Logo Passei Direto
Buscar
Material
páginas com resultados encontrados.
páginas com resultados encontrados.
left-side-bubbles-backgroundright-side-bubbles-background

Crie sua conta grátis para liberar esse material. 🤩

Já tem uma conta?

Ao continuar, você aceita os Termos de Uso e Política de Privacidade

left-side-bubbles-backgroundright-side-bubbles-background

Crie sua conta grátis para liberar esse material. 🤩

Já tem uma conta?

Ao continuar, você aceita os Termos de Uso e Política de Privacidade

left-side-bubbles-backgroundright-side-bubbles-background

Crie sua conta grátis para liberar esse material. 🤩

Já tem uma conta?

Ao continuar, você aceita os Termos de Uso e Política de Privacidade

left-side-bubbles-backgroundright-side-bubbles-background

Crie sua conta grátis para liberar esse material. 🤩

Já tem uma conta?

Ao continuar, você aceita os Termos de Uso e Política de Privacidade

left-side-bubbles-backgroundright-side-bubbles-background

Crie sua conta grátis para liberar esse material. 🤩

Já tem uma conta?

Ao continuar, você aceita os Termos de Uso e Política de Privacidade

left-side-bubbles-backgroundright-side-bubbles-background

Crie sua conta grátis para liberar esse material. 🤩

Já tem uma conta?

Ao continuar, você aceita os Termos de Uso e Política de Privacidade

left-side-bubbles-backgroundright-side-bubbles-background

Crie sua conta grátis para liberar esse material. 🤩

Já tem uma conta?

Ao continuar, você aceita os Termos de Uso e Política de Privacidade

left-side-bubbles-backgroundright-side-bubbles-background

Crie sua conta grátis para liberar esse material. 🤩

Já tem uma conta?

Ao continuar, você aceita os Termos de Uso e Política de Privacidade

left-side-bubbles-backgroundright-side-bubbles-background

Crie sua conta grátis para liberar esse material. 🤩

Já tem uma conta?

Ao continuar, você aceita os Termos de Uso e Política de Privacidade

left-side-bubbles-backgroundright-side-bubbles-background

Crie sua conta grátis para liberar esse material. 🤩

Já tem uma conta?

