Atlas of Small Animal Wound Management and Reconstructive Surgery

Foreword xi

Preface xii

Acknowledgments xiii

About the Companion Website xiv

1. The Skin 1

Skin Function 2

Skin Structure 2

Cutaneous Adnexa 5

The Hypodermis 8

Cutaneous Circulation 8

Pinna:: Cutaneous Considerations 10

Congenital Skin Disorders 10

2. Basic Principles of Wound Healing 17

Introduction 18

Wound Healing 18

Acute Versus Chronic Open Wounds 29

Species Variations in Wound Healing 29

“Artificial Skin” 30

3. Basic Principles of Wound Management 33

Introduction 34

Patient Presentation 34

Mechanisms of Injury and Wound Terminology 34

Wound Classification 35

Options for Wound Closure 37

“Pointers” in Selecting the Proper Closure Technique 43

Basic Wound Management in Six Simple Steps 44

Exposed Bone:: Osteostixis 49

Acute Versus Chronic Wounds 50

4. Topical Wound Care Products and Their Use 53

Wound Exudate 54

Wound Drainage Systems 54

Negative Pressure Wound Therapy (NPWT) 60

Concept of Moist Wound Healing (MWH) 67

Topical Wound Care Products 69

The Maggot and Leach in Wound Care 79

Common Topical Antiseptic and Cleansing Agents 81

Alternative Forms of Wound Therapy 85

Concluding Remarks 89

Plate 1:: Vacuum-Assisted Closure 92

5. Dressings, Bandages, External Support, and Protective Devices 95

Introduction 96

Dressings:: The Primary Layer 96

Dressings:: The Secondary Layer 111

Dressings:: The Tertiary Layer 112

Preventing Bandage Displacement 113

Tie-Over Dressing/Bandage Technique 114

Pressure Points:: Bandage Options 115

Bandage “Access Windows” 115

Bandaging Techniques for Skin Grafts 115

Bandaging Techniques for Skin Flaps 115

Splints, Casts, Reinforced Bandages 115

Miscellaneous Protective Devices 116

Plate 2:: Basic Bandage Application for Extremities 124

Plate 3:: Tape Stirrups and Padding Dos and Don’ts 126

Plate 4:: Elasticon Bandage Platforms and Saddles 128

Plate 5:: Spica Bandages/Splints 130

Plate 6:: Schroeder-Thomas Splint 132

Plate 7:: Schroeder-Thomas Splint:: Security Band Application 136

Plate 8:: Body Brace 138

Plate 9:: Tape Hobbles for the Rear Extremities 140

6. Common Complications in Wound Healing 143

Improper Nutritional Support 144

Medications and Their Influence on Healing 145

Hypovolemia and Anemia 146

The Nonhealing Wound:: General Considerations 146

Failure to Heal by Second Intention 147

Scarring and Wound Contracture 152

Infection and Biofilm Formation 154

Draining Tracts 158

Use of Tourniquets for Lower Extremity Procedures 165

Seromas 166

Hematomas 167

Exposed Bone 167

Wound Dehiscence 169

7. Management of Specific Wounds 173

Bite Wounds 174

Burns 183

Inhalation Injuries 195

Chemical Burns 196

Electrical Injuries 197

Radiation Injuries 201

Frostbite 204

Projectile Injuries 205

Explosive Munitions:: Ballistic, Blast, and Thermal Injuries 227

Impalement Injuries 227

Pressure Ulcers 228

Hygroma 234

Snakebite 239

Brown Recluse Spider Bites 240

Porcupine Quills 240

Lower Extremity Shearing Wounds 243

Plate 10:: Pipe Insulation Protective Device:: Elbow 248

Plate 11:: Pipe Insulation to Protect the Great Trochanter 250

Plate 12:: Vacuum Drain Management of Elbow Hygromas 252

8. Regional Considerations 255

The Canine and Feline Profiles 256

Plates 13A and 13B:: Surgical Technique Menu 258

9. Tension-Relieving Techniques 265

Introduction 266

Skin Tension in the Dog and Cat 266

Plate 14:: Tension Lines 282

Plate 15:: Effects of Skin Tension on Wound Closure 284

Plate 16:: Patient Positioning Techniques 286

Plate 17:: Undermining Skin 288

Plate 18:: Geometric Patterns to Facilitate Wound Closure 290

Plate 19:: V-Y Plasty 292

Plate 20:: Z-Plasty (Option I) 294

Plate 21:: Z-Plasty (Option II) 296

Plate 22:: Multiple Z-Plasties 298

Plate 23:: Relaxing/Release Incisions 300

Plate 24:: The “Hidden” Intradermal Release/ Relaxing Incision 302

Plate 25:: Multiple Release Incisions for Extremity Wounds 304

Plate 26:: Suture Options to Alter Skin Traction and Retraction 306

