Risultati e complicanze incontrate nelle chirurgie ricostruttive con lembi cutanei nel cane e nel gatto
Abstract
Difetti cutanei di notevole entità conseguenti a interventi di chirurgia oncologica in cui vengono rimosse masse tumorali di dimensioni importanti o ferite superficiali caratterizzate da un’abbondante perdita di tessuto possono necessitare di tecniche di chirurgia ricostruttiva più o meno avanzata. In questi casi, quando la guarigione per prima intenzione non è possibile, la scelta terapeutica può ricadere sulla guarigione per seconda intenzione, sull’utilizzo di tecniche di chirurgia ricostruttiva o su un approccio combinato tra le due opzioni. La ricostruzione di tali difetti può avvenire mediante lembi locali, lembi assiali o innesti liberi, a tutto spessore o a spessore parziale. I lembi locali includono una vascolarizzazione casuale, motivo per cui sono detti “lembi casuali”, e possono essere preparati su uno stesso piano (lembi di avanzamento o lembi ad H) o su un piano di fulcro (lembi di rotazione, di trasposizione e di interpolazione). Al contrario, i lembi assiali comprendono una vena ed un’arteria cutanea diretta, che ne garantiscono una vascolarizzazione migliore. I lembi liberi sono invece innesti cutanei privi della loro vascolarizzazione e provenienti da un sito donatore lontano dal difetto cutaneo che si intende richiudere, i quali possono essere a tutto spessore (quando includono epidermide ed intero derma) o a spessore parziale (quando includono epidermide ed una porzione di derma variabile). Indipendentemente dal tipo di procedura chirurgica attuata, uno dei fattori più importanti per la sopravvivenza del lembo è la sua vascolarizzazione. Lo sviluppo di complicanze può palesarsi all’incirca 1 settimana dopo la chirurgia includono deiscenza, edema, sieroma, ematoma e necrosi del lembo, che possono essere classificate in minori o maggiori a seconda della necessità di un secondo intervento chirurgico per ottenere la guarigione completa della ferita. Questo studio comprende 28 casi di ricostruzione cutanea in 23 cani e 5 gatti, comprendenti di 13 lembi locali, 14 lembi assiali ed 1 lembo libero. Diciannove pazienti (70%) in totale sono andati incontro a complicanze post-operatorie, di cui 8 maggiori (29,6% dei pazienti totali) e 12 minori (42,8%). Inaspettatamente i lembi locali hanno avuto la più bassa percentuale di complicanze; tra i lembi assiali, l’85,7% ha sviluppato complicanze, di cui 6 (4,8%) maggiori, che hanno necessitato di una revisione chirurgica. L’unico soggetto a cui è stato praticato un lembo libero è andato incontro a complicanze maggiori (deiscenza totale del lembo) che hanno richiesto la revisione chirurgica. Per concludere, sebbene le chirurgie ricostruttive possano essere cruciali per la guarigione di ampi difetti cutanei, essere a conoscenza delle difficoltà associate ai vari tipi di lembo aiuta il medico veterinario a prevedere eventuali complicanze e a gestire correttamente il post-operatorio, aumentando le probabilità di successo della procedura.
Full text
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Dipa imen o di Scienze Medico-Ve e ina ie
Co so di Lau ea Magis ale a Ciclo Unico in Medicina Ve e ina ia
“OUTCOME AND CHALLENGES IN SKIN
RECONSTRUCTION WITH DIFFERENT CUTANEOUS
FLAPS IN DOGS AND CATS”
“RISULTATI E COMPLICANZE INCONTRATE NELLE
CHIRURGIE RICOSTRUTTIVE CON LEMBI CUTANEI NEL CANE
E NEL GATTO”
Rela o e:
Chia .ma P o .ssa MARINA MARTANO
Co ela o e:
Do . ANDREA FAVA
Lau eanda:
SILVIA SUDIRO
ANNO ACCADEMICO 2023-2024
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Somma io
1. RIASSUNTO .............................................................................................................................. 3
2. ABSTRACT ................................................................................................................................ 4
3. PARTE GENERALE ................................................................................................................. 5
3.1 The Skin ............................................................................................................................... 5
3.1.1 Skin Func ion and Ana omy ........................................................................................... 5
3.1.2 Cu aneous ci cula ion ..................................................................................................... 6
3.2 Basic p inciples o wound healing ...................................................................................... 7
3.2.1 In oduc ion and Phases o Wound Healing ................................................................... 7
3.2.2 Wound Con ac ion ...................................................................................................... 10
3.2.3 Species Va ia ions in Wound Healing ......................................................................... 11
3.2.4 S ages o Wound Healing and hei Clinical Rele ance .............................................. 12
3.3 Basic P inciples o Wound Managemen ........................................................................ 12
3.3.1 Basic Wound Classi ica ion ......................................................................................... 12
3.3.2 Age o he Wound: Clinical Signi icance .................................................................... 14
3.3.3 Op ions o Wound Closu e ......................................................................................... 14
3.3.4 Basic Wound Managemen .......................................................................................... 16
3.3.5 Topical Wound Ca e P oduc s and Thei Use .............................................................. 18
3.3.6 D essing, Bandages and P o ec i e De ices ................................................................ 20
3.4 Flap Classi ica ion ............................................................................................................. 22
3.4.1 Tension- elie ing Techniques and Local Flaps ........................................................... 22
3.4.2 Local Flaps ................................................................................................................... 25
3.4.3 Dis an laps .................................................................................................................. 28
3.4.4 Axial Flap Techniques ................................................................................................. 29
3.4.5 F ee Skin G a s ........................................................................................................... 34
4. PARTE SPECIALE .................................................................................................................. 38
4.1 Ma e ials and Me hods ..................................................................................................... 38
4.2 Resul s ................................................................................................................................ 39
5. DISCUSSION ........................................................................................................................... 45
6. CONCLUSIONS ....................................................................................................................... 54
7. REFERENCES ........................................................................................................................ 55
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1. RIASSUNTO
Di e i cu anei di no e ole en i à conseguen i a in e en i di chi u gia oncologica in cui engono
imosse masse umo ali di dimensioni impo an i o e i e supe iciali ca a e izza e da
un’abbondan e pe di a di essu o possono necessi a e di ecniche di chi u gia icos u i a più o
meno a anza a.
In ques i casi, quando la gua igione pe p ima in enzione non è possibile, la scel a e apeu ica può
icade e sulla gua igione pe seconda in enzione, sull’u ilizzo di ecniche di chi u gia icos u i a
o su un app occio combina o a le due opzioni.
La icos uzione di ali di e i può a eni e median e lembi locali, lembi assiali o innes i libe i, a
u o spesso e o a spesso e pa ziale. I lembi locali includono una ascola izzazione casuale, mo i o
pe cui sono de i “lembi casuali”, e possono esse e p epa a i su uno s esso piano (lembi di
a anzamen o o lembi ad H) o su un piano di ulc o (lembi di o azione, di asposizione e di
in e polazione). Al con a io, i lembi assiali comp endono una ena ed un’a e ia cu anea di e a,
che ne ga an iscono una ascola izzazione miglio e. I lembi libe i sono in ece innes i cu anei p i i
della lo o ascola izzazione e p o enien i da un si o dona o e lon ano dal di e o cu aneo che si
in ende ichiude e, i quali possono esse e a u o spesso e (quando includono epide mide ed in e o
de ma) o a spesso e pa ziale (quando includono epide mide ed una po zione di de ma a iabile).
Indipenden emen e dal ipo di p ocedu a chi u gica a ua a, uno dei a o i più impo an i pe la
sop a i enza del lembo è la sua ascola izzazione. Lo s iluppo di complicanze può palesa si
all’inci ca 1 se imana dopo la chi u gia includono deiscenza, edema, sie oma, ema oma e nec osi
del lembo, che possono esse e classi ica e in mino i o maggio i a seconda della necessi à di un
secondo in e en o chi u gico pe o ene e la gua igione comple a della e i a.
Ques o s udio comp ende 28 casi di icos uzione cu anea in 23 cani e 5 ga i, comp enden i di 13
lembi locali, 14 lembi assiali ed 1 lembo libe o.
Dicianno e pazien i (70%) in o ale sono anda i incon o a complicanze pos -ope a o ie, di cui 8
maggio i (29,6% dei pazien i o ali) e 12 mino i (42,8%). Inaspe a amen e i lembi locali hanno
a u o la più bassa pe cen uale di complicanze; a i lembi assiali, l’85,7% ha s iluppa o
complicanze, di cui 6 (4,8%) maggio i, che hanno necessi a o di una e isione chi u gica.
L’unico sogge o a cui è s a o p a ica o un lembo libe o è anda o incon o a complicanze maggio i
(deiscenza o ale del lembo) che hanno ichies o la e isione chi u gica.
Pe conclude e, sebbene le chi u gie icos u i e possano esse e c uciali pe la gua igione di ampi
di e i cu anei, esse e a conoscenza delle di icol à associa e ai a i ipi di lembo aiu a il medico
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e e ina io a p e ede e e en uali complicanze e a ges i e co e amen e il pos -ope a o io,
aumen ando le p obabili à di successo della p ocedu a.
2. ABSTRACT
Repai ing la ge cu aneous de ec s may be necessa y ollowing oncological su ge y in ol ing he
emo al o la ge umo s, o o suppo he healing p ocess o supe icial wounds cha ac e ized by
signi ican issue loss. In hese cases, in which healing by p ima y in en ion is no easible, he
emaining he apeu ic op ions a e healing by seconda y in en ion, he use o econs uc i e su ge y
echniques o a combina ion o he wo.
De ec econs uc ion can be achie ed using local laps, axial laps and ee g a s, which may be
ull o pa ial hickness. Local laps, also known as " andom laps," ha e an unde ined ascula
supply coming om he subde mal plexus and can be designed in he same plane (such as
ad ancemen o H laps) o on a pi o poin (such as o a ion, ansposi ion, and in e pola ion
laps). Axial laps, in con as , con ain a de ined cu aneous a e y and ein, p o iding supe io
ascula iza ion. Skin g a s lack di ec ascula iza ion, a e ha es ed om a dono si e dis an om
he de ec , and can be ull hickness (including he epide mis and he de mis) o pa ial hickness
(including he epide mis and a pa ial po ion o de mis).
Rega dless o he ype o su gical p ocedu e pe o med, one o he mos impo an ac o s
esponsible o he su i al o he lap is i s ascula iza ion. Complica ions a e expec ed o occu
abou 1 week a e su ge y, and include dehiscence, edema, se oma, hema oma and lap nec osis,
and hey can be sub-classi ied as mino o majo , depending on whe he su gical e ision is
equi ed o achie e success ul wound healing. Mino complica ions can be ea ed medically,
whe eas majo complica ions may equi e su gical e ision and can subsequen ly heal by second
in en ion, o h ough a new econs uc i e and i s in en ion closu e.
