1887

Tension-relieving techniques and local skin flaps

image of Tension-relieving techniques and local skin flaps
GBP
Online Access: GBP25.00 + VAT
BSAVA Library Pass Buy a pass

Abstract

Most skin defects seen in small animal patients are created either by traumatic injury or by surgical resection of a diseased area of tissue. In cats and dogs the elasticity of skin, along with the frequent presence of adjacent loose skin in many areas of the body, allows the primary closure of many wounds. However, techniques to reduce tension or to harvest skin from adjacent areas can help, in some cases, to produce a tension-free closure that is less likely to result in wound-healing complications. A working knowledge of such techniques is essential, as their required use cannot always be predicted preoperatively. In situations where primary closure was anticipated but cannot be achieved due to unforeseen circumstances, these techniques can become invaluable. Many of the techniques described in this chapter are very simple and will often be used in combination during wound reconstruction. The chapter considers Blood supply to the skin; Skin tension; Techniques to overcome skin tension; and Complications of skin flaps. : Hemimaxillectomy and transposition flap for a maxillary mass; Axillary flaps after excision of a thoracic mass. : Walking sutures; Skin stretching; V-Y plasty; Z-plasty; Single pedicle advancement flap; Bipedicle advancement flap; Rotation flap; Transposition flap; Axillary fold flap; Inguinal fold flap

Loading full text...

Full text loading...

