Skin Fold Advancement Flaps for Closing Large Sternal and Inguinal Wounds in Cats and Dogs

Skin fold advancement flaps can be created from the elbow and flank folds to close large wounds in the pectoral and inguinal regions of cats and dogs, respectively. The attachments of the laterally facing (outer) and medially facing (inner) layers of the skin fold to the adjacent limb are divided to produce a U-shaped pedicle graft attached to the trunk. This mobilizes skin that can be advanced over large wounds involving the ventral chest or abdomen, or both. The use of skin fold advancement flaps enables direct closure of large skin defects without undue tension and without compromising the mobility of the adjacent limb.     

Skin-fold advancement flaps for closing large proximal limb and trunk defects in dogs and cats

OBJECTIVE: To describe the use of skin-fold advancement flaps for covering large skin defects in dogs and cats. STUDY DESIGN: Clinical study. ANIMALS: Eight client-owned animals: 6 dogs and 2 cats. METHODS: Six dogs and 2 cats underwent reconstruction of soft-tissue wounds resulting from traumatic, neoplastic, or infectious lesions. Skin-fold flaps were created by division of the medial and lateral attachment to the proximal limb or the dorsal and ventral attachment to the trunk, enabling closure of adjacent defects on the trunk or proximal limb, respectively. RESULTS: Skin-fold flaps proved effective for closing defects in all animals. Necrosis of a portion of the flap occurred in 2 dogs due to technical errors, but the resultant defects remained amenable to primary closure. All wounds ultimately healed primarily, without major complications. CONCLUSION AND CLINICAL RELEVANCE: The skin-fold advancement flap is a versatile technique that lends itself to use in a variety of locations, depending on which attachments are divided. The clinical results are comparable with those reported for axial pattern and subdermal plexus flaps.     

Clinical evaluation of random skin flaps based on the subdermal plexus secured with sutures or sutures and cyanoacrylate adhesive for reconstructive surgery in dogs

OBJECTIVE: To evaluate the use of subdermal plexus skin flaps for closing defects after excision of cutaneous and subcutaneous tumors in dogs and to compare outcome of flaps secured with sutures and those secured with butyl-cyanoacrylate and intermittent sutures. STUDY DESIGN: Clinical study. ANIMALS: Fifteen dogs. METHODS: After excision of cutaneous or subcutaneous tumors the skin defect was reconstructed by random flaps based on the subdermal plexus. Flap skin edges were apposed with simple interrupted 4-0 monofilament nylon sutures (group 1; 5 dogs) or nylon sutures alternated with butyl-cyanoacrylate adhesive (group 2; 10 dogs). Flaps were evaluated every 48 hours when bandages were changed, until complete healing. RESULTS: Random flaps based on the subdermal plexus were effectively used to close wound defects; mean flap survival was 89%. Partial flap necrosis occurred in 4 dogs. Wound margins apposed with butyl-cyanoacrylate had thinner and more esthetic scars than sutured margins. CONCLUSION: Random flaps based on the subdermal plexus proved to be versatile for covering limb wounds after excision of cutaneous or subcutaneous tumors. Mean survival rate was comparable to that reported for axial pattern flaps. Butyl-cyanoacrylate adhesive was easy to apply, allowed accurate margin apposition with good cosmetic outcome and reduced sutures needed. CLINICAL RELEVANCE: Cyanoacrylate adhesive should be considered in lieu of suture closure to secure random skin flaps based on the subdermal plexus in dogs.     