This s udy in ol ed 28 cases o skin econs uc ion in 23 dogs and 5 ca s, consis ing o 13 local
laps, 14 axial laps and 1 ee g a .
Nine een pa ien s (70%) de eloped pos -ope a i e complica ions o any kind, wi h 8 pa ien s
(29,6% o all pa ien s) expe iencing majo complica ions and 12 (42,8%) expe iencing mino
complica ions. Unexpec edly, local laps had he ewes majo complica ions a e (7,6%); o he
axial laps, 85,7% p esen ed any complica ions, wi h 6 o hem (42,8%) expe iencing majo
complica ions ha equi ed e ision su ge y. The dog ha unde wen a ee lap p ocedu e
expe ienced majo complica ions ( o al dehiscence o he lap) ha equi ed su gical e ision.
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In conclusion, e en hough su gical econs uc i e echniques may be c ucial o suppo he healing
p ocess o la ge cu aneous de ec s, being awa e o he challenges associa ed wi h each ype o lap
will help he e e ina ian o o esee complica ions, managing he pos -ope a i e pe iod co ec ly
and imp o ing he o e all long- e m success a es.
3. PARTE GENERALE
3.1 The Skin
3.1.1 Skin Func ion and Ana omy
The skin, being he body's la ges and p ima y p o ec i e o gan, co e s he en i e ex e nal su ace
and se es as he o emos physical ba ie agains en i onmen al ac o s. I s oles include
egula ing empe a u e, p o ec ing agains ul a iole (UV) ligh , auma, pa hogens,
mic oo ganisms, and oxins. The skin also con ibu es o senso y pe cep ion, immunologic
su eillance, gene al homeos asis and con ol o insensible luid loss. Addi ionally, i is highly
adap i e, exhibi ing di e en hicknesses and specialized unc ions ac oss a ious body si es
(Kani akis, 2002).
The skin is composed o h ee laye s: he epide mis, he de mis and subcu aneous issue (Kani akis,
2002)(Fig. 1).
The epide mis is a s a i ied, squamous epi helial laye ha is p ima ily composed o wo ypes o
cells, dend i ic cells and ke a inocy es; he ke a inocy es di e om he dend i ic cells by
possessing in e cellula b idges and ample amoun s o cy oplasm (Mu phy, 1997).
In hai -bea ing a eas, he epide mis consis s o h ee majo laye s: he s a um cylind icum
(s a um basale), he s a um spinosum (s a um malpighii o p ickle cell laye ) and he s a um
co neum; he se o s a um cylind icum and s a um spinosum laye s o m he s a um
ge mina i um (Pa le ic, 2018). The epide mis is a con inuously enewing laye ha p oduces
s uc u es like swea glands, nails and pilosebaceous appa a uses; he basal cells o he epide mis
unde go p oli e a ion cycles, ensu ing he enewal o he ou e epide mis (Chu, 2008).
The de mis consis s o collagenous, e icula and elas ic ibe s embedded in a mucopolysaccha ide
g ound subs ance, p ima ily made up o hyalu onic acid and chond oi in sul u ic acid. In dogs and
ca s, he de mis is di ided in o he supe icial s a um papilla e and he deep s a um e icula e;
he s a um papilla e con ains ine elas ic and e icula ibe s, whe eas he s a um e icola e is
composed o coa se, densely in e wo en collagen bundles (Pa le ic, 2018).
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The mos pliable skin (axilla, lank, do sum o he neck) has a g ea e numbe o elas ic ibe s in
he papilla y laye , as well as small and mo e loosely wo en de mal collagen bundles, whe eas
less pliable skin, (on he ail, ea , digi al pads) ha e wide , mo e closely packed collagen bundles
wi h ewe elas ic ibe s (Pa le ic, 2018).
The hypode mis o supe icial ascia is associa ed wi h he o e lying de mis; his subcu aneous
issue is composed p ima ily o a nes led in loosely o ganized collagenous and elas ic ibe s
(Fahie & She ko, 2007).
The cu aneous appendages (adnexa) o he skin include he hai ollicles, sebaceous glands and
swea glands. O he cu aneous glandula s uc u es include he mamma y glands, sup acaudal
glands, anal sacs, supe icial ci cumanal glands and pe ianal glands; all hese s uc u es ha e an
ec ode mal o igin (Pa le ic, 2018)
3.1.2 Cu aneous ci cula ion
In dogs and ca s, di ec cu aneous a e ies a e esponsible o supplying la ge a eas o skin; hey
un pa allel o he skin in he hypode mis and a ise om pe o a o a e ies. Musculocu aneous
a e ies, which un pe pendicula o he su ace o he skin, b anch o he pe o a o a e ies and
supply small po ions o he skin. Te minal a e ies and eins b anch om he di ec cu aneous
essels and o m he subde mal (deep o subcu aneous) plexus, cu aneous (middle) plexus and
subpapilla y (supe icial) plexus (Ki pens eijn, 2013).
Fig. 1: C oss-sec ion o skin and panniculus. F om And ews’ Diseases o he Skin: Clinical
De ma ology (10 h ed., p.1) by W.D. James, T.G. Be ge , and D.M. Els on, 2006, Philadelphia:
Else ie Saunde s. Copy igh 2006 by Else ie Saunde s.
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The subde mal plexus (Fig. 2) is he p ima y ascula ne wo k o he skin, wi h essels gene ally
unning in he subcu aneous a y and a eola issue on he deep ace o he de mis, pa icula ly in
he middle o dis al po ions o he limbs whe e no panniculus muscle is p esen ; he plexus
supplies he hai bulb and ollicle, ubula glands, deepe po ions o he duc s and he a ec o pili
muscle. B anches o he subde mal plexus ise in o he de mis o o m he middle o cu aneous
plexus. B anches o he cu aneous plexus ascend and descend in o he de mis o supply he
sebaceous glands and suppo he capilla y ne wo ks a ound he hai ollicles, ubula gland duc s
and a ec o pili muscle. The supe icial plexus lies in he ou e laye o he de mis, wi h capilla y
loops p ojec ing in o he de mal papilla y bodies o supply he epide mal papillae and adjacen
epide mis. (Pa le ic, 2018; Mayhew, 2017)
3.2 Basic p inciples o wound healing
3.2.1 In oduc ion and Phases o Wound Healing
By de ini ion, a wound is a b eak o loss o cellula and ana omic con inui y, wi h impai men o
he issue’s p o ec i e o physiological unc ions; in pa icula , su gical wounds a e c ea ed in he
p ocess o esec ing diseased o damaged skin egions (Pa le ic, 2018).
A ho ough unde s anding o he wound healing p ocess is i al o a co ec app oach o wound
ca e.
Fig. 2: Vascula supply o canine and eline skin. F om BSAVA Manual o Canine and Feline
Wound Managemen and Recons uc ion, au ho Philipp Mayhew (2017).
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Wound healing is a complex and dynamic p ocess, ha can be simpli ied in o h ee phases: 1) he
in lamma o y phase; 2) he p oli e a i e phase; 3) he ma u a ion/ emodeling phase (Sussman &
Ba es-Jensen, 2012). These phases o e lap in ime, since hey’ e no mu ually exclusi e.
Each phase o wound healing is egula ed by cy okines, signaling molecules ha can di ec cellula
ac i i ies, leading o he p oduc ion o p o eins, enzymes, p o eoglycans and o he essen ial
componen s o ex acellula issue epai .
1) The in lamma o y phase is he ini ial s age o wound healing, cha ac e ized by hemos asis
and in lamma ion. Hemos asis begins wi h collagen exposu e du ing wound o ma ion,
ac i a ing bo h he in insic and ex insic clo ing cascades; issue inju y also eleases
h omboxane A2 and p os aglandin 2-alpha in o he wound bed, inducing a s ong
asocons ic o esponse. Addi ionally, he ex a asa ion o blood cons i uen s o ms a
blood clo , ein o cing he hemos a ic plug. Thus he ini ial esponse limi s hemo hage
and p o ides an ex acellula ma ix o cell mig a ion (Sinno, Sa aya, 2013). Pla ele s a e
among he i s esponde cells in wound healing, playing a c ucial ole in o ming he
hemos a ic plug; hey sec e e a ious chemokines, including epide mal g ow h ac o
(EGF), pla ele -de i ed g ow h ac o (PDGF), ib onec in, ib inogen, on Willeb and
ac o , se o onin and his amine. These ac o s aid in s abilizing h ough clo o ma ion and
a ac and ac i a e mac ophages and ib oblas s. Addi ionally, pla ele s help con ol
bleeding and limi he ex en o inju y (Sinno, Sa aya, 2013). Following complemen
ac i a ion and pla ele ec ui men , neu ophils a e he nex cells o mig a e o he wound;
hey a e esponsible o sca enging deb is, opsonizing and lysing o eign o ganisms ia
complemen media ion and des oying bac e ia h ough oxida i e bu s mechanisms, such
as he o ma ion o supe oxide and hyd ogen pe oxide (Sinno, Sa aya, 2013). The key ole
in wound healing is media ed by mac ophages ha no only di ec ly phagocy ose bac e ia
and o eign ma e ials, bu also sec e e nume ous enzymes and cy okines, collagenases,
in e leukins and ans o ming g ow h ac o (TGF). Addi ionally, mac ophages elease
pla ele -de i ed g ow h ac o and ascula endo helial g ow h ac o (VEGF), ini ia ing
g anula ion issue o ma ion and hus ansi ioning in o he p oli e a i e phase and issue
egene a ion (Sinno, Sa aya, 2013).
2) The p oli e a i e phase is usually conside ed o span o e 5-20 days a e inju y, al hough
some ex books indica e i begins as ea ly as 3 days a e inju y (Pa le ic, 2018). The
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p oli e a i e phase consis s o epi helializa ion, angiogenesis, g anula ion issue o ma ion
and collagen deposi ion (Sinno, Sa aya, 2013). Epi helializa ion begins wi h ke a inocy es
a he wound edge and om de mal appendages, such as hai ollicles, swea glands and
sebaceous glands; his p ocess in ol es cell de achmen and mi o ic di ision, s imula ed
by epide mal g ow h ac o , ib oblas g ow h ac o and a ious cy okines. Fib oblas
g ow h ac o , pla ele -de i ed g ow h ac o and ascula endo helial g ow h ac o also
ini ia e and p omo e angiogenesis (Janis, Ha ison, 2016). A key e en in he healing
p ocess is new blood essel o ma ion, e med neoangiogenesis. Neoangiogenesis is a
complex p ocess ha elies on ou in e ela ed phenomena, including: cell pheno ype
al e a ion, chemoa ac an -d i en mig a ion, mi ogenic s imula ion and he local
de elopmen o suppo i e ex acellula ma ix (Pa le ic, 2018). Unlike asculogenesis,
which e e s o he ex-no o o ma ion o new essels, angiogenesis in ol es he
de elopmen o hin-walled endo helium o m exis ing essels (Janis, Ha ison, 2016). A
healing wound is de ined by inc eased me abolic demands and shows high sensi i i y o
changes in oxygen a ailabili y. Fib oblas s i s appea in he wound a e 24 hou s, and
hey equi e adequa e oxygen supply o collagen p oduc ion: wi hou oxygen, chemical
bonds will no o m app op ia ely o o m ma u e collagen (Janis, Ha ison, 2016).
