Hi everyone, and welcome along to this, webinar. I'm, Linda. I'm a soft tissue surgeon currently working at the University of Edinburgh in the referral hospitals, and today I'm going to talk about hard graft and try to give you some tips on managing patients with a big open wound or closing a difficult wound after reception of a tumour.
So we're going to go quickly through about patient management and touch on wound management because obviously they're very important steps when you have a patient with a big wound and then go through some skin reconstruction techniques. We'll talk about simple things that you can do to help relieve tension on your wound. We're gonna go over what a subdermal plexus is and perhaps some tips and tricks about how to use those effectively.
We'll Cover and act your pattern flaps, so just what they are and where you could think about using them and finish off with skin grafts. So it is an overview of lots of different advanced techniques that you can use to close those difficult wounds. So I think it's always important when we think about a patient that's come in and they've had a traumatic wound that you think about the whole patient rather than focus on the wound because at that stage, you know, they could run into trouble if they've lost a lot of blood and they're hypovolemic, you need to address that first.
If they're in lots of pain, you need to think about addressing that. And sometimes it's challenging when you're faced with a patient with a big sort of skin laceration, a big flap of skin, you want to focus on that, you want to think about getting your wound clean, but ultimately you need to manage the patient as a whole. So you need to deal with any life threatening injuries first, and this might be in the case of a traumatic injury, a severe bleed or it could be in the case of this cat, and it's a road traffic accident, the radiograph bottom right, you can hopefully see that there's a fracture laxation of the sternnabra, and multiple rib fractures, there's pulmonary contusions going on, there's some subcut emphasis.
And we have some photos of this cat later, so it's important in this case, obviously to stabilise them and really important when you're thinking of your triage to think about your major, major body systems assessment. So these are the three things that are going to kill the animal, sort of sooner rather than later if you don't address them. And the first one is the cardiovascular system.
So, what's happening with the heart rate, the blood pressure, do they need volume resuscitation? What's happening with the airway? Like, are they moving oxygen well?
Do you need to think about sedating or providing oxygen or maybe intubating them depending on how severe they are and what's happening with their neurologic system so. Or is their mentation appropriate? Are you worried about a head trauma?
Could they have done something to their spine? So this is actually a photo of that cat that I showed you the radiograph of, and, and you can see that we have clipped her. And you might be able to see a little wound in the centre and and as you know from that radiograph, there was some subcu emphysema, so they are indications to surgically explore the wound and we will come back to her a bit later in the talk.
So I wanted to touch upon after we've stabilised our patient, like what do we do with our open wound management. I think it's important to think about what your ultimate goal is and initially after the patients come in with a traumatic sort of laceration or . Dog, you know, dog bite, injury or other wounds that we commonly see.
You need to think about and decontaminating the wounds, so removing sort of the surface debris and bacteria, and you want to think about debridement, that means, staged or surgical, it could be surgical, it could be using dressings and removal of necrotic tissue and foreign materials. So classically thinking about a. Is often lots of gravel and and or possibly grass or things like that and the wound that you need to remove before you can think about how you're going to long term manage that and patient.
And then when we've got an open wound, it's obviously a source of infection that can lead to systemic illness and disease, so we want to think about sort of guarding against systemic infection. What can we do to stop the bacteria getting in and then ultimately whilst we're doing wound management, we want to establish a healthy granulation tissue bed. And once we have this granulation tissue, we sort of know that things are progressing in the right direction, so often infections under control, often the patient, you know, .
I hopefully then in a good position to allow us to do a definitive surgery to get the wound healed. So we can see that photo and bottom right is a very chronic wound in a cat. It was from an RTA.
It has been managed for a while, so the cat's over that initial phase of sort of needing lots of support for its injuries, so you know, volume support and things and. And it's actually had the wound for a period of weeks and it's formed an SR, which is that black area in the middle. This is effectively a scab of necrotic tissue, so dead material, and the wound's got to a stage where it can't heal now it needs by itself, it needs some intervention and at this stage we would remove the SR.
You can see that there's some granulation tissue underneath the SR which is great, and the cat has actually done a really good job of epithelializing the wound, so all of this paler pink tissue around the wound is the new epithelial cells. So we're just gonna cycle back a little bit and talk about what do we do with this patient that's come in with a wound and what's our ideal first steps for open wound management. So I think .
We always want to sort of protect the wound, so we don't want any further hair and debris to go in it. So I normally put lots and lots of sterile lubricant in the wound. We want to think about doing a wide clip, so this photo is actually a patient that was getting ready.
For an ex app and it's just to show you how big the clip is, so you know, with our wound patients and similar to that cap that I showed you, we want a really big clip, so we just can identify all the skin that's been damaged and then we can explore the track surgically if we need to. You can absolutely clean the skin and dilute chlorohexidine is useful. It's important to remember that ideally you don't put any any wound cleaning solution in the actual wound itself.
So chlorohexidine's been shown to sort of inhibit fibroblastic. So for the actual damaged skin and tissue underneath, we want to just use sterile saline and ideally we would take a . Bacteriology swab after we've done wound lavage.
