What is the best way to close...

Re: What is the best way to close...

Tim Charlesworth — Wed, 07 Jan 2015 16:30:51 GMT

+ 1 to the above. Really important to let the mass decide the margin. Apologies for not answering the original question before. If the mass is caudal femoral then they can usually be closed simply or with a local flap. If the defect is big then I would use a caudal superficial epigastric axial pattern flap. This is using the artery that supplies the main mammary chain (the one that bleeds lots if you don't tie it off when starting a mammary strip) so the flap pivots from the inguinal canal and can reach and cover medial, caudal and lateral thigh defects. It's a robust flap but it will be a big job so need to make sure resection is curative (would take 3cm laterally and skim some muscle underneath as the flap would comfortably cover this defect). You could potentially use a lateral genicular flap but these are very fragile and often don't work as well as they should. If the owner didn't want a "big" surgery (which is reasonable) then closing the defect as much as possible and leaving a small unsutured wound is perfectly reasonable as long as the owner knows it will take time to heal, as always it is all about client communication. I'd much rather leave a small open wound then knowingly close a very tight wound!

Tim

Re: What is the best way to close...

Miriam Lodewyks — Wed, 07 Jan 2015 15:35:21 GMT

Within reason, margins should not be effected by your ability to close the wound. Hence, PLAN AHEAD.

To do this you do need to know what the mass is and decide what margins you need.

Only then can you get creative with skin. It's wonderful elastic stuff, play with it! and leaving a 1cm open wound in the middle is really no biggy, will heal almost as fast as the sutured margins.

Re: What is the best way to close...

Richard Carter — Wed, 07 Jan 2015 14:02:40 GMT

or leaving an open hole? It does heal in the end, perhaps not so pretty or you can do staged repair when the initial operation has granulated etc

Re: What is the best way to close...

David Mills — Wed, 07 Jan 2015 01:45:41 GMT

[quote user="Andrew Mellor"]

then close without dog ears etc. caudal thigh on a lab will have loads of loose skin and if you are concerned with increased morbidity instil local into the wound bed/ edges.

[/quote]

What's the problem with dog ear(s)?

Re: What is the best way to close...

Andrew Mellor — Tue, 06 Jan 2015 19:23:13 GMT

I know we are way beyond the original post now but why do people do circular incisions? Is this not making life difficult for youerself. Circular Incisions can be closed by many methods such as centripetal closure making the circle a star , or a combined v closure which ends up with a zig zag closure , but far more simple is to elongate the circle into an ellipse or fusiform excision which will then close without dog ears etc. caudal thigh on a lab will have loads of loose skin and if you are concerned with increased morbidity instil local into the wound bed/ edges.

I once walked into our op room and a relatively new grad was stood in tears because she had taken margins as she had been told to do at uni - on a distal limb. only then did she stop and wonder how she was going to close it. I ended up boning out a toe and using this skin to flap back onto the metatarsal area. planning is so important and hence why knowing what your lump is before you excise.

Sorry I am ranting, it has been a long week these last 2 days !

Re: What is the best way to close...

Evelyn Barbour-Hill — Mon, 05 Jan 2015 23:07:29 GMT

[quote user="Busybee"]Unfortunately, the mass had actually grown further since I last saw it last week so was left with quite a skin-deficit laterally as well. Hope my reconstruction heals ok![/quote]

I note that nobody ever answered your original question.

Re: What is the best way to close...

Busybee — Mon, 05 Jan 2015 19:52:48 GMT

Agree with all the above and had discussed these issues at length with the owner. Their thinking was the mass was growing so much, it had to be removed and due to the previous masses and surgeries, it was likely to be a mast cell tumour. I did do a quick pre-op FNA and could see some mast cells so we removed the mass with 2cm margins and thankfully, due to the mass actually being in the subcutis, I was able to excise the adipose tissue deep to it thoroughly too (thankfully for once, the dog was overweight!). The owners had not been too happy about taking a lot of muscle away and would agree to further surgeries if really required so I left the muscle well alone. The dog a 14 year old lab.

Unfortunately, the mass had actually grown further since I last saw it last week so was left with quite a skin-deficit laterally as well. Hope my reconstruction heals ok!

Re: What is the best way to close...

Tim Charlesworth — Mon, 05 Jan 2015 09:01:48 GMT

+ 1 to the last post. You could just take a preop FNA - if it's full of mast cells then fair enough excise it (you only need 2cm not 3cm laterally but make sure you take adequate deep margin). Just explain to the owner that you need a diagnosis before you can give the best advice about how to treat it as otherwise you risk significantly increasing patient morbidity,

Best of luck,

Tim

Re: What is the best way to close...

Tim Charlesworth — Mon, 05 Jan 2015 09:01:48 GMT

Best of luck,

Tim

Re: What is the best way to close...

Braden Collins — Mon, 05 Jan 2015 02:05:06 GMT

Has it had at least a FNA to check for mast cells? How big is the mass? A 1 inchdefect would indicate maximum margins of 1.25cm (if the mass had no size so in reality will struggle to be 1cm margins).

The concern I always have with doing this sort of surgery without an accurate diagnosis is that if the mass is benign you've done a bigger surgey than needed with the associated increase in pain and recovery time, where as if the mass is malignant you will have achieved insufficient margins and your revision surgery will need to be much more complicated, expensive and "bigger" as your new margins will be from the margins of the prefious surgery, including deep. I would seriously talk to the client about what you're trying to achieve here. If they won't biopsy but will consider a revision surgery if malignant, I would do a marginal resection. that way if it's benign you've cured it, and if it's malignant you at least have made less of a dogs breakfast of it.