Use of the scrotum as a transposition flap for closure of surgical wounds in three dogs

OBJECTIVE: To describe use of the scrotum as a pedicle flap to cover defects created by tumor excision in the perineum or caudal and medial aspect of the thigh. STUDY DESIGN: Clinical study. ANIMALS: Three dogs. METHODS: After tumor excision and prescrotal castration, an incision was made around the base of the scrotum, leaving a pedicle on the side opposite the skin defect. After removal of the tunica dartos and abdominal fascia, the scrotal skin was stretched and shaped to the defect, then sutured in position with a simple interrupted pattern. Bandages that were changed every 48 hours compressed the flaps, and healing was observed until sutures were removed. RESULTS: Two dogs had first intention healing in 15 days, whereas 1 dog developed necrosis of 10% of the flap, and this area healed by second intention. CONCLUSION: In male dogs, the scrotal skin can be used as a pedicle flap for reconstructive surgery of wounds in the perineum and the proximomedial and caudal aspect of the thigh. CLINICAL RELEVANCE: The perineal region remains a surgical challenge because of the lack of the available skin for reconstruction of surgical wounds. The scrotal skin should be considered for use as a transposition flap to cover skin defects in this region.     

Large trunk wounds.

Management of large trunk wounds begins with good wound management and bandaging. When a healthy wound bed exists and adequate tissue is present, the wound is closed. Fortunately, there is an abundance of loose trunk skin in most animals, and wound closure can be accomplished by simple reconstructive techniques, such as undermining and tension or "walking sutures." Nevertheless, some wounds and areas of the torso may require more advanced tension-relieving techniques, skin stretching, and tissue implants or flaps to achieve tension-free closure and successful wound healing. Use of these techniques allows wound closure and good cosmetic results for even those wounds that initially may seem foreboding.     

Axial pattern flap based on the lateral caudal arteries of the tail in the dog: an experimental study

OBJECTIVE: To determine applicability and size limits of an axial pattern flap based on the lateral caudal arteries in dogs to reconstruct caudodorsal trunk skin defects. STUDY DESIGN: Experimental study. ANIMALS: Ten mature, mixed breed dogs. METHODS: The lateral caudal vessels of the tail were incorporated in the flaps of the treatment group (n=5) and were ligated in the control group (n=5). Flaps were rotated and placed into experimentally created caudodorsal skin defects on the trunk. The length and area of tissue that remained viable in each flap were determined. RESULTS: Mean (+/-SD) survival area (222.8+/-32.9 cm2) and length (25.1+/-4.5 cm) of vascularized flaps were significantly greater (P<.05) compared with control flaps (94.9+/-13.4 cm2 and 14.61+/-4.7 cm). Necrosis occurred in all control flaps, resulting in lower percentage flap area (48.8%) and length (47.1%) survival compared with vascularized flaps (78.1%, 77.5%). CONCLUSIONS: Axial pattern flap based on lateral caudal arteries of the tail was successfully elevated and transferred in a single procedure, with 78% survival for closure of large experimentally created caudodorsal trunk defects in dogs. CLINICAL RELEVANCE: Large cutaneous defects of the caudodorsal trunk area in dog could be reconstructed with tail axial pattern flap. Limitations in terms of size and changes in animal appearance have to be considered before flap elevation.     

Use of a latissimus dorsi myocutaneous flap for one-stage reconstruction of the thoracic wall after en bloc resection of primary rib chondrosarcoma in five dogs

Objective— To describe a thoracic wall reconstructive technique using a latissimus dorsi myocutaneous flap after en bloc resection of primary rib chondrosarcoma and report outcome in 5 dogs.
Study Design— Retrospective study.
Animals— Dogs (n=5) with primary rib chondrosarcoma.
Methods— Medical records (2003–2005) were reviewed for signalment, staging investigations, surgical findings, complications, and outcomes. Owners and veterinary surgeons were contacted for outcome information.
Results— A latissimus dorsi myocutaneous flap provided an air-tight thoracic wall closure after chondrosarcoma resection. Paradoxical respiratory movement of the flap occurred; however, from physical examination and blood gas analysis (2 dogs), ventilation was adequate. All flaps survived, 1 had superficial skin necrosis distally and 2 had minor wound dehiscence. One dog without tumor-free margins died of tumor-related disease 56 days after surgery. Tumor recurrence did not occur in 4 dogs with tumor-free margins. One dog was euthanatized 10 months after surgery for unrelated disease; 3 dogs were alive at writing (median follow-up: 20 months; range, 18–27 months) and all had a satisfactory functional and cosmetic outcome.
Conclusions— Reconstruction of ventral thoracic wall defects using a latissimus dorsi myocutaneous flap yields a functional, cosmetic outcome.
Clinical Relevance— A latissimus dorsi myocutaneous flap can be used as a successful 1-stage reconstructive technique for ventral thoracic wall defects.     