Plate 27:: Walking Suture Technique 308

Plate 28:: Skin Stretchers to Offset Incisional Tension 310

Plate 29:: “Tension” Suture Patterns 312

Plate 30:: Retention Sutures 314

Plate 31:: Stent 316

Plate 32:: Skin “Directing” for Maximum Coverage 318

Plate 33:: Relaxing Incision to Reduce Flap Tension 320

10. Skin-Stretching Techniques 323

Physiology of Skin Stretching 324

Presuturing 324

Load Cycling 324

Skin Stretchers 326

Skin Expanders 335

Plate 34:: Presuturing Technique 338

Plate 35:: Application of Skin Stretchers 340

Plate 36:: Skin Stretchers to Enhance Length of Axial Pattern Flaps 342

Plate 37:: Skin Stretcher Substitution for Presuturing 344

Plate 38:: Skin Expanders 346

11. Local Flaps 351

Introduction 352

Advancement Flaps 353

Rotating (Pivoting) Flaps 356

Plate 39:: Single Pedicle Advancement Flap 370

Plate 40:: Bipedicle Advancement Flap 372

Plate 41:: Transposition Flap (90 degrees) 374

Plate 42:: Transposition Flap (45 degrees) 378

Plate 43:: Transposition Flap (Oblique Angle) 380

Plate 44:: Local Facial Flap Options vs. Auricular Axial Pattern Flap 382

Plate 45:: Transposition Flaps in Partial Wound Closure 384

Plate 46:: Interpolation Flap 386

Plate 47:: Rotation Flap 390

Plate 48:: Forelimb Fold Flap 392

12. Distant Flap Techniques 395

Distant Flaps 396

Direct Flaps 396

Indirect Flaps 396

The Delay Phenomenon 400

Plate 49:: Direct Flap:: Single Pedicle (Hinge) Flap 402

Plate 50:: Direct Flap Closure of Knee Defect 406

Plate 51:: Direct Flap:: Bipedicle (Pouch) Flap 408

Plate 52:: Indirect Flap:: Delayed Tube Flap 414

13. Axial Pattern Skin Flaps 417

Introduction:: Axial Pattern Flaps 418

Island Arterial Flaps 418

Reverse Saphenous Conduit Flaps 421

Secondary Axial Pattern Flaps 421

Options to Extend the Length of Axial Pattern Flaps 427

Plate 53:: Four Major Axial Pattern Flaps of the Canine Trunk 430

Plate 54:: Skin Position and Axial Pattern Flap Development 432

Plate 55:: Omocervical Axial Pattern Flap 434

Plate 56:: Thoracodorsal Axial Pattern Flap 436

Plate 57:: Lateral Thoracic Axial Pattern Flap 438

Plate 58:: Superficial Brachial Axial Pattern Flap 440

Plate 59:: Caudal Superficial Epigastric Axial Pattern Flap 442

Plate 60:: Cranial Superficial Epigastric Axial Pattern Flap 444

Plate 61:: Deep Circumflex Iliac Axial Pattern Flap:: Dorsal Branch 446

Plate 62:: Deep Circumflex Iliac Axial Pattern Flap:: Ventral Branch 448

Plate 63:: Flank Fold Flap:: Hind Limb 450

Plate 64:: Genicular Axial Pattern Flap 452

Plate 65:: Reverse Saphenous Conduit Flap 454

Plate 66:: Caudal Auricular Axial Pattern Flap 456

Plate 67:: Superficial Temporal Axial Pattern Flap 458

Plate 68:: Lateral Caudal (Tail) Axial Pattern Flap 460

14. Free Grafts 463

Free Skin Grafts 464

Classification of Free Grafts 465

Graft Thickness 465

Partial-Coverage Grafts 466

Dermatomes 467

Preservation by Refrigeration 467

Intraoperative Considerations 472

Bandaging Technique for Skin Grafts 472

Use of Plates 473

Plate 69:: Punch Grafts 476

Plate 70:: Pinch Grafts 478

Plate 71:: Strip Grafts 480

Plate 72:: Stamp Grafts 482

Plate 73:: Sheet Grafts 484

Plate 74:: Dermatome:: Split-Thickness Skin Graft Harvesting 486

Plate 75:: Mesh Grafts (With Expansion Units) 488

Plate 76:: Mesh Grafts (With Scalpel Blades) 490

15. Facial Reconstruction 493

Introduction:: Facial Reconstructive Surgery 494

Plate 77:: Repair of Upper Lip Avulsion 515

Plate 78:: Repair of Lower Labial Avulsion 516

Plate 79:: Wedge Resection Technique 518

Plate 80:: Rectangular Resection Technique 520

Plate 81:: Full-Thickness Labial Advancement Technique (Upper Lip) 522

Plate 82:: Full-Thickness Labial Advancement Technique (Lower Lip) 524

Plate 83:: Buccal Rotation Technique 526

Plate 84:: Lower Labial Lift-Up Technique 528

Plate 85:: Upper Labial Pull-Down Technique 530

Plate 86:: Labial/Buccal Reconstruction with Inverse Tubed Skin Flap 532

Plate 87:: Skin Flap for Upper Labial and Buccal Replacement (Facial [Angularis Oris] Axial Pattern Flap) 536