The e m g anula ion issue is de i ed om he g anula appea ance o newly o ming
issue when incised and i s edge is isually examined (Fig. 3). G anula ion issue is a ma ix
o ib in, ib onec in, collagen, p o eoglycans and glycop o eins; i ills in body de ec s
while p o iding a ascula sca old o epi helial cell mig a ion, and i also o ms a ba ie
o in asi e bac e ia. Ea ly g anula ion issue begins o o m app oxima ely 4 days a e an
uncomplica ed inju y (Pa le ic, 2018).
3) Du ing he ansi ion om g anula ion issue o sca ma u a ion, collagen emodeling
occu s, wi h a balance be ween collagen deposi ion and collagen ca abolism, and ype III
collagen g adually dec eases, as ype I collagen inc eases. Collagen deposi ion is di ec ly
ela ed o he ensile s eng h o a wound: h ee weeks a e inju y, he sca has 20% o i s
inal s eng h, and o e he nex se e al weeks he sca will achie e only 70-80% o he
ensile s eng h o no mal skin (Villedieu, 2023). The ma u a ion phase usually akes 20-
365 days.
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o inancial cons ain s, ha would p eclude su ge y in a o o open wound managemen )
(Pa le ic, 2018). Second in en ion healing is o en a p ac ical and economical me hod o wound
closu e, as long as adequa e wound ca e is p o ided. Howe e , in some cases, healing can be
p olonged, wi h he cos s o hospi al isi s, bandage ma e ial and opical medica ions equaling o
exceeding hose o su gical closu e (De nell, 2006).
3.3.4 Basic Wound Managemen
Ini ial managemen o open wounds can be summa ized in six simple s eps: p e en u he wound
con amina ion, deb ide dead/dying issue, emo e o eign deb is and con aminan s, p o ide
adequa e wound d ainage, es ablish a iable ascula bed and selec he app op ia e me hod o
closu e (Pa le ic, 2018).
Upon admission, he pa ien ’s wounds should be empo a ily p o ec ed om u he auma and
hospi al-bo ne bac e ia wi h a opical an imic obial, s e ile d essing and p o ec i e w ap; s e ile
gauze mois ened wi h saline con aining an an ibio ic o a non-i i a ing an imic obial agen is
use ul o main aining issue hyd a ion and con olling he in ec ion un il de ini i e wound epai
can be pe o med. Fo de ini i e wound cleansing and su gical managemen , co e he exposed
wound wi h s e ile gauze pads soaked in s e ile saline o an imic obial solu ion be o e clipping he
skin and p epa ing he de ec o su ge y. Fu should be emo ed om a ound he wound a ea, as
i ends o e ain discha ge, leading o issue mace a ion and bac e ial g ow h; emo ing u also
makes pe iodic wound cleansing and bandages eapplica ions easie .
Fig. 6: La ge open wound healing by second in en ion, h ough con ac ion and
epi helializa ion ( igh ). Healing by second in en ion equi es owne compliance, since
equen bandage changes a e needed. On he le , he en i y o he cu aneous de ec he day
o he su ge y.
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Deb idemen is necessa y whene e nec o ic issue o deb is emains in a wound a e ini ial
cleaning. While a small amoun o deb idemen migh be done wi hou seda ion o anes hesia,
analgesia and chemical es ain a e ypically equi ed, especially o agg essi e su gical
deb idemen (De nell, 2006).
Deb is adhe en o he subcu is should be manually emo ed o main ain cu aneous ci cula ion;
manual emo al o g oss deb is ollowed by p essu e la age wi h iso onic liquids will elimina e
any mic oscopic pollu an s ha emain a e he i s deb idemen . Small- o-mode a e sized
wounds a e o en la aged wi h 500-1000 ml o egula saline o lac a ed Ringe ’s solu ions
(Pa le ic, 2018).
Gene ally, lea ing a wound exposed allows o he bes d ainage o con amina ed o in ec ed
wounds. D ains may be employed du ing closu e o limi dead space and p o ide an ou le o he
e acua ion o issue luids ha may collec in ha egion; in he absence o de i alized issue and
o eign deb is, d ains can o e an ou le o pu ulen discha ges ha may o he wise collec o
dissemina e in o su ounding issues (Pa le ic, 2018).
3.3.4.1 Wound Deb idemen
Wound deb idemen alls in o wo b oad ca ego ies: selec i e and non-selec i e.
Selec i e deb idemen speci ically a ge s nec o ic issue, whe eas non-selec i e deb idemen is
less p ecise and can unin en ionally ha m iable issue o a ying ex en s.
Selec i e deb idemen me hods include: au oly ic deb idemen (using gels and d essings ha
c ea e an op imal en i onmen o he body’s na u al p ocesses o b eak down nec o ic issue),
enzyma ic deb idemen (applying exogenous p o eoly ic enzymes o sepa a e non iable issues)
and bio he apies, such as u ilizing maggo s o selec i ely consume nec o ic issue. Selec i e
deb idemen , al hough slowe and less agg essi e, mo e accu a ely a ge s nec o ic issue and
minimizes ha m o heal hy issue. Non-selec ing deb idemen includes su gical (scalpel, issue
excision)(Fig.7) and mechanical (we - o-d y d essings) deb idemen (Pa le ic, 2018).
Ini ial su gical deb idemen is c ucial o la ge wounds, o o hose wi h deep issue inju y; he
goal is o emo e all ob ious nec o ic issue and deb is, o en using a laye ed app oach, s a ing
wi h supe icial de i alized issues and mo ing o he deepe ones.
Assessing issue iabili y can be subjec i e, wi h he mos eliable indica o s being colo and
a achmen : issues ha a e ex emely ligh o da k and no a ached o deepe planes should be
18
emo ed, while ques ionable issues should be le o ee alua ion. Ac i e bleeding om he cu
su ace indica es iabili y, bu ac o s such as sys emic o local hypo ension, issue empe a u e,
asocons ic ion and coagula ion de ec s can a ec bleeding, he e o e elying solely on bleeding
o de e mine issue iabili y may esul in emo ing iable issue. (De nell, 2006).
En-bloc deb idemen , in ol ing he comple e excision o all a ec ed issue wi h a bo de o no mal
issue, is ano he su gical deb idemen me hod; his echnique is simila o emo ing a malignancy,
and is ese ed o wounds ha a e clea ly in ec ed o whe e laye ed deb idemen is unlikely o
esul in a heal hy wound (De nell, 2006).
Mul iple deb idemen p ocedu es could be necessa y, since a single deb idemen a emp is o en
no su icien o achie e a heal hy wound bed ha could unde go p ima y o delayed p ima y
closu e; his is especially ue o wounds wi h p og essi e issue changes in ela ions o ascula
comp omise o deep issue inju y.
3.3.5 Topical Wound Ca e P oduc s and Thei Use
The p ope use o opical and sys emic medica ions can signi ican ly accele a e he healing
p ocess, when second in en ion healing is o eseen, leading o a as e eco e y wi h ewe
complica ions and side e ec s. Medica ion ha enhance wound healing wo k in a ious ways,
such as in main aining a mois en i onmen (e.g., hyd ogels, hyd ocolloids), p o iding a local
Fig.7: Nec o ic lap on a dog’s o elimb, be o e and a e su gical deb idemen .
19
ene gy sou ce (e.g., mal odex in, honey, suga ), educing wound edema by hyd ophilic ac ion,
inc easing he concen a ion o g ow h ac o s, p o iding a sou ce o healing subs ance (e.g.,
collagen, biologic memb ane biosca olds), con olling in ec ion (e.g., opical and sys emic
an imic obials), aiding deb idemen (e.g., opical enzymes), inc easing he oxygen con en and
inc easing blood low (e.g., lase , UV adia ion, elec ical s imula ion) (K ahwinkel, 2006).
Au oly ic deb idemen e e s o he body’s na u al p ocess o deb idemen happening a a cellula
le el wi hin a wound; mois u e- e aining gels and d essings can be used o p omo e selec i e
deb idemen by so ening o mace a ing de i alized issues, acili a ing phagocy ic cells ac i i y,
and enabling p o eoly ic enzyme lique ac ion o non iable issue. Many o hese opical gel-like
compounds a e lamina ed o syn he ic memb anes, c ea ing a d essing pla o m o easie
applica ion o la wound su aces. Simila ly, o he mois u e- e aining ba ie d essings (occlusi e
and semi-occlusi e) can be used o p omo e p o eolysis wi hin he wound (Pa le ic, 2018)
Hyd ocolloids a e ypically composed o pec in, gela in and ca boxyme hyl-cellulose, wi h a ilm
o adhesi e backing, hus ac ing as a bandage; hey abso b wound luid and exuda e, swelling in o
a gel-like mass ha main ains a mois en i onmen conduci e o healing. Hyd ocolloids a e
ecommended o pa ial and ull- hickness wounds, and a e sa e o use on bo h g anula ing and
nec o ic wounds. Wounds co e ed wi h hyd ocolloids ha e lowe in ec ion a es in human
medicine han hose co e ed wi h gauze, ilm, hyd ogels o oams, as hey also p o ec he wound
om con amina ion and aid in au oly ic deb idemen ; d essings con aining hyd ocolloids equi e
less equen changes compa ed o con en ional bandages, as hey a e o mula ed o emain on he
wound o up o 7 days; howe e hey should be eplaced i s ike- h ough is obse ed
(K ahwinkel, 2006).
Hyd ogels a e wound d essings composed by 80-90% o wa e o glyce in, a ailable in shee o m
o se e as bandages; hey abso b a minimal amoun o luid bu a e capable o dona ing la ge
amoun s o mois u e o he wound, making hem sui able o minimally o mode a ely d aining
wounds, such as ab asions, blis e s, bu ns, ulce s and pa ial- hickness dono si es. Hyd ogels a e
bene icial in he la e s ages o wound healing, on wounds ha ha e heal hy g anula ion issue,
dec eased d ainage and e idence o epi helializa ion (K ahwinkel, 2006). (Fahie & She ko, 2007)
Mal odex in is a D-glucose polysaccha ide wi h 1% asco bic acid ha , when applied o a wound,
o ms a hyd ophilic ilm d essing ha c ea es a mois en i onmen o nu u e wound healing.