Ao continuar, você aceita os Termos de Uso e Política de Privacidade

Prévia do material em texto

Jolle Kirpensteijn 
DVM, PhD, DipACVS, DipECVS
and
Gert ter Haar 
DVM, PhD, DipECVS, MRCVS
Department of Clinical Sciences of Companion Animals
Faculty of Veterinary Medicine
University of Utrecht
The Netherlands
Manson Publishing/The Veterinary Press
Reconstructive Surgery
and Wound
Management of the
Dog and Cat
Copyright © 2013 Manson Publishing Ltd
ISBN: 978-1-84076-163-4 
All rights reserved. No part of this publication may be reproduced, stored in a retrieval system or
transmitted in any form or by any means without the written permission of the copyright holder or in
accordance with the provisions of the Copyright Act 1956 (as amended), or under the terms of any
licence permitting limited copying issued by the Copyright Licensing Agency, 33–34 Alfred Place,
London WC1E 7DP, UK.
Any person who does any unauthorized act in relation to this publication may be liable to criminal
prosecution and civil claims for damages.
A CIP catalogue record for this book is available from the British Library.
For full details of all Manson Publishing Ltd titles please write to:
Manson Publishing Ltd, 73 Corringham Road, London NW11 7DL, UK.
Tel: +44(0)20 8905 5150
Fax: +44(0)20 8201 9233
Email: manson@mansonpublishing.com
Website: www.mansonpublishing.com
Commissioning editor: Jill Northcott
Project manager: Kate Nardoni
Copy editor: Peter Beynon
Design: Cathy Martin
Layout: diacriTech, India
Colour reproduction: Tenon & Polert Colour Scanning Ltd, Hong Kong
Printed by: Grafos SA, Barcelona, Spain
www.mansonpublishing.com
Contents
Preface 5
Acknowledgements 5
Contributors 6
Foreword 7
Abbreviations 8
Chapter 1
Introduction 9
Gert ter Haar, Sjef C. Buiks, Marijn van Delden,
Tjitte Reijntjes, Rick F. Sanchez and 
Jolle Kirpensteijn
Anatomy 10
Blood supply 10
Skin tension 12
Tension-relieving suture patterns 13
Skin flaps and their classification 13
Reconstruction of the head 15
Eyelid reconstructive techniques 15
Reconstruction of the neck and trunk 17
Reconstruction of the forelimb 17
Reconstruction of the hindlimb 17
Wound closure techniques 18
Complications in performing plastic and
reconstructive surgery 18
References 19
Chapter 2
Wound management: a new protocol
for dogs and cats 21
Tosca van Hengel, Gert ter Haar and 
Jolle Kirpensteijn
Introduction 22
Wound healing 22
Wound management 28
A protocol for wound management in 
dogs and cats 42
Cost-effectiveness and patient and 
owner benefit 43
Conclusion/summary 43
References 45
Chapter 3
General reconstructive 
techniques 49
Sjef C. Buiks, Marijn van Delden and 
Jolle Kirpensteijn
Triangular lesion 50
Square lesion 51
Bow tie technique 52
Walking sutures 54
Releasing incisions 56
Mesh releasing incisions 58
Advancement (U-) flap 59
Double advancement or H-flap 62
V-Y plasty 64
Z-plasty 65
Reading man procedure 68
Transposition flap 70
Interpolation flap 72
Rotation flap 75
Chapter 4
Avascular and microvascular 
reconstructive techniques 77
Guido Camps and Jolle Kirpensteijn
Introduction 78
Background to avascular and 
microvascular skin surgery 78
Avascular mesh graft 79
Microvascular flap transfer 82
Conclusion/summary 92
References 92
Chapter 5
Reconstructive techniques of the facial 
area and head 95
Sjef C. Buiks and Gert ter Haar
Unilateral modified nasal rotation flap 96
Bilateral modified nasal rotation flap 98
Full-thickness labial advancement flap 
(lower lip) 100
4
Full-thickness labial advancement flap 
(upper lip) 102
Full-thickness buccal rotation flap 104
Transposition skin flap for upper labial 
and buccal replacement 106
Facial artery axial pattern flap 108
Superficial temporal artery axial pattern
flap 110
Caudal auricular axial pattern flap 112
Pedicle flap for pinnal defects 114
Chapter 6
Reconstructive techniques of
the eyelids 117
Rick F. Sanchez
H-plasty 118
Z-plasty 121
Semicircular skin flap 126
Rhomboid flap 128
Modified cross lid flap 131
Lip-to-eye mucocutaneous subdermal 
plexus rotating flap 134
Superficial temporal artery axial pattern 
flap for reconstruction of the upper eyelid 139
Entropion repair and the arrowhead 
method for correction of lateral canthal
entropion involving the upper and 
lower eyelid 144
Stades technique for correction of upper 
eyelid entropion/trichiasis 146
Munger–Carter flap adaptation of the 
Khunt–Szymanowski–Fox–Smith procedure
for correction of lower eyelid ectropion
and macroblepharon in dogs 149
Chapter 7
Reconstructive techniques 
of the neck and trunk 153
Marijn van Delden, Sjef C. Buiks and 
Gert ter Haar
Omocervical axial pattern flap 154
Thoracodorsal axial pattern flap 156
Cranial superficial epigastric axial 
pattern flap 160
Cutaneous trunci myocutaneous flap 162
Latissimus dorsi myocutaneous flap 166
External abdominal oblique muscle flap 170
Tensor fascia lata flap 173
Episioplasty 176
Scrotal flap 178
Tail flap/lateral caudal axial pattern flap 180
Chapter 8
Reconstructive techniques 
of the forelimb 183
Sjef C. Buiks, Tjitte Reijntjes and 
Jolle Kirpensteijn 
Lateral thoracic artery axial pattern flap 184
Superficial brachial axial pattern flap 186
Axillary (forelimb) fold flap 189
Flexor carpi ulnaris muscle flap 193
Phalangeal fillet (digit I or dewclaw [P-I]) 196
Phalangeal fillet (digits II–IV) 200
Fusion podoplasty 204
Segmental pad transfer 207
Chapter 9
Reconstructive techniques 
of the hindlimb 209
Tjitte Reijntjes and Jolle Kirpensteijn 
Deep circumflex iliac axial pattern flap 210
Caudal superficial epigastric axial 
pattern flap 213
Flank fold flap 216
Genicular axial pattern flap 220
Cranial sartorius muscle flap 222
Caudal sartorius muscle flap 224
Reverse saphenous conduit flap 227
Metatarsal pad transfer 230
Index 233
5
in the treatment of animals with skin defects caused
by injury or tumour resection. Why should one buy
this book? If you are interested in skin surgery and
you learn best by seeing a procedure performed, this
atlas will show you all the procedures currently
available in veterinary medicine and surgery using
clear illustrations and step-by-step instructions.
Consider it a cookbook with lots of ideas and
recipes. A word of warning though – like cooking,
surgery is a skill not mastered to the same degree by
everyone. In addition, conditions are variable and
do not remain constant. Use this book wisely, allow
it to give you inspiration and evaluate each wound
as an individual challenge to close. Every animal,
and thus every wound, is different. This is why
reconstructive surgery is so much fun!
Jolle Kirpensteijn
Gert ter Haar
Preface
The idea of designing a colour atlas of
reconstructive techniques in dogs and cats started a
couple of years ago during our lectures to residents
in surgery. The plan was that the illustrations in the
atlas would be comparable to the gold standard set
by the excellent drawings in the books written by
Michael Pavletic and Steven Swaim, with the
additional advantage that they would demonstrate
each reconstructive procedure step by step and
using real tissues. In addition to being close
personal friends, Michael and Steven have been
immense sources of knowledge for this atlas. We
would like to acknowledge and sincerely thank
these two pioneers in reconstructive surgery for
showing us the way to proceed, and we advise every
reader to add their volumes to their library.
The main goal of this atlas is to provide an
overview of reconstructive techniques in dogs and
cats, illustrated with high-quality pictures, as an aid
Acknowledgements
An atlas of this nature takes the input and hard
work of a great number of people. We are indebted
to many people for their assistance and support
while writing this book.
First, we sincerely thank our five students,
Marijn van Delden, Sjef Buiks, Tjitte Reijntjes,
Guido Camps and Tosca van Hengel, who were
involved in the making of this atlas. As part of their
training in scientific research, they dedicated three
full months to studying the literature, bothveterinary and human, preparing the actual
surgeries, and performing the surgeries under our
close supervision. Without their enthusiasm,
dedication, perseverance and logistical skills we
would not have been able to write this book.
Special thanks are in order for Joop Fama, who
single-handedly took all the photographs in this
atlas and did an outstanding job. It is unbelievable
how many hours he spent on not only taking the
photographs, but in processing and editing all the
material afterwards. There would not have been an
atlas if it had not been for Joop’s support.
We owe thanks to Harry van Engelen and the
veterinary technicians for providing all the
materials we needed, even at short notice, and for
cleaning up after us! 
We are very grateful for the contribution of Rick
Sanchez. Without his eye for detail and concise
knowledge of this specialist area, the quality of the
eyelid reconstruction chapter would not have been
so high.
Thanks are due to Jill Northcott from Manson
Publishing Limited for being very patient and
believing in the end result while extending deadline
after deadline. We thank Peter Beynon for
performing an outstanding editing job, Bouvien
Brocks for a final check and Kate Nardoni and
Cathy Martin for making it even more beautiful
than originally planned. It has been a pleasure
working with them. 
6
Contributors
Sjef C. Buiks DVM
Department of Clinical Sciences of Companion Animals
Faculty of Veterinary Medicine
University of Utrecht
Utrecht, The Netherlands
Guido Camps MS
Department of Clinical Sciences of Companion Animals
Faculty of Veterinary Medicine
University of Utrecht
Utrecht, The Netherlands
Marijn van Delden DVM
Department of Clinical Sciences of Companion Animals
Faculty of Veterinary Medicine
University of Utrecht
Utrecht, The Netherlands
Gert ter Haar DVM, PhD, DipECVS, MRCVS
Department of Clinical Sciences of Companion Animals
Faculty of Veterinary Medicine
University of Utrecht
Utrecht, The Netherlands
and
Department of Veterinary Clinical Sciences
Royal Veterinary College
University of London
Hertfordshire, United Kingdom
Tosca Hengel DVM
Department of Clinical Sciences of Companion Animals
Faculty of Veterinary Medicine
University of Utrecht
Utrecht, The Netherlands
Jolle Kirpensteijn DVM, PhD, DipACVS, DipECVS
Department of Clinical Sciences of Companion Animals
Faculty of Veterinary Medicine
University of Utrecht
Utrecht, The Netherlands
Tjitte Reijntjes DVM
Department of Clinical Sciences of Companion Animals
Faculty of Veterinary Medicine
University of Utrecht
Utrecht, The Netherlands
Rick F. Sanchez DVM, DipECVO, MRCVS
Department of Veterinary Clinical Sciences
Royal Veterinary College
University of London
Hertfordshire, United Kingdom
7
Foreword
Wound management and reconstructive surgery are
challenges that small animal practitioners encounter
on a regular basis. The techniques for dealing with
these challenges involve both science and art, and
the practitioner must have an understanding of
both to attain a cosmetic and functional result from
his/her efforts. This textbook provides practitioners
with information to help attain such results.
The authors’ interests and abilities in small
animal surgery underlie the preparation of the
book. Professor Jolle Kirpensteijn has a worldwide
reputation for his expertise in surgical oncology and
reconstructive surgery. His service as president of
the World Small Animal Veterinary Association
attests to his reputation. His experience and his
teaching ability at the university and at inter -
national levels well qualify him to prepare a book of
this nature. Dr Gert ter Haar’s credentials reflect his
interest and high qualifications in veterinary surgery
and in particular veterinary ear, nose and throat
surgery. His presidency of the International
Veterinary Ear, Nose, and Throat Association
indicates his renown in the latter field. Thus, prepa -
ration of this book has been in the hands of two
well-qualified individuals.
The book’s design is to give the practitioner
information on techniques and materials to manage
wounds in preparation for reconstructive surgery
and then to provide step-by-step guidance in the
various procedures needed to perform the recon -
struction. The content of the book is thorough,
covering the basics of anatomy and wound healing
and progressing on to management, reconstruction
and aftercare of wounds. The topics and techniques
are not only inclusive, but they are arranged in a
very organized way. For example, reconstructive
techniques are arranged anatomi cally. If a prac -
titioner is presented with a wound on a certain body
part, he/she can go to that section of the book to see
what the options are for reconstruction. The
authors strongly emphasize the use of various skin
flaps for reconstruction. The advantage of flaps is
their potential for maintaining a blood supply and,
therefore, viability at all times during transfer and
healing.
Because ‘a picture is worth a thousand words’,
the use of high-quality pictures in this step-by-step
approach makes the book very user friendly.
Steven F. Swaim DVM, MS
Professor Emeritus
Department of Clinical Sciences and 
Scott-Ritchey Research Center
College of Veterinary Medicine
Auburn University, Alabama, USA
8
Abbreviations
ASA acetylsalicylic acid
ATP adenosine triphosphate
EDTA ethylenediamine tetra-acetic acid 
EGF epidermal growth factor
FGF fibroblast growth factor
GM-CSF granulocyte–macrophage colony-
stimulating factor
HBOT hyperbaric oxygen therapy
IFN interferon
IL interleukin
IM inflammatory mediator
IP inducible protein
LLLT low-level laser therapy
LRS lactated Ringer’s solution
MCP monocyte chemoattractant protein
MIP macrophage inflammatory protein-1
MMP matrix metalloproteinase
MSRA methicillin-resistant Staphylococcus
aureus
NAP neutrophil-activating peptide
NSAID nonsteroidal anti-inflammatory drug
PDGF platelet-derived growth factor
PF4 platelet factor 4
PMN polymorphonuclear cell
PSIS porcine small intestinal submucosa
SFAF skin fold advancement flap
SSD silver sulfadiazine
TAO triple antibiotic ointment
TCC tripeptide-copper complex
TGF transforming growth factor
TNF-! tumour necrosis factor alpha
TNP topical negative pressure (therapy)
VEGF vascular endothelial growth factor
Chapter 1
Introduction
9
Gert ter Haar, Sjef C. Buiks, Marijn van Delden, Tjitte Reijntjes, Rick F. Sanchez and
Jolle Kirpensteijn
• Anatomy
• Blood supply
• Skin tension
• Tension-relieving suture patterns
• Skin flaps and their classification
• Reconstruction of the head
• Eyelid reconstruction techniques
• Reconstruction of the neck and trunk
• Reconstruction of the forelimb
• Reconstruction of the hindlimb
• Wound closure techniques
• Complications in performing plastic and reconstructive surgery 
• References
Introduction10
In the last two decades, wound management and
skin reconstructive techniques for dogs and cats have
advanced dramatically and many articles and several
textbooks and manuals dealing with wound
reconstruction and wound closure tech niques have
been published. The aim of this book is not to
provide the reader with in-depth knowledge on
skin reconstruction techniques or theoretical
background information, but to describe in detail,
step by step, the most commonly used recon structive
techniques in dogs and cats. How ever, the basic
knowledge necessary to understand and use the
information provided in this book will be discussed.
The basic anatomy and physiology of the skin with
regard to cutaneous blood supply and skin tension
lines are discussed in this chapter. A general
description of reconstructive terminology, including a
classification of the different types of flaps and skin
grafts used in small animal recon structive surgery, is
also included. An introduction to these flaps and skin
grafts is provided as well as information regarding
their use in specific locations on the body.
Anatomy
The skin of dogs and cats is quite different from
human skin.Skin thickness, hair growth and
circulation vary regionally between species and
between dog and cat breeds to some degree.1,2 The
skin consists of two main layers, the epidermis
and the dermis.3–5 The general composition of the
outer layer, the epidermis, is of avascular
keratinized stratified squamous epithelium. The
thicker vascular dermis lies underneath the
epidermis and consists of tough fibroelastic tissue
with a supportive and nourishing function. The
dermis rests on a layer of loose connective tissue,
known as the subcutis or hypodermis, which is
composed of adipose tissue, the cutaneous trunci
muscle (where present) and direct cutaneous
arteries and veins. This layer is particularly
abundant in most dogs and cats, but the quantity
and elasticity of the skin will vary depending on the
breed and on the physical condition of the animal.1,3
Variations in structure are present at different sites
of the body surface. For example, the nose and
footpads have a thick protective keratin layer, while
the skin between the hindlimbs is fairly thin and
sparsely haired. In addition, in most skin areas there
are specialized epithelial appendages, such as hair
follicles and sebaceous glands.6 The eyelids are
dorsal and ventral folds of thin skin that are contin -
uous with the facial skin, and their free edges meet
to form the lateral and medial canthi.7 Histo-
logically, the lids may be divided into four portions:
the outermost layer of typical skin, the orbicularis
oculi muscle layer, a stromal layer that contains a
tarsal plate near the eyelid edge, and the innermost
layer of palpebral conjunctiva.7
Blood supply
Musculocutaneous vessels are the primary vessels
supplying the skin in humans, but they play only a
minor role in dogs and cats, rendering certain skin
grafting techniques commonly used in man of
limited use. In dogs and cats, direct cutaneous
arteries are responsible for supplying large areas of
skin. They run parallel to the skin in the hypo -
dermis and arise from perforator arteries (1).
Musculocutaneous arteries, which run perpen -
dicular to the surface of the skin, branch off the
perforator arteries and supply small portions of the
skin (1).
1 Diagram depicting the unique vascular supply to the animal
(feline and canine) skin and underlying tissues. 1, epidermis;
2, subcutis; 3, panniculus muscle; 4, skeletal muscle;
a, superficial plexus; b, middle plexus; c, deep or subdermal
plexus; d, segmental artery; e, perforator artery; f, direct
cutaneous artery. The perforator arteries that supply the
skeletal muscle terminate as small musculocutaneous arteries
perpendicular to the skin after supplying their direct
cutaneous arteries. The direct cutaneous arteries branch to
form a deep, middle and superficial plexus.9
1
2
3
4
d
ee
a
b
c
f
1
Introduction 11
Terminal arteries and veins branch from
the direct cutaneous vessels and form the subdermal
(deep or subcutaneous) plexus, cutaneous (middle)
plexus and subpapillary (superficial) plexus (1).2–4,8,9