So, lavage is really, really important for our wounds and one of the main things that we can do early on to address contamination and remember the little adage, the solution to pollution is dilution. So it doesn't matter like really what fluid you use, but you just want to be putting high volume of fluid through that wound. If it's really heavily contaminated, you could consider using water.
Ideally we would finish with something isotonic, so, salina Hartman's, I think there's, you know, Sort of not strong evidence to suggest one's better than the other, and then you ideally want to use the setup and using a 20 mL syringe and a 18 gauge green needle, so this will reduce tissue edoema. So obviously putting lots of fluid into the damaged tissue, you don't want to cause too much swelling. This is the situation, that we use, so, a couple of things to point out.
We've got this poor dog who had really bad dog bites to her face, and, and we've got her anaesthetized, so we've stabilised her first. We've made sure that she's fluid resuscitated, she had analgesia on board, and we felt like she didn't have other injuries that were going to negatively affect her anaesthetic. We've anaesthetized her.
We've got her wounds over a tub table so we can lavage as much as we want, trying to keep the rest of her dry and you can see the people that are touching her have got sort of barrier nursing PPE on, so we've got gloves and a gown, so we're not going to sort of try, try to limit cross-contamination from other patients to this patient and then from this patient to other. Patients, you can see the set up there where we've got a drip tubing, we've got a three way tap and a syringe and then the needle, so we're gonna be able to apply the lava with the sort of most ideal pressure. And yeah, you can see that she's had a dressing in place.
You might just buy the sutures that are in place and the wound is actually looking pretty clean and it's still open at this stage. So with our traumatic cases, we need to think about is surgical exploration appropriate, and I've got a couple of examples for you and when do we do the surgery. So I think often if they've got penetrating injuries, so similar to that cap that I showed you with the small injury over the sternum that we had radiographs for and we knew that there was tracking air, so there definitely been penetration in.
The chest, then ideally you want to explore these things within 24 hours of injury, and this often applies to bite wounds. So bite wounds over the thorax or the abdomen, if there's gas or neck, there's gas tracking in on your imaging. You ideally want to at least offer surgical explorer.
The point of the surgery is to assess the local structures and follow the tracks to their full extent. You don't want to obviously damage or contaminate healthy tissues or cavities, but often you'll find injuries perhaps if the bites are over the abdomen, you may find injuries to the . Intestine, that needs needs sorting out.
Again, if it's over the thorax, sometimes the teeth have actually sort of gone through the lungs and they may need sorting out as well. So the point is to examine and manage injuries to deeper structures. If the wounds are over joint joints, you need to think about trying to flush those out.
So often we'll use an ingress and an egress needle and we'll put you know, 1 litre of sterile saline through the joints. So here we have a cat who was a suspected RTA, lots of bruising, had a very palpable inguinal body wall rupture, and once she was stabilised, so she did need a lot of fluid therapy. I think we had her in the hospital for about 12 hours or so before we felt it was appropriate to anaesthetize her.
And she actually didn't have an external wound, but we wanted to do surgery for the body wall rupture, and part of that surgery was an abdominal explore and unfortunately she had had a crush injury to the root of her meentry, which meant that lots of her intestine was ischemic, and so we needed to perform a resectionostomosis as well. So just an example of why wound exploration is important. And here we have that little cat again, so things to note the very big clip and we're not sure, you know, we've included the abdomen as well, and here we have just the skin .
Skin incision and actually you can see that lots of the body wall has been traumatised and this is going all the way into her thorax. So really important that we explore the thoracic cavity from this wound and in sort of the least . Flushed and lavaged to try to stop infection further down the line.
Again, timing's quite important, so we want to try to decide when the patient is stable enough for a GA but not delay the surgery because that will allow infection to become more established or more likely. So we're gonna just go over debriding, and this is debridement is obviously a very important part of managing wounds, and, and there's several ways of doing it. I think the way that we're most familiar with is probably stage surgical debridement.
So this is where we, we look at the wounds sort of with the head. We'll aim to remove all the obviously dead and devitalized tissue. It is possible to convert a contaminated wound, so say laceration, dog's been running, got cut on a fence.
There's sort of lots of grass and things like that in the wound. You could convert that to a clean wound with one stage debridement. However, if there's lots of necrotic tissue or you're worried that there's going to be ongoing necrosis, so this wound was a dog bite.
It had been debrided and then closed, but you can see that there's been an of skin necrosis, so this was. 3 to 4 days after the initial bite injury and you can see that the edges don't look healthy at all, so it was actually infected and the patient had like quite a horrible sort of sepsis and vasculitis going on. So at this stage you wouldn't want to just close this wound again.
You'd want to manage it open so that you can decide the skin. At that very healthy skin edges, healthy granulation tissue before you decide to do your definitive surgery to close the wound. So we just quickly touch on dressings, they're obviously very useful if you're going to manage the wound open and they can achieve lots of different things.
So again, there's no right or wrong answer, like lots of things in veterinary medicine, you need to decide what is the. Aim at this stage for the patient, if it's ongoing debridement, you've got a really heavily contaminated or in infected wound using something like that's going to be de debriding like a wet to dry or an intrasite is going to be useful if you actually want to encourage secondary intention healing with . Allowing the epithelial cells to grow over granulation tissue, then providing a voice, the moist wound environment might be helpful.