20
Mal odex in seems o educe pain and s imula e g anula ion and epi helializa ion. The p oduc
comes as a hyd ophilic powde and as a gel: he powde is p e e ed o exuda ing wounds, and
he gel is p e e ed o d ie wounds (K ahwinkel, 2006).
Suga and honey a e common and eadily a ailable subs ances ha can aid in wound healing.
Suga is an excellen opical d essing o ea ing open and con amina ed wounds. I s bene i s
include apid an ibac e ial ac ion, and osmo ic p ope ies o exuda i e wounds, enhancing
g anula ion issue o ma ion and epi helializa ion and accele a ing wound healing (Ma hews &
Binning on, Wound Managemen Using Suga , 2002).
Honey con ains many nu ien s and mine als, has a bac e icidal e ec due o hyd ogel pe oxide
libe a ion and a phy ochemical cons i uen ; when used as a opical d essing, honey dec eases
in lamma o y edema, accele a es sloughing o de i alized issue and nou ishes he wound. These
ac o s con ibu e o enhance g anula ion and epi helializa ion (Ma hews & Binning on, Wound
Managemen Using Honey, 2001).
3.3.6 D essing, Bandages and P o ec i e De ices
Bandaging open wounds is essen ial o e ec i e wound managemen : unbandaged wounds a e
p one o desicca ion which can lead o healing delay and highe incidence o in ec ion and sca ing;
mo eo e , e e ina y pa ien s a e likely o lick unp o ec ed wounds, u he comp omising he
healing p ocess. An op imal bandage se es o shield he wound om con amina ion and ex e nal
mechanical o ces, manage exuda e, p o ide s uc u al suppo and com o , and c ea e a
mic oen i onmen conduci e o ac i e wound healing (Campell, 2006).
The p ima y laye o he bandage, also known as he con ac laye o d essing, is he ma e ial ha
comes di ec ly in con ac wi h he wound, and hus should be s e ile. This laye se es se e al
oles, including p o ec ion, deb idemen , abso p ion o exuda e, deli e y o opical medica ions
and p omo ion o healing. The quali ies o p ima y d essings a y, wi h occlusi eness and
abso p ion being wo o he mos impo an .
We - o-d y and d y- o-d y bandages ha e always been used o deb iding wounds. The we - o-d y
echnique in ol es mois ening a gauze wi h s e ile saline (0.9% NaCl) o lac a ed Ringe solu ion
be o e applying i o wounds wi h iscous exuda e o nec o ic issues. The exuda e is hen dilu ed
and abso bed in o he ou e bandage laye , he luid e apo a es and he bandage d ies and adhe es
o he wound. The d y- o-d y app oach in ol es applying d y gauze o wounds wi h low- iscosi y
21
exuda e, whe e he exuda e is abso bed, e apo a es om he ou e bandage laye s and he d essing
d ies and adhe es o he wound (Campell, 2006).
Al hough e icien in elimina ing nec o ic issue, we - o-d y and d y- o-d y bandages ha e se e al
disad an ages: bo h heal hy and unheal hy issue could adhe e o he gauze and be emo ed wi h
he d essing; a d y en i onmen does no suppo he cells o p o eases in ol ed in cleanup and
epai o he wound; bac e ia can pene a e mois ened gauze mo e easily han occlusi e d essings,
hus inc easing he isk o in ec ion; and ibe s o m he adhe ed gauze may emain in he wound
bed and ac as a nidus o in lamma ion.
Fo all hese easons, we - o-d y and d y- o-d y bandages a e no longe conside ed he s anda d o
ca e in human medicine, and hei use should be limi ed in e e ina y medicine (Campell, 2006).
The second laye o a bandage se es as he bulk o abso p i e componen , commonly comp ising
olled co on, cas padding, abso p i e combina ion pads, gauze pads and oll gauze. In cases o
wounds wi h copious discha ge, his laye acili a es he wicking and e en ion o luids om he
wound su ace. The abili y o his in e media e laye o e ain mois u e hinges on he olume o
luid eleased om he wound, he d essing’s abso p i e p ope ies and he a e a which mois u e
e apo a es h ough he ou e w ap (Pa le ic, 2018).
To cons uc he seconda y laye , co on padding is o e lapped by 50% o p o ide an o de ly, mo e
uni o mly hick suppo i e laye , om a dis al o p oximal di ec ion. Tape s i ups and padding
a ound p essu e poin s a e commonly applied p io o applica ion o he second laye . Following
one o wo ounds o co on padding, sel -adhe en gauze is used o s abilize he co on laye be o e
adding mo e laye s o co on o gauze. The inal ou e co e o gauze p epa es he bandage o he
e ia y laye , p o iding uni o m comp ession, enhancing s abili y and minimizing he isk o he
bandage being oo igh . A hicke seconda y laye can educe he isk o ci cula o y comp omise
ha may occu i he ou e elas ic co e is applied wi h mode a e ension (Pa le ic, 2018).
The ou e o e ia y laye unc ions as he secu ing componen o he bandaged inne laye . Mos
e ia y w aps a e sel -adhe en due o hei ex u e and sligh ly acky su ace. Howe e , applying
excessi e elas ic ension, especially on bandages co e ing he ex emi ies wi h a hin seconda y
laye , can jeopa dize ci cula ion (Pa le ic, 2018).
Bandages can shi o slip as a esul o a numbe o ac o s, including he con ou o he body
egion bandages, he lack o a ic ional body su ace o esis slippage, he no mal e ec s o
g a i y and body mo ion, and subsequen s e ching and loosening o he bandage laye s.
22
The ie-o e d essing echnique is employed o secu e bandages in a eas whe e con en ional w aps
a e less e ec i e, such as he unk, head o neck. This me hod in ol es placing 2-0 mono ilamen
su u e loops in he skin su ounding he wound, app oxima ely 2-3 cm om he wound’s edge.
A e posi ioning he d essing on he wound su ace, he su u e is laced be ween opposing loops
in a c issc oss pa e n, e ec i ely immobilizing he wound wi hou es ic ing nea by mo emen
(Pa le ic, 2018).
3.4 Flap Classi ica ion
3.4.1 Tension- elie ing Techniques and Local Flaps
Skin de ec s seen in small animals ypically esul om auma ic inju ies o su gical emo al o
diseased issue. In ca s and dogs he na u al elas ici y o he skin, along wi h he p esence o loose
skin in many a eas o he body, o en allows o p ima y wound closu e; howe e , in some cases
i is necessa y o seek o ension- elie ing echniques o o use skin laps o achie e a ension- ee
closu e and minimize he isk o complica ions du ing healing. Excessi e ension can lead o
dehiscence by ea ing su u es o dis up ing he blood supply o he skin; his issue is pa icula ly
p onounced in highly mobile a eas, such as he join s, whe e mo emen ampli ies he e ec s o
ension. High- ension closu es can also lead o inc eased sca issue o ma ion and g ea e pos -
ope a i e pain (Mayhew, 2017).
To manage skin ension, se e al echniques can be chosen, including skin unde mining,
manipula ing wound geome y, walking su u es, c ea ing elaxing incisions, skin expande s,
incisional ‘plas y’ echniques (such as he Z-plas y o he V-Y plas y) (Mayhew, 2017).
Su geons should also ca e ully conside he di ec ion o incisions, ideally aligning hem pa allel
o he lines o skin ension o minimize s ess. Addi ionally, he closu e echnique should be
planned o a oid o educe he o ma ion o “dog ea s”, o pucke s, a he ends o he su u e line
(Hedlund, 2006).
Unde mining he skin a ound a wound is he simples me hod o elie e ension, allowing he ull
elas ici y o he skin o be used. The skin should be unde mined deep o he panniculus muscle
laye o p ese e he subde mal plexus and di ec cu aneous essels, o in he loose a eola ascia
deep o he de mis i he panniculus muscle is absen . Ele a ed skin should include a po ion o
he supe icial ascia wi h he de mis o p ese e he di ec cu aneous a e ies; i is c ucial o use
a auma ic echniques, such as cu ing wi h a sha p scalpel blade ins ead o scisso s, and a oiding
23
ins umen s ha c ush issue, such as Allis issue o ceps, o a oid inju y o he subde mal plexus
(Hedlund, 2006).
The shape o he wound can also in luence ension a he wound ma gins. Closing ci cula , squa e
o ec angula de ec s h ough simple apposi ion can lead o he o ma ion o “dog ea s”, a e m
ha e e s o an excess olding o ga he ing o skin and a y issue a he end o an incision line,
commonly seen in p ocedu es ha in ol e a signi ican amoun o skin, a o issue. Con e ing
hese shapes in o an ellipse, when possible, can imp o e he cosme ic ou come, hough i equi es
he emo al o mo e skin. Ci cula and squa e wounds can also be closed by c ea ion o a
iangula ing o s a -shaped closu e made up o small laps ha o m as skin is ad anced inwa d
o m he sides o he ci cle; his echnique may educe ension a he ma gins, al hough he cen al
poin may s ill be p one o dehiscence due o limi ed blood supply o esidual ension (Mayhew,
2017).
The walking su u e is a me hod o dis ibu ing ension su u es o e a wide su ace a ea when skin
unde mining and su u e closu e echniques alone a e insu icien o wound apposi ion. Indi idual
“walking” su u es pull he skin owa d he de ec in small inc emen s; mul iple su u es ha e a
cumula i e e ec in main aining he unde mined skin in posi ion as i is ad anced o he cen e o
he de ec (Pa le ic, 2018). This ension- elie ing echnique has se e al disad an ages: excessi e
placemen o su u es mus be a oided o p e en occlusion o he subde mal plexus blood supply
o inad e en liga ion o di ec cu aneous essels. Mo eo e , walking su u es should no be
u ilized alongside axial pa e n laps. Addi ionally, walking su u es may exace ba e wound
in ec ions, as he bac e ial load equi ed o ini ia e in ec ion dec eases as he quan i y o su u e
ma e ial in a wound inc eases; in he e en o in ec ion, walking su u es can also c ea e
compa men s ha obs uc e ec i e d ainage (Mayhew, 2017).
Mul iple punc a e elaxing incisions (Fig. 8), o mesh expansion, in ol e placing s agge ed pa allel
ows o s ab incisions h ough skin su ounding he wound o acili a e ad ancemen o skin
ma gins o e he wound. In essence, his echnique con e s a single la ge wound in o mul iple
small wounds ha heal much mo e apidly by second in en ion. Incisions a e made pa allel o and
app oxima ely 1 o 2 cm om he skin ma gins on bo h sides o he wound, and hey a e
app oxima ely 1 cm in leng h and a e spaced 1 o 2 cm apa . The second ow o elaxing incisions,
i needed, is placed app oxima ely 1 o 2 cm om he i s ow, wi h incisions again pa allel o he
skin ma gins bu s agge ed in posi ion ela i e o hose in he i s ow. S agge ing o elaxing
24
incisions helps o ensu e ascula i y o skin ma gins. A e econs uc ion, con ac d essings and
p o ec i e bandages a e applied un il he expanded punc ua e incisions ha e healed by con ac ion
and epi helializa ion (Fowle , 2006).