When a cutaneous trunci muscle is present, the
subdermal plexus lies both superficial and deep to
the muscle. The vessels of the subdermal plexus also
run in the subcutaneous fatty tissue of the middle
and distal portion of the limbs, where the cutaneous
trunci muscle is absent. The superficial and middle
plexuses lie within the dermis. The capillary loop
system that originates from the superficial plexus
and supplies the epidermis is poorly developed in
dogs and cats compared to man, apes and swine.3
The subdermal plexus in dogs and cats is therefore
of major importance in reconstructive skin surgery
and should always be preserved when undermining
skin for local flaps, especially when no direct
superficial arteries can be incorporated into the
proposed flap. Axial pattern flaps are based on
direct cutaneous arteries and veins that supply a
specific region of dermal tissue. Since the terminal
branches of these vessels supply the subdermal
plexus, axial pattern flaps have better perfusion
than local flaps and are widely used in veterinary
reconstructive surgery. The main canine integu -
mentary vasculature, with its superficial arteries, is
illustrated in 2.10
2 Topographical anatomy of the superficial arteries of the canine skin used in axial pattern flaps. 1, facial; 2, superficial temporal; 3,
caudal auricular; 4, superficial cervical branch of omocervical; 5, cutaneous branch of thoracodorsal; 6, lateral thoracic; 7, superficial
brachial; 8, cranial superficial epigastric; 9, caudal superficial epigastric; 10, deep circumflex iliac; 11, cutaneous branches of
superficial lateral coccygeal; 12, medial genicular; 13, saphenous.10
1
2
3 4
5
6
8
9
10
11
12
13
7
2
Introduction12
Skin tension
Tension on the wound edges is the most common
reason for skin reconstructions to fail and occurs
when insufficient skin is available to close the initial
defect. Closing wounds under tension, particularly
on extremities, may create vascular and lymphatic
compromise to distal areas or reduce perfusion to
wound edges, thus causing delayed healing or
wound dehiscence.11,12 Eyelid reconstruction is
further complicated by the fact that tension and scar
formation can interfere with eyelid movement and
affect corneal function. 
The elasticity of canine and feline skin is
primarily the result of the lack of firm attachment
of the subcutis to the bone, muscle and fascia. The
skin is loose and abundant on most parts of the
body, particularly on the neck and trunk, but is less
pliable on the limbs, tail and head, especially
around the bridge of the nose, nasal planum and
medial canthi. This is the result of linear alignment
of fibrous tissues within the skin in this area. The
skin tension lines have fixed directions on the
topographical anatomy of the dog.1,5,13–15 In breeds
with abundant skin (e.g. the Shar Pei), tension lines
are of less importance when considering recon -
structive surgery. 
The tension lines of the head and neck
region resemble the orientation of the underlying
muscles (3). The tension lines of the trunk are
perpendicular to the body axis and the tension lines
3 Skin tension lines of the head, neck, trunk and limbs in the dog.13 The tension lines of the head and neck region resemble the
orientation of the underlying muscles, while those of the trunk are perpendicular to the body axis. The tension lines of the limb are
generally parallel to the long axis of the limb on the cranial surface, but perpendicular to the long axis of the limb laterally and
caudally.
3
Introduction 13
of the dorsal thoracoabdominal region are parallel
to the body axis. The tension lines of the limbs are
generally parallel to the long axis of the limb on the
cranial surface, but perpendicular to the long axis of
the limb on the lateral and caudal surfaces (3).13
Generally, incisions should always be made
parallel to tension lines to minimize wound tension
during closure. Incisions that are made at an angle
or perpendicular to these lines may result in wound
deformation, wound dehiscence and necrosis.16
If incisions cannot be made parallel to the tension
lines, methods to reduce skin tension should be
employed on closure. These include (from simple to
more advanced techniques) undermining the wound
edges, selecting tension-relieving suture patterns,
using tension-releasing incisions, or skin stretching
and tissue expansion techniques. If these methods
do not allow primary closure of the wound, second
intention healing or reconstruction with skin flaps
or grafts have to be considered. 
Tension-relieving suture patterns
Mild tension on skin wound edges can usually be
relieved by using subdermal sutures, including the
strong subdermal fascia. The subdermal fascia
tolerates tension better than subcutaneous tissue or
the skin itself. Walking sutures in successive rows
can be used to relieve mild to moderate tension.
They gradually advance the skin from the edge of a
wound towards the centre (from both sides).
Walking sutures are placed throughthe fascia of the
body wall at a distance closer to the centre of the
wound than the bite through the subdermal fascia
(see Chapter 3).1,5
The most commonly used external tension-
relieving suture is the vertical mattress suture, but
horizontal mattress sutures, with or without rubber
tubing stents, and far-near-near-far or far-far-near-
near suture patterns can be used as well. Primary
wound closure and second intention healing are
discussed in Chapter 2, and tension-releasing
incisions, including releasing incisions, V-Y plasties
and Z plasties, are discussed in Chapter 3. Dis -
cussion of skin stretching and tissue expansion
methods is beyond the scope of this book. 
Skin flaps and their classification
Wounds can be closed by primary closure, delayed
primary closure or secondary closure or they can
heal by second intention (see Chapter 2).1,17 Skin
flaps useful for primary or secondary closure of
wounds of the integument can be classified using
different criteria (e.g. based on location, blood
supply or geometric shape). Classification based on
the blood supply of the flap distinguishes subdermal
plexus flaps from axial pattern flaps. Subdermal
plexus flaps are based on local skin vasculature
from the flap base, whereas axial pattern flaps are
based on a direct cutaneous artery and vein.
Erroneously, the term ‘pedicle flap’ is sometimes
used as a synonym for a subdermal plexus flap,
but pedicle flaps normally are based on
musculocutaneous vessels, which are of minor
importance in dogs and cats, as discussed above.5
The principle behind the technique is that local
skin in an area with relative abundance or
elasticity is used to close the primary wound. The
created secondary wound can be closed relatively
tension free.
Subdermal plexus flaps are easy to perform and
often recreate the appearance of the original hair
coat as well. However, they cannot be performed
in areas with movement or increased tension.
Additionally, the vascularity of the flap often limits
its length. A flap with a direct cutaneous artery
included has a better chance of survival than flaps
without. Increasing the length of the flap or failing
to include sufficient vascularity to the flap will
increase the chance of dehiscence of the tip of the
flap. The wider the base, the more chance that a
direct cutaneous branch is included in the flap, thus
improving viability. Subdermal plexus flaps can be
subdivided into advancement flaps, rotation flaps,
transposition flaps and interpolation flaps:18,19
• Advancement flaps are formed in adjacent skin
by making slightly diverging incisions from the
wound to the flap’s base, parallel to the tension
lines, to allow advancement into the wound.
The U-flap or French flap is a skin flap that is
mobilized by undermining and advancing the
skin in the direction of the wound axis. The
indications for this type of flap include
relatively square wounds and tension-free skin
in the direct vicinity of the wound. Slightly
divergent incisions will broaden the skin flap
base. Bilateral U-flaps will create an H-flap,
decrease tension and improve viability.
Many variations of this flap type, including
the V-Y, Z, reading man flap and rotation
flaps, have been described. 
• Rotation flaps are local subdermal flaps that
are pivoted over a defect with which they share
a common border. 
• Transposition flaps are rectangular local
subdermal flaps that bring additional skin into
defects when transposed, with one edge of the
flap being a portion of the original defect.5
• Interpolation flaps are rectangular flaps that
are rotated into a defect with the pedicle
passing over intact skin and usually sutured
into a tube. 
The skin fold advancement flap (SFAF) is a special
subdermal plexus flap that uses the abundance of
skin in the region of the proximal or caudal parts of
the limbs (skin fold) to close inguinal or sternal
defects.20
Introduction14
Axial pattern flaps contain a specific cutaneous
artery, vein and nerve that supply a specific region
of dermal tissue. Therefore, axial pattern flaps have
a more robust blood supply compared with
randomly chosen local flaps, which rely on the
subdermal plexus for their blood supply. When
surrounding tissue has been excised from the
supplying artery, but the flap remains attached to
the donor bed by this cutaneous vessel, the flap is
called an island or insular flap. A peninsular flap
remains attached to the skin surrounding the
cutaneous artery.21
Flaps created in adjacent skin are called local
flaps, of which the advancement, rotation and
transposition flaps are examples. Flaps where the
donor site is distant from the recipient (defect) area
are called distant flaps. They usually require
multiple-stage reconstruction and transfer, but can
be transferred in one stage by microvascular
anastomosis of an artery and vein. The inter pola-
tion flap, or tubed pedicle flap, is an example of a
distant flap. A tubed pedicle flap is used to walk an
indirect, distant flap to a recipient site (see Chapter
3). Pouch flaps (bipedicle) and hinge flaps (single
pedicle) are other distant flaps used to reconstruct
skin defects on the distal extremities. 
Chapter 4 presents the current knowledge on
microvascular transfers, provides background
information on transfers and location of recipient
vessels, describes the most successful techniques
used in veterinary medicine and provides a detailed
overview of the results of published scientific
articles in this field. Apart from these microvascular
techniques, free avascular skin grafts can be used.
They are most commonly used for defects that
cannot be reconstructed by direct apposition of skin
flaps (e.g. on the limbs). Skin grafts are segments of
epidermis and dermis that are completely detached
from the donor site (and donor vessels) and
transferred to a recipient site. Most skin grafts used
in dogs and cats are derived from the same animal
(autogenous). Allografts (same species, different
individual) and xenografts (different species)
have been described, but are not used routinely.
Skin grafts can also be classified as full or split
thickness. Full-thickness skin grafts incorporate the
entire dermis and epidermis and are more easily
harvested by veterinary surgeons who do not have
special equipment than split-thickness grafts. Skin
grafts are further classified as sheet, mesh, strip or
seed depending on the configuration of the
graft.11,15,17,22 Of these, full-thickness mesh grafts
are preferred for most wound reconstructions
because of their ease of use, success of graft take
and final cosmetic outcome. Mesh grafts are formed
by placing multiple staggered rows of parallel
incisions through the graft to allow expansion.
Additionally, the release of fluid (serum, blood
and exudate) produced by the host site is facilitated.
This mesh graft technique is also described in
Chapter 4. 
Flaps that contain tissue other than skin and
subcutaneous tissue are called compound or
composite flaps and may include muscle
(myocutaneous), cartilage or bone. When only
muscle is used, flaps are referred to as muscle flaps.
They have an excellent blood supply and tissue
volume and can be used for rebuilding defects of
the trunk, abdomen and limbs.23 Myocutaneous or
musculocutaneous flaps are compound flaps in
which a skeletal muscle is elevated with the over -
lying skin. These flaps have enjoyed considerable
popularity in human reconstructive surgery and
have clinical potential in small animal
reconstructive surgery as well. Several individual
muscles in the dog and cat are expendable
without sacrificing regional function and could
therefore be used. However, myocutaneous flaps
are more technically demanding to perform; in most
cases, local flaps, axial pattern flaps or free grafts
can and should be used instead. Muscle and
myocutaneous flaps are mainly used for recon -
struction of the trunk. They are described in detail
in Chapter 7 and include the external abdo minal
oblique and tensor fascia lata muscle flaps and the
cutaneous trunciand latissimus dorsi myocut -
aneous flaps. The latissimus dorsi flap is suitable for
closing defects on the trunk and on the forelimb as
low as the elbow joint. The cutaneous trunci flap is
a thinner flap and can be used to close defects on
the thoracic and abdominal region as well as large
wounds more distal on the forelimb. The latter flaps
have great potential because of their size, ease of
elevation, expendability and versatility. Whereas it
was previously assumed that the latissimus muscle
had to be included when har vesting these com -
pound flaps in order to reduce flap necrosis, no
significant differences were found in flap survival
rates between cutaneous trunci and latissimus dorsi
flaps.24
Finally, omental flaps can be used to cover soft
tissue defects. As with muscle flaps, they enhance
healing by combating infection, controlling adhe -
sion and contributing to circulation and drainage. 
Selection of a particular technique is influenced
by the size and location of the wound and the
availability of adjacent donor skin. In most
instances, more than one option is available and
some wounds may require a combination of
flaps.21,23 The most commonly used reconstructive
Introduction 15
techniques are described in this book. The relatively
easy reconstruction techniques that can be
performed on any part of the body are discussed in
Chapter 3, starting with the simplest techniques and
progressing to the more complex procedures.
Reconstruction of specific anatomical areas is sub -
sequently discussed in Chapters 5–9, describing the
flaps from cranial to caudal and from proximal to
distal. Chapters 5 and 6 describe reconstruction of
the facial area (head and eyelids, respectively),
Chapter 7 describes reconstruction of the neck and
trunk and Chapters 8 and 9 describe
reconstructions of the forelimb and hindlimb,
respectively. 
Reconstruction of the head
Reconstruction of facial defects is often required
after radical resective surgery of tumours, for
closure of traumatic wounds, for the repair of burns
or chemical damage to the skin and for a variety of
palpebral problems. However, facial defect
reconstruction can be very challenging, as not only
is cosmesis of importance to owners, but the repair
of defects in close proximity to the eyes, nostrils,
ears and lips must provide for normal function of
these structures and prevent secondary problems.22
The specificity and complex nature of eyelid
reconstructive surgery and how it relates to surface
ocular problems is discussed in a separate,
dedicated chapter (Chapter 6).
The bridge of the nose is more difficult to
reconstruct than other areas of the face due to a
paucity of local tissues. A modified nasal rotation
flap (see Chapter 5) has been adapted by the
authors for use in veterinary patients as it allows
for a cosmetic closure of this difficult area using
local tissues. Both unilateral and bilateral versions
of this flap are described.
As lips often have an abundance of loose skin,
especially in dogs, most lip defects can easily be
reconstructed using geometric closure techniques
and advancement of local tissues. With the help
of surgical textbooks, simple rectangular and
wedge resections should not create a problem
for veterinary surgeons. Full-thickness labial
advancement of the lower and upper lip, buccal
rotation and labial/buccal reconstruction with
transposition skin flaps are more elaborate surgical
techniques and are discussed in Chapter 5. 
Most other facial defects can be closed using
local available tissues. Subdermal plexus flaps and
axial pattern flaps are the most useful techniques
for this purpose. Examples of subdermal plexus
flaps commonly used in this area are the
transposition flap, the rotation flap and the
advancement flaps. These techniques are described
in Chapter 3. The three axial pattern flaps that can
be used for the reconstruction of large facial defects
are the facial artery, superficial temporal and caudal
auricular axial pattern flaps, all of which are
described in Chapter 5. The omocervical axial
pattern flap can be used for reconstruction of the
caudal parts of the head in some patients, but is
more commonly used in the neck area and therefore
described in Chapter 7. Finally, in addition to the
above-mentioned techniques, defects involving the
auricle can be closed using subdermal plexus flaps.
When small avulsions of the ear heal by second
intention, the wound margins will contract, leaving
a cupped or folded ear. The treatment of small
avulsions of the pinna is purely cosmetic (i.e.
resection of the surrounding tissue to form a new
contour of the pinna). This flap is described in the
literature as a pedicle flap for repair of large defects
of the ear, using skin located on the neck and/or the
dorsum of the head, and it is discussed in Chapter 5.
Eyelid reconstructive techniques
There are over 20 individually recognized
techniques for surgery of the eyelids in the
veterinary literature. This book describes only those
that pertain to the reconstruction of large eyelid
defects, whether caused by aplasia, trauma or
tumour removal. Additionally, flaps designed for
the reconstruction of eyelid shape and position
relative to the eye are included. 
There are several points that apply specifically to
eyelid surgery and must be considered by the
surgeon during eyelid reconstruction. Eyelid tissue
is extremely delicate and very well perfused. Eyelids
heal relatively fast, but they also swell markedly in
the postoperative period. Although swelling is
usually a short-lived problem, it can lead to an
inability to blink, unwanted trichiasis (skin hairs
that contact the eye) and patient discomfort. Until
swelling subsides, the use of a temporary tarsorr -
haphy can prove very helpful in such cases. 
Maintenance of eyelid function and anatomy
must be considered by the surgeon when per -
forming eyelid reconstructive surgery. The eyelids
serve a very important function in keeping the eye