So it's all about thinking what do you want to achieve and what dressing is going to do that for you. So I've got a picture of a leaven so everything's very absorbent, it's useful if you've got like a sort of infected wound that's producing a lot of fluid, but in that case you might also want to consider a wet to dry. Here I just wanted to include a little slide on tie over dressings.
These are super useful. So it's basically, if you haven't come across them before, it's a way of keeping dressing materials locally on the wound so that you don't have to put big bulky bandages on. They're really useful for sort of on the face and neck.
So this is the first image on the left is a dog that had rotten salivary gland abs. Well, I, I. 2 With a the necrotic wound from the bite and you can see the edges still sort of not looking very healthy, but the tissue underneath is looking fairly healthy and then yeah really great for perineal wounds that are difficult to manage.
This was a cat by abscess. And here we have the dog that I showed you earlier, the dog with the bites to her face and she has a tressing in place, so sort of trying to. Reduce the bulkiness of the bandage for her and you can see we've put a slightly occlusive layer, so that's a, you know, incontinence or pee pad that we've cut and used and we put a wet drying a very debriding dressing and usually we change these every day under sedation.
The main sort of disadvantage of using gauze for debridement is it's quite painful, so usually we'll keep the patients hospitalised on opioids. Another advantage of these tie over dressings is that they do provide some skin stretching, so they can help you when you ultimately come to close the wound. They give you a little bit of extra tissue to play with.
And yeah, they're really useful. So if you haven't come across them or you haven't tied a tried a tie over tongue twister, then that would be a good thing to consider when you have your next patient with a wound. So the other thing to think about when we're managing these wounds is open, when is the correct time to close the wound?
And so there's lots of things to consider. So of course it depends on patient and owner finances and whether how you're managing the bandages. So if the dog's having to be hospitalised for them, then sometimes doing surgery can actually be cost effective because you can get them out of the hospital sooner.
You absolutely don't want to close wounds if you're worried that there's gonna be ongoing skin necrosis. You don't want to close them if you think there's still a chance that it's infected or the infection isn't under control. You might want to consider closing them if they're near something that's going to be adversely affected by wound contraction.
So this is often if they're near an orifice like the eye, the mouth, if or over a joint where if you get a lot of contraction, the function of the joint is gonna reduce, or if they're around sort of the anus or the. Where you need to really conserve that anatomy. So sometimes we'll choose to close those using a skin flap or something so that we don't get contraction, but often in wounds, even big wounds will heal with time if you allow them to contract, and that could be something that you discuss with the owners.
So there's obviously positives and negatives of Everything and you need to sort of really trying to make an individual plan. The images of a poor dog that had neck tizing and fasciitis, she lost a lot of skin around her perineum and the big lens are areas that we haven't been able to close despite doing quite a large advancement flap, and we've left those areas to heal by secondary intention. So I think that's another thing.
And to sort of appreciate and and build into your plan that sometimes it is not possible to fully close a wound and if your surgery can make it smaller, then you will have reduced, reduced the healing time, but it's something to discuss with the owner and and sort of remind yourself and your team that it's not a failure if you haven't completely been able to close the wound. If the wound's smaller, it will still ultimately heal more quickly and you still might have achieved something with your surgery. So we're gonna move on to talk about sort of multiple er tension relieving techniques and the the principle that you really want to adhere to with any wound is you don't want tension on the skin.
So you, it doesn't matter if the skin edges are sort of slightly averted, that's actually a sign that you've dissipated the tension in the deeper layers and it doesn't matter if you're sort of, there is a bit of tension in the muscle underlying. But you just don't want tension on the skin edge. So the, the main thing that I do for all of my wounds, so whether this is a wound from a traumatic injury or a wound similar to this photo, so this is a soft tissue sarcoma, hopefully you get the impression of a mass in the centre of the circle, the section that I'm resecting.
I will then put multiple, sort of tension relieving sutures, and I don't do walking sutures or anything. I use, a longer lasting suture material, so I'd use something like PDS and I would try to put it in the strength. Holding layer, which is often the dermis, so you're doing this sort of subdermal suture where you're taking quite a deep bite of the skin, you're nearly coming through the skin, but you're not, and that is your subcutaneous or subdermal layer.
Or ideally, if you can't include a muscle, then the muscle has always got a thin layer of fascia, which is very high in collagen and again a really good strength holding layer. So the photo is trying to show you this resection of a mass on the flank of a boxer and the Debeki is grasping the paniculus muscle, and this is a really good layer to put sutures in because it does have that high collagen fascia. So I will do simple interrupted sutures and I'll do them with a buried knot, and because they're interrupted, they do spread tension across the wound and help to dissipate tension.
So my, the most common thing I do when I'm closing a big wound is put lots of simple simple interrupted subdermal or fascial sutures with PDS and then and that takes the tension off my skin. Then if I've got quite good apposition, I'll just then put skin sutures, or if I don't think my skin acquisition is ideal, I'll sometimes then put a layer of intradermals and then skin sutures. So 2 to 3 layer closure is fine for even big wounds like I showed you in in that staffy.