Surgical treatment of lumbosacral foraminal stenosis using a lateral approach in twenty dogs with degenerative lumbosacral stenosis

Objectives— To describe clinical signs, magnetic resonance imaging (MRI) and surgical findings using a lateral approach to the lumbosacral intervertebral foramen and to evaluate clinical outcomes in dogs with or without concurrent dorsal decompression and annulectomy.
Study Design— Retrospective study.
Animals— Dogs (n=20) with degenerative lumbosacral stenosis (DLSS).
Methods— Medical records (2002–2006) of dogs that had lumbosacral lateral foraminotomy alone or in combination with dorsal decompression were reviewed. Degree of dysfunction was assessed separately for each pelvic limb; dogs with unilateral signs were included in group A, those with bilateral signs in group B. Retrieved data were: signalment, history, neurologic status on admission, 3 days, 6 weeks, and 6 months postoperatively, duration of clinical signs, results of MRI, surgical site(s), intraoperative findings, and outcome.
Results— Based on the clinical and MRI findings unilateral foraminotomy was performed in 8 dogs, bilateral foraminotomy in 1 dog, unilateral foraminotomy with concurrent dorsal decompression in 7 dogs, and bilateral foraminotomy with concomitant dorsal decompression in 4 dogs. Surgery confirmed the presence of foraminal stenosis in all dogs, with osteophyte formation and soft tissue proliferations being the most common lesions. Outcome was good to excellent in 19 dogs and poor in 1 dog. Mean follow-up was 15.2 months (range, 6–42 months).
Conclusion— Lateral foraminotomy addresses compressive lesions within exit and middle zones of the lumbosacral foramen.
Clinical Relevance— Successful surgical management of DLSS is dependent on recognition and correction of each of the compressive lesions within the lumbosacral junction.     

Introduction to myocutaneous and muscle flaps

Myocutaneous and muscle flaps provide an added dimension to reconstructive surgery in small animals. Myocutaneous flaps composed of a muscle unit and the overlying skin can be utilized for skin wound closure, especially when the additional bulk of the transplanted muscle can be utilized for padding or closure of body cavities. Alternatively, muscle units alone can be employed for a variety of conditions, including closure of defects of the thorax and abdominal cavities and management of chronic bone infections. They also facilitate bone healing when delayed unions and nonunions occur. This article discusses the newer myocutaneous flaps and muscle flaps clinically applicable in small animal surgery.     

Distant abdominal and thoracic pedicle skin flaps for treatment of distal limb skin defects

The treatment of large skin defects of the distal limbs of dogs and cats can be difficult due to the lack of skin available for primary wound closure or the creation of local skin flaps. Distant pedicle skin flaps provide an acceptable alternative for wound closure with full thickness skin and provide a cosmetic result. Fourteen animals (10 dogs and four cats) that had distant pedicle skin flaps are reviewed. The technique allowed 100 per cent wound coverage in 10 of 14 animals and greater than 95 per cent skin flap survival occurred in 12 of 14 animals. Complications associated with the procedure were most commonly wound infection and partial suture line dehiscence, however these did not detract from the final outcome. Flap release was in one or two stages, however the outcomes did not appear to be affected by the release protocol.     

Clinical evaluation of axial pattern skin flaps in dogs and cats: 19 cases (1981-1990).