protected and in spreading the tear film and
removing debris from the corneal surface. Direct
closure of an eyelid defect should only be attempted
when the defect accounts for less than 25% of the
length of the eyelid, as closure is unlikely to
interfere with eyelid function in these cases.25
Closure of larger defects requires reconstruction
with other techniques such as Z- and H- plasties
and flaps such as the rhomboid flap, lip-to-eye
Introduction16
mucocutaneous subdermal plexus rotating flap,
modified cross-eyelid flap and superficial temporal
artery axial pattern flap. As the upper eyelid is more
mobile than the lower eyelid, some of these
procedures are designed to favour its complete
reconstruction by using tissue from the third eyelid
or the lower eyelid.
Reconstructions that allow for an eyelid margin
that is as anatomically correct as possible are pre -
ferred. However, recreating a hair-free eyelid margin
can be difficult, as many techniques resort to the use
of peripalpebral skin. In order to resolve this problem,
some surgeons advocate suturing conjunctiva to the
edge of the new eyelid tissue. Others (personal
communication, Prof. M. Boevé) suggest cutting the
edge of the transposed skin that serves as the new
eyelid margin at a 45° angle to its surface so as to
eliminate hair follicles from the transposed edge. As
meibomian gland secretion prevents evaporative loss
of the tear film, removal of a large percentage of the
eyelid margin could predispose the eye to dryness.26
Therefore, tear film quality should be re-examined
before and after surgery. 
Reconstruction is also indicated when
misalignment of the eyelids with respect to the eye
has developed over time (i.e. marked partial facial
droop and upper eyelid entropion–trichiasis).
This misalignment can cause corneal irritation and
interfere with sight. The aim in such cases is to
reconstruct the eyelids so that they are in an
anatomically correct position, they fit the globe
relative to its size and they do not shift away from
the eye with a change in headposition. 
Lastly, the medially located puncta of the
conjunctival side of the upper and lower eyelids are
an essential part of the nasolacrimal duct system
and should be preserved or reconstructed whenever
possible. Large, nonabsorbable suture material may
be used in punctal and canaliculi reconstruction by
feeding the suture all the way to the nasal ostium
and leaving it in place for re-epithelialization to
occur around it. 
Other points to consider are not exclusive to
eyelid surgery. Postoperative graft shrinkage may
lead to graft deformation. However, although a
small change in graft size may be relatively
unimportant elsewhere, in the eyelid it can lead
to trichiasis, ectropion, entropion, inability to blink
and secondary corneal problems. These are painful
and may compromise sight through pigmentary
or ulcerative keratitis and scarring. Therefore,
the eyelid reconstruction should always be slightly
larger than the defect it is meant to fill and it should
protrude approximately 1 mm from the wound
margin to allow for tissue shrinkage.25
Absorbable and nonabsorbable suture materials
may be used in eyelid reconstruction techniques,
which often require a two-layer closure. Deep
sutures should be absorbable and in either a simple
interrupted or simple continuous pattern. Skin may
be closed with absorbable or nonabsorbable
material depending on the proximity of the suture
material to the eye and how much patient
cooperation is required to facilitate their removal.
In this book, 6-0 polyglactin has been used for
closure of deeper tarsoconjunctivae and skin in
areas of close proximity to the eyelid margin. For
skin closure in areas not near the eyelid margin, 5-
0 polyamide or similar has been used. Generally,
when apposing two parts of the eyelid margin, a
tarsal plate ‘holding’ suture with a buried knot is
placed before alignment and apposition is achieved
with a figure-of-eight suture pattern. Thin eyelids
may only allow for a figure-of-eight pattern that
has to hold, align and appose the tissue. Needle
designs include reverse cutting and round choices.
Magnification (2.5" to 4") is recommended when
performing eyelid surgery as it helps the surgeon to
visualize the entry and exit points of fine suture
material and to identify delicate structures such as
the lacrimal puncta.
Finally, the skin should be prepared aseptically
prior to surgery. However, soap-containing
solutions should be avoided in areas near the eye.
For eyelid and ocular surface preparation, dilute
solutions of iodine in sterile saline are commonly
used. A solution of iodine in saline in a ratio of 1:10
may be used for preparing the eyelid tissue and a
1:50 ratio may be used for preparing conjunctival
surfaces; higher concentrations could be slightly
irritating to the conjunctival and corneal
epithelium. Conjunctival tissues should be carefully
and thoroughly irrigated. Sterile cotton buds may
be used with care if hairs and mucus need to be
removed. Skin should be free of infection and
prophylactic, postoperative, topical and oral
antibiotics should be used as needed.
Reconstruction of the eyelids is described in
Chapter 6 and includes H-plasty, Z-plasty,
semicircular flap, rhomboid flap, modified cross-lid
flap, lip-to-eye flap and the superficial temporal
artery axial pattern flap techniques. Reconstruction
of misalignment of the eyelids with respect to the
eye is also covered in Chapter 6. The selected
techniques increase in complexity from the
arrowhead method for correction of lateral canthal
entropion involving the upper and lower eyelid, to
the Stades technique for correction of upper eyelid
entropion–trichiasis and the Munger–Carter flap
adaptation of the Khunt–Szymanowski–Fox–Smith
procedure.
Introduction 17
Reconstruction of the neck and trunk
Reconstruction of skin defects in the neck or trunk
area is usually relatively easy in dogs and cats
because of the considerable amount of loose skin in
this area. In most cases, defects can be closed using
local skin flaps. However, after radical resective
surgery of tumours, for closure of large traumatic
wounds or for reconstruction in areas with
compromised blood supply, other techniques have
to be used. In addition, reconstruction of the caudal
part of the trunk, and in particular the perineal
area, is more challenging because of less available
skin.
The axial pattern flaps that can be used for
reconstruction of large defects in the neck or trunk
area are the omocervical, the thoracodorsal and
the cranial and caudal superficial epigastric flaps.
The first three flaps are described in Chapter 7. The
caudal superficial epigastric axial pattern flap is
described in Chapter 9, since this versatile flap
is more commonly used to close defects of the
hindlimb.
The muscle and myocutanous flaps that can be
used for reconstruction of the neck and trunk in
dogs and cats are also described in Chapter 7. They
include the external abdominal oblique and tensor
fascia lata muscle flaps and the cutaneous trunci
and latissimus dorsi myocutaneous flaps.
Reconstruction of surgical wounds in the
perineal region is challenging, since local skin is
often not applicable for local flaps because of a high
risk of necrosis. However, an axial pattern tail
flap, based on the lateral caudal arteries, can be
used to close large caudodorsal trunk and perineal
defects. The scrotal flap, used as a subdermal plexus
flap, can also be used to close defects in the perineal
area. Finally, excessive skin folds around the vulva
require episioplasty or vulvoplasty in case of
perivulvular dermatitis, but excessive skin here can
also be used to close adjacent defects. Chapter 7
ends with a description of these three techniques. 
Reconstruction of the forelimb
Reconstruction of skin defects of the forelimb, as
described in Chapter 8, can be complicated because
of the lack of loose skin and the fact that most
axial pattern flaps will not be able to reach the
distal part of the limb. In small lesions, defects can
be closed using local skin flaps. However, after
radical resective surgery of tumours, for closure of
large traumatic wounds or for reconstruction in
areas with compromised blood supply, other
techniques have to be used. 
The axial pattern flaps that can be used for
reconstruction of large defects in the forelimb
include the omocervical, the thoracodorsal, the
cranial superficial epigastric, the lateral thoracic
and the brachial flaps. The latter will be discussed
in Chapter 8. Both the peninsular and island varia -
tions of the brachial axial pattern flap are described.
The forelimb fold transposition flap technique
utilizes the thin elastic skin fold of the forelimbs
and is a skin fold advancement flap, not an axial
pattern flap. Because of the sheer size of the flap,
minor vessels run within the flap and even the
lateral thoracic artery might be included. It is a
versatile flap that can be used for defects of the
upper arm or sternal region and is therefore
described in Chapter 8.
Two large myocutaneous flaps, the cutaneous
trunci and latissimus dorsi myocutaneous flaps, can
be created from the thoracolumbar region to close
defects of the forelimb. Both flaps, but especially the
thinner more mobile cutaneous trunci flap, can be
used to cover defects near the elbow joint. Since
they originate from the trunk and are also used to
close defects of the trunk, these flaps are described
in Chapter 7. The flexor carpi ulnaris muscle flap
can be used in cases of chronic recurrent problems
where other techniques have failed, or in cases with
large defects of the antebrachium where skin and
subcutis are lost and bone is visible. This muscle
flap is more likely to stay attached and remain in
place on a bony surface than skin flaps and is
described in Chapter 8. 
Reconstruction of defects involving the foot are
especially challenging. Many new techniques have
been developed to close these defects with a better
outcome than with local flaps, including fusion
podoplasty, segmental pad transfer and phalangeal(toe) fillet flap. The toe fillet technique is specifically
worth mentioning because of its versatility and
excellent results. Either digit 1 or 2 and digit 5 can
be used for this technique. All of the above-
mentioned techniques are described in Chapter 8.
Last, but not least, mesh grafting is often used for
distal limb lesions, especially in cats, when no local
tissue is available at all. This technique is described
in Chapter 4.
Reconstruction of the hindlimb
Surgeons have more options for reconstruction
of skin defects of the hindlimb than the forelimb.
In small lesions, defects can be closed using local
skin flaps. However, as with the forelimb, other
techniques have to be used for closure of large
wounds.
The axial pattern flaps that can be used for
reconstruction of large defects in the hindlimb
include the deep circumflex iliac, the caudal
Introduction18
superficial epigastric, the genicular and the reversed
saphenous conduit flaps. The latter technique is
unique because of the ligation of veins and
arteries proximally, reversing the blood flow. An
adequate blood supply is secured through
anastomoses with other vessels. The hindlimb
(flank) fold transposition flap technique utilizes the
thin elastic skin flank fold of the hindlimbs in
a similar way to the transposition flap of the
forelimbs. This versatile flap can be used for defects
of the upper limb or inguinal region. Both the
unilateral and bilateral techniques are described in
Chapter 9. Muscle flaps that can be used on the
hindlimb are the cranial and caudal sartorius flaps. 
Options for reconstruction of defects of the foot
of the hindlimb are similar to those of the forelimb.
In addition to the techniques described in Chapter
8, metatarsal pad transfer as a salvage procedure
for extensive damage to the underfoot is described
in Chapter 9.
Wound closure techniques
Most plastic surgery and reconstructive techniques
used in dogs and cats involve the creation of new
surgical wounds. The general surgical principles of
using aseptic techniques, proper instruments and
delicate tissue handling while creating a surgical
wound apply here as well. In addition, appropriate
suture materials and suture techniques must be
used for reconstructive surgery. For a complete
discussion of types of suture materials and suture
techniques, the reader is referred to general surgical
textbooks. The authors prefer to use monofilament
absorbable suture material of the smallest size
possible for apposition of subcutaneous tissues.
Depending on the size of the animal, monofilament
absorbable 2-0 to 4-0 suture material (e.g.
polyglecaprone) is advised. Both interrupted and
continuous suture patterns can be used. The inter -
rupted suture technique can be modified to allow
for a decrease in skin tension; for example, using a
walking suture pattern or mattress suture pattern as
discussed above. 
For most types of grafts, skin closure using
nonabsorbable suture material in an interrupted
pattern is the preferred option, again with a
preference for monofilament over braided material.
Nonabsorbable monofilament 3-0 or 4-0 suture
materials (e.g. polyamide) generally suffice.
However, where appropriate, straight wounds can
be closed by suturing only the subcutaneous or
subcuticular layers in a continuous pattern,
resulting in a highly cosmetic outcome. Mono fila-
ment absorbable material is most commonly used.
Finally, tissue glue or skin staples can be used for
skin closure in reconstructive surgery; however, the
cost of tissue glue limits its use, as generally large
wounds have to be closed. Skin staples are
increasingly used, since they are easy to insert and
allow for rapid closure without loss of safety or
cosmetic effect. The end result of stapling the skin is
no worse than that of interrupted skin sutures, but
it is less cosmetically attractive than using a
continuous subcutaneous suture pattern. The in -
creased cost of staples compared with normal
suture material usually outweighs the cost of the
increased anaesthesia and surgical time required
when large flaps have to be sutured. In this book,
both interrupted skin sutures and staples have been
used for skin closure. 
Complications in performing plastic
and reconstructive surgery 
Complications of wound closure in plastic and
reconstructive surgery are similar to those in
general soft tissue surgeries and include wound
dehiscence, infection, haematoma or seroma form -
ation and excessive scar formation. In addition,
closure of wounds on the extremities under
excessive tension can lead to oedema or circulatory
compromise of the tissues distal to the
wound.15,17,21,27,28 Most complications can be
avoided by proper preoperative planning and
skin mobility assessment, by using a meticulous
surgical technique and achieving haemostasis.
The chances of flap survival will increase if the size
and localization of the wound is suitable for
receiving the flap, if the wound is neither contami -
nated nor infected and if the wound is not more
than 4–6 hours old. It is also important that the
recipient bed for the flap is properly prepared.
Reconstruction can be carried out immediately after
tumour resection or on a fresh wound. In other
cases it is advisable not to close the wound too soon
and to wait until contamination is resolved, the
local circulation has improved and a healthy gran -
ulation bed has formed. Contaminated or infected
wounds should be managed (delayed closure) for a
few days with medications and bandages until all
tissues are ready for closure (see Chapter 2).
Infection is, next to excessive skin tension, the
major cause of flap rejection. Thus, the preparation
of a healthy wound bed is one of the most
important aspects of reconstructive surgery.
Another potential complication is the
development of dead space, which can lead to
the formation of abscesses, seromas or haem -
atomas.15,17,21,27,28 Formation of dead space can be
overcome by placing drains, using subcutaneous
and walking sutures and applying bandages. The
authors recommend the use of either passive or
active drains whenever possible, while taking care
not to damage the blood supply at the base of the
flap by making exit ports. 
Whenever possible skin flaps should be bandaged
after surgery to provide support, prevent (self-
inflicted) trauma and allow for absorption of
wound fluids. The wound and flap should be exam -
ined at regular intervals postoperatively to check if
there is oedema because of impaired venous or
lymphatic outflow, infection or colour changes.
Tension can be relieved by making releasing
incisions. Some degree of ischaemia resulting in
necrosis may occur in any flap. With partial-
thickness necrosis, the necrotic tissue usually
sloughs spontaneously and re-epithelialization
occurs rapidly from the graft margins. When
necessary, gentle wound debridement can be
helpful. Full-thickness necrosis is best treated by
wound debridement and proper wound manage -
ment (see Chapter 2). Clean wounds can be allowed
to heal by second intention healing or a new
reconstructive procedure can be planned. 
References
1. Swaim SF, Henderson RA (1997) (eds) Small
Animal Wound Management, 2nd edn.
Williams & Wilkins, Philadelphia, 
pp. 143–275.
2. Pavletic MM (1991) Anatomy and circulation
of the canine skin. Microsurg 12:103–112.
3. Dyce KM, Sack WO, Wensing CJG (1996)
(eds) Textbook of Veterinary Anatomy.
WB Saunders, Philadelphia.
4. Scott DW, Miller WH (1995) Muller & Kirk’s
Small Animal Dermatology, 5th edn.
WB Saunders, Philadelphia, pp. 45–46.
5. Hedlund CS (2002) Surgery of the
integument. In: Small Animal Surgery, 2nd
edn. (eds TW Fossum, CS Hedlund, DA Hulse
et al.) Mosby, St. Louis, pp. 134–228.
6. Young B, Heath JW (2000) Wheater’s
Functional Histology, 4th edn. Churchill
Livingstone, Edinburgh, p. 157.
7. Samuelson DA (2007) Ophthalmic anatomy.
In: Veterinary Ophthalmology, 4th edn.
(ed KN Gelatt) Blackwell Publishing, Ames,
pp. 37–148.
8. Pavletic MM (1993) The integument. In:
Textbook of Small Animal Surgery,2nd edn.
(ed D Slatter) WB Saunders, Philadelphia,
pp. 260–268.
9. Daniel RK, Williams HB (1973) The free
transfer of skin flaps by microvascular
anastomoses: an experimenal study and a
reappraisal. Plast Reconstr Surg 52:16–31.
10. Evans HE (1993) Miller’s Anatomy of the
Dog, 3rd edn. WB Saunders, Philadelphia.
11. Smeak D (2006) Reconstruction techniques
using tension relieving and axial pattern flaps.
Proceedings of 13th ESVOT Congress,
pp. 146–150.
12. Anderson D (1997) Practical approach to
reconstruction of wounds in small animal
practice. Part 2. In Pract 19:537.
13. Oiki N, Nishida T, Ichihara N et al. (2003)
Cleavage line patterns in Beagle dogs: as a
guideline for use in dermatoplasty. Anat
Histol Embryol 32:65–69.
14. Irwin DH (1966) Tension lines in the skin of
the dog. J Small Anim Pract 7:593–598.
15. Hedlund CS (2006) Large trunk wounds.
Vet Clin North Am Small Anim Pract