So here we have a dog and that had a bite and it had lots of skin necrosis, so it's a Labradoodle, its head is to the left and it's sort of it's . Front leg is, is to the left as well, and you can see that we're trying to primarily close the wound, but we're not able to. So we're using skin sutures, so we're not repeatedly traumatising the edges, and that's another really good top tip.
So every time you're doing a resection or and trying to close a wound, if you put these skin sutures in, so just a loop of PDS held with a . Mosquito hemostat, then you don't have to repeatedly pick the edges up with your forceps, you're not repeatedly causing micro trauma to the edges that you want to heal and you really want to preserve that blood supply. As you can see here it's just not going to go, so we need to think of another plan.
So we've done a huge clip. This is the same dog and we have clipped pretty much the whole dog and we've draped. So we've sort of pulled up the skin on its dorsum and going over the other side, and we've included that skin in our drape so that then we.
Access that skin for closing it. And this is another dog, the dog that I showed you the paniculus muscle for and for this dog, sorry, just to go back a slide, and we actually did a rotation flap, so that's a subdermal plexus flap, so we advanced skin in from the dorsum. And this dog here, we used part of the inguinal fold so you can get the impression that this is coming up here from the leg, and that's another type of subdermal plexus flap.
And this Image was to show you how you can use towel clamps effectively to sort of intraoperatively skin stretch and also allow yourself to do some surgical planning. So I have put the towel clamps on where I think I can get the skin together neatly and sort of seeing if there's tension I'll be able to move the leg around and check if I'm happy with that closure. If I wasn't happy, it's no problem at all, just take the towel clamps off.
They've only, they haven't damaged the skin or if they have, it's only just where the. Pressure, you know, the two points are and then I can move the skin around and see if if it fits better in a different location in a slightly different location or a different confirmation. So I think using The towel clamps is another top tip, and I will often do this for things like mammary strips where you know you just want to take a little bit of pressure off.
I'll put the towel clamps all the way along the wound, and then I will remove the tel clamps one at a time and put my sub subdermal tension relieving sutures in, and the twel clamps do the job of taking the pressure whilst I'm allowing the sutures so you don't have that horrible situation where the knots are sliding and things. So that's another one of my top tips. So we're gonna move on to talk about subdermal plexus flaps now.
So these are advancements are rotation flaps and our inguinal flank fold flaps, inguinal or axilla flank fold flaps. It's important just to remind yourself of the vascular system, the cutaneous vascular system, and how this is different in the cat and dog to man. So in the cats and dogs, we have the image on the left there.
So we have these direct cutaneous arteries which run parallel to the skin and then lots of little vessels coming off. Whereas in people they don't have this, so it's much more difficult to move a lot of skin around in people. It's really important to note where these perforating arteries are coming off, and they are below the hypodermis, below the paniculus muscle.
So again, that paniculus muscle that I was telling you was a really good strength holding layer is the layer that you have to undermine beneath for any skin closure. So you might need to be deeper than you think and not directly onto the sort of body wall but definitely beneath all of the subcat. And if you're just moving the dermis, then you actually haven't got the blood supply to the skin and that could be a reason for your wound to break down and fail.
OK. So, as I said, the subdermal plexus flat, this level of undermining is really important for that, so it's beneath the paniculus muscle. And these flaps are when you take a full thickness area of skin and you cut along 3 out of 4 edges and then you basically slide the skin into the correct position.
So the images on the right is a dog with a big soft tissue sarcoma on its dorsum and its tail is to the bottom of the image. And then you can see how we've closed it, so we've resected the wound and then we've basically made two parallel incisions away from the wound edge and undermined all of that skin on the dorsum, that loose skin beneath the paniculus muscle, and then slid it into place. So these are really, really useful flaps.
And they are quite accessible, and I think maybe people are doing them with just undermining rather than making the cuts. But if you have got a large area and you can't primarily close it without tension, then do consider doing an advancement flap, you know, please revise how to do it. There are some guidelines that you need to follow, .
And you need to, when you're doing a subdermal plexus flap, you need to think about where the blood supply from the flap is coming and in this case it's coming from the base. So this this sort of dorsal cranial part is the base of the flap, the blood supply is coming. In there, so you need to make sure that that base is wider than the tip, and you need to make sure that the flap is usually 2 times the deficit of 2 times the wound deficit or the area that you need to close so that you can close it without tension.
Other . Examples of subdermal plexus flap there's a rotation flap or an Hplasty which is actually two advancement flaps, so using the skin from each side of the wound and they can be really . Fairly simple to apply and very useful.
So just just to sort of really highlight the things that I do and my tips to preserve the cutaneous blood supply. So, just the sort of third time I've said it, but be really careful where you're undermining, make sure you're beneath the paniculus muscle. Trying to preserve any direct cutaneous arteries and you want to minimise damage by using an a traumatic technique, so think about how you're undermining and using your surgical instruments.