Tissue expande s a e in la able de ices ha a e su gically placed nea a wound, o s e ch he skin
o e ime; once he skin has been su icien ly s e ched, he expande s a e emo ed, and he newly
c ea ed loose skin is used o co e he de ec . This me hod is especially use ul in dis al limbs whe e
o he econs uc ion op ions a e limi ed, bu i equi es mul iple su gical p ocedu es (Mayhew,
2017).
Incisional plas y echniques, such as he V-Y and Z-plas y a e use ul o p o iding mode a e
ension elie in cases whe e p ima y closu e is no possible due o excessi e ension, bu aising
a local lap should could be a oided o no possible. (Mayhew, 2017).
A V-Y plas y can be conside ed when a small amoun o elaxa ion is needed. A V-shaped incision
is made adjacen o he wound wi h he poin o he “V” acing away om he wound; a e
unde mining he skin be ween he V and he wound, he p ima y de ec is closed. The “V” incision
is hen su u ed by placing su u es al e na ely back and o h be ween he wo a ms o he V; when
Fig. 8: Mul iple punc a e elaxing incisions, o allow wound closu e.
25
ension begins o de elop in closu e, he emaining a ea is closed o o m he s em o he “Y”
(Fowle , 2006)
In a Z-plas y p ocedu e, wo adjacen equila e al aingula laps a e o med and ansposed o
ex end he leng h o hei long axis, he eby dec easing ension a he p ima y wound si e. This
me hod is designed o achie e a mode a e educ ion in ension; howe e , mul iple Z-plas ies can
be a anged in se ies o inc ease he ex en o ension elie . This echnique is e ec i e only when
he skin a ound he Z can be eadily unde mined and is su icien ly lax; in a eas wi h signi ican
sca issue o ma ion whe e he skin is immobile, ension may no be adequa ely elie ed
(Mayhew, 2017).
3.4.2 Local Flaps
Local subde mal plexus laps a e ypically ha es ed om skin adjacen o he p ima y de ec ; hey
canno be con e ed in o an “island” lap (meaning he base canno be comple ely se e ed) and
gene ally suppo smalle a eas o skin compa ed o axial pa e n laps. Ne e heless, hey a e
among he mos commonly used laps in gene al p ac ice, because o hei simplici y and e sa ili y
(Mayhew, 2017).
Local laps can be classi ied as ad ancemen , o a ional, ansposi ion and in e pola ion laps. This
classi ica ion is based acco ding on hei me hod o ans e ; o example, ad ancemen laps a e
mo ed in a o wa d di ec ion and o a ional laps a e o a ed o pi o ed in o posi ion. Local laps
depend on he subde mal plexus ci cula ion, unless a di ec cu aneous a e y and ein a e included
in he base o he lap (Pa le ic, 2018).
Selec ing he app op ia e lap ype depends on a ious ac o s, bu he simples lap wi h he
highes likelihood o success should always be chosen (Mayhew, 2017). Ideal dono si es ha e
su icien skin o ele a e a lap wi hou c ea ing a seconda y de ec ha is di icul o close, and
dono si es p one o excessi e mo ion and s ess should be a oided whene e possible, as hey a e
suscep ible o wound dehiscence o may impai local mobili y (Pa le ic, 2018).
As a gene al guideline, su geons should design laps wi h a base sligh ly wide han i s body o
a oid unin en ional na owing o he pedicle. Flaps should be sized app op ia ely o co e he
ecipien bed wi hou excessi e ension; in some cases, using wo o mo e small laps may be
p e e able o a single la ge pedicle g a , whe e ci cula ion a he dis al end o he lap migh be
comp omised (Pa le ic, 2018).
32
The do sal b anch o he deep ci cum lex iliac essel is employed in laps o co e ing de ec s in
he caudal ho ax, la e al abdominal wall, ipsila e al lank, la e al lumba a ea, medial o la e al
high, g ea ochan e and pel ic a ea. The en al b anch o he deep ci cum lex iliac a e y
supplies he lank old, u ilized o co e de ec s in he caudola e al abdominal wall, inguinal, pel ic
o sac al de ec s. Bo h he do sal and en al b anches o igina e c anio en al o he wing o he
ilium (Hedlund, 2006). The lank old lap, a mo e limi ed a ia ion o he en al deep ci cum lex
iliac axial pa e n lap, is e ec i ely employed o closing challenging wounds in he inguinal
egion. P ecise lap measu emen is essen ial in his a ea, as excessi e ension du ing dono si e
closu e can esul in es ic ed limb mobili y and inc eased isk o dehiscence (Pa le ic, 2018)-
The genicula axial pa e n lap is supplied by he genicula b anches o he saphenous a e y and
medial saphenous ein. The genicula a e y ex ends c anially o e he medial aspec o he s i le
and e mina es on i s c anio-la e al su ace; his lap is employed o co e de ec s in he p oximal
wo- hi ds o he ibia and has been desc ibed o epai ing de ec s ex ending om he s i le o he
ibio a sal join on bo h he la e al and medial sides o he hindlimb (Obe , e al., 2019).
Fig. 13: Caudal supe icial epigas ic lap, used o close a la ge cu aneous de ec on he high o a
mixed-b eed dog ollowing mas cell umo emo al.
33
The caudal au icula a e y axial pa e n lap, classi ied as a ansposi ion lap, u ilizes he
s e nocleidomas oid b anches o he caudal au icula a e y and ein (Pope, 2006). The inclusion
o hese di ec cu aneous essels enables he cons uc ion o laps longe han con en ional
ansposi ion laps elian on he subde mal plexus. This lap o igina es a he caudal aspec o he
ea and may ex end o he c anial o midscapula egion; howe e , he isk o lap ailu e inc eases
wi h g ea e ex ension owa d he scapula (Pope, 2006). The caudal au icula axial pa e n lap can
be used o econs uc he ea , do sum o he head, o ex end u he os ally o close de ec s
o e lying he o bi al a ea (Pa le ic, 2018).
The la e al caudal a e ies o he ail a e u ilized o econs uc ing de ec s in ol ing he pe ineum
and caudodo sal unk. Addi ionally, he ail skin may se e as a lap o co e ing de ec s on he
hind limb. These la e al caudal essels o igina e om he caudal glu eal a e ies and ha e mul iple
anas omo ic connec ions wi h he medial caudal a e y. The use o his lap necessi a es ampu a ion
o he ail (Hedlund, 2006).
The cu aneous b anch o he supe icial empo al a e y can be de eloped in o an axial pa e n
lap using he skin o e lying he empo al muscle. This lap is pa icula ly sui able o epai ing
acial de ec s wi hin i s a c o o a ion and is mos e ec i e o mid acial de ec s, as la e al acial
de ec s may be closed wi h a simple local lap (ad ancemen o ansposi ion), depending on he
size and loca ion o he wound (Pa le ic, 2018).
The e e se saphenous condui lap, while no a ue axial pa e n lap, is dissec ed and unc ions
simila ly o axial pa e n laps. I s ascula supply o igina es om he medial saphenous essels.
Unlike axial pa e n laps, hese essels do no es ablish a di ec cu aneous ascula supply bu
ins ead gi e ise o nume ous small cu aneous b anches along hei pa hway, se ing as a ascula
condui ha suppo s mul iple small cu aneous angiosomes. This lap is highly e ec i e o
econs uc ing wounds in ol ing he a sus and me a a sus. The p ima y p e equisi es o he
success o his lap a e he absence o auma o he deep ascula s uc u es o he me a a sus and
paw. Typically, a e ial blood low h ough he medial saphenous essels is di ec ed om p oximal
o dis al, wi h enous e u n lowing in he opposi e di ec ion. In he c ea ion o he e e se
saphenous lap, howe e , he medial saphenous a e y and ein a e liga ed a hei poin o o igin
om he emo al a e y and ein; as a esul , blood low h ough hese essels becomes e og ade,
34
acili a ed by colla e al connec ions be ween he saphenous essels and o he a e ies and eins in
he dis al ex emi y, hence he e m e e se saphenous condui lap (Fowle , 2006).
3.4.5 F ee Skin G a s
Skin g a ing is a su gical p ocedu e used o speed up healing in wounds wi h se e e skin
abno mali ies and p oduce bo h unc ional and es he ic esul s. This ea men en ails ans e ing
skin om a dono loca ion o a ecipien si e o u ilizing skin om o he sou ces o p omo e wound
epi helializa ion and con ac ion while sho ening healing ime.
G a s can be classi ied as au og a s, allog a s, o xenog a s. Au og a s a e de i ed om he
same animal, allog a s om o he membe s o he same species, and xenog a s om di e en
species. Au og a s, which en ail ans e ing skin om one pa o he pa ien 's body ( he dono
si e) o he inju ed egion, a e he mos widely used due o hei ease o applica ion and minimal
isk o skin g a ejec ion (Ib ahim, Soliman, Ko b, & Ali, 2020)
Based on ascula supply, g a s a e classi ied in pedicle g a s, which main ain an a ached
ascula supply o he wound, and ee g a s, which lack ascula a achmen s. F ee g a s u he
di ide in o shee o island g a s, including echniques such as pinch, punch and unnel g a ing.
Island g a s p o ide ocal co e age, p omo ing epi helial g ow h om he su ounding edges and
illing in e ening spaces; in con as , shee skin g a s (Fig. 14) o e comp ehensi e de mal
co e age and may in ol e meshing o su gically c ea ed enes a ions (Schumache & Hanselka,
1989).
35
The ecipien wound bed si e may equi e se e al weeks o medical managemen o c ea e an
en i onmen conduci e o g a accep ance. To enhance g a up ake, g anula ion issue should be
e en wi h he su ounding skin o p omo e epi helializa ion and con ac ion. Any suspec ed
in ec ions should be cul u ed o iden i y speci ic bac e ial popula ions, along wi h an imic obial
sensi i i y and speci ici y es ing, as educing he bac e ial load wi h an ibio he apy and co ec
deb idemen o he wound is c i ical o g a success (Pezzani e & Hend ickson, 2021).
G a s can be ha es ed using manual o mo o ized echniques o ensu e uni o m hickness o he
g a ; howe e , manual me hods a e mo e commonly used in e e ina y medicine se ings due o
p ac ical and inancial conside a ions (Williams, Pezzani e, & Hend ickson, 2024).