/content/chapter/10.22233/9781905319558.chap6

Figures

Image of 6.1
6.1 Vascular supply to canine and feline skin is through direct cutaneous vessels that emerge from the underlying skeletal muscle to supply the subdermal plexus located at the level of the panniculus muscle. Drawn by S.J. Elmhurst BA Hons (www.livingart.org.uk) and reproduced with her permission.
Image of 6.2
6.2 Tension lines of the skin. Drawn by S.J. Elmhurst BA Hons (www.livingart.org.uk) and reproduced with her permission.
Image of 6.3
6.3 Excessive tension during closure of a lateral defect on the distal limb has created a tourniquet effect that must be alleviated immediately to avoid foot necrosis.
Image of 6.4
6.4 Undermining below the subdermal plexus.
Image of 6.5
6.5 Manipulation of wound geometry. Conversion of circular, square or rectangular defects into an ovoid configuration can facilitate closure and improve cosmesis. Circular defects can be closed by bringing together three triangular flaps. Square defects can be closed in an X-configuration. Drawn by S.J. Elmhurst BA Hons (www.livingart.org.uk) and reproduced with her permission.
Image of 6.6
6.6 Multiple relaxing incisions can be created to allow tension relief at the closure of a primary defect over the limb. Illustrated on a cadaver specimen.
Image of 6.7
6.7 A chronic non-healing wound over the lateral stifle is a good indication for Z-plasty.
Image of 6.8
6.8 Multiple Z-plasties can be aligned in series, oriented perpendicular to the long axis of a wound. The cumulative magnitude of tension relief will be additive. The tip of each triangle for each Z (A, B, C, etc.) is transposed into its opposing wound bed and sutured. Drawn by S.J. Elmhurst BA Hons (www.livingart.org.uk) and reproduced with her permission.
Image of 6.9
6.9 Defects on the head are especially amenable to single pedicle advancement flap development.
Image of 6.10
6.10 H-plasty. When a single pedicle advancement flap provides inadequate tension relief, two opposing flaps can be created and sutured in place in an H configuration. Illustrated on a cadaver specimen.
Image of 6.11
6.11 Large ‘dog ears’ can be excised but their excision should not narrow the base of axial pattern or subdermal plexus flaps. Illustrated on a cadaver specimen.
Image of 6.12
6.12 Defects on the lateral or medial metatarsal region are good candidates for bipedicle advancement flaps as few other reconstructive procedures are possible in these areas. The releasing incision was left open to heal by secondary intention after closure of the primary defect.
Image of 6.13
6.13 A rotation flap is one option for closure of a large ovoid shaped defect created by resection of a tumour over the lateral thigh (see Operative Technique 6.7 ).
Image of 6.14
6.14 Creation of a bipedicled distant direct flap for the reconstruction of a wound over the metatarsal and phalangeal region in a dog. The flap is created by making parallel incisions in the skin overlying the trunk. The skin is undermined deep to the cutaneous trunci muscle. The flap edges are sutured to the wound. Final outcome about 2 months after surgery.
Image of Untitled
Image of Untitled
Image of Untitled
Image of Untitled
Image of Untitled
Image of Untitled
Image of Untitled
Image of Untitled
Image of Untitled
Image of Untitled
Image of Placement of a walking suture in the wound bed is demonstrated. A bite of the underlying wound bed is taken, followed by a bite of the deep dermis 1–2 cm more distant from the wound margin.
Placement of a walking suture in the wound bed is demonstrated. A bite of the underlying wound bed is taken, followed by a bite of the deep dermis 1–2 cm more distant from the wound margin. Placement of a walking suture in the wound bed is demonstrated. A bite of the underlying wound bed is taken, followed by a bite of the deep dermis 1–2 cm more distant from the wound margin.
Image of Skin-stretching kit: self-adherent Velcro-covered skin patches; elastic connecting tape; and tissue glue (cyanoacrylate). These can be purchased from department stores.
Skin-stretching kit: self-adherent Velcro-covered skin patches; elastic connecting tape; and tissue glue (cyanoacrylate). These can be purchased from department stores. Skin-stretching kit: self-adherent Velcro-covered skin patches; elastic connecting tape; and tissue glue (cyanoacrylate). These can be purchased from department stores.
Image of The wound has been packed with dressing and a tie-over bandage applied. Adhesive patches have been applied to the clean and dry skin around the wound.
The wound has been packed with dressing and a tie-over bandage applied. Adhesive patches have been applied to the clean and dry skin around the wound. The wound has been packed with dressing and a tie-over bandage applied. Adhesive patches have been applied to the clean and dry skin around the wound.
Image of Stretching tapes in place.
Stretching tapes in place. Stretching tapes in place.
Image of V-shaped incision.
V-shaped incision. V-shaped incision.
Image of The skin has been undermined and the defect closed. The arrow shows the direction of movement of the skin.
The skin has been undermined and the defect closed. The arrow shows the direction of movement of the skin. The skin has been undermined and the defect closed. The arrow shows the direction of movement of the skin.
Image of The incision is closed in a Y shape.
The incision is closed in a Y shape. The incision is closed in a Y shape.
Image of Planning a Z-plasty. The arms are of equal length and at 60-degree angles to the central limb, which is perpendicular to the wound. The tip of triangle 1 (A) will be moved to opposite position Y, and the tip of triangle 2 (B) will be moved to opposite position X. This will allow stretching of the skin in the direction of the X–Y axis.
Planning a Z-plasty. The arms are of equal length and at 60-degree angles to the central limb, which is perpendicular to the wound. The tip of triangle 1 (A) will be moved to opposite position Y, and the tip of triangle 2 (B) will be moved to opposite position X. This will allow stretching of the skin in the direction of the X–Y axis. Planning a Z-plasty. The arms are of equal length and at 60-degree angles to the central limb, which is perpendicular to the wound. The tip of triangle 1 (A) will be moved to opposite position Y, and the tip of triangle 2 (B) will be moved to opposite position X. This will allow stretching of the skin in the direction of the X–Y axis.
Image of Z-plasty used to close a defect over the lateral stifle (see Figure 6.7). Triangular skin flaps are transposed into their opposing wound beds.
