Options available for closing this skin deficit?

Re: Options available for closing this skin deficit?

Glenn Hodgson — Thu, 09 Apr 2015 23:45:46 GMT

Woops, wrong skin defect thread.... Should really pay more attention to the Internet...

Re: Options available for closing this skin deficit?

listhestar — Thu, 09 Apr 2015 12:01:53 GMT

Looks good. I am glad to know I am not the only one with lots of wound photos on their phone... 'one I prepared earlier anyone '

Lisa

Re: Options available for closing this skin deficit?

Hannah Wynne Richards — Thu, 09 Apr 2015 11:52:11 GMT

Well done. Looks great.

Wynne

Re: Options available for closing this skin deficit?

Glenn Hodgson — Thu, 09 Apr 2015 11:28:32 GMT

This has healed a treat, thank you for asking.

Took 3 months but worth the effort.

In the end it was vetericyn that made the difference. Mamuka and silver gels did not seem to help, but were in the face of the infection. Seemed to make it too wet and over granulate.

See images for interests sake.

JAGER DICKER – WOUND MANAGEMENT

20/12/15

02/01/15

14/01/15

21/01/15

02/02/15

02/03/15

03/03/15

06/03/15

09/03/15

Measuring: 9.5 height, 3cm wide

11/03/15

Measuring: 8cm height, 1.5cm wide

20/03/15

Measuring W 1.5cm x L 7.5cm

23/03/15

Re: Options available for closing this skin deficit?

Glenn Hodgson — Thu, 09 Apr 2015 11:28:31 GMT

This has healed a treat, thank you for asking.

Took 3 months but worth the effort.

In the end it was vetericyn that made the difference. Mamuka and silver gels did not seem to help, but were in the face of the infection. Seemed to make it too wet and over granulate.

See images for interests sake.

JAGER DICKER – WOUND MANAGEMENT

20/12/15

02/01/15

14/01/15

21/01/15

02/02/15

02/03/15

03/03/15

06/03/15

09/03/15

Measuring: 9.5 height, 3cm wide

11/03/15

Measuring: 8cm height, 1.5cm wide

20/03/15

Measuring W 1.5cm x L 7.5cm

23/03/15

Re: Options available for closing this skin deficit?

listhestar — Thu, 09 Apr 2015 10:46:24 GMT

[quote user="Hannah Wynne Richards"]Thanks to all, esp Listhestar, Yantha, and Tim[/quote]

Welcome, what happened in the end?

Lisa

Re: Options available for closing this skin deficit?

Hannah Wynne Richards — Wed, 14 Jan 2015 14:27:47 GMT

The 1sy op (6 weeks ago) has healed well,and deruced the size of the deficit, so (being a cowardly surgeon) I've decided on 2 further stages. I've blunt-dissected a triangular area on the lateral surface, freshened the edges, and mattress sutured down to the axilla.If this does well, I'll repeat on the medial surface in another 6 weeks. In the mean time, there's healthy granulation tissue, and I'll keep on manuka, antibiosis and metacam.

Thanks to all, esp Listhestar, Yantha, and Tim

Wynne

Re: Options available for closing this skin deficit?

Hannah Wynne Richards — Wed, 14 Jan 2015 09:22:27 GMT

Thanks I'll let you know in aprox 10 days if my results are as good as C H Brinkley's.

Wynne

Re: Options available for closing this skin deficit?

Tim Charlesworth — Wed, 14 Jan 2015 09:16:16 GMT

The axillary skin fold flaps (what they're normally called aot "elbow skin fold" or "bingo wing flap") are less risky than thoracodorsal APF's, just treat it as any "random" skin flap. Best of luck - always good to have diagrams!

Tim

Re: Options available for closing this skin deficit?

Hannah Wynne Richards — Wed, 14 Jan 2015 09:00:25 GMT

Thamks. Yantha has just emailed me a paper JSAP C H Brinkley.It doesn't involve omentum, so I think I'll try that. - and it has DIAGRAMS.