Also think about not repeatedly picking up the skin edges that you want to heal with forceps, and you can see here another photo of A flap that we're doing a labial lip flap, and we've used stay sutures on the edges so we can move the skin around without repeatedly picking it up. So I think thinking about your health sed principles and gentle tissue handling, preservation of blood supply, avoiding hematomas and things like that are really, really important for successfully managing big wounds. So just to touch upon the axilla and inguinal flank fold flats, these are a form of subdermal plexus flap, they're really useful.
So if you think about dogs or cats' legs, they have this triangle of skin where the leg is sort of attaching to the body wall and you can actually unfold that skin and then you have a really nice robust subdermal plexus flap. So for our axilla fold, and this is really useful for wounds on the . Proximal anti-breaking, so around the elbow and beneath the shoulder, around the elbow, and it could be medial so on the pectoral region.
And hopefully you can see the flank fold is sort of being outlined there and you can make a cut and if you imagine it's two bits of skin, two bits of triangular skin that are pressed together, and you can unfold that skin as long as you preserve one of the attachments. So often. The wound is directly abutting the fold and that counts as one of the cuts and then you can cut .
Two more attachments, as long as you think about the wide base for the subdermal plexus flap and you don't you don't disrupt the base of the flap, so the blood supply coming in. And here is the diagram of the inguinal fold. So again showing you the hash area is places where the wound could be and very useful for pelvic limb or sort of cord or mammary area and again you want to unfold that flap and sort of undermine it and and use it to close the deficit.
So I just wanted to talk and move on to axial pattern flaps, and these are quite different to subdermal plexus flaps. So these are basically subdermal plexus flaps are more random. You, you can sort of think about where the most skin is and how you can bring that in by either advancement or rotation.
Axial pattern flaps are ones that have a Direct cutaneous artery and vein. They're very specific. They've got very clear guidelines, anatomic guidelines as to what skin you can move around.
And basically, if you want to perform these, and this is what I do, and if I'm going to do one, I'll look up in the textbook, I will find the guidelines for the flap, I will think, is this gonna be appropriate for the, you know, wound that I need to close? I is the blood supply still there? Has it been damaged with the initial trauma?
Or the surgical site and then is the flap going to close what I need it to close. So here's a simplified diagram sort of showing you the more common flaps that we think about. I would say the most accessible one is the cordal superficial epigastric, so it's using that vessel that supplies the mammary chain it supplies.
The caudal three mammary glands and you know from doing mammary strips that it's easy to close that donor site and it's really useful you can sort of move it around to the, proximal pelvic limb and you can move it to the other side and if you've got an injury to the sort of ventral body wall, and you You can sort of get it around the hip region. The thoracco dorsal is another one that I've used, and it comes, the vessel comes out at this caudal shoulder depression, and it's very useful again, if the elbow fold has been damaged, but you've got wounds sort of around the elbow, and, you know, maybe one of those horrible sort of calcul sorry, not calcul tendon, . Eleon exposure injuries and you need a robust piece of skin.
So the advantages of the axial pattern flaps, this is compared to the subdermal more random flaps, is that they do cover a large area and they allow you to close big areas with minimal tension and they you can apply them sort of logically following the anatomic guidelines, but you know you just need to look them up for every single flap and the. Reported flap survival is good, so around 90 to 100%, and the image is a according to official epigastric, so the flap has been raised and it's showing you that direct cutaneous artery and vein going in, so it comes out and at the inguinal region. I'm sure you guys have all come across it when you remove those mammary glands, it bleeds a lot if you accidentally hit it, but it can be really useful for moving that piece of skin around, .
Yeah, they're fairly advanced technique, but I think if, if you're doing a lot of surgery, you know, you could, Could attempt these, but you would definitely need to do do some thorough research beforehand and sort of make sure you have time and and sort of a surgical marker pen and things so you can draw everything out before you make the cuts. The disadvantage is, we are elevating a flap of skin and then we're turning it around and putting it in a different location. So this image here is 2 weeks post-op, so it's got really good hairy growth, and this guy had a rib wall resection, and we had to close it using a myocutaneous flap, but the thoraco door.
Was the skin flap that we used. You can see that there's a big fold just caudal to his elbow, and that is where we've rotated the flap 180 degrees, so it's the flap going over the sort of shoulder region and then you move it down ventrally and the fold is the base of the flap. So we need to be careful that we don't over rotate the flap and compress the vessels, and we also need to be careful that we don't.
Do anything to damage those vessels, so you would never sort of trim or or cut the base, and it's one of those things that you need to be really careful when you're describing to the owner what you're planning on doing because it can look unsightly and and even, you know, for us who are used to dealing with wounds and things, we never love a dog ear as a surgeon, but this dog ear is very important and you just need to remind yourself of that. So sometimes they can end up with different hair coat patterns or colours, and that's something to just think about and discuss with the owner and obviously like often we're doing it when they've had a big wound or they've had a big tumour, so ultimately if you can get the area closed with skin, you're still winning, but just something to bear in mind and and sort of pre-discuss with owners. So just a few, differences between dogs and cats.