Nineteen axial pattern skin flaps were used in 16 dogs and cats to provide skin for repair of extensive cutaneous defects. Retrospective evaluation of medical records was used to determine percentage flap survival, postoperative complications, and long-term outcome of axial pattern skin flaps. The most common indication for use of axial pattern flaps was to augment wound closure following tumor resection (n = 7). Other indications included trauma (n = 5), chronic nonhealing wounds (n = 4), urine-induced cellulitis (n = 1), idiopathic dermal necrosis (n = 1), and chronic lymphoplasmocytic dermatitis (n = 1). Mean flap survival (+/- SD) was 96% (+/- 8). Postoperative complications included wound drainage (n = 15), partial dehiscence of the sutured flap (n = 7), distal flap necrosis (n = 6), infection (n = 3), edema (n = 3), and seroma formation (n = 2). After a median follow-up time of 5 months, evaluation of animals indicated that surgery provided successful wound reconstruction with good cosmetic results. Reconstruction of large cutaneous defects is facilitated by axial pattern flap application regardless of cause of wound. Postoperative complications are common but amenable to standard wound management techniques such as drain placement and surgical debridement of devitalized distal flap skin.     

Brow suspension for treatment of ptosis and entropion in dogs with redundant facial skin folds

Brow suspension surgery was performed on 7 dogs with redundant facial skin folds, associated ptosis, and entropion. The surgical technique involved subcutaneous placement of polyester mesh strips to suspend the upper eyelid from the dorsal frontalis muscle and the underlying periosteum of the skull. Visual impairment associated with ptosis was resolved in all dogs at the 2 week reevaluation period. Upper eyelid position was maintained in 4 of 7 dogs available for long-term follow-up. One dog developed persistent draining tracts in the region of the implant, and removal of part of the implanted mesh was eventually required. Upper eyelid height in this dog, however, was maintained following mesh removal, probably because of fibrosis around the implant. Brow suspension is an option for surgical management of upper eyelid ptosis and entropion in dogs with redundant skin folds and avoids the need for facial skin fold excision.     

Facial reconstructive surgery

Reconstruction of facial defects can be very challenging, even in the hands of an experienced surgeon. Most defects can be repaired using local available tissues. Lip defects can be reconstructed using geometric closure techniques and advancement of local tissues. Forehead defects can be reconstructed using skin grafts, caudal auricular flaps, or rotational or transposition flaps. Care must be taken to minimize tension on eyelids and maintain the integrity of the facial nerve. Cheek defects can be reconstructed using local advancement, superficial temporal, omocervical, and caudal auricular flaps. The bridge of the nose can be very difficult to reconstruct due to a paucity of local tissues; however, skin grafts, indirect pedicle flaps, and superficial temporal flaps can be considered. .     

Transfer of Free Vascular Cutaneous Flaps by Microvascular Anastomosis Results in Six Dogs

Skin defects on the distal extremities of six dogs were reconstructed with free vascular cutaneous transfers by microvascular anastomosis. The donor flaps were based on the superficial cervical artery and vein. In five of the dogs, bone was exposed and skin was lost from half of the circumference of the limb. Two had infected fractures with sequestra and three had acute shearing injuries. The sixth dog had sensory denervation of the left antebrachium and a carpal acral lick granuloma. Before surgery, the patency of potential recipient vessels was confirmed with arteriography in five dogs and an ultrasonic doppler in one dog. Microvascular technique was used to reestablish circulation to the flaps after they were transferred to the recipient site. Total ischemic time of the flaps averaged 100 minutes. All flaps survived. Successful reconstruction of the cutaneous defects was achieved in these six cases.     

Rapid Tissue Expansion for the Development of Rotational Skin Flaps in the Distal Portion of the Hindlimb of Dogs: An Experimental Study

In phase I, tissue expanders were implanted subcutaneously over the lateral crural region of four dogs. The expanders were inflated daily to maintain a constant intraluminal pressure for 7 days. All animals tolerated the pressurized expanders well. Some animal patient discomfort was associated with repeated injections into the subcutaneous filling port. One dog developed a limited area of tissue loss and exposure of the expander. Tissue response to the expanders included epidermal hyperplasia, dermal collagen compression with early fibroplasia, and subcutaneous granulation tissue formation adjacent to the expander pocket. In phase II, a second group of four dogs underwent rapid skin expansion over 7 days. The pressure applied to the expanding skin was determined daily and adjusted to approximate the value reported for capillary pressure in the dog. Tissue discoloration occurred in two dogs, suggestive of impaired circulation. Skin flaps were developed from expanded skin and rotated over the talocrural region. Wound dehiscence occurred along the distal flap margin in three phase II dogs. These wounds healed by second intention. Branches of the caudal saphenous artery were identified, using angiography, as the primary blood supply to the skin flaps.     