Plate 88:: Feline Facial Axial Pattern Flap 538

Plate 89:: Cleft Lip Repair (Primary Cleft, Cheiloschisis, Harelip) 540

Plate 90:: Unilateral Rostral Labial Pivot Flaps 542

Plate 91:: Bilateral Rostral Labial Pivot Flaps 544

Plate 92:: Oral Commissure Advancement Technique 546

Plate 93:: Brachycephalic Facial Fold Correction 548

Plate 94:: Cheilopexy Technique for Drooling 550

16. Myocutaneous Flaps and Muscle Flaps 553

Introduction 554

Myocutaneous Flaps 554

Muscle Flaps 554

Plate 95:: Latissimus Dorsi Myocutaneous Flap 568

Plate 96:: Cutaneous Trunci Myocutaneous Flap 570

Plate 97:: Latissimus Dorsi Muscle Flap 572

Plate 98:: Latissimus Dorsi Bipedicle Muscle Flap 574

Plate 99:: Triceps Replacement with Latissimus Dorsi Muscle 576

Plate 100:: External Abdominal Oblique Muscle Flap 578

Plate 101:: Caudal Sartorius Muscle Flap 580

Plate 102:: Cranial Sartorius Muscle Flap 582

Plate 103:: Temporalis Muscle Flap 584

Plate 104:: Transversus Abdominis Muscle Flap 586

Plate 105:: Semitendinosus Muscle and Myocutaneous Flaps 588

Plate 106:: Flexor Carpi Ulnaris Muscle Flap 590

Plate 107:: Cranial Tibial Muscle Flap 592

Plate 108:: Internal Obturator Muscle Flap 594

Plate 109:: Superficial Gluteal Flap for Perineal Hernia Closure 596

17. Oral Reconstructive Surgical Techniques 599

Introduction 600

Cleft Palate 601

Palatal Defects/Oronasal Fistulas 602

Plate 110:: Mucosal Flaps 606

Plate 111:: Palatoplasty:: Bipedicle Advancement Technique 608

Plate 112:: Cleft Palate Repair:: Mucoperiosteal Flap Technique 612

Plate 113:: Palatine Mucosal Flap 614

Plate 114:: Soft Palate/Pharyngeal Mucosal Flaps 616

Plate 115:: Full-Thickness Labial Flap Closure of Oronasal Fistulas 618

Plate 116:: Cartilage Grafts for Palatal Fistulas 620

Plate 117:: Angularis Oris Mucosal Flap 622

18. Foot Pad Reconstruction 625

Introduction 626

Pad Laceration and Lesion Excision 626

Digital Pad Transfer 631

Metacarpal/Metatarsal Pad Transfer 632

Accessory Carpal Pad 632

Pad Grafting 634

Digital Flaps for Wound Closure 634

Fusion Podoplasty 634

Plate 118:: Digital Flap Technique:: Major Digital/ Interdigital Defects 642

Plate 119:: Digital Flap Technique:: Major Defects of Digits Two or Five 644

Plate 120:: Digital Pad Transfer 646

Plate 121:: Metatarsal/Metacarpal Pad Transfer 648

Plate 122:: Pad Grafting 650

Plate 123:: Segmental Pad Grafting Technique 652

Plate 124:: Fusion Podoplasty 654

19. Major Eyelid Reconstruction 657

Introduction 658

The Eyelids 658

Plate 125:: Skin Flap Options for Cutaneous Defects of the Eyelid Regions 660

Plate 126:: Lip-to-Lid Procedure 662

Plate 127:: Oral Mucosal Graft onto Skin Flap 666

Plate 128:: Third Eyelid–Skin Flap Reconstruction of the Lower Eyelid 668

20. Nasal Reconstruction Techniques 671

Introduction:: Nasal Anatomy 672

Traumatic Wound Management 672

Neoplasia 673

Neoplasms and Surgical Margins 673