Cats have a sort of decreased cutaneous perfusion to dogs, so sometimes they've got slower healing and increased risk of flag necrosis. So just to talk about postoperative care, so I think these are for any of your big wounds that you've reconstructed and obviously they're going to be some degree of discomfort and pain, so think about how you're managing their analgesia, really important to get these animals eating early, so I think if you can do good pain relief, maybe think about keeping them in the hospital for, you know, 24, 48 hours so you can give them injectable analgesia. Think about have you placed the surgical drain if we're moving big bits of skin around then often it is useful to have a drain.
If you're doing it for an oncologic surgery, then you may argue against them and just sort of. Warn the owner that a seroma is likely to happen if they've got a drain in place, you know, do everything you can to protect that drain so and keep it covered, make sure the animal can't interfere with it with a bust collar or a t-shirt, make sure that you're using sort of clean hands and gloves when you're handling it and think about when to remove it. So really when the fluid production is tailoring off, you want to remove the drain so that you don't end up with an ascending infection.
I, I don't bandage my flats. I don't want to do anything to compress the blood supply. I don't even use like a primaple or an adhesive dressing afterwards.
And some people will still like to because they, they want that in place until the fibrin seals happened. I think you often don't need to carry on with antibiotics unless it's, you know, they, they've been on antibiotics and, and from a dog bite or something like that, but as I said earlier, often by the time you're doing your reconstructive surgery, you've been managing them as an open wound for a period of time. They've got healthy granulation tissue which once I've got granulation tissue established, I often will stop antibiotics.
I would use them perioperatively, so you know, give them an injection of a . IV injection 30 minutes before my first incision because often these are surgeries that do take quite a long time, so you're approaching your sort of 90 minute mark, but I wouldn't carry on with a therapeutic course. Really important that the patient doesn't lick or scratch or interfere, and as, as we all know, the skin can be quite itchy when it's healing, so make sure you keep some sort of bust colour or protection in place until the skin's definitely healed for two weeks, I would say.
So what are our complications of performing skin reconstructions using flaps? So I think sbroma is a really common one, and we'll talk a little bit how I manage those. Edoema, so the the flat tip can sort of get a bit swollen and edematous, sometimes you can get bruising.
Infection is, is a, is a risk and as I said, I don't use therapeutic antibiotics, but I do keep a good eye out for infections, so increased swelling, bruising, . Increased heat, any sort of discharge from the wound, I'll ask the owner to monitor for all of those and I'll see the patient back ideally after about 5 days, and then, you know, take a bacter urology swab and start empirical antibiotics if I think there is an infection. Dehisance is often due to tension, so this was a dog who had a massive tumour removed.
I've used the elbow folds and flapping it up and then a sort of advancement flap. So that's another thing to bear in mind that often you have to do more than one technique to close a wound. You can see where the sort of two flaps have come together.
There's a little bit of dehissance. I think this is because there was still tension on the wound. But you can see it doesn't look infected and I've actually put a little tie over dressing there and I just kept that covered and it's granulated so now I wouldn't do anything further, I would just leave this to heal by secondary intention.
We can get fat necrosis if we've over rotated our axial pattern flaps, and we've compromised or we've done something to compromise the the base, so always think about where's the blood supply coming. How do I manage a serumma? So if I've moved a big bit of skin around, I'm essentially expecting a seruma.
I will tell the owners what to look out for, even if I put a surgical drain, I'll often expect a small seruma. I'll see like gradually you'll you'll see sort of a fluid swelling developing 3 to 5 days after. Surgery, and I will ask them to monitor for signs of infection.
So an abscess is often painful, really hot, the skin looks angry and red, seroma, you know, the, the animal isn't bothered by it and is systemically well. And ideally you should never drain a seroma because it's just. In introducing infection if you are going to take a sample, if you're worried it's an abscess, make sure that you have aseptically prepared the skin, you're wearing sterile gloves and sort of doing everything to avoid introducing bacteria.
If you're happy it is this aroma then doing things like cold compressing, ice packing can be useful, massage can be useful, . If you are worried that it's an abscess, then you need to treat it or an infection, you need to treat it like an infection anywhere else and a way to do that is establishing drainage. So it could be that you decide to take out a few of your skin sutures and maybe a couple of your subcuts.
Sutures and, and create a little hole for drainage. Do try to think about doing that in the most central part of the wound, so you get drainage. I would then definitely take take a bacteriology swab, but start empirical antibiotics using my first choices amoxic or cephparoxime, so a good sort of broad spectrum antibiotics, whilst I'm waiting for the culture.
If it's really bad and there's a bit of necrosis involved, sometimes you have to debride a little bit of that area as well. The image is, . I think it's actually Teddy, that dog that I showed you that had the rotation flap, to be fair, it wasn't infected, but it was definitely sort of vascular compromise.
The flap was really engorged. I think some of the vessels had the veins had been compressed, so it was really bruise licking, and we'd applied a vacuum assisted wound therapy, so negative pressure wound therapy to sort of help with that blood supply, and it can be helpful for infection as well. And how to deal with flat necrosis dehisants.
So I think the main things that you want to do is think about how to prevent that. So, think about all those things we talked about that's really important, the house the principles, so very gentle and tissue handling, be as a traumatic as possible, do everything you can to avoid tension that includes sort of good hemostasis so you don't get hematoma building up. I think one of those things is really important to talk about and tip or flap necrosis with owners again it happens sort of.