Use of Buccal Mucosal Flaps for the Correction of Congenital Soft Palate Defects in Three Dogs

Objective —To present an alternative surgical technique for the repair of soft palate defects in dogs.
Animal Population —Three Foxhound cross dogs.
Methods —Bilateral buccal mucosal flaps, based at the palatoglossal arches, were raised. One flap was rotated so that the mucosal side created the floor of the nasopharynx. The second flap was rotated so that the mucosal side formed the roof of the oropharynx. The mucosa of the remnant of the soft palate and the pharyngeal walls was incised and the flaps sutured to these free mucosal edges. The caudal ends of the two flaps were sutured to each other.
Results —Complete closure of the soft palate defect was obtained in all three dogs. The dogs were monitored for between 1.5 and 3 years postoperatively, and no long-term problems were encountered.
Conclusions —This surgical technique resulted in an excellent functional separation of the oropharynx and nasopharynx and allowed reconstruction of a large bilateral soft palate defect.
Clinical Relevance —By using the buccal mucosal flaps, as described in this report, a tension-free closure of large soft palate defects can be obtained, thereby eliminating a major cause of failure of this type of reconstructive surgery.     

Complications and outcome after thoracodorsal axial pattern flap reconstruction of forelimb skin defects in 10 dogs, 1989-2001

OBJECTIVE: To determine (1) the frequency and extent of complications associated with thoracodorsal axial pattern flap reconstruction of forelimb skin defects in dogs and (2) outcome after treatment of such complications. STUDY DESIGN: Retrospective clinical study. SAMPLE POPULATION: Ten dogs. METHODS: Medical records for 10 dogs that had a thoracodorsal axial pattern skin flap reconstruction of a forelimb skin defect were reviewed. RESULTS: Three dogs had complete flap survival. Partial necrosis of the distal flap, ranging from an estimated 2% to 53% (mean, 21%) of the flap surface area, occurred in 7 dogs. Six dogs required surgical management of the skin necrosis, resulting in successful resolution in 5 dogs, whereas, in 2 dogs, the wound healed by second intention. Positive bacterial cultures were obtained from 3 dogs with distal flap necrosis. Seroma formation was noted in 2 dogs; the entire flap survived in 1 dog, whereas the second dog developed distal flap necrosis. Edema and bruising of the distal portion of the flap were noted in 8 dogs; distal flap necrosis subsequently developed in 7 dogs. Partial incisional dehiscence, which healed by second intention, occurred in 2 dogs. Of 6 owners available for follow-up, all were satisfied with the functional outcome, but 1 owner was not satisfied with the cosmetic appearance. CONCLUSIONS: Partial flap necrosis was a frequent complication of thoracodorsal axial pattern flap reconstruction of forelimb skin defects and required additional wound care or surgical intervention to achieve healing. CLINICAL RELEVANCE: Thoracodorsal axial pattern flaps can provide full-thickness skin coverage of extensive skin defects of the forelimb, but owners should be aware of the likelihood of local wound complications.     