Pinch g a ing (Fig. 15), he simples echnique, equi es minimal equipmen : a scalpel blade,
humb o ceps and Mayo scisso s. The o ceps a e used o en o he skin, and g a s measu ing
Fig. 14: Mesh skin g a on he hindleg o a dog.
36
8-10 mm in diame e a e excised. Excess subcu aneous issue is immed, and he g a s a e s o ed
in saline-soaked gauze. Small pocke s, app oxima ely 1 cm in diame e , a e c ea ed in he ecipien
bed’s g anula ion issue using a scalpel blade, in o which he g a s a e placed. The g a si e is
co e ed wi h non-adhe en o pe oleum-imp egna ed d essings, ollowed by a p essu e bandage
(Williams, Pezzani e, & Hend ickson, 2024). O e all, pinch g a ing has a 75% success a e, wi h
minimal dono si e de ec s (Schumache & Hanselka, 1989).
Punch g a ing, simila o pinch g a ing, u ilizes addi ional ools, including 6 and 8 mm skin
punches. The 8 mm punch ha es s g a s, including epide mis and de mis, om he dono si e.
A e emo ing subcu aneous issue, he g a s a e placed in saline-soaked gauze. A 6 mm punch
c ea es holes in he g anula ion issue a he wound si e, which a e hen cleaned and illed wi h
skin plugs. The g a si e is d essed as in pinch g a ing (Williams, Pezzani e, & Hend ickson,
2024). This me hod has demons a ed up o a 95% success a e, wi h epi helializa ion occu ing
wi hin 47 days when g a s a e placed a 5-15 mm apa (Schumache & Hanselka, 1989).
Tunnel g a ing includes ex ac ing leng hy s ips o skin om he dono loca ion; hese g a s can
be ull o pa ial hickness, 2-5 mm b oad, and somewha longe han he ecipien wound bed. A
shee skin ansplan is equen ly aken om he dono si e and spli in o s ips o emo e he
unde lying ascia and subcu aneous adipose issue, which imp o es g a iabili y, and he dono
loca ion is hen la gely closed using su u es. Tunnels a e o med in he ecipien g anula ion issue,
a leas one cen ime e apa , and long o ceps a e used o guide he ansplan h ough hese unnels
and secu e i o he su ounding skin; he wound is hen ea ed as di ec ed o pinch and punch
g a ing, and g anula ion issue co e ing he g a s is su gically emo ed in 6-10 days. This
Fig. 15: Pinch g a ing, o aid second in en ion healing in a la ge open wound on he unk o a
mixed-b eed dog. The dono si e (le ) was he skin on he side o he neck, jus c anial o he
de ec . The g a was hen p o ec ed wi h a ie-o e bandage.
37
app oach akes mo e dono issue han pinch o punch g a ing and has an 80% success a e,
making i app op ia e o di icul - o-bandage loca ions, such as highly mobile egions
(Kalamano a, Ande son, Cus , & Ful on, 2020).
Skin g a healing occu s in ou main s ages: adhesion, plasma ic imbibi ion, e ascula iza ion,
and o ganiza ion (Hend ickson, 2021). In he adhesion s age, ib in o ms be ween he g a and
he wound bed wi hin hou s o placemen , so i is impo an o minimize any gap o a oid
complica ions. Ano he ac o leading o g a ailu e is mo emen , so bandaging and immobilizing
he a ea is ad ised o minimize he isk o complica ions. Plasma ic imbibi ion occu s du ing day
1-4 ollowing g a ing when nu i ion and oxygen o suppo he g a comes om he ib in clo
su ounding he g a . Re ascula isa ion occu s du ing days 3-7 ia inoscula ion and capilla y buds
om he ecipien bed pene a ing in o p eexis ing essels o he g a . Then he o ganiza ion phase
occu s, when he o iginal ib in clo is eplaced by ib ous issue as he g a is ancho ed in place
pe manen ly. A p ope a achmen be ween he ecipien bed and he g a occu s wi hin 9 days
(Hend ickson, 2021). The key o ensu e a success ul healing and g a e en ion is pos ope a i e
managemen in each o hese c i ical s ages; in pa icula , i is ad ised o lea e he i s bandage
change, o minimize he isk o g a dislodgemen . In egions whe e bandaging is di icul , ie-
o e bandages may be conside ed (Williams, Pezzani e, & Hend ickson, 2024).
38
4. PARTE SPECIALE
4.1 Ma e ials and Me hods
Medical eco ds o 28 pa ien s (23 dogs and 5 ca s) ha unde wen econs uc ion o ex ensi e
skin de ec s a he Ve e ina y Teaching Hospi al (OVUD) o he Depa men o Ve e ina y
Medical Sciences o Pa ma be ween 2021 and 2024 we e e ie ed and analyzed. Twen y- i e
cases in ol ed su gical excision o malignan umo s wi h wide ma gins, 2 in ol ed he excisions
o benign masses ha did no necessi a e wide ma gins and 1 in ol ed he econs uc ion o a la ge
skin de ec o igina ed om he dehiscence o a su gical wound pe o med a ano he e e ina y
clinic. Da a collec ed included signalmen (age, sex, species, b eed), e iology o he su gical de ec ,
umo ype and loca ion (in case o umo excision), s a us o clinical ma gins (clean o in il a ed
by he umo ), du a ion o pos -ope a i e NSAIDs (Non-S e oidal An i-In lamma o y D ugs)
adminis a ion, inse ion o su gical closed d ains, days o hospi aliza ion and occu ence o pos -
ope a i e complica ions.
All ea men op ions we e ho oughly discussed wi h he owne s p io o su ge y, who we e
in o med ha pa ien s unde going wide neoplas ic excision and possible subsequen second
in en ion healing would equi e p olonged pos -ope a i e ca e, such as equen bandage changes.
The p e-ope a i e ea men plan sugges ed o he owne s in ol ed a comple e blood coun (CBC),
a biochemical panel o assess hepa ic and enal unc ion, ine-needle aspi a ion (FNA) o he
lesion, s aging wi h 3 iews ho acic adiog aphs and abdominal ul asound o de ec dis an
me as asis, and CT scan when needed o su gical planning; ca diopa hic pa ien s we e also
ad ised o unde go an echoca diog aphy o ensu e ha hey could wi hs and anes hesia.
When majo bleeding du ing su ge y was an icipa ed, a coagula ion panel was also pe o med and
he animal blood- yped.
All eline pa ien s we e equi ed FIV/FeLV sc eening.
The s aging o pa ien s wi h mas cell umo s also included guided FNA o he spleen and li e , o
e alua e me as a ic sp ead, and a CT scan wi h con as medium inocula ion and CT
lymphangiog aphy o sen inel lymph node esea ch.
The incidence o complica ions and clinical ou comes we e e alua ed by clinical examina ion and
documen ed by pic u es o he su gical si e du ing ollow-up appoin men s scheduled acco ding o
he ype o wound, su gical echnique u ilized and healing p ocess.
Pos -ope a i e complica ions eco ded we e: edema, se oma, hema oma, dehiscence (pa ial o
o al) and nec osis (pa ial o o al). Complica ions we e sub-classi ied as mino when hey we e
39
managed conse a i ely, and majo when su gical in e en ion was necessa y acco ding o le
Blanc e al (2000).
The su gical wound was managed ei he wi h bandages o ie-o e d essings and he applica ion
o opical wound ca e p oduc s, o p omo e healing and p o ide p o ec ion. Bandage change
equency was de e mined by wound appea ance and by he condi ion o he bandage, ypically
occu ing e e y 1-3 days un il g anula ion issue o ma ion. Du ing each bandage change, he
wound was i iga ed wi h s e ile saline (0.9% NaCl) solu ion and cleansed wi h gauze swabs.
Ini ial ollow-up appoin men s we e scheduled 5 days a e discha ge, in case o p ima y closu e,
e e y day when an open wound was p esen , and subsequen ly planned acco ding o he wound’s
s a e and e en ual complica ions.
When a close d ain ube was applied du ing su ge y, he animal was hospi alized un il i s emo al.
Eigh p ocedu es (29.6%) we e associa ed wi h an excellen ou come, meaning hey healed
success ully wi hou any complica ions; a good ou come was achie ed in 40% o cases, which
healed well and only p esen ed mino complica ions.
4.2 Resul s
Signalmen
Twen y- h ee dogs and 5 ca s we e included in his s udy.
Dog b eeds included 9 mixed-b eed dogs, 3 Lab ado Re ie e s, 2 Golden Re ie e s, and 1 each
o he ollowing b eeds: Ame ican S a o dshi e Te ie , Be nese Moun ain Dog, Boxe , Cocke
Spaniel, F ench Bulldog, Ge man Shephe d, I alian G eyhound, Pug, whe eas all 5 ca s we e
Domes ic Sho hai ca s. Body weigh anged om 8.5 kg o 43kg (mean 25.17 kg) o dogs and
om 2.5kg o 7 kg (mean 4.86 kg) o ca s. Age a p esen a ion anged om 2 o 14 yea s old
(mean 8.3 yea s old). The s udy included 9 in ac males, 2 cas a ed males, 2 in ac emales and 15
spayed emales.
P esen ing complain
The skin de ec was he esul o umo emo al in 22 dogs and 5 ca s, and o a ch onic open wound
in 1 dog. Tumo s included 16 mas cell umo s (57.1%), 6 so - issue sa comas (21.4%), 2
squamous cell ca cinomas (7.1%), 1 ib osa coma (3.5%) and 1 malignan epi helioma (3.5%); he
benign masses we e 2 in undibula cys s (7.1%). The comple eness o excision was e alua ed
his ologically in all cases; umo excision was classi ied as comple e in all pa ien s excep one, in
he case o a mixed-b eed dog ha p esen ed a la ge (7x7 cm) cu aneous mass on he igh side o
40
he unk, diagnosed as a malignan epi helioma, ha was excised and hen managed as an open
wound.
One dog p esen ed o a la ge skin de ec de i ed om he dehiscence o a su gical wound a e
o eign body emo al.
Fi e pa ien s su e ing om mas cell umo unde wen 2 o 3 ounds o adju an cy o educ i e
chemo he apy be o e he su gical p ocedu e, wi h Vinblas ine a a dose o 2 mg/m² and we e
ope a ed be ween 12 o 15 days (mean 14 days) a e he las ea men .
P eope a i e diagnos ic es s
Cy ology examina ion by FNA was pe o med in e e y pa ien unde going neoplas ic excision,
and 3 o hese pa ien s also unde wen incisional biopsies o con i m h ough his opa hology he
ini ial diagnosis.
Compu ed omog aphy (CT) was pe o med o su gical planning in 17 pa ien s; 11 pa ien s did
no unde go a CT scan because i was deemed no necessa y o su gical planning, bu ecei ed
ei he abdominal ul asounds, 3 iew ho acic adiog aphs o bo h o comple e he oncological he
s aging and ensu e me as asis we e no al eady p esen .