36:847–872.
16. Straw R (2007) Reconstructive surgery in
veterinary cancer treatment. Proceedings of
the World Small Animal Veterinary
Association, Sydney.
Introduction 19
Introduction20
17. Pavletic MM (2010) Atlas of Small Animal
Wound Management and Reconstructive
Surgery, 3rd edn. Wiley–Blackwell, Ames, 
pp. 31–50.
18. Gregory CR, Gourley IM (1990) Use of flaps
and/or grafts for repair of skin defects of
the distal limb of the dog and cat. Probl Vet
Med 2:424–432.
19. Pope ER, Swaim SF (1986) Wound
management in cats. Vet Med 81:503.
20. Hunt GB, Tisdall PL, Liptak JM et al. (2001)
Skin-fold advancement flaps for closing large
proximal limb and trunk defects in dogs and
cats. Vet Surg 30:440–448.
21. Dupré G (2007) Complications in plastic
and reconstructive surgery. Who is guilty:
the patient, the owner, the vet? Proceedings
of the 56th Congresso Internazionale
Multisala SCIVAC, Rimini, pp. 207–208.
22. Pope ER (2006) Head and facial wounds
in dogs and cats. Vet Clin North Am Small
Anim Pract 36:793–817.
23. Szentimrey D (1998) Principles of
reconstructive surgery for the tumor patient.
Clin Tech Small Anim Pract 13:70–76.
24. Pavletic MM, Kostolich M, Koblik P et al.
(1987) A comparison of the cutaneous trunci
myocutaneous flap and latissimus dorsi
myocutaneous flap in the dog. Vet Surg
16:283–293.
25. Stades F, Gelatt KN (2007) Eyelid surgery.
In: Veterinary Ophthalmology, 4th edn.
(ed KN Gelatt) Blackwell Publishing, Ames,
pp. 563–617.
26. Ofri R, Orgad K, Kass PH et al. (2007)
Canine meibometry: establishing baseline
values for meibomian gland secretions in
dogs. Vet J 174:536–540.
27. Degner DA (2007) Facial reconstructive
surgery. Clin Tech Small Anim Pract
22:82–88.
28. Pope ER (1996) Plastic and reconstructive
surgery. In: Complications in Small Animal
Surgery. (eds AJ Lipowitz, DD Caywood,
CD Newton, A Schwartz) Williams &
Wilkins, Baltimore, pp. 641–662.
• Introduction
• Wound healing 
• Wound management
• A protocol for wound management in dogs and cats
• Cost-effectiveness and patient and owner benefit
• Conclusion/summary
• References
Chapter 2
Wound management: a new
protocol for dogs and cats
Tosca van Hengel, Gert ter Haar and Jolle Kirpensteijn
21
Introduction
Wounds can be defined as injuries to the body
that result in disruption of the continuity of the
body structure.1 They are encountered frequently
in veterinary practice and therefore a veterinarian
should be familiar with all processes involved in
wound healing and the options for wound
management. Although there are differences in
the types of wounds, which include incisions,
abrasions, burns, avulsions, ruptures, punctures,
contusions, lacerations and bite and shot wounds,
the main principles of wound healing are the same
for all types.
Wounds can be classified in several ways. One of
the most important distinctions to make is between
open and covered, or closed, wounds. In closed
wounds the superficial layer is still intact and
protects the wound against contamination; in open
wounds there is a disruption of the skin or mucous
membrane. Further classification of open wounds
can be based on the degree of contamination, which
partly depends on the duration of the injury:2–4
• Category 1. Clean wounds: nontraumatic
wounds not involving the respiratory,
oropharyngeal, gastrointestinal or urogenital
organs with no visible contamination; within
0–6 hours after surgery.
• Category 2. Clean-contaminated wounds:
nontraumatic wounds where respiratory,
oropharyngeal, gastrointestinal or urogenital
organs are opened without spillage of contents;
clean wounds in which a drain is placed; in
cases of small breaches in aseptic technique;
within 0–6 hours after surgery.
• Category 3. Contaminated wounds:
traumatic wounds less than 4–6 hours old;
inflammatory processes without purulent
exudate; procedures that are contaminated
with contents of the gastrointestinal organs
or infected urine; serious breaches in aseptic
technique.
• Category 4. Infected or dirty wounds:
traumatic wounds more than 4–6 hours old
or with obvious contamination or signs of
infection (4); inflammatory processes with
purulent exudate or necrotic tissue;
perforation of the gastrointestinal organs or
infected urogenital organs and serious faecal
contamination. An infected wound contains
more than 105 bacteria per gram of tissue.
Wounds can also be classified by the length of time
they have been present (acute or chronic wounds)
and by the thickness of the skin surface that is lost
(full-thickness or partial-thickness). In chronic
wounds, underlying factors preventing wound
healing can usually be identified and need to be
addressed for standard treatment to be successful.
With full-thickness skin loss the complete dermis
and epidermis are lost, but with partial-thickness
skin loss the dermis is still partly intact. Adnexal
structures in the partly intact dermis can serve as a
source for epithelial cells, which are needed for
wound healing.3
Wound healing 
As stated above, all wounds heal in a similar
fashion, divided into four distinctive phases.
However, depending on the type of wound and
its classification, one or several phases of wound
healing can be accelerated, delayed or complicated
by several factors. In addition, several phases of
wound healing can be found at the same time in all
wounds. Although the phases of wound healing are
the same in dogs and cats, there are some important
differences in wound healing between these two
species and the clinician must take these into
Wound management: a new protocol for dogs and cats22
4 An infected wound with a purulent discharge and partial
dehiscence.
4
consideration.5–7 Every wound will follow the
general wound healing pathway of four consecutive
phases: the acute inflammatory phase; the
breakdown or debridement phase; the reparation
or proliferation phase; and the remodelling or
maturation phase.2–4,8–11 To aid wound healing,
to direct and stimulate the healing process and to
make the right decisions in wound management, a
clinician has to be familiar with these processes of
wound healing.
Inflammatory phase
Directly after wounding, the wound fills with blood
and lymph from damaged vessels. This is followed
by an immediate vasoconstriction of the damaged
vessels, mediated by catecholamines, serotonin,
bradykinin, prostaglandins and histamine, which
lasts 5–10 minutes and helps minimize blood loss.9
Subsequent vasodilation dilutes toxic substances,
provides nutrients and results in blood clot
formation mediated by activated platelets. The
blood clot protects the wound, dries to form a scab
and enables wound healing to proceed underneath
it. Vasodilation also allows fluid containing cells,
such as lymphocytes, polymorphonuclear cells
(PMNs) and macrophages, and chemotactic
factors, such as cytokines and growth factors, to
reach the injured area.1,3,4,8,9 The activated platelets
are also responsible for initiation of wound
healing through the release of cytokines and
essential growth factors. Within 24–48 hours,
local monocytes migrate into the wound and
become macrophages, whichalso produce a wide
array of essential growth factors. Wound macro -
phages, endothelial cells and fibroblasts mediate the
healing process from this point on.1,3,4,8,9 The
migration of PMNs, lymphocytes and macrophages
is stimulated by chemotactic factors such as
complement, growth factors and cytokines.1,3,4,8,9
Research has shown that PMNs, which dominate
the wound in the early stages, are not essential in
uncomplicated wound healing, but macrophages,
more dominant from day 5 on, are needed.3,9,12
The mediators that initiate inflammation in
healing wounds are soluble factors released by
resident cells of the wound bed and by platelets
and leucocytes delivered by the circulation after
the disruption of intact skin. These factors initiate
a series of events that attempt to stabilize the
wound, remove invading organisms and return
the wound to its pre-injury architecture. This
depends on the production, regulation and control
of inflammatory mediators (IMs).13 IMs are usually
found in two groups of wound healing soluble
factors: cytokines and growth factors. Cytokines
are extremely potent and usually act within a short
distance of their release as intracrine, autocrine or
paracrine signals. They can be subcategorized as
chemokines, lymphokines, monokines, interleukins
(ILs) and interferons (IFNs).13–15 The growth factors
that play essential roles in wound healing, such as
platelet-derived growth factor (PDGF), epidermal
growth factor (EGF), fibroblast growth factor
(FGF) and vascular endothelial growth factor
(VEGF), can be referred to as connective tissue
growth factors given their function locally and rare
systemic effects.13–15
The IMs currently known to be crucial to the
wound healing process are IL-1, IL-2, IL-4, IL-6, 
IL-8, granulocyte–macrophage colony-stimulating
factor (GM-CSF), G-CSF, M-CSF, macrophage
inflammatory protein (MIP)-1, monocyte chemo -
attractant protein (MCP)-1, neutrophil-activating
peptide (NAP)-2, IFN-inducible protein (IP)-10,
IFNs, transforming growth factor (TGF)-#, tumour
necrosis factor alpha (TNF-!), platelet factor 4
(PF4) and PDGF.13,15
More specifically, in the inflammatory stage,
platelets release PDGF, TGF-#, FGF and EGF,
which orchestrate the early chemoattraction and
activation of cells involved in wound healing. After
clot formation, epithelial cells begin to migrate from
the wound periphery onto the exposed tissue in
response to EGF, TGF-!, TGF-#, GM-CSF and
FGFs. These induce the epithelial cells to migrate
and cover the wound. Fibroblast proliferation is
stimulated by TGF-# and IL-1, angiogenesis is
activated by EGF and IL-8, and neutrophil wound
infiltration is triggered by TNF-! and NAP-2.13–15
The inflammatory phase is characterized by the
five classical signs of inflammation (i.e. redness,
pain, heat, swelling and loss of function; also
known as rubor, dolor, calor, tumor and functio
laesa, respectively).
Debridement phase
Necrotic or dead tissue impedes wound healing and
therefore its removal is an essential phase in the
healing process.8,9,16 This necrotic tissue is a
stimulus for inflammation and provides a good
environment for bacteria to proliferate. PMNs and
macrophages have an important function in
removing the debris and cleaning the wound
and are regulated by the previously-mentioned
cytokines and growth factors.13,15 As mentioned
above, macrophages play the most important role
by assuring cytokine secretion and secretion of
proteinases and other proteolytic enzymes that
digest damaged wound bed matrix and allow
migration by other connective tissue cells.
Wound management: a new protocol for dogs and cats 23
The inflammatory exudate formed in the previous
phase provides all the necessary phagocytic cells
and proteolytic enzymes to deal with the demar -
cation. This phase ends with the rejection of
nonvital tissue (5).4 In some instances these two
phases are combined into one phase. The next
phase, the proliferation phase, is marked by
invasion of fibroblasts, accumulation of collagen
and the formation of new endothelial structures. 
Proliferation phase
Approximately 3–5 days after injury, the signs of
inflammation subside, the wound becomes
cleaner because of the debridement process and the
repair of the wound can start. The proliferation
phase can be divided into three processes
(granulation, contraction and epithelialization) and
is characterized by proliferation of fibroblasts
and endothelial and epithelial cells.3,4,8,9 The period
before these phases is sometimes called the lag
phase because the wound does not gain strength in
the first few days after wounding.9 Monocytes, after
they have been activated to macrophages, produce
their own growth factors, including PDGF, TGF-!,
TGF-#, IGF-1, VEGF and TNF-! along with the
growth factors produced by damaged parenchymal
cells, and the stored growth factors released by
stimulated platelets. These cytokines orchestrate the
proliferative phase of wound repair. Fibroblasts
invade the wound and begin to lay down new
matrix mainly in the form of collagen and
glycosaminoglycans. Concurrently, neovasculari -
zation begins to take place and granulation tissue is
formed.3,8,9,13
Granulation
The main components of granulation tissue are
fibroblasts and capillaries. The capillary network
occurs through sprout formation of capillary
endothelial cells on the wound surface.4 Endothelial
buds and sprouts are formed through mitosis and
these expand and contact other buds or already
hollow capillaries.4 Next, the capillary network is
intertwined with fibroblasts. The fibroblasts
migrate from the surrounding tissues and develop
from fibrocytes, but they also originate from
undifferentiated pericapillary cells, mesenchymal
cells and monocytes. Fibrin and fibronectin in the
wound are important for the formation of
granulation tissue because they serve as a
framework to support inwardly growing cells.3,4,8,9
The fibroblasts produce collagen and fibrin is
slowly replaced by the collagen deposited.17,18 The
deposition of collagen is controlled by epithelial
cells and fibroblasts themselves, which both have
collagenase activity.3 Collagen production reaches
its maximum on approximately the 9th day of
wound healing, but the net collagen synthesis
increases up to 4–5 weeks after injury.4 Endo-
genously produced vitamin C is essential to the
production of collagen.3 Once the wound is filled
with granulation tissue, a reduction takes place of
the number of cells and the amount of collagen
fibres. Furthermore, the collagen fibres undergo
continuous remodelling by breakdown and rebuild -
ing of fibres.4
Granulation tissue is characterized by a red,
irregular surface because of the newly formed
capillary buds (6, 7). It is fragile tissue that
functions as a barrier to infection.8,9,18 A healthy bed
of granulation tissue acts not only as a barrier
against environmental contamination, but also as a
scaffold for migrating epithelial cells. The supply of
nutrients, the removal of toxic metabolites and the
presence of oxygen are the main factors that
Wound management: a new protocol for dogs and cats24
5 A wound with obvious necrosis and advanced demarcation
demonstrating the need for surgical debridement in order to
allow continuation of wound healing.
5
determine how the barrier functions.3 However,
hypoxia can stimulate the formation of new
capillaries.18
Wound contraction
The wound surface and the wound cavity become
smaller because of the specific activities of
fibroblasts with contractile properties during and
after the formation of granulation tissue in the
wound. These specialized fibroblasts, called myo -
fibroblasts, are the main contributors, but normal
fibroblasts are also capable of aiding wound
contraction.3,4,8,17 Myofibroblasts attach themselves
to the dermis under the skin edges and to the
underlying fascia or panniculus muscle layer.3 They
orientate themselves parallel to each other on the
wound surface. After attaching they contract,
pulling the adjacent skin to the centre of the
wound.3Wound contraction thus involves a process
that pulls the borders of the skin adjacent to the
wound towards the centre of the wound. This
centripetal movement is especially striking in areas
of the body with loose skin (e.g. the trunk). The
quantity and elasticity of the skin differ between
species and breeds. Wound contraction normally
begins 5–9 days after wounding.9
Wound contraction stops when the tension of the
surrounding skin becomes too high or when the
edges of the wound contact each other. If wound
contraction is excessive, wound contracture can
occur. This is a pathological process and results in
limited motion of the underlying structures.11
Excessive granulation tissue can impede contraction
by preventing the skin from gliding over the wound
surface. Also, a normal amount of granulation
tissue can impede wound healing when it is of poor
quality.17 Another factor that can inhibit wound
contraction is pressure on the wound, because the
wound edges are pushed away from each other.17
When applying a bandage, it is recommended that
pressure is kept off the wound by distributing it
around the wound.17
After wound contraction, the surrounding skin
has been thinned. This will be restored by pro -
liferation of epithelial cells and connective tissue,
called intussusceptive growth.3,8,18
Wound management: a new protocol for dogs and cats 25
6, 7 (6) A large burn wound before debridement. (7) The same wound after 4 weeks of intensive care demonstrating a healthy
bed of granulation tissue.
6 7
Epithelialization
Epithelialization occurs when there is a partial or
full disruption of the epidermis. This process
includes proliferation of basal epithelial cells from
the adjacent skin edges and their moving over and
adhesion to the surface of the wound (8).3,4,8 The
cells fill in the area of the wound that is left after
wound contraction, provided the area to be covered
is not too large. The epidermal cells make use of the
underlying fibroangioblast tissue layer, which needs
to be healthy in order for proper epithelialization to
occur. The activity of the epithelial cells leads to
inhibition of the formation of granulation tissue
and prevention of excessive formation of granu -
lation tissue.4 In closed wounds, however, epithelial
cells migrate over the exposed dermis and through
the fibrin clot.8,18 The movement of new epithelium
stops due to contact inhibition. The total duration
of epithelialization can range from days to weeks,
depending on wound size and the condition of the
granulation tissue.8 During this stage of wound
healing, concentrations of growth factors involved
in earlier phases of wound healing are reduced,
while others including TGF-# are increased.
The surface of the wound that has become
epithelialized is known as the epithelial scar and is
Wound management: a new protocol for dogs and cats26
8 A wound showing healthy granulation (red) and advancing
epithelialization (pink).
9 A wound that has healed by second intention
demonstrating advanced maturation and obvious scar
formation.
thin and fragile.3 Therefore, care must be taken
when applying bandages to wounds in this phase
because migrating cells are easily removed from the
surface when changing the bandage.4
Maturation phase
The remodelling or maturation phase is charac -
terized by increasing strength of the scar as a result
of remodelling of tissue.4 Collagen III is replaced by
the stronger collagen I, the collagen bundles become
thicker and the number of cross-linkages between
collagen fibres is increased.1,3,4,8,11,18 The newly
formed collagen is arranged parallel to the tension
lines of the skin.3,8 This phase can take several
weeks to 1 year after the traumatic event, but
ultimately the healed wound will never regain its
original strength.9 In addition, the newly formed
skin has no or insufficient hair follicles, sweat and