6 to 10 days after surgery, so that's just how long it takes for skin necrosis to show and again, it could be a factor to do with the initial traumatic injury, could be just to do with the the surgery. If, if you do have a little area of necrosis, you often just need to manage, manage it as an open wound. And, as I said right at the beginning, it's often a much smaller area than if you hadn't done the reconstruction surgery and most owners are OK if you pre-warn them and you've sort of, talked about how you, how you're going to manage it.
So you know, just with dressings until granulation tissue is formed and then leave that granulation tissue to heal by secondary intention. So to finish off the top, we're gonna talk about skin grafts, and these are actually completely the opposite to skin flaps. So with.
The graft, we're moving a piece of skin and we're essentially making it avascular and we're moving it to a distal location so it doesn't have any vascular or nerve supply. It needs to get all of its nutrition from the recipient site. So a graft is a piece of skin which is dead and you put it on, it may come to life later.
A flap is a piece of skin which is alive when you put it on, but it may die later. I think that's a pretty, pretty good quote and sums it up eloquently. So that's just repeating what I said.
So why would we choose to use the skin graft? So it's really for wounds to the distal extremities, so the feet. So below the hock and the carpus and and if there's skin.
More than half the circumference of the leg, that's not gonna heal, usually doesn't heal by secondary intention without surgical intervention if the wounds over the joints and it's there's gonna be contraction that's gonna affect how that joint works. So skin flaps skin grafts are a little bit complicated in that they need very. The after for quite a long time, so you need to keep the graft completely immobilised, so with a splinted dressing or even an extensive ketal fixator, immobilising the joint above and below the graft for at least 2 weeks.
So you know, a significant time frame and often the patients are hospitalised for that whole time. And we would do them where we can't get a flap to reach, so that's what I was saying this sort of distal distal extremities. So this slide was really just to remind us that at first the skin graft doesn't have its own supply of nutrients and it has to receive all the nutrition from the recipient site.
So these are the sort of disadvantages, so it does take a lot of time and that's including the aftercare. You need to sort of manage owner expectations, so cosmetically they do look a little bit different, and in my hands, cat grafts seem to be a little bit more successful and dog ones there's they're sort of variable graft survival. So the most common one that we do is something called a full thickness mesh skin graft.
So you need a in people they have a special machine called the dermatome, they take a split thickness graft and interestingly the split thickness graft will not. Be hairy, but for our patients obviously they're mostly a lot hairier than us and actually moving the hair around is going to be better for functionality and cosmesis. The meshing of the graft allows the sort of fluid that builds up under the graft to be managed and and what we don't want is summa or a hematoma forming between the graft and the granulation tissue bed because that's going to affect the nutrition of the graft.
And, and the advantage of the split, the full thickness one is that we move hair follicles, sweat glands, etc etc. So we end up with a sort of better results. And there are many other types of skin graft, but the ones that I use the most are the split, the full thickness mesh graft or these little smaller grafts which are full thickness as well, punch grafts or strip grafts can be quite useful and and depending on sort of if the wound, the surface that we're trying to get to close is quite uneven and it's quite difficult to get that mesh graft on.
Or punch grafts are quite a nice way, a bit of a less risky way of achieving a skin graft, and it doesn't sort of matter if some of the punches don't survive, some of them do. It's a good way of bringing epithelial cells and sort of just helping those epithelial cells to come in and rather than relying on them. The, the ones surrounding the wounds to grow in, you can just put islands of epithelial cells throughout the wounds.
So here's an example of punch graph. This is from a textbook, Tobias and Johnson, as you can see cosmetically it's on distal distal foot. You can see that the wound is granulated but hasn't quite epithelialized.
They've moved. These islands of skin cells and you can see that it has helped and provide epithelial tissue, but cosmetically looks a bit different. There's still a lot of non-haired skin there so something to just point out and and remind owners.
So when we're going to do any Sort of skin graft, ideally, we want to do, put the graft onto a healthy bed of granulation tissue. So here the pictures on the right are showing sort of a wound after debridement. You can see there's some tendon and visible, there is.
Granulation tissue and then after, you know, sort of 10 days of management, there's this really nice healthy granulation tissue, it's that really nice bright red colour, it doesn't look infected. And just before we're putting the graft in, we need to cut the epithelialized edges off and control that bleeding and and then take the graft. So this often will use the flank of the dog or the cat.
It's basically any area that you can close without tension. And then different to a skin flat, we want to get the graft as thin as possible. So we need to remove all of that subdermal fat and we just really want the dermis, and we want to be able to see through the skin and we want to be able to see the hair follicle, so we get this nice sort of cobblestone bumpy appearance and you can do this with sharp scissors in the photo or a number 11 blade, you need to change the blade frequently, it gets blunt.
And quite quickly. And then here's another example, so this is using . The keeping the graft in place and then cutting the sort of hypodermis off and using a roll of bandage and stay suture to create some tension and so that can be be a good way of achieving it rather than removing it completely and pinning it out.