Be o e su ge y, a CBC was pe o med, as well as a biochemical panel including kidney and li e
p o iles; in pa ien s in which enal unc ion was no op imal, a u inalysis was also pe o med, in
o de o accu a ely assess enal unc ion.
Comple e blood coun e ealed abno mali ies in 12 pa ien s (44%): mild anemia in was obse ed
in 5 cases (18.5%), mild leukopenia in 2 (7.4%), mode a e neu ophilic leukocy osis in 3 (11%),
mild neu ophilic leukocy osis in 2 (7.4%), se e e h ombocy openia in 1 (3.7%) and mild
h ombocy openia in 1 (3.7%). The coagula ion p o ile e ealed abno mali ies in 4 pa ien s
(14.8%), wi h 2 o hem p esen ing mildly highe p o h ombin and ac i a ed coagula ion imes,
and 2 pa ien s p esen ing mildly lowe imes. (Willa d & T ed en, 2011).
The biochemical panel e ealed abno mali ies in 11 pa ien s (40.7%): se e ely ele a ed alkaline
phospha ase was no ed in 2 pa ien s (7.4%), mildly ele a ed alkaline phospha ase in 4 (14.8%),
se e ely ele a ed C-Reac i e P o ein (CRP) in 2 (7.4%), se e ely ele a ed ansaminases in 1
(3.7%) and mildly ele a ed ansaminases in 1 (3.7%) (Oikonomidis & Milne, 2023); 2 pa ien s
we e diagnosed wi h Ch onic Kidney Disease (CKD). One ca p esen ed hype glycemia, bu
diabe es melli us was excluded, and a s ess o igin was suspec ed. One pa ien was diagnosed wi h
Cushing’s disease be o e he e ision su ge y.
The day o he p ocedu e blood gasses analysis and mic ohema oc i we e conduc ed o all
pa ien s.
41
Su gical p ocedu e
All pa ien s we e adminis e ed p ophylac ic cephazolin (22 mg/kg, IV) 30 minu es p io o su ge y,
and he adminis a ion was epea ed e e y 90 o su ge y; cephazolin was also adminis e ed un il
24 hou s pos -ope a i ely in all animals.
Pa ien s we e anes he ized, and he a ec ed a ea o he body was widely clipped, bo h a he
su gical si e and dono si e, in case a econs uc i e echnique was planned, and p epa ed o
asep ic su ge y. Depending on he loca ion o he lesion, hen mo ed o he ope a ing oom and
while he pa ien was app op ia ely posi ioned on he ope a ing able.
Malignan umo s we e excised wi h a la e al ma gin o 1 o 3 cm (median 2 cm), and a dep h o
1 ascial plane, while benignan masses we e excised wi h a la e al ma gin o 0.5 o 1 cm, assu ing
o emo e he mac oscopically abno mal issue.
The excision was pe o med using a combina ion o sha p and blun dissec ion and elec ocau e y,
wi h hemos asis also achie ed ia elec ocau e y.
Recons uc ion o he su gical wounds was achie ed using a ious lap echniques: 13 local laps
(5 ad ancemen laps, 4 o a ion laps and 4 ansposi ion laps, wi h no in e pola ion laps
u ilized), 14 axial pa e n laps (1 ho acodo sal lap, 2 supe icial b achial laps, 2 caudal
supe icial epigas ic laps, 3 lank old laps, 1 genicula lap, 2 caudal au icula laps, 1 angula is
o is and 2 supe icial empo al laps) and 1 skin g a . One la ge umo was excised and le o heal
by second in en ion, using ension- elie ing echniques o b ing he wound ma gins owa ds he
cen e o he de ec .
In aope a i e complica ions eco ded we e 1 case o anaphylaxis due o me hylene blue
inocula ion ( o sen inel lymph node iden i ica ion) and 1 case o hypo ension due o p o use
bleeding, as a consequence o he excision o a e y la ge mass (7x7 cm), diagnosed as a malignan
epi helioma, on he le side o he unk.
The majo i y (89%) o he pa ien s we e hospi alized o 1 o 3 days (mean 1.7 days) ollowing he
su ge y, in o de o ecei e app op ia e pain managemen and moni o ing.
48
meaning ha neoplas ic de elopmen may s ill occu on he mamma y glands o pseudop egnancy
may de elop, and o his eason o a iohys e ec omy should be conside ed i no al eady
pe o med.
The only skin g a p ocedu e pe o med (case n. 28), in ended o close a wound on a dog o elimb,
esul ed in dehiscence and equi ed a second su gical p ocedu e, despi e p ope ha es ing and
co ec pos -ope a i e managemen . Po en ial causes o jus i y his g a ailu e may include
excessi e ension, inadequa e g a adhe ence o he ecipien bed and insu icien immobiliza ion.
The key poin s o lap su i al a e minimizing ension and ensu ing adequa e blood supply; any
dis u bance o hese wo ac o s can lead o complica ions.
When planning a su ge y in ol ing la ge skin de ec s closu e, ension o he su gical b each can
be educed by aligning he su u e lines pa allel o he skin ension lines; ension- elie ing
echniques, such as unde mining, elaxing incisions, and ension- elie ing su u es can also be
employed o educe ension o closu e. Howe e , ca e mus be aken in applying hese me hods,
and ension- elie ing su u es such as in e up ed ho izon al ma ess su u es in pa icula , as hey
end o obs uc capilla y blood low ha can lead o nec osis. The ension a he closu e si e can
be a ec ed by he ana omical loca ion o he wound: his is pa icula ly ue o wounds in close
p oximi y o join , since a icula mo emen can inc ease s ain on he su u e lines.
Addi ionally, he choice o su u e pa e n can a ec wound ension, he e o e clinical judgmen is
equi ed o selec a mono ilamen ma e ial o a su icien size o su u e he wound wi hou
auma izing he skin. Fo example, in sensible a eas, good ension dis ibu ion is ob ained by
in ol ing plas ic ubing bol e s in kno s.
A po en ial complica ion ollowing he closu e o la ge cu aneous wounds is he de elopmen o
dead space leading o se omas o hema omas when comple e hemos asis is no achie ed o he
animal eco e s om anes hesia oo quickly and oo anxiously. To p e en his, ac i e d ains such
as Jackson P a d ains, can be used, since hey pull se ous luid om he dead space, p omo ing
adhesion o he lap. Se oma and hema oma a e gene ally mino complica ions ha usually do no
equi e su gical e ision o he wound, howe e he luid buil -up can inc ease ension o he su u e
lines and cause discom o o he pa ien , heigh ening he chance o dehiscence and sel - auma.
In his s udy 8 Jackson P a d ains we e placed, none heless 2 o hese pa ien s de eloped se oma
which was ea ed conse a i ely; his complica ion may ha e been due o inco ec d ain
placemen o i s mal unc ion, o because he d ain was emo ed oo ea ly, while excessi e
49
in lamma o y luid was s ill being p oduced. Ensu ing p ope hemos asis and d ainage o he
wound a e always indica ed o a oid pos -ope a i e complica ions, since luid buil -up no only
pu s ension on he su u e lines, bu also c ea es and en i onmen conduci e o in ec ion.
Excessi e ension is he mos common cause o lap dehiscence. Since dehiscence is he main
complica ion leading o lap ailu e, he su geon mus ake e e y p ecau ion o educe closu e si e
ension; his includes assessing he p esence o adequa e loose skin be o e su ge y, using ension-
elie ing echniques when needed du ing su ge y, applying bandages and splin s o educe mo ion
in he pos -ope a i e pe iod and e en lea ing a pa o he wound open o heal by second in en ion
i necessa y. Also, when a emp ing o close a ch onic wound o e ise a ailed lap, non- iable
issue mus be iden i ied and emo ed be o e closu e.
Fig. 17: Se oma o ma ion o a dog’s elbow ollowing a ho acodo sal axial
pa e n lap p ocedu e; dis al lap nec osis can also be seen.
50
To p e en nec osis, he ascula u e o he lap, including he di ec cu aneous essels and he
subde mal plexus, mus be ca e ully p ese ed; his equi es ha issues be handled delica ely
du ing su ge y and adequa ely p o ec ed in he pos -ope a i e pe iod, a oiding igh bandages ha
could limi he ci cula ion o he lap. In local lap p ocedu es, o p e en his complica ion om
happening he base o he lap should be wide han i s ip, and he ex emi ies o he lap should
be ounded, a oiding sha p angles.
No ably, none o he 5 ca s included in he s udy de eloped majo complica ions; his is uncommon
in e e ina y econs uc i e su ge y, gi en he ac ha many di ec cu aneous a e ies ha e been
mapped in dogs, bu only a ew laps – such as he ho acodo sal, caudal supe icial epigas ic,
Fig. 18: Nec osis and dehiscence o a caudal au icula axial pa e n lap,
pe o med o econs uc a la ge cu aneous de ec a e mas cell umo
excision.
51
e e se saphenous condui , supe icial empo al and caudal au icula - ha e been desc ibed in ca s
(Moo es, 2009). This highligh s he need o cau ion when using canine da a o aising laps in
ca s, due o di e ences in he amoun o skin ha can be aised and in lap co e age. The success
obse ed in his s udy sugges s ha esul s like his can be achie ed by ex ensi e knowledge o
su gical echnique and di e ences in wound healing be ween species, mo eo e , he high elas ici y
o he eline skin compa ed o dogs may help in achie ing wound closu e wi hou ension.
In ec ion is a common complica ion (16-60% acco ding Pa le ic, 1981) epo ed in he e e ina y
li e a u e abou econs uc i e su ge y; howe e , in his s udy i was only obse ed in wo pa ien s
(7%) (cases n. 2 and case n. 15), in bo h o which mic obial cul u es e ealed he p esence o mul i-
esis an bac e ia ha we e ea ed acco ding o he cul u e and sensi i i y es s esul s. Bo h o
hese pa ien s we e managed as an open wound, healing by second in en ion, wi hou de eloping
u he in ec ion.
Su gical si e in ec ions usually p esen as se osanguinous o pu ulen discha ge om he wound.
Discha ge was no ed in one case (case n. 12) and his inding was ollowed by a single cou se o
an imic obials o ea men wi hou p e ious cul u e and sensi i i y es , he e o e, al hough he
wound healed une en ully, he ac ual p esence o an in ec ion could no be p o ed. Fu he mo e,
discha ge may be no ed wi hou an unde lying in ec ion and can be a ibu able o he
in lamma o y and deb idemen phases o wound healing, since in bo h o hem he p esence
se osangiunous in lamma o y exuda e can be expec ed. The e o e i is essen ial o co ec ly
in e p e he cause o discha ge o a oid imp ope use o an imic obials. The lowe in ec ion a e
epo ed in his s udy, compa ed wi h he li e a u e (Pa le ic, 2018; Moo es, 2009; Nelson, 2011)
may be a ibu ed o op imal su gical s anda ds o s e ili y, he adminis a ion o p ophylac ic
Ce azolin in he pe i-ope a i e pe iod, and he opical use o an imic obial c eams con aining
Chlo amphenicol and collagenase in he managemen o open wounds.