Deep circumflex iliac cutaneous free flap in cats

OBJECTIVE: To develop and assess the survival of a microvascular cutaneous free flap based on the ventral branch of the deep circumflex iliac (DCI) artery and vein in cats. STUDY DESIGN: Experimental study. ANIMALS: Phase 1: 6 feline cadavers; Phase 2: 2 adult cats; Phase 3: 10 adult cats. METHODS: Phase 1: Selective angiographic study of the deep circumflex iliac artery was completed in 6 feline cadavers. After injection of the DCI artery with barium, high-detail radiographs were made of skin flaps harvested from the lateral flank and thigh region. The extent of the cutaneous angiosome was mapped with regard to the underlying anatomical landmarks. Phase 2: An island flap based on anatomic boundaries of the DCI angiosome derived from phase 1 of the study was elevated in 2 cats. Flaps were observed for 3 weeks for survival. Phase 3: Free skin flaps based on the DCI vessels were harvested in 10 cats and transferred to the dorsal interscapular region. Flaps were evaluated for 2 weeks for survival. Tissue samples were collected for histopathology, and angiograms of the flaps were completed. RESULTS: Phase 1: Angiograms revealed a large primary cutaneous angiosome of the DCI artery located over the lateral femoral region, which extended from the iliac crest to the level of the patella. Phase 2: All island flaps survived for 3 weeks. Phase 3: Six free flaps survived for 2 weeks, and 4 flaps failed completely. Failure of 1 flap occurred because of avulsion of the venous and arterial anastomosis postoperatively. Another cat had intraoperative hemorrhage, which resulted in anemia and hypovolemia and likely caused the flap to fail. The other 2 flaps that failed had poor perfusion intraoperatively and had the longest ischemia times. CONCLUSIONS: The cutaneous DCI free flap in cats may be clinically useful in reconstruction of large cutaneous wounds. The length of ischemia time for successful cutaneous free flap transfer in the cat may be shorter than in other species. CLINICAL RELEVANCE: Large wounds created by trauma or oncologic ablative surgery in cats could be reconstructed with cutaneous microvascular free flap. Additional studies assessing the critical ischemia time of cutaneous flaps in cats and evaluating the use of this flap clinically are needed.     

Cutaneous wound healing in the cat: a macroscopic description and comparison with cutaneous wound healing in the dog

OBJECTIVE: To describe the macroscopic features of first and second intention cutaneous wound healing in the cat and compare with the dog. STUDY DESIGN: Experimental study. ANIMALS: Domestic shorthaired cats (6) and beagle dogs (6). METHODS: Square, open cutaneous wounds created on the dorsal aspect of the thorax were evaluated for 21 days for temporal and spatial development of granulation tissue, wound contraction, epithelialization, and total healing. To evaluate first intention healing, breaking strength of sutured linear cutaneous wounds was measured at 7 days post-wounding. Laser-Doppler perfusion imaging was used to measure cutaneous perfusion. RESULTS: First intention healing: sutured wounds in cats were only half as strong as those in dogs at day 7 (0.406 versus 0.818 kg breaking strength). Second intention healing: cats produced significantly less granulation tissue than dogs, with a peripheral, rather than central distribution. Wound epithelialization and total wound healing (total reduction in open wound area from contraction and epithelialization) were greater for dogs than for cats over 21 days. Wound contraction on day 7 was greater for dogs, but not on day 14 or 21. Cutaneous perfusion was initially greater for dogs than for cats, but no differences were detected after day 7. CONCLUSIONS: Significant, previously unreported differences in cutaneous wound healing exist between cats and dogs. In general, cutaneous wounds in cats are slower to heal. Cats and dogs also appear to use different mechanisms of second intention healing. In cats wounds close mainly by contraction of the wound edges, whereas in dogs wounds close more from central pull, and epithelialization. CLINICAL RELEVANCE: Surgeons should view the cat as a unique species, which presents its own special challenges in wound healing, and should take this into account when planning treatment of feline wounds, either by primary closure, or by second intention healing.     

Extradural spinal juxtafacet (synovial) cysts in three dogs

Three dogs were presented for investigation of spinal disease and were diagnosed with extradural spinal juxtafacet cysts of synovial origin. Two dogs that were presented with clinical signs consistent with pain in the lumbosacral region associated with bilateral hindlimb paresis were diagnosed using magnetic resonance imaging. Both cysts were solitary and associated with the L6-7 dorsal articulations; both the dogs had a transitional vertebra in the lumbosacral region. A third dog that was presented with progressive paraparesis localised to T3-L3 spinal cord segments and compression of the spinal cord at T13-L1 was diagnosed using myelography. A solitary multiloculated cyst was found at surgery. Decompressive surgery resulted in resolution of the clinical signs in all three dogs. Immunohistological findings indicated that one to two layers of vimentin-positive cells consistent with synovial origin lined the cysts.