Nasal Reconstruction Options 673

Options for Managing Nasal Stenosis 682

Plate 129:: Septal Coverage Using Cutaneous Advancement Flaps 692

Plate 130:: Bilateral Sulcus Flap Technique 694

Plate 131:: Septal Resection Technique 696

Plate 132:: Dorsal Nasal Splitting Technique to Enhance Exposure of Septum 698

Plate 133:: Alar Fold Flaps 700

Plate 134:: Musculofascial Island Labial Flap 702

Plate 135:: Labial Mucosal Inversion Technique 706

Plate 136:: Nasal Reconstruction with the “Lip-to- Lid Technique” Variation 708

Plate 137:: Oral Mucosal Graft with Nasal Stenting 710

Plate 138:: Intranasal Septal Window Technique 712

Plate 139:: Cantilever Suture Technique 714

21. Cosmetic Closure Techniques 719

Cosmetic Considerations 720

Causes of Scars 720

Minimization of Scarring 720

Dog Ears 722

Plate 140:: Scar Concealment 724

Plate 141:: W-Plasty 726

Plate 142:: Dog Ear:: Surgical Correction 728

22. Preputial Reconstructive Surgery 731

Introduction 732

Surgical Conditions 732

Surgical Techniques 742

Plate 143:: Preputial Ostium Enlargement 756

Plate 144:: Preputial Ostium Reduction 758

Plate 145:: Preputial Advancement Technique 760

Plate 146:: Phallopexy 764

Plate 147:: Urethral Reconstruction for Subanal Hypospadias 766

Plate 148:: Preputial Urethrostomy Technique 768

Plate 149:: Urine Diversion Technique 770

23. Pinnal Reconstructive Surgery 773

Introduction 774

Anatomy of the Pinna 774

Surgical Conditions 779

Wound Management and Reconstructive Surgical Techniques 780

Aural Hematoma Management Options 786

Plate 150:: Skin Advancement Closure:: Rostral Pinnal Base 796

Plate 151:: Skin Advancement Closure:: Caudal Pinnal Base 798

Plate 152:: Transposition Flap Technique for Smaller Medial Pinnal Defects 800

Plate 153:: Transposition Flap Technique for Minor Lateral Pinnal Defects 802

Plate 154:: Large Transposition Flap Closure After Major Medial Pinnal Resection 804

Plate 155:: Transposition Flap for Major Lateral Pinnal Defects 806

Plate 156:: Direct Flap Reconstruction of the Pinna 808

Plate 157:: Resection of the Terminal Third of the Pinna 810

Plate 158:: Inverted “Triangle” Resection of the Central Third of the Pinna 812

Plate 159:: Incisional Drainage of Aural Hematomas 814

Plate 160:: Bandaging the Pinna 816

Plate 161:: Vacuum Drain Management of Aural Hematomas 818

24. Miscellaneous Reconstructive Surgical Techniques 821

Omentum 822

Scrotum 822

Tail Fold Intertrigo (Screw Tail) 823

Disorders of the Vulva 827

Managing Skin Fold Inversion of Urethrostomies 835

Fecal Incontinence:: Treatment Options 835

Plate 162:: Omental Flap Options 838

Plate 163:: Scrotal Flap Technique 840

Plate 164:: Caudectomy for Tail Fold Intertrigo 842

Plate 165:: Episioplasty 844

Plate 166:: Fascia Lata Sling and Silicone Banding for Managing Fecal Incontinence 846

Plate 167:: Spiral Rectal Diaphragm Technique (Rectal Rifling) 848

Index 851