Howe e , hese indings may be biased due o he ac ha he majo i y (96.5%) o he
econs uc i e su ge ies in ol ed in his s udy a e su gical cu aneous econs uc ions ollowing
umo excision, meaning ha he wound unde going econs uc ion was su gically c ea ed,
he e o e clean and s e ile. In ec ion a es could be way highe i con amina ed o ch onic wounds
we e pa o he s udy, which happened only in case n. 15: hese con amina ed o in ec ed wounds
should be managed by delayed closu e, meaning ha hey should be ea ed as an open wound
un il a heal hy g anula ion bed can be obse ed, and con amina ion is esol ed.
52
Fi e pa ien s (cases n. 5, 9, 10, 21, 28) su e ing om mas cell umo unde wen 2 o 3 sessions
o adju an chemo he apy p io o he su gical p ocedu e, ecei ing a dose o 2 mg/m² o
Vinblas ine o educe he umo size in o de o acili a e skin econs uc ion. O hese pa ien s,
ou (80%) de eloped pos -ope a i e complica ions, wi h he mos common being dehiscence (2
cases o pa ial dehiscence and 2 o o al dehiscence); wo o hese pa ien s (40%) (case n. 21 and
n. 28) equi ed su gical e ision, and hei healing imes (72 and 124 days) we e some o he
longes eco ded in his s udy. This may sugges ha chemo he apy can cause delays in wound
healing and likely a ec s wound s eng h (Co nell & Wal e s, 1995). Anyways, his is no only
due o he e ec o chemo he apeu ic d ugs on apidly di iding cells, bu also o he
immunode iciency ha can occu in oncologic pa ien s unde going chemo he apy, ha can lead o
being mo e exposed o pos -ope a i e in ec ions. Howe e , cy o educ i e chemo he apy may be
ex emely bene icial o hose pa ien s wi h la ge neoplasm, whose excision would o he wise lead
o mo e ex ensi e econs uc i e su ge y. The iming o adminis a ion, mechanism o ac ion and
dose o he d ug a e ac o s ha a ec wound healing, so ex ensi e knowledge o chemo he apeu ic
d ugs is impo an in o de o co ec ly adminis e hem wi hou inc easing he isk o
complica ions. In hese cases, he delay in wound healing may also be ela ed o he ac ha mas
cell umo s may a ec he healing p ocess due o he elease o his amine and hepa in om hei
cy oplasmic g anules. This sugges s ha he adminis a ion o his amine blocke s be o e su ge y
may be help ul in lowe ing he isk o healing complica ions, al hough he e is no published da a.
Suppo ing his heo y, one o he i e dogs (case n. 21) men ioned p e iously expe ienced
pe iope a i e anaphylac ic shock due o he mas cell umo deg anula ion, and la e de eloped
o al dehiscence o he lap, leading o he need o su gical e ision. Howe e , his co ela ion is
based on a small sample size, and a la ge numbe o cases would be needed o p ope ly suppo
his heo y.
Chemo he apy may also induce immunode iciency, and ha could cause complica ions in wound
healing; simila ly, immunocomp omised ca s wi h FIV (Feline Immunode iciency Vi us) o FeLV
(Feline Leukemia Vi us) may also no ep esen ideal candida es o econs uc i e p ocedu es.
O he 3 non-oncologic pa ien s, only 1 (case n. 15) de eloped complica ions, a case o pa ial
dehiscence and pa ial nec osis ha did no equi e addi ional su ge y and was ea ed medically.
While hese esul s may lead us o belie e ha non-oncologic pa ien s ha e be e o e all su gical
ou comes, i mus be emembe ed ha neoplas ic excision was he main eason o skin
econs uc ion in his s udy, so esul s may be biased due o he lack o su icien cases o suppo
his heo y.
53
In his s udy, a pa ien (case n. 22) unde going econs uc i e su ge y ollowing a so - issue
sa coma emo al expe ienced bo h mino and majo complica ions, leading o he need o h ee
su gical e isions o he lap. Each ime, dehiscence occu ed in he pos -ope a i e pe iod, and
o he complica ions associa ed we e edema, se oma o ma ion and nec osis; he lap ul ima ely
healed by second in en ion a e almos h ee mon hs o ca e. I was la ely disco e ed ha his
pa ien su e s om hype ad enoco icisms, he e o e he delayed wound healing may be a ibu ed
o excessi e co icos e oids p oduced by he ad enal glands; his could no ha e been obse ed
be o e su ge y, since no biochemical al e a ions associa ed wi h Cushing’s synd ome (such as
inc eased alkaline phospha ase and ansaminases) we e p esen . This obse a ion highligh s how
unde lying me abolic diseases such as Cushing’s synd ome a ec wound healing, bu also how
co icos e oids can be de imen al o he healing p ocess. Pa ien s wi h CKD, diabe e melli us and
hypo hy oidism could also ake longe o heal. The e o e, a comple e ho ough p eope a i e
examina ion o he pa ien should always be pe o med.
This inding suppo s he p inciple ha a comple e blood coun (CBC) and biochemical panel
should be manda o y o e e y pa ien be o e su ge y, in o de o o esee possible complica ions,
wa n he owne abou he addi ional isks o lap ailu e and begin medical ea men . Condi ions
commonly diagnosed h ough CBC and biochemical panels ha could lead o complica ions in
wound healing include anemia, h ombocy openia, leukopenia, coagula i e diso de s and ch onic
in lamma ion. Malnu i ion can also lead o di icul ies in wound healing, especially when lacking
p o eins o an adequa e calo ic in ake.
Finally, ano he impo an ac o in wound healing ha is o en o e looked is owne compliance.
Owne s mus be ully in o med abou he isks associa ed wi h hese p ocedu es and he need o
equen ollow-up appoin men s; hey should also always be educa ed on how o p ope ly manage
hei pe in he pos -ope a i e pe iod, and he impo ance o keeping hei pe on s ic es and in
a sa e and clean en i onmen . The impo ance o keeping an Elizabe han colla on hei pe a all
imes should always be emphasized, as a majo cause o wound dis up ion in e e ina y medicine
is sel auma: i is well known ha su u es can be pain ul o i ch, hus leading animals o bi e,
sc a ch o lick he wound ha could cause e y se e e damage o he a ea. This occu ence
un o una ely happened in one pa ien (case n. 21), leading o a case o o al dehiscence ha
equi ed a second su gical in e en ion ollowed by second in en ion healing o he wound, leading
o he longes eco ded healing ime in his s udy, o 124 days.
This s udy has se e al limi a ions ha should be aken in o conside a ion.
54
Due o i s e ospec i e na u e, he comple eness o he da a ob ained and he sample size could
no be con olled: ideally, an equal numbe o dogs and ca s should be included, as well as an
adequa e numbe o cases o e e y ype o p ocedu e.
The p ocedu es we e all conduc ed in he same Ve e ina y Teaching Hospi al by a e y es ic ed
g oup o su geons; hence, a mul i-ins i u ional p ospec i e s udy may be ecommended.
Fu u e s udies should include de ined su gical p o ocols o all ypes o econs uc i e p ocedu e;
i may also be use ul o include he measu emen s o he skin de ec s and laps, as well as eco ding
he measu emen s o he dehiscence a ea o accu a ely es ima e i in pe cen ages.
Ano he no ewo hy limi a ion is o he ac ha mos o he econs uc ions (27 ou o 28) we e
o de ec s c ea ed ollowing umo excision, excluding p ocedu es in ol ing he econs uc ion
o acu e o ch onic wounds, which can in luence he esul s. Open wounds a e gene ally mo e
di icul o clean and p epa e o asep ic su ge y han in ac skin, and ch onic wounds may also
ha e al e ed skin lo a ha could impac on wound healing– his may be he eason why
pos ope a i e in ec ion a es in e e ina y li e a u e a e lowe han hose eco ded in o he s udies.
6. CONCLUSIONS
The o iginal pu pose o his s udy was o e alua e challenges and ou comes associa ed wi h a ious
skin econs uc ion echniques ollowing la ge wounds c ea ion in e e ina y medicine.
I can be concluded ha he simples echniques, such as local laps should always be p e e ed
o e he mo e complex ones, such as axial laps, whene e possible; his is due o lowe
complica ion a es and educed healing ime, pa icula ly o he econs uc ion o smalle de ec s.
Axial laps included in his s udy esul ed in highe complica ion a es, and his con adic s he
da a in e e ina y li e a u e (Moo es, 2009): axial laps usually esul in less complica ions, due o
hei known ascula iza ion. The di e ence in esul s may de i e om he excessi e leng h o he
laps, leading o dis al lap nec osis, and o he ac ha hese econs uc i e p ocedu es usually
a e pe o med o co e mo e ex ensi e de ec s.
The mos commonly encoun e ed complica ion was dehiscence.
In o de o minimize he isk o complica ions, p ope p eope a i e planning and skin mobili y
e alua ion a e c ucial, as well as a co ec su gical echnique and app op ia e haemos asis.
The chances o lap su i al will inc ease i he wound si e and size a e sui able o econs uc ion,
i he wound is nei he con amina ed o in ec ed and i i is no olde han 4–6 hou s. I is also
c i ical ha he ecipien bed o he lap is adequa ely p epa ed. The lap should be examined a
egula in e als ollowing su ge y, o assess wound healing and manage complica ions.
55
Mino complica ions can be ea ed medically, whe eas majo complica ions may equi e su gical
e ision o can heal by second in en ion, o h ough a new econs uc i e and i s in en ion closu e.
Complica ions a e expec ed o occu wi hin 1 week a e su ge y; ne e heless, a good o excellen
ou come appea s possible i he wound is p ope ly managed in he pos -ope a i e pe iod. Owne
compliance is a key ac o in he success o he p ocedu e, and hey should be in o med abou he
p obable need o addi ional isi s and cos s in ol ed wi h ea men o majo complica ions. The
addi ional cos o a e ision su ge y and o he subsequen medica ions should be conside ed,
pa icula ly in cases in which p o ac ed open wound ea men may be necessa y.
To conclude, while cu aneous laps may be c ucial o aid he healing p ocess o la ge skin de ec s,
ecognizing he limi a ions and challenges associa ed wi h each ype o lap will enable su geons
o o esee complica ions, managing he pos -ope a i e pe iod co ec ly and imp o ing he o e all
long- e m success a es.
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