sebaceous glands, poor moveability and elasticity
and an absence of pigment (9).4 The signals for the
remodelling phase are still largely unknown, but
blocking TGF-# activity has been implicated in
excessive scarring, suggesting that it may play a role
in halting scar formation by encouraging cell
apoptosis.15
8
9
Differences between acute and chronic
wounds
As mentioned above, wounds can be divided into
acute and chronic wounds. Understanding the
differences between these two types of wounds is
important for proper wound management. In
chronic wounds there is a lack of orderly pro -
gression through the four phases of wound healing
(10). The sequence of wound healing, described
above, is disturbed. For instance, the wound fluid in
chronic and acute wounds differs biochemically. In
chronic wounds the levels of inflammatory
cytokines are raised for a prolonged period and
there seems to be an excess of matrix
metalloproteinases (MMPs) and serine protein -
ases.13,19 These lead to a breakdown of the matrix,
which is needed for epithelialization, and to the
breakdown of the growth factors and cytokines
important for wound healing.19
An important cause of chronic wounds is
infection, which causes a sustained inflammatory
phase. Persistent inflammation results in further
trauma to wound tissue and prevents healing.20
Many other factors influence wound healing
including malnutrition, radiation, use of
corticosteroids and underlying metabolic
diseases.2,11,20 To resume the normal repair process,
these factors need to be addressed. 
Differences in wound healing between
dogs and cats
For many centuries it was thought that wound
healing was the same for all mammals. In the last
decades researchers have discovered that although
all species follow the same phases of wound healing,
they do not all heal in the same way. Differences
between horses and ponies and between rabbits and
humans were found, and there also seemed to be
differences between cutaneous wound healing in
dogs and cats.5–7 Research into wound management
has predominantly been in dogs. Recent studies in
cats make previous assumptions that results can be
extrapolated to cats questionable.
A few studies have been carried out to investigate
the differences between wound healing in dogs and
cats. One of these differences is the vascular supply
of the skin. One study showed that dogs appeared
to have a higher density of tertiary and higher order
vessels than cats. This was in accordance with a
laser Doppler perfusion study, which concluded that
the intact skin of cats was less perfused than the
intact skin of dogs.5,21 Additionally, the breaking
strength of a wound in cats is approximately 50%
less than that in dogs 7 days after primary closure.5
There is also a difference in the rate and pattern of
production of granulation tissue. The formation of
granulation tissue takes longer in cats compared
with dogs. In cats, granulation tissue first appears at
Wound management: a new protocol for dogs and cats 27
10 A chronic nonhealing wound on the hock of a dog.
the wound edges, in contrast to dogs where it
appears simultaneously on the entire exposed
surface.7 The colour of the granulation tissue is
paler in cats.7 Rates of wound contraction,
epithelialization and total healing are all reduced in
cats compared with dogs.7 However, the role of
subcutaneous tissue in wound healing in the dog
and the cat is similar in both species.6
Complications in wound healing also differ
between dogs and cats. Pseudohealing and
formation of indolent pockets are much more
common in cats.7 Pseudohealing refers to a sutured
wound that appears well healed but, after removal
of the sutures, dehiscence occurs under normal
stresses.7 Pseudohealing is often observed with bite
wounds. Indolent pockets, also called indolent
ulcers, are chronic pockets in the subcutis that are
lined with mature collagen and contain a thin,
serous, modified transudate.7 Wound contraction
does not occur in these wounds.17
Because of the lower breaking strength of sutured
wounds in cats, some authors have advised leaving
sutures for a few days longer in cats after surgery
comparedwith dogs.7 This is especially important
when larger parts of the subcutis have been
removed during surgery. More research is needed to
better understand the differences in wound healing
between the two species and to translate them into
practice.
10
Wound management
Many of the wounds that the veterinarian is
confronted with will heal naturally, but there are
wounds that may need intervention (e.g. large
wounds or necrotic and infected wounds). In
addition, some wounds may heal better, quicker or
have a better cosmetic outcome following some
kind of stimulation. 
In patients presented with acute wounds that are
still bleeding, the first step in wound management is
to stop the bleeding. With major haemorrhage this
can be performed by compression of the wounded
area.4 For minor bleeding, the use of specialized
dressings with haemostatic properties is possible
(e.g. alginates with calcium, adrenaline-soaked
gauzes or gelatin sponges).2,4
The second step and primary goal after stopping
significant haemorrhage is to try to reduce the level
of contamination and prevent further contam -
ination. Contaminated wounds are preferably
cleaned within the ‘golden period’. This period of
4–6 hours after wounding is the period in which a
contaminated wound can turn into an infected
wound because of proliferation of bacteria to more
than 105 per gram of tissue.3,4 Tissue invasion by
bacteria after this period makes it almost impossible
to remove them by irrigation.3,4
Debridement
Debridement is indicated whenever necrotic tissue
or debris exists in a wound and might impede
wound healing. Small amounts of debridement may
be feasible without sedation or anaesthesia, but
generally anaesthesia is required for aggressive
debridement. There are several methods of
accomplishing debridement of wounds: surgical,
mechanical, autolytic, enzymatic, chemical and
biosurgical.2,22 The objective of debridement is to
convert the open contaminated wound into a
surgically clean wound, which can be closed
primarily or secondarily or treated as an open
wound if closure is not possible.23 The choice of
which method to use depends on the wound and
the patient. Important factors to consider are
the amount of necrotic tissue, the laxity and
elasticity of the surrounding tissue, the presence or
absence of a clear demarcation line between
necrotic and viable tissue and whether or not the
patient can tolerate anaesthesia (11). Because of
these variable factors, more than one debridement
procedure may be necessary before a healthy wound
can be created.
Surgical
Surgical debridement is used most commonly and
involves the surgical removal of necrotic tissue from
the wound (12). It is especially important when
considering surgical closure of the wound. The goal
is to remove all obvious necrotic tissue and debris.
However, during the inflammatory phase of wound
healing, it is often difficult to distinguish necrotic
nonviable tissue from healthy viable tissue because
of incomplete tissue demarcation. The assessment
of tissue viability, often based on colour and
attachment, is subjective and there is a risk of
removing healthy tissue.2 The layered approach is
often used for surgical debridement.2 This means
that superficial devitalized tissue is removed first,
followed by the deeper tissues. Nonattached,
extremely light or dark tissues should be removed in
layers to the level where active bleeding is present.
Questionably viable tissue should be left in place
and re-evaluated later. The surgeon has to
take factors affecting tissue circulation, such as
vasoconstriction or vasodilatation, and tissue
Wound management: a new protocol for dogs and cats28
11 Debridement of an infected burn wound.
12 Surgical debridement.
11
12
temperature into consideration when using this
layered approach.2 En-bloc debridement involves
complete excision of the wound and all affected
tissue, with a border of normal tissue. This
technique should be reserved for wounds that are
obviously infected or where layered debridement
would not likely result in a healthy wound.2
Mechanical
Mechanical debridement is performed using wet-to-
dry or dry-to-dry dressings after layered surgical
debridement or as the sole means of debridement. In
the wet-to-dry technique, a primary dressing of
gauzes wetted with isotonic saline, lactated Ringer’s
solution (LRS) or 0.05% chlorhexidine diacetate is
placed on the wound.2,24 Several layers of wet gauze
followed by several layers of dry gauze should be
added and covered with an absorptive layer and,
finally, an external layer. As the fluid evaporates
and the bandage dries, it adheres to the wound
surface. When removing the dressing, the adhering
tissue is removed at the same time. Wet-to-dry
bandages are typically changed daily and used only
until healthy granulation tissue starts to appear in
the wound. Dry-to-dry dressings work by means
of the same principle, but there is no solution added
to the dressing. 
Although these forms of debridement are
effective in removing necrotic tissue and the
dressings are relatively cheap, they have several
disadvantages. Firstly, debridement is nonselective,
since both healthy and necrotic tissue adhere to the
dressing and are subsequently removed.2,24 The
removal of healthy granulation tissue and epithelial
cells, as well as wound fluid-containing growth
factors and cytokines, combined with the dry
environment created, can delay wound healing.
Furthermore, the risk of infection is increased and
because bandage changes are painful, multiple
sedations may be necessary. For these reasons and
because newer bandage materials are available
nowadays that interact with wound tissues and
keep the wound moist, some authors feel that wet-
to-dry and dry-to-dry dressings no longer meet the
expected standard of care in veterinary medicine.24
Autolytic
Autolytic debridement is the most selective method
of debridement and it is painless. Autolytic
debridement of devitalized tissue is essential to
promote wound healing. It depends on the whole
area being kept moist so that natural enzymatic
reactions can take place. Wound exudate is
preserved on the wound surface and natural
components, such as enzymes and leucocytes,
remove necrotic tissue. Autolytic debridement can
be performed with interactive dressings such as
hydrogels, hydrocolloids, hydrofibres and foam
dressings.2,9,24 Hydrogels are recognized as the
standard treatment in human medicine and are
considered to be gentle debriders, promoting
rehydration of nonviable tissues. Hydrosorb® and
Hydrosorb Comfort® are hydrocellular gel
dressings made from 60% water and are therefore
suitable for keeping granulation tissue and young
epithelium moist.25
Another example of autolytic debridement is the
use of honey or sugar, which can be applied as a
topical medication. Because of its high osmolarity, it
attracts fluids and provides a moist environment,
which encourages autolytic debridement.26–28
Enzymatic
With enzymatic debridement, proteolytic enzymes
are applied to the wound to break down the
necrotic tissue. It is a very selective method
of debridement and is painless. Proteolytic
enzymes or derivatives of bacteria (Bacillus
subtillis) can be used in wounds with small amounts
of necrotic tissue or debris. The enzymes are
processed in powders or creams, which can be
applied to the wound. The most commonly used
enzymes are trypsin, fibrinolysin, chymotrypsin,
desoxyribonuclease, papain-urea and collagenase.23
In animal wounds, enzymatic debridement is
sometimes used as an adjunct to mechanical and
chemical wound debridement, especially in patients
with a high anaesthetic risk. Enzymatic agents
break down necrotic tissue, yet leave viable tissue
intact, provided they stay in contact with the wound
for a sufficient time. However, the effectiveness of
enzymatic debridement is questionable and a long
exposure time is required to remove the nonviable
tissue.2,23
Chemical
Chemical debridement can be performed with
antiseptics such as Dakin’s solution (0.25%solution of sodium hypochlorite), chlorhexidine
(bisbiguanide chlorhexidine-diacetate solution,
0.05%), povidone–iodine (1%) and hydrogen
peroxide.22 However, it is a nonselective manner of
debridement and cells important for wound healing
are also damaged. Chemical debridement is not
generally recommended.
Biosurgical
Biosurgical debridement uses the placement of
medical maggots (Lucilia sericata) into the wound.
The maggots produce enzymes that dissolve the
necrotic tissue, but spare healthy tissue, and are
therefore selective.2,22 The maggots used for this
purpose are specially bred and therefore expensive.
Maggots may be indicated for management of deep
wounds, which are difficult to debride by other
means.
Wound management: a new protocol for dogs and cats 29
Wound irrigation and topical medications
Wound irrigation
Dirty or contaminated wounds can be cleaned by
irrigation. Obvious debris, necrotic tissue, dirt and
bacteria will be washed away by fluid under
pressure. Many fluids have been used for this
purpose including tap water, physiological solutions
(e.g. isotonic saline, LRS) or antiseptic solutions
(e.g. povidone–iodine, chlorhexidine diacetate,
sodium hypochlorite). 
In cases where there is severe contamination,
simple initial cleaning with warm tap water can be
performed.2 However, tap water has been shown to
be toxic to fibroblasts because it may contain
cytotoxic trace elements such as fluoride, nitrates,
arsenic, cadmium, copper, cyanide, lead, mercury
and selenium.8 Furthermore, it has an alkaline pH
and is hypotonic. This might result in intracellular
diffusion of water molecules, cellular and
mitochondrial swelling and, therefore, reduction of
oxidative phosphorylation and adenosine
triphosphate (ATP) production.8 However, the use
of tap water has never been proven to either delay
wound healing or increase the risk of wound
infection.29,30 The irrigation pressure should not be
too high because it may damage tissue and push
contamination further into the wound. Specialized
equipment, which produces a pulsating stream of
water with a pressure of about 0.6 kg/cm2 (8 psi), is
available.4 This pressure can also be achieved
by using a 19 gauge needle and a syringe of at least
30 ml (13).4
In minimal to moderately contaminated wounds,
cleaning should preferably be performed using
isotonic saline or LRS. In selected patients, dilute
antiseptic solutions such as 0.05% chlorhexidine or
1% povidone–iodine solution can be used. Saline
and LRS can remove bacteria and foreign matter
mechanically, are isotonic and should be used in a
sterile form. They can be used safely in any
situation, but are not bacteriostatic.2 They are used
widely with good results in wounds that are not
highly contaminated. Because the physical aspect of
wound cleansing is the most important function of
irrigation, the use of antiseptic solutions may not be
necessary. However, antiseptic solutions used in the
concentrations mentioned above aid in decreasing
bacterial contamination without resulting in
substantial damage to the exposed tissues.31
Topical antibiotics and antiseptics
When dealing with infected wounds, the use of
systemic antibiotics is preferred in order to prevent
the toxic effects on cells important for wound
healing that occur after topical administration.
However, for a systemically given antibiotic to
reach the wound area, a good blood supply is
Wound management: a new protocol for dogs and cats30
needed. In general, the use of antibiotics should be
minimized to prevent the development of bacterial
resistance and they should be used only for infected
wounds.32 When necessary, broad-spectrum
antibiotics are given for 5–7 days, preferably based
on the results of a bacteriological culture and
antibiogram (14). Pending the results of culture and
sensitivity, the initial antimicrobial therapy can be
guided by a Gram stain.2
The use of topical antibiotics and antiseptics is
controversial. They are used to prevent or treat
wound infections and to increase the rate of healing,
but research, especially in vitro, has shown that the
use of medications on wound healing may have an
adverse effect.2,31,33,34
Topical antibiotics should promote normal
healing by protecting the wound from infection.
However, topical antibiotics have no effect on dead
tissue, haematomas or proteolytic enzymes causing
necrosis. Infection results from bacterial invasion of
open lymphatics and blood vessels. Haemostatic
mechanisms seal the bacterial infiltrates in deeper
tissue. Pathogenic bacteria can replicate and
overwhelm local host defences, resulting in
infection. Antibacterial agents must be present in
sufficient quantities at the time of bacterial invasion
or within 1 hour to assist the host defences in
eliminating these pathogens.16,22,33 Topical and
systemic antibiotics have no beneficial effect once
infection is established. The presence of wound
coagulum prevents antibiotics from reaching
effective levels in deep tissues and prevents systemic
antibiotics from reaching superficial bacteria. The
effectiveness of topical and systemic antibiotics may
be extended to 24 hours with gentle cleansing of the
contaminated wound.16,22,33 Use of antibiotics
should never replace surgical, mechanical or
enzymatic debridement, but should be used in
combination with these procedures. Topical
antibiotic selection should be based on the
following considerations: spectrum of activity, dose,
pharmacokinetics, tissue and systemic toxicity,
timing, route of administration and type of
preparation (i.e. lavage, ointment, cream or
powder).16,22,33 The topical antibiotic selection
should be broad spectrum, bactericidal and have a
low risk of toxic or allergic reactions. Indications
include wounds older than 4 hours, marked soft
tissue injury or bacteria present after debridement.
Antibiotics should be administered at initial
presentation and be continued until 5 days after
wound closure or development of a healthy
granulation tissue bed. The advantages of
antibiotics over antiseptics include selective
bacterial toxicity, effectiveness in the presence of
organic matter and combined efficacy with systemic
antibacterial therapy.16,22,33 The disadvantages
include expense, reduced antimicrobial spectrum,
potential for bacterial resistance, creation of
superinfections and increased risk of nosocomial
infections. In addition, epithelialization may be
delayed by topical antimicrobials that have a
petroleum base. In-vitro studies have shown that
topical antimicrobials administered at bactericidal
concentrations are either cytotoxic or impair local
cell function. Commonly used topical antibiotics
are gentamicin, nitrofurazone, cephalosporins,
mafenide, triple antibiotic ointment (TAO), silver
sulfadiazine (SSD) and tris-ethylenediamine tetra-
