about this is the first time I, I ordered that, I asked people the, the.

Lady doing the orders in, in my hospital to, to buy, what I thought was called fishing weights, and these are fishing shots. And she, she told me how big do you want them. I said, as big as possible.

And what came back was actually fishing weights, which are like super hot iron balls like this. So, if you live in an English speaking country, make sure that you ask for fishing shots and not fishing weights. And the last, tip that is a bit more, involved, a bit more advanced, but I wanted to try and put things for everyone, is the caudal superficial epigastric flap, which is, a skin flap that every one of you can do.

It's really not difficult technically and can really help you in a lot of situations. I'm not going to go too much into, well, not at all actually, and in the, in the theory of actual pattern flaps, but these are skin flaps that basically rely on, on, on the known, direct cutaneous artery and vein. And in this case, it will be one that you see all the time when we operate on mammary tumours, and that's the caudal superficial.

Epigastric artery that comes out of the inguinal ring there and travels along the mammary chain, usually at least until, well, in between the, the, the second and the third mammary gland, in dogs and cats that can extend a little bit by anastomosis with the cranial superficial epigastric can go a little bit further. So it it means that if we elevate a piece of skin that can go from the midline there, along the midline and, and, and at a distance, this, if you take the same distance from the, the line of the nipples there to the midline and you take the same distance laterally, this is the lateral aspect of your, of your flap. And this flap, as you can see, can, can include the second mammary glands in dogs and cats, but that's a bit risky, or risky .

It is quite safe to to include the the third mammary gland in both species, you know that cats only have 4 mammary glands. And this flap can be elevated and you elevate that as you would do for a mammary tumour, so you elevate everything really flush with the abdominal fascia, which is very important, and you make sure that you don't damage, the, the vessels at the inguinal frame in there. And this skin can be brought in lots and lots of directions.

It can be used to reconstruct things on the flank, it can be used to reconstruct the internal aspect of the leg. I use it quite regularly to reconstruct the the perineum as well, which is otherwise an area that's not very easy to reconstruct. This is such a case, of a dog that had a, a mast cell tumour very close to the anus, as you see.

And what we're going to do is, position the animal so that we can reach the primary tumour, as well, but also, be ready to elevate the, the, the skin flap. So this skin flap is being drawn here. And you see we're going to keep the second mammary gland in, in, in this case, we might be able to trim it later.

It's always better to take a flap a bit longer and trim it shorter, rather than the other way around. Here we're going to detach it completely and as long as we preserve the insertion of the vessel coming onto the memory chain, then that's going to, survive perfectly. You see that these vessels are being contained here, the inguinal canal is there.

We're not going to dissect them too much. We don't want to fragilize them. But once we do this, this piece of skin is now able to rotate in all directions as you can see in this little movie.

That we're going to actually rotate it 180 degrees to be able to reconstruct the perennium on this dog. So we are closing here the wound completely. We, we've not touched the tumour yet, and that's for oncological concerns.

We don't want to contaminate this with any mass cells in case we have no clean margins. So we're going to protect the flap while we actually resect the tumour, we see here. So the resection of the tumour is not our point today, but you see we end up with a, a pretty large wound between the vulva and the anus that's hidden there.

And we're going to create a bridging incision to bring our flap. And we're going to oppose the flap there, and we can fold the flap on itself when we need a bit more width than we need, actually, . Length rather.

So you see that we're just applying the flap as, as, neatly as possible and we can trim the excess that we have if we do have any, and that's the position. That we have, you see the flap being taken there, being rotated 180 degrees, just covering all the perennium. This flap can really be super useful, it's not very difficult to do.

And that's a bit more advanced step, but if you've never used an actual pattern flap before, this is really the one I would advise you to start with, and can help you in a, in a lot of, situations, either because it can go really far if you leave it unfolded, or if you need more width, again, you can fold it on itself, which double the, the, the width you have available, and it will, cover a large area. So I'm going to just slip this and these were the, the, the 5 tips I wanted to, to give you. So again, use towel clams to mobilise the skin and place it exactly as you want and be able to do that several times, find the, the trial and error to find the best position, use releasing.

Decisions that can really help you in situations where you really want to be closed, at the expense of creating more wounds. Don't forget the far near far future pattern that will really help you when you have moderate tension that can really make the difference between a wound that holds and the wound that hisses. The progressive closure with your little fishing shots, that's also a really nice way to have a wound progressively closed with minimal effort.

And then the superficial or epigastric, so pattern flap we've just seen is a little bit more involved but really can help you, in, in lots of situations. We use that very often, and it's a very nice one to do. And as for the wound we had the, to start with, well, we ended up closing it.

I wouldn't say that we didn't. Sweat a little bit, at some point thinking that we would never close, but we've combined, several flaps together and that he'll find on this dog, had a bit of seroma here, but that, that he'll completely fine. So again, applying basic, techniques and, and, and some of the tips I've given you can take you out of lots of situations.

So obviously, I can't, cannot take, take questions for this, but feel free to contact us if you want, and to, and, and the questions might be passed on to us if you have any pressing problems with, with the tips I've just given. Thank you very much.