Wynne

Re: Options available for closing this skin deficit?

listhestar — Tue, 13 Jan 2015 19:56:54 GMT

[quote user="Hannah Wynne Richards"]

I've alsodug out some printed notes from a BSAVA course I went on in Nov 2006 "Wounds that make your skin crawl" No peinted diagrams,and I didn't draw any, so I'm none the wiser.

Wynne

[/quote]

Hi Wynne

I've found a paper, unsure how to get it to attach. Blasted thing. Not sure if it would be any use?

Lascelles, B. D. X., & White, R. A. (2001). Combined omental pedicle grafts and thoracodorsal axial pattern flaps for the reconstruction of chronic, nonhealing axillary wounds in cats. Veterinary Surgery, 30(4), 380-385.

That's the reference but it will not upload as a pdf onto here for me for some reason

Lisa

Re: Options available for closing this skin deficit?

Hannah Wynne Richards — Tue, 13 Jan 2015 17:07:54 GMT

I've alsodug out some printed notes from a BSAVA course I went on in Nov 2006 "Wounds that make your skin crawl" No peinted diagrams,and I didn't draw any, so I'm none the wiser.

Wynne

Re: Options available for closing this skin deficit?

Hannah Wynne Richards — Tue, 13 Jan 2015 16:46:46 GMT

Help I've forgotten how to start a private convesation - and I'm really not sure how to make the flap. I've tried Sissons, but beyond the fact that the thoraco dorsal artery follows the latissmus dorsi and teres major, I really can't visualise it. Where does it come from? Where do I incise for the flap? I'm tempted to just undermine the edges, close the wound a bit more, and put stay sutures, keep on oral metacam and manuka, and re-op to close a bit more in 6 weeks. I just wish I could refer, but that's a non-starter with this one

Wynne

Re: Options available for closing this skin deficit?

Hannah Wynne Richards — Tue, 13 Jan 2015 16:38:43 GMT

I will

Wynne

Re: Options available for closing this skin deficit?

Tim Charlesworth — Tue, 13 Jan 2015 15:55:16 GMT

Dear Anon,

I think most of the suggestions seem reasonable. Cats are slower to heal than dogs so although leaving to 2nd intention (esp when funds low etc) is reasonable, it will take quite some time. Flushing/debriding the wound to get it nice and clean would be the first step whatever you decide. Re skin stretching - its hard to get this to work properly, don't order in Pav's kit as you can get the same equipment from Hobbycraft for a few pounds. Use adhesive velcro pads if you want to try this (in fact message me if possible and I'll talk you through what to buy/how to do it). If you want to do something fancy then I would do bilateral inguinal skin fold advancement. The abstract for the dog technique is:

http://www.ncbi.nlm.nih.gov/pubmed/21495989

but the same landmarks etc should be applicable to the cat. You'll need the full article which has some easy to follow and relevant diagrams but you'll need Wiley access to get it.

Wrt primary or secondary (leaving the gran bed intact) closure - I'd leave the gran bed if healthy and close over it, it will be q exudative so you will need to put a drain in. I would not graft and I'm not a fan of stent sutures but they have their place. If you undermine lots you may even be able to close this simply as it's not any bigger than the average injection site sarcoma resection which is usually closed as a simple midline scar.

Re the axillary wound - thoracodorsal APF's are v good for these but they can be unforgiving. If you don't preserve the nutrient artery (thoracodorsal) then the flap will fail and this can be catastrophic so take your time, use drains. Don't bandage it, don't try to "tack it down" and ensure you maintain BP with IVFT at surgical rates. Omentalisation works but I've not had a problem in cases that I haven't omentalised.

Sorry, don't want to write a whole wound-management chapter here so just message me if you need any help,

Tim

Re: Options available for closing this skin deficit?

Martin Atkinson — Tue, 13 Jan 2015 15:42:04 GMT

I've used meshes of sterile pig skin (Biosist I believe) before on these albeit not on one this big, and they've worked well. You suture them in and they form a scaffold for the epithelium to grow over, but they are expensive. Other than that I feel you are looking at some form of pinch grafting. And of course it goes without saying self mutilation needs to be avoided.