acetic acid (EDTA).22
The general advantages of antiseptics such as
iodine compounds, chlorhexidine and hypochlorite
(Dakin’s) solutions over topical antibiotics are the
broader spectrum of activity against bacteria and
other microorganisms and fewer problems with
bacterial resistance.16,22,33 However, they are often
less powerful when a specific infection has to be
treated or prevented.16,22,33 Antiseptics should
preferably be applied to intact skin, since
application on open wounds can result in severe
tissue inflammation, which decreases resistance to
infection, wound strength, granulation tissue
formation, contractile ability and rate of
epithelialization. Furthermore, they increase the
intensity and duration of inflammation and are
toxic to human keratinocytes and fibroblasts.32
Gentamicin
Gentamicin has efficacy against gram-negative
bacteria and Staphylococcus spp. It has been used
as a topical antibiotic rather than a systemic one
because of the toxicity risks associated with the
latter. Wounds treated with 0.1% gentamicin
solution or cream have been shown to be
effective in controlling bacterial growth, with no
negative effects on wound contraction and
epithelialization.35,36 However, isotonicgentamicin
solutions are preferred as they do not inhibit wound
contraction and even promote epithelialization.10
Nitrofurazone
Nitrofurazone has a broad gram-positive spectrum
and also hydrophilic properties because of its
polyethylene base. Water is drawn into the wound
and the viscous exudate becomes thinner and more
diluted, making it less toxic and easier to absorb
into bandages. However, it may have a negative
impact on epithelialization.10,22
Cephalosporins
Cefazolin is characterized by a broad gram-positive
spectrum of activity and efficacy against some 
gram-negative organisms. Topically administered
cefazolin is highly bioavailable, reaches high
concentrations in the wound fluid and is rapidly
absorbed.10 In one study, patients treated for
Staphylococcus aureus infections by wound
irrigation demonstrated concentrations of
cefazolin in wound fluid well above the miminum
inhibitory concentrations, which remained high for
24 hours.37
Wound management: a new protocol for dogs and cats 31
13 Irrigation of a contaminated wound using a syringe and
needle.
14 Taking a swab from a contaminated wound for culture
and sensitivity testing.
13
14
Mafenide
Mafenide (hydrochloride or acetate) is a topical
sulpha compound, available as an aqueous spray,
with a wide spectrum activity against gram-negative
bacteria. Because mafenide is active against
Pseudomonas and Clostridium spp. and methicillin-
resistant Staphylococcus aureus (MRSA), it is
particularly useful for severely contaminated,
chronic wounds.10 It has been used mainly for the
treatment of burn wounds in humans, but allergic
reactions (contact and/or irritant dermatitis) have
been reported.38
Triple antibiotic ointment
TAO (neomycin, polymyxin B and bacitracin in
a petrolatum base) is a safe and effective topical
agent used mainly for the prevention of skin and
wound infections. It is effective against many
pathogenic bacteria, but usually not against
Pseudomonas spp. Resistance to TAO does not
develop readily and complications and adverse
reactions are rare.39 Because of its zinc content it
may stimulate epithelialization.10,22
Silver compounds
The best known silver compound antibiotic used
in wound dressings is SSD cream. SSD is a
combination of silver and the antibiotic
sulfadiazine. It is most commonly used in wound
dressings for burn treatment in humans, because of
the broad-spectrum action against pathogens
(especially against Pseudomonas spp.).22,32,33 Silver
is also used as an antimicrobiological component
of modern wound dressings in other patients.
However, side-effects, including allergic reactions,
silver staining of the wound, hyperosmolality,
methaemoglobinaemia and haemolysis, have been
reported.40,41 To date there is insufficient evidence to
establish whether silver-containing dressings
promote wound healing or prevent wound
infection.41
Iodine compounds
Two types of iodine formulations are available,
povidone–iodine and cadexomer iodine. The active
component against microorganisms of both these
products is free iodine, which has a broad
antimicrobial spectrum against gram-positive
and gram-negative bacteria, viruses, fungi and
protozoa.31,33,42 Povidone–iodine solution (0.1–1.0%)
is recommended as it is rapidly bactericidal, but not
cytotoxic, to cells responsible for wound healing.43
A disadvantage of the use of iodine is inactivation by
organic matter, which is always present in open
wounds; however, there is no known bacterial
resistance. Residual activity lasts only 4–8 hours,
therefore frequent reapplication of dressings is
required. Iodine absorption from the wound may
cause excess systemic iodine concentrations and
transient thyroid dysfunction. The low pH of the
solution can cause or intensify metabolic acidosis and
contact hypersensitivities may occur in as many as
50% of dogs scrubbed with povidone–iodine.10 In a
0.5% concentration, povidone–iodine is cytotoxic to
fibroblasts.10 While some in-vitro studies have shown
impairment of wound healing, others have
demonstrated improvement of wound healing when
povidone–iodine is used. However, the relevance of
these data for in-vivo conditions is questionable.44
The cadexomer iodine products are newer, less toxic
and have been found to be beneficial to wound
healing.33
Chlorhexidine solution
Chlorhexidine digluconate is frequently used for
wound lavage, but other solutions, including
chlorhexidine diacetate and chlorhexidine
dihydrochloride, have been used. Chlorhexidine
digluconate has a wide spectrum of activity against
gram-positive and gram-negative bacteria, but a
variable and inconsistent efficacy against viruses
and fungi. Chlorhexidine binds to the protein of the
stratum corneum of the skin, creating a persistent
residue that lasts for a few hours.36,45,46 The
bactericidal activity of chlorhexidine has been
reported to be significantly higher than the activity
of povidone–iodine in vivo.47 Chlorhexidine has a
low toxicity when used as a skin cleanser or as an
aqueous solution for wound asepsis.45,48 Even
though it may be toxic for fibroblasts in vitro,
rinsing with diluted chlorhexidine (0.05%) has no
negative effect on wound healing. However, when
used intra-articularly, this concentration may cause
synovial ulceration, inflammation and fibrin
accumulation.45 For wound irrigation a 0.02%
solution is recommended, but a less diluted 0.05%
solution can probably be used safely in dressings.48
Prontosan
Prontosan is a wound irrigation solution containing
polyhexanide, a polymeric biguanide and cationic
preservative. It inhibits the growth of micro -
organisms and aids in the removal of dirt and debris
from chronic wounds.49,50,51 It is commonly used as
an antiseptic in chronic wounds and burn wounds
in people, but to date there are no studies of its use
in companion animals. It has less toxicity on
primary human fibroblasts and keratinocytes than
other topical antiseptics.49 However, commercially
available wound dressing products can reduce the
antibacterial efficacy of poly hexanide.50 This is
most likely due to poly hexanide’s strong cationic
character and, therefore, its limited compatibility
with the anionic matrices that can be present in
certain wound dressing materials.50
Wound management: a new protocol for dogs and cats32
Dakin’s solution
Dakin’s solution (sodium hypochlorite 0.5%) is
bactericidal to the organisms commonly present
in open wounds. It releases free chlorine and
oxygen into tissues, killing bacteria and liquefying
necrotic tissue.10 It is detrimental to neutrophils,
fibroblasts and endothelial cells and therefore
most authors do not recommend the use of
Dakin’s solution in open wounds.10 However, there
is a renewed interest in its use nowadays because
of its aggressive debridement activity and its 
broad-spectrum activity against microorganisms.48
When used, it is indicated only for severely
contaminated or infected wounds and only early in
the debridement phase of wound healing. A
0.005% solution is recommended in these cases to
prevent cytotoxic effects on the cells responsible for
wound healing.16,31
Tris-ethylenediamine tetra-acetic acid
Tris-EDTA added to lavage solutions increases
the permeability of gram-negative bacteria to
extracellular solutes, making them more susceptible
to destruction by lysozymes, antiseptics and
antibiotics.10,22,52 Tris-EDTA solution can be
prepared by adding 0.5 g of EDTA and 6.05 g of
tris to 1 litre of sterile water. Sodium hydroxide
is used to adjust the pH of the solution to pH 8,
after which the solution can be mixed and
autoclaved for 15 minutes.10 Tris-EDTA in sterile
water rapidly lyses Pseudomonas aeruginosa,
Escherichia coli and Proteus vulgaris.10,22 The
addition of tris-EDTA to chlorhexidine gluconate
solution increases antimicrobial effectiveness and,
similarly, tris-EDTA has a synergistic activity
against bacteria when combined with topical
antibiotics.10,22,52
Glycerol
Glycerol (also known as glycerin) is a trihydroxy
alcohol usually obtained by saponification of
lipids.53In medicine, glycerol has been used in the
treatment of brain oedema, as a laxative and in
cough syrups, throat lozenges and suppositories.
The beneficial effects of the chemical on the skin
have been recognized for a long time and include
improvement of stratum corneum hydration, skin
barrier function and skin mechanical properties, as
well as acceleration of wound healing processes.53
Impairment of the epidermal cell proliferation
related to reduced epidermal glycerol content and
ATP was demonstrated in AQP3 null mice. Glycerol
supplementation resulted in correction of the
defective epidermal cell proliferation and enhanced
wound healing rates.53 Antimicrobial effects have
also been attributed to glycerol. An antimicrobial
effect, more pronounced at 36°C (96.8°F) than at
4°C (39.2°F), has been demonstrated. Gram-
negative species were found to be more susceptible
to glycerol than the gram-positive ones.53,54 Because
of its antimicrobial effects, while providing an
excellent moisturized wound healing environment,
glycerol is currently one of the most commonly used
topical medications used in dressings for wounds in
the repair phase of wound healing in the authors’
hospital.
Honey
Honey has been used in wound management for
centuries, but was partly forgotten by modern
medicine in the last century. Because of the growing
desire to use more natural products and problems
associated with bacterial resistance, a renewed
interest has taken place in the therapeutic use of
honey in wound management in both human and
veterinary medicine. Recent research has shown
that using honey can significantly reduce the total
healing time.55,56 The functions and mechanisms of
the action of honey on a wound are summarized in
Table 1.
Honey exerts antimicrobial activity because of its
high osmolarity and low pH. A low pH favours
repair of wounds. Honey contains inhibin, an
enzyme that generates hydrogen peroxide, and
glucolactone and/or gluconic acid, which act as a
mild disinfectant and mild antibiotic, respectively.
Honey also provides antioxidants, which protect
wound tissues from damage imparted by free
oxygen radicals.34,57,58
Wound management: a new protocol for dogs and cats 33
Table 1. Functions of honey.
• Antimicrobial activity.
• Anti-inflammatory activity.
• Decrease oedema.
• Neutralize odours.
• Stimulate granulation.
• Stimulate epithelialization.
• Source of nutrition.
Honey stimulates the processes of granulation
and epithelialization because of the improved
nutrition of cells important to wound healing, the
creation of a moist environment and because
hydrogen peroxide promotes angiogenesis, growth
of fibroblasts and the mobilization and activation of
epithelial cells.26,57,59,60 Debridement is also
stimulated by the osmotic effect and the moist
environment. When necrotic tissue is present,
however, surgical debridement is advised before
application of honey. 
Honey used for treatment of wounds should be
sterile, as nonsterile honey can contain Clostridium
botulinum spores, which can cause botulism.56,60
Sterilization must be done with gamma irradiation
because heat will destroy the enzymes and,
consequently, the antimicrobial activity of
honey.34,56,60
Honey has no reported toxic side-effects and is
nonadherent to the wound surface. (Note:
Application on open wounds is known to be painful
in humans.) Its use would be specifically indicated
in the treatment of wounds infected with bacteria
resistant to antibiotics and in chronic nonhealing
wounds (15).60–62 An occlusive or absorbent
secondary dressing is needed to prevent leakage of
the honey. Honey does not diminish wound exudate
and initially dressings have to be changed at least
daily. Once a healthy granulation tissue bed is
present and epithelialization has begun, application
of honey dressings may be ceased.34
Honey is a natural product and any effect could
be influenced by the species of bee, the flowers used,
geographic location or processing and storage
conditions.34,56,60 In addition, even though
inhibition of bacterial growth has been demon -
strated in vitro, the scientific merit of studies
suggesting increased wound healing has been
questioned.34
Sugar
Sugar has a similar hyperosmolarity-induced
antimicrobial effect to honey and it has also been
used in wound management.26,27 Since the
antimicrobial actions of sugar depend on its
concentration, this effect will be lost when sugar is
used in highly productive wounds.27 This problem
can partly be prevented by multiple (3–4 times
daily) bandage changes along with thorough
lavage of the wound in the first 24–48 hours.
Bandage changes can become less frequent when
undissolved sugar remains in the wound.34 Sugar
also provides nutrients, has a deodorizing action
and stimulates granulation and epithelialization.27
There are no known adverse effects of sugar
on wound healing, but application of sugar on
a wound is reported to be painful in humans.27
Sugar treatment should be replaced by treatment
with a (semi-)occlusive dressing, such as hydrogel or
hydrocolloid, after the formation of a healthy
granulation bed.22,27
Maltodextrin
Maltodextrin (a D-glucose polysaccharide) is
available in a hydrophilic powder or gel form
containing 1% ascorbic acid. It is used as a wound-
healing stimulant on contaminated and infected
wounds.10 It is reported to stimulate healing by
supplying glucose for cell metabolism via hydrolysis
of its polysaccharide component.10 Its hydrophilic
property draws fluid through the tissue, keeping it
moist. Maltodextrin causes chemotaxis of
neutrophils, lymphocytes and macrophages into the
wound. In addition to reducing odour, exudate,
swelling and infection, it may enhance early
granulation tissue formation and epithelial
growth.10,34,63 Maltodextrin also has antibacterial
and bacteriostatic properties.63 After debridement
and lavage, a 5–10 mm layer of maltodextrin is
applied to the wound. It should then be covered
with a nonadherent primary bandage followed
by absorbent wrap and outer tertiary bandage
layer, and changed daily.63 It can be used from the
early inflammatory stage to the repair stage of
healing.10
Tripeptide-copper complex 
Tripeptide-copper complex (TCC), a hydrogel with
chemoattractant properties for mast cells as well
Wound management: a new protocol for dogs and cats34
15 Application of a honey-based ointment to a chronic
nonhealing wound on the limb.
15
as monocytes and macrophages, stimulates several
biological activities during acute wound
healing.22,34,63 It is thought to increase angiogenesis,
collagen deposition, epithelialization and wound
proteases, ultimately improving the wound
environment.34,63 In dogs, TCC has been shown to
advance open wound healing, mainly stimulating
granulation tissue formation, especially during
the first 7 days.12,63 The median time for coverage
of the wound with granulation tissue was
significantly shorter using TCC in rabbits compared
with a control group.64 Topical TCC has also
been shown in a recent study to be an effective
stimulant of healing of ischaemic open wounds in
rats.65 TCC is applied to the wound after
debridement and lavage, starting in the late
inflammatory phase and continuing through the
proliferative phase. A nonadherent primary
bandage pad should then be placed over the wound,
followed by a secondary absorptive layer and a
tertiary outer layer, which need to be changed
daily.22,63
Zinc
Zinc is an essential trace element in the body and
serves as a cofactor in numerous transcription
factors and enzyme systems, including zinc-
dependent MMPs, that augment autodebridement
and keratinocyte migration during wound repair.66
Zinc deficiency of hereditary or dietary cause
can lead to delayed wound healing. Oral zinc
supplementation may be beneficial in some
human patients; however, topical administration
appears to be superior. This is due to its action in
reducing superinfections and necrotic material
(autodebridement) via enhanced local defence
systems and collagenolytic activity, inaddition to
the sustained release of zinc ions, which stimulate
epithelialization of wounds.66 Studies have shown
unequivocally that topical zinc therapy reduces
wound debris and advances epithelialization in
surgical wounds in the rat.66,67 Median healing
times and the occurrence of S. aureus in wounds
both decreased compared with a placebo group in
humans.68 Zinc oxide has also been shown to
enhance wound contraction in rabbits, but studies
of its use and toxicity in dogs and cats are not
available.64
Aloe vera
Aloe vera gel is extracted from the mucilaginous
zone of the aloe vera leaf and it contains 75
potentially active constituents.10,34,69 Aloe vera has
anti-inflammatory effects, antifungal activity and
an antibacterial activity against P. aeruginosa.10 It
enhances contraction of wounds and increases
breaking strength through increased collagen
activity. It stimulates fibroblast replication and has
antiprostaglandin activity against thromboxane A,
which is produced in burnt dermal tissue and
pressure sores.69 Aloe vera gel has therefore been
used extensively in human burn wounds.
Cumulative evidence tends to support the view that
aloe vera might be an effective intervention in
wound healing for first- and second-degree burns.70
A recent study performed in rats showed a
significant decrease in wound diameter and
increased healing rate of created wounds after
application of aloe vera gel compared with a control
group.71 Aloe vera reportedly also has analgesic
activity due to the presence of a salicylate-like
substance.69 Indeed, application of aloe vera cream
on the surgical site was proven to be effective in
reducing postoperative pain, healing time and
analgesic requirements in patients compared with a