Either way, either way can be useful. And once we've got the donor bit of skin, we want to mesh it so often the meshes will form. And sort of inadvertently as you're making it as thin as possible, but here just showing cutting you ideally want a centimetre hole and staggered and not too close together so that you damage the skin.
And remember the point of the mesh is to allow the extraate to be removed and not build up. So. This was just to say how do we prepare the recipient bed, ideally you do this before you raise the graft, because once you've got the graft and you've made it really thin, sort of timing is really important.
You need to get the graft into position, ideally less than 20 minutes after you've cut it off, so to try to. Keep that skin alive. So the recipient bed, you want to remove any fluid, crust, dead tissues, you want to cut the epithelial border so you've got a fresh wound and you want to be careful that you have done good hemostasis so you don't get a hematoma between the skin and the granulation bed.
And here is a photo, an intraoperative photo of the graph being placed. So just highlighting again, once you've started raising the graft, you need to get it in position as quickly as possible. You want to have the graft really stretched out so that there isn't a gap and there's good contact between the granulation tissue and the graft.
You then sort of suture it in place. This is using ethylo, put a few sutures in the middle of the graft to keep it in place, and then sutures around the edge. Ideally try to match the direction of hair growth.
So why would our grafts not fail? So I think it's all about the nutrition of the graft. So if there's anything that's disturbed that, so again seroma, hematoma, movement, so if the graft is, is not stable and moving, those little vessels are not going to be able to grow in, and infection I think is a real, can be a real issue.
So if you've got infection, you've got more fluid, you know, you've got all those white cells going and just the nutrition of the graft is compromised. So here we have a little cat that was the one that I showed the interoperative photo of, and you can see that she's had a big clip and we're trying to drape in the donor site, . In the same as the recipient type, so you don't need to reposition the cap.
This is, and you can see the wound on her flank is where we've removed the skin from. It's just closed as we would close any wound, and then her graft leg has been immobilised, so with a modified Robert Jones and a splint, and we just don't want any movement at all. The dressings are really important for grafts, so you want a completely non-adherent dressing, and this is gonna be our gnet, so that Vaseline impregnated gauze.
So I usually put ginet immediately onto the graph, then then even to absorb any of that fluid, and then our big support dressing. And you want to do the dressing changes under GA ideally, so there's no inadvertent movement from the patients and people, you know, have different opinions. You want to do them sort of frequently so that if there is infection, things you can act on it, but not too frequently that you're disturbing things, so.
Maybe day 3 to 5, and post-op for the first one, and then day 7 and day 10. After 14 days you can change your lighter dressing, but usually still keep it covered because at this point the nerves are growing in and sometimes the patient can get a bit irritated by the graft. So quickly, what to expect.
So this is a dog graft 5 days post-op, actually looking quite good. You can see that the graft is quite pink, so you think, yes, it's got some nutrition. Usually days 1 to 3, the graph looks really pale because it, it hasn't, the blood supply hasn't grown in.
Day 7 it should look less edematous and a bit pinker, and weeks 2 to 3 we should start seeing hairs. So this is 7 days post-op in the Chihuahua. You can see that there are some little areas of necrosis at the edge, but actually very happy with how this graft is taken.
It's very pink and there's some hairs growing. Here is a dog skin graft that went wrong. It was infected.
You can see that the whole skin graft is white and very necrotic looking, and we had to debride it and we had sort of very exuberant granulation tissue underneath. So I think this had just been infected. Here's a little example of punch grafts in one of my patients, so, yeah, a very accessible way of starting off doing grafts.
Here is the Siamese cat that I showed you, this is the initial injury, so an RTAD gloving and circumference of the foot, had skin removed. He was the second photo on the right is. After some wound management, so we're getting a good granulation tissue bed here, was the graft, 3 days post-op, so looking quite pale, but then in 14 days post-op, you can see that the little meshed areas have epithelialized.
You can see that there's some hair starting to grow and we nearly had complete graft survival, so that was a great success. Good patient to manage. So, just to finish off, it was a big run through of lots of skin reconstruction techniques.
Hopefully I've managed to give you my top tips and as I was going along. I think in summary, the things that I would do is if you're considering managing a big wound with surgery, whether that be from a mass resection or from a wound, you really need to give yourself time to think about what you're going to do and think about having 2 to 3 different ways of closing it and making sure that you've clipped and prepped enough so that you can do all of those plans. So you know, using an advancement flat.
Is slightly different to an actopathic, make sure you've got a few different options available to you. Make sure that you've revised your anatomy and you know those those and the steps for those different procedures and maybe write them out and have them accessible to you in theatre. Remember that and sort of tissue handling is really, really important and one of the top things that we can do as a surgeon to encourage survival of our flats.
I think it's important to think about the complications and how you're going to monitor for them and also to have discussions with an owner and definitely don't be afraid to use more than one technique to close the wound and if there is tension, consider leaving part of it open to heal by secondary intentions, so granulation tissue and epithelialization and sort of if you've talked about owners with that beforehand, they're usually very on board . Good luck, they're very can be challenging but really great cases to manage and er nice to see, see the wounds closed. Thanks so much for listening.
I hope it was useful.