Re: Options available for closing this skin deficit?

Hannah Wynne Richards — Tue, 13 Jan 2015 15:32:47 GMT

Thanks John. It's in for further surgery tomorrow.

Wynne

Re: Options available for closing this skin deficit?

Hannah Wynne Richards — Tue, 13 Jan 2015 15:29:31 GMT

Sooner than using lead, I'd prefer a quick release knot - the sort you'ld use to tether a horse for grooming. You could then untie, tighten and retie daily.

Wynne

Re: Options available for closing this skin deficit?

Sammy82 — Tue, 13 Jan 2015 15:24:08 GMT

Sounds like an easy method, my only worry would be the lead. I would be scared of the animal eating the lead, even with a collar as it might fall off and probably being covered in some secretion might smell quiet appetizing for cats and dogs.

Re: Options available for closing this skin deficit?

Will McMullan — Tue, 13 Jan 2015 14:56:46 GMT

A good technique for applying tension to close large defects is using horizontal mattress sutures, with drip line stents about 1cm long on either side of the wound, then use those little lead balls that look like pacman (get them from fishing tackle shops) which you can squeeze to hold the suture in position. The suture will loosen overnight as the skin stretches, and you can loosen the lead ball, move it along the suture material and reapply tension each day. You can achieve quite amazing reduction in defects with this method, and it's much less of a faff than velcro straps.

As an aside, I know axillary wounds can be a nightmare to close, but Pavletic claims to almost never need to omentalise these. His approach is always to deal with the tension, either by closing in multiple layers or with walking sutures etc, or using a flap.

Good luck!

Re: Options available for closing this skin deficit?

Sammy82 — Mon, 12 Jan 2015 20:06:15 GMT

I understand healthy granulation tissue as the body's effort to heal, providing blood supply and healing factors. We use it as a bed for skin transplants, so what's the reason behind removing it for a skin flap or simple skin closure? It seems to make sense to freshen it up and remove dried secretion to avoid closing in bacterial contamination. Obviously overgrowing granulation as you get in horses is a different kettle of fish.

Re: Options available for closing this skin deficit?

Evelyn Barbour-Hill — Mon, 12 Jan 2015 19:43:47 GMT

[quote user="John Flynn"]

[quote user="David Mills"]As an aside, do people routinely close over granulation tissue or resect it before closing? I've seen a variety of approaches with a variety of success/not - and am always undecided. I was always under the impression that the 'purist' way was to resect and then close.[/quote]

I close over.

[/quote]

I'd usually shave off the surface, but not try to resect it all. Perhaps I fell asleep in that lecture, but I never really understood the necessity to cut out all the granulation tissue.

Re: Options available for closing this skin deficit?

John Flynn — Mon, 12 Jan 2015 19:39:29 GMT

I close over.

Re: Options available for closing this skin deficit?

John Flynn — Mon, 12 Jan 2015 19:37:22 GMT

Hi Hannah,

If there's definitely no more healing to be had (can always leave alone and come back to in 6 weeks if not sure), then I'd personally do a thoracodorsal axial pattern flap to give a tension free closure. Quite easy to do in a cat with instructions open in front of you and a little forward planning even if your first time - just make sure skin is in a "neutral" position before starting to cut (pull it up and let it drop down again and make sure not caught under the recumbent surgical patient) and use a sterile surgical pen to draw the vessel and where your cuts will be and measure the legth required using a piece of something non-stretchy like string... and clip double what you reckon you'll need

I've always been concerend at causing peritonitis by stealing some omentum and doing that techniuqe, but I suspect it's a pretty low risk and probably pretty straightforward also.

John.

Re: Options available for closing this skin deficit?

Hannah Wynne Richards — Mon, 12 Jan 2015 10:36:17 GMT

Sorry An On for elbowing my problem in onyours - but they are similar!

Wynne