Z-plasty used to close a defect over the lateral stifle (see Figure 6.7). Triangular skin flaps are transposed into their opposing wound beds. Z-plasty used to close a defect over the lateral stifle (see Figure 6.7 ). Triangular skin flaps are transposed into their opposing wound beds.
Image of The tips of triangles 1 and 2 are shown in their new positions. After primary wound closure the Z is seen to elongate.
The tips of triangles 1 and 2 are shown in their new positions. After primary wound closure the Z is seen to elongate. The tips of triangles 1 and 2 are shown in their new positions. After primary wound closure the Z is seen to elongate.
Image of The Z and the primary defect have been closed.
The Z and the primary defect have been closed. The Z and the primary defect have been closed.
Image of The flap is gradually advanced over the defect by progressive lengthening and undermining. Tension can be judged by exerting traction on stay sutures placed in the flap tip.
The flap is gradually advanced over the defect by progressive lengthening and undermining. Tension can be judged by exerting traction on stay sutures placed in the flap tip. The flap is gradually advanced over the defect by progressive lengthening and undermining. Tension can be judged by exerting traction on stay sutures placed in the flap tip.
Image of Flap sutured in place. A small closed suction drain has been placed to drain dead space and promote flap adhesion to the wound bed.
Flap sutured in place. A small closed suction drain has been placed to drain dead space and promote flap adhesion to the wound bed. Flap sutured in place. A small closed suction drain has been placed to drain dead space and promote flap adhesion to the wound bed.
Image of A semicircular incision starting from one tip of a triangular or square defect creates a flap that can be rotated over a primary wound in the direction of the arrows.
A semicircular incision starting from one tip of a triangular or square defect creates a flap that can be rotated over a primary wound in the direction of the arrows. A semicircular incision starting from one tip of a triangular or square defect creates a flap that can be rotated over a primary wound in the direction of the arrows.
Image of The defect pictured in Figure 6.13 is closed using a rotation flap. The donor defect will be closed primarily.
The defect pictured in Figure 6.13 is closed using a rotation flap. The donor defect will be closed primarily. The defect pictured in Figure 6.13 is closed using a rotation flap. The donor defect will be closed primarily.
Image of The flap has been sutured in position over a closed suction Jackson–Pratt drain.
The flap has been sutured in position over a closed suction Jackson–Pratt drain. The flap has been sutured in position over a closed suction Jackson–Pratt drain.
Image of 90 degrees transposition flap. The red arrows show that the length of the flap is equal to the length from the pivot point to the distal margin of the defect. The black arrow shows the direction of rotation of the flap to cover the defect.
90 degrees transposition flap. The red arrows show that the length of the flap is equal to the length from the pivot point to the distal margin of the defect. The black arrow shows the direction of rotation of the flap to cover the defect. 90 degrees transposition flap. The red arrows show that the length of the flap is equal to the length from the pivot point to the distal margin of the defect. The black arrow shows the direction of rotation of the flap to cover the defect.
Image of Once the transposition is complete the flap is sutured into place and the donor site is sutured. There will be some kinking of the skin at the flap base, which increases with the degree of rotation.
Once the transposition is complete the flap is sutured into place and the donor site is sutured. There will be some kinking of the skin at the flap base, which increases with the degree of rotation. Once the transposition is complete the flap is sutured into place and the donor site is sutured. There will be some kinking of the skin at the flap base, which increases with the degree of rotation.
Image of For closure of this wound over the elbow joint an axillary fold flap was created by incising the proximal, distal and lateral sides of the axillary fold. The flap’s base was its medial attachment to the thoracic limb.
For closure of this wound over the elbow joint an axillary fold flap was created by incising the proximal, distal and lateral sides of the axillary fold. The flap’s base was its medial attachment to the thoracic limb. For closure of this wound over the elbow joint an axillary fold flap was created by incising the proximal, distal and lateral sides of the axillary fold. The flap’s base was its medial attachment to the thoracic limb.
Image of Flap sutured into position. This flap will need protection from pressure necrosis over the point of the elbow. Deep bedding and strict rest, possibly in combination with spica splinting of the limb, should be considered.
Flap sutured into position. This flap will need protection from pressure necrosis over the point of the elbow. Deep bedding and strict rest, possibly in combination with spica splinting of the limb, should be considered. Flap sutured into position. This flap will need protection from pressure necrosis over the point of the elbow. Deep bedding and strict rest, possibly in combination with spica splinting of the limb, should be considered.
Image of A large defect was present over the lateral abdomen, from the excision of a tumour that was not cleanly resected at the first attempt. An inguinal fold flap was created by incision of its medial, lateral and distal attachments and was rotated dorsally into the defect.
A large defect was present over the lateral abdomen, from the excision of a tumour that was not cleanly resected at the first attempt. An inguinal fold flap was created by incision of its medial, lateral and distal attachments and was rotated dorsally into the defect. A large defect was present over the lateral abdomen, from the excision of a tumour that was not cleanly resected at the first attempt. An inguinal fold flap was created by incision of its medial, lateral and distal attachments and was rotated dorsally into the defect.
Image of Flap sutured into place over a closed suction drain.
Flap sutured into place over a closed suction drain. Flap sutured into place over a closed suction drain.

More like this

/content/chapter/10.22233/9781905319558.chap6
dcterms_title,dcterms_description
-contentType:Journal
5
5
This is a required field
Please enter a valid email address
Approval was a Success
Invalid data
An Error Occurred
Approval was partially successful, following selected items could not be processed due to error