placebo group.72 However, further well-designed
trials with sufficient details of the contents of aloe
vera products should be carried out to determine
the effectiveness of aloe vera in wound healing
before its use can actively be recommended in dogs
and cats.
Acemannan 
Acemannan is a derivate of the aloe vera plant and
is available as a hydrogel or as a foam.10,22 It acts
as a growth factor, stimulating macrophages to
enhance IL-1, which stimulates fibroblast
proliferation, and TNF-! secretion, which
stimulates angiogenesis, epidermal growth and
motility, and collagen deposition.34,63 In a topical gel
form, it enhanced contraction and epithelialization
of paw wounds in dogs and stimulated granulation
tissue formation over exposed bone.8,63 A recent
study in rats demonstrated that acemannan
significantly enhanced oral wound healing via the
induction of fibroblast proliferation and
stimulation of keratinocyte growth factor-1, VEGF
and type I collagen production.73 However, another
study failed to demonstrate any significant
advantage of acemannan dressings over moist saline
gauze dressings for the treatment of pressure
ulcers.74 As with aloe vera, application is indicated
after debridement and lavage of the wound, from
the inflammatory phase until the end of the
proliferation phase.63 Bandages should be changed
daily. 
Live yeast cell extracts
Live yeast cell derivative is a water-soluble extract
from brewer’s yeast.34 It is reported to contain
substances that increase wound oxygen
consumption, angiogenesis, epithelialization and
collagen synthesis.34,47 In horses it has been
suggested that live yeast cell extracts prolong
healing time by delaying epithelialization and
inhibiting contraction, while favouring the
Wound management: a new protocol for dogs and cats 35
formation of exuberant granulation tissue.34 In a
study on wound healing in diabetic mice, it was
clearly demonstrated that live yeast cell extracts
improve the formation of granulation tissue,
epithelial migration and wound closure.75 Although
prospective studies in dogs or cats are lacking,
one experienced researcher states that he believes
live yeast cell extracts do enhance epithelialization
in dogs.36
Growth factors
For more than 20 years, clinical trials have been
conducted on the application of topical exogenous
recombinant growth factors to accelerate the
healing of chronic wounds. The results have been
conflicting.76 Some trials have been encouraging,
but most have been somewhat disappointing.15,76 To
date only one recombinant growth factor, PDGF,
has been approved by the US Food and Drug
Administration, and it is for use in diabetic foot
ulcers in humans only.11,15,16 However, a single
growth factor will not be able to resolve all issues of
repair or strengthen all vulnerabilities of chronic
wounds and although not yet commercially
available, other growth factors are currently
undergoing investigation as an adjunctive treatment
for nonhealing wounds in humans. These include
TGF-#, FGF, VEGF, keratinocyte growth factor,
EGF, IGF and others such as platelet activating
factor, growth hormone, thrombin, colony-
stimulating factors, L-arginine and MMPs. Their
use in the treatment of chronic wounds in veterinary
patients warrants further study before they can be
recommended.
PDGF is released from the alpha granules of
platelets and is responsible for the production of
TGF-#. A recombinant PDGF product, becaplermin
gel, is commercially available.11 It is strongly
chemotactic for monocytes, neutrophils, fibroblasts
and smooth muscle cells. It also has mitogenic
properties, promoting the mitosis of fibroblasts,
endothelial cells and smooth muscle cells. It was
shown to stimulate angiogenesis, wound
contraction, granulation tissue formation and
wound remodelling in experimental rabbit and rat
studies.3,8 When used in phase III trials in people
with diabetic foot ulcers, PDGF gave a persistent
10% overall increase in the rate of complete
healing.11,15
Another growth factor that has been tested
extensively for use in diabetic and pressure-related
ulcers is TGF-#. It is derived from platelets and
numerous other cells involved in wound healing. It
has a powerful mitogenic effect on macrophages,
smooth muscle cells and osteoblasts. Like PDGF, it
stimulates angiogenesis and fibroplasia as well as
keratinocyte migration, but has an inhibitory effect
on the production of MMPs, keratinocyte
proliferation, endothelial cell growth, lymphocytes
and epithelial cells.3,8 TGF-# has been shown to
increase granulation tissue and collagen formation
as well as wound tensile strength when applied
locally in some animal models of normal or
impaired healing; however, in limb wounds in
horses, no beneficial effects were noted.34
Platelet-derived products offer an advantage over
individual cytokines or growth factors, because a
large number of mediators are easily available in
high concentrations when platelets are activated.
Degranulating platelets release growth factors and
many wound healing mediators. Topical application
of growth factors derived from platelets encouraged
repair of previously nonhealing wounds in human
patients. Accelerated epithelial differentiation and
more mature granulation tissue formation were
found in wounds of the distal limb of horses when
treated with a platelet-derived wound healing
gel.34,77
Wound closure 
One of the most important decisions to make
during wound management is whether or not
a wound should be surgically closed and, if so,
when. Wounds that are left to heal through the
formation of granulation tissue, contraction and
epithelialization because of severe infection or being
too large to close primarily, constitute healing by
second intention (secondary wound healing or
healing per secundam). Second intention healing
can be very effective; however, the healing time
can be very long and can be complicated in areas of
the body with high motility, and excessive
contraction and scar tissue formation can lead to
wound contracture. Primary wound healing
(wound healing per primam) is obtained through
direct adhesion of the wound edges (after primary
closure using sutures, staples or glue) directly after
injury and before or after granulation tissue
formation (delayed primary and secondary closure,
respectively).Primary closure
Primary wound closure is defined as direct closure
of the wound after lavage and debridement.
Primary wound closure is indicated and preferred
for clean wounds, including surgical wounds and
contaminated wounds that have been debrided and
are less than 6 hours old.3,4 The wound healing
process is in principle the same as with the open
wounds described earlier, but all the phases are
much shorter and many of them are not visible.
Primary closure leads to a more rapid anatomical
and functional recovery than delayed and secondary
closure (16).
Wound management: a new protocol for dogs and cats36
• Passive drains are easier to insert and cost less
than active drains. The most commonly used
passive drain is the Penrose drain, a soft
latex tube. Passive drains have to be placed in
the most dependent part of the wound in
order to allow fluid to drain from the
wound under gravity. The drain should be
secured to the skin with sutures proximally
and distally or dorsally and ventrally. One
of the disadvantages of passive drains is the
risk of ascending infection, especially when
the drain is left in place for several days or is
left uncovered. It is therefore recommended
that the drain is covered with a sterile
dressing to minimize this risk, prevent
leakage of the fluid into the environment
and allow for assessment of the quantity of
fluid that has been produced.3 Another
disadvantage of passive drains is that it is
not possible to place a drain in every area of
the body because of its dependency on
gravity.3 An Elizabethan collar should be
used to prevent the patient from removing
the drain, especially when a dressing is
not used. 
Wound management: a new protocol for dogs and cats 37
After the golden period of 4–6 hours, primary
closure will become less desirable because of the
increased chance of wound infection.3 If the level of
contamination, tissue viability, depth of tissue
damage or vascular supply is questionable, other
options should be considered.2 With uncomplicated
healing after primary closure of a wound, the
sutures can generally be removed in 7–10 days
in dogs.4
Delayed primary closure
Delayed primary closure is defined as a wound that
is not closed immediately, but is managed as an
open wound until it is clean and without formation
of granulation tissue.10 Closure is therefore usually
performed within 3–5 days after the emergence of
the wound. Delayed closure allows for drainage of
the wound, a decrease in contamination and the
development of a clear demarcation line between
viable and necrotic tissue prior to surgery. 
Secondary closure
Secondary closure is defined as closure of the
wound after the formation of granulation tissue and
is most commonly used for contaminated or
infected wounds. There are two methods of
secondary closure:2–4 (1) leaving the existing
granulation tissue intact and separating the edge
of the skin from the granulation tissue bed and
advancing the skin over the granulation bed; and
(2) excision of the granulation tissue bed followed
by primary closure.
The second method is usually the preferred
method because the wound edges are more mobile
for closure, cosmetic results are better and the
incidence of infection is lower.3 Important factors in
choosing between the two methods are the
thickness and health of the granulation tissue bed
and the mobility of the skin edges.2 The total
healing time is still reduced when compared with
healing by second intention.
Drainage
Dead space can result when suturing a large
wound. Fluid accumulation in these spaces is a
good medium for growth of bacteria. Drains can be
placed to prevent accumulation of fluids. For
minimally contaminated wounds with minimal
dead space formation, surgical debridement,
lavage and primary closure usually suffices, and
drainage is often not necessary. In moderately
contaminated wounds or where there is a large dead
space, drainage is recommended. For grossly
contaminated and infected wounds, delayed
primary or secondary closure is recommended.3
The most common types of drains used are
passive and active drains:
16 Well-healed wound after primary closure.
16
• Active drains work by creating a vacuum
through the drain. This vacuum will remove
the fluid from the wound by suction, thus
eliminating the need for gravity. Therefore,
this type of drain can be placed anywhere on
the body. An additional advantage is the
reduced risk of infection. The use of active
drains is slightly more elaborate than that of
passive drains, since the containers in which
the wound fluid accumulates will need to be
emptied regularly (17).
Wound dressings and bandages
Dressings refer to materials that are applied
directly to the surface of a wound; bandages are
wraps primarily used to hold plain and
medicated dressings in place. Other functions of
bandages are support or immobilization of body
parts, applying pressure to control haemorrhage,
obliteration of dead space or cavities and
protection of a wound from external trauma
and contamination. Bandages consist of three
defined layers: a primary layer (contact dressing),
a secondary or intermediate (absorptive) layer, and
a tertiary or outer (protective) layer.3,8,10,24,63
The functions of wound dressings are detailed in
Table 2. The most important function is to allow for
moist wound healing. Wounds that are kept in a
moist environment have a reduced total healing
time because of preservation of the voltage
gradient.24 During the proliferation phase of wound
healing, this gradient will stimulate the formation of
granulation tissue and epithelialization. Growth
factors are kept on the wound, leucocytes are not
trapped in a scab and are functional, and the mildly
acidic pH and warm temperature are optimal for
wound healing. The moist environment also
prevents trauma due to adherence of the dressings.
In addition, autolytic debridement takes place in a
moist environment by maintaining exudate with
enzymes at the wound surface.24
The primary or contact layer of the dressing can
be adherent or nonadherent and occlusive, semi-
occlusive or nonocclusive.3,8,10,24 In general, an
adherent contact layer is used when wound
debridement is required, whereas a nonadherent
contact layer is selected when granulation tissue
has formed. Occlusive dressings are impermeable to
air and fluid and are used on low exudative wounds
to maintain a moist environment. Semi-occlusive
dressings allow air to penetrate and exudate to
escape from the wound surface. The modern, most
commonly used nonadherent (semi-) occlusive
moisture-retentive dressings provide the desired
moist environment for wound healing. They are
also known as interactive dressings. Dressings
belonging to this group include hydrocolloids,
hydrogels, hydrofibres, alginates, foams and
polyethylene glycol dressings. The traditional
gauzes are considered to be passive dressings and
can be used both dry as an adherent or wet as a
nonadherent dressing. In contrast to the synthetic
dressings, biological dressings are derived from
natural sources such as porcine submucosa
or equine amnion. They may have similar pro -
perties to the dressings discussed above. Finally,
topical medications can be added to a dressing
(see Topical antibiotics and antiseptics) to create
an antimicrobial dressing. Table 3 provides an
overview of this classification of wound dressings.
The most important point to remember when
choosing a dressing is that there is no single dressing
that is perfect for all wounds in all phases of wound
healing. Every wound requires initial and follow-up
assessments to assess whether wound dressing
changes are required. 
Nonocclusive dressings
Gauzes are nonocclusive dressings and are available
in adherent and nonadherent forms as well as in
sterile and nonsterile forms.3,10 Because they are
relatively inexpensive, they are commonly used in
veterinary medicine and especially in wet-to-dry
bandages during the debridement phase. They are
not recommended in more mature wounds because
changing a dried dressingwill disrupt granulation
tissue.24 Because they dry easily after application to
the wound, it is important to keep the dressings wet
in order to provide a moist wound environment
when used on more mature wounds. This requires
changing the dressing every 8–12 hours. A
secondary absorptive layer and a tertiary protective
Wound management: a new protocol for dogs and cats38
17 Closed suction (active) drains inserted after surgery.
17
layer are required to prevent migration of bacteria
from the environment through the pores of the
dressing.
The use of gauze is recommended in acute,
nondebrided wounds that have to be inspected
and irrigated regularly. Modern dressings are only
cost-effective when they are changed daily or less
frequently.24 They are therefore not recommended
when there is still a considerable chance of infection
because this requires more regular inspection and
cleaning.
Gauzes can be impregnated with different types
of fluids and topical medication. Hypertonic saline
dressings, for example, can be used in the early
phases of wound healing because of their
bactericidal mechanism and debridement properties
by attracting fluid and debris from the wound. In
contaminated or infected wounds, gauzes can be
impregnated with antimicrobials. 
Moisture-retentive dressings
Moisture-retentive dressings can be divided into
occlusive and semi-occlusive dressings.10,24 Whereas
occlusive dressings are impermeable to water and
water vapours, semi-occlusive dressings are
impermeable only to water, allowing a certain
amount of moisture to be lost as vapour. Both types
of dressings protect the wound against external
contamination and excessive drying, and in
addition, semi-occlusive dressings prevent wetting
and maceration of the wound. The same dressing
can be considered to function as both an occlusive
and a semi-occlusive dressing, depending on the
moisture vapour transmission rates, which are
influenced by the secondary and tertiary bandage
layers.78
When choosing an occlusive dressing, particular
attention must be paid to the skin surrounding the
wound. Because of the moist environment, the risk
of maceration of the skin is greater. To prevent
maceration, the dressing can be cut to the size of the
wound and the wound edges can be protected with
zinc oxide. Another aspect to take into consid -
eration is the amount of granulation tissue that is
formed, because excessive granulation tissue
formation is possible when using occlusive
dressings.79 It is generally recommended to change
to semi-occlusive dressings when hypergranulation
is observed or expected.79,80
An advantage of occlusive dressings over semi-
occlusive dressings is greater stimulation of 
re-epithelialization.79 They are therefore generally
recommended in noninfected partial-thickness or
advanced granulating wounds. A disadvantage of
occlusive dressings is that no oxygen, important for
collagen synthesis, can reach the wound from the
environment.47 However, low oxygen tension also
stimulates angiogenesis.81 Infection rates are low
with occlusive dressings because the natural
substances that inhibit bacterial growth accumulate
in the wound fluid and wounds are protected
against environmental contamination.24 When
removing a (semi-)occlusive dressing, it can have a
purulent appearance and foul odour.22,24 This
should not be mistaken for infection. 
Wound management: a new protocol for dogs and cats 39
Table 3. Overview of wound dressings.
Interactive dressings Passive dressings
• Hydrocolloid. • Gauzes:
• Hydrogel. ° Adherent.
• Hydrofibre. ° Nonadherent.
• Foam.
• (Silver) alginate.
• Polyurethane film.
Biological dressings
• Bovine collagen.
• Equine amnion.
• Porcine small intestinal submucosa.
Table 2. General functions of wound dressings.
• Provide a moist environment.
• Provide a warm environment.
• Protect from trauma.
• Protect from external contamination.
• Application of topical medication.
• Immobilization of the wound.
• Support of the wound edges.
• Absorb exudate.
• Prevent or reduce oedema.
• Provide an aesthetic appearance.
expensive. Used during the proliferation phase,
hydrogels may cause formation of exuberant
granulation tissue.79 They can also be used to
rehydrate a wound by applying the hydrogel
together with fluid onto the wound.
Hydrofibres
Hydrofibres are composed of sodium carboxy-
methylcellulose. A gel is formed when there is
contact with wound exudate and a moist wound
environment is created. Hydrofibres can absorb
large amounts of wound fluid and are therefore
indicated in moderate to heavily exudating
wounds.3,8,24
There are two different applications of
hydrofibres: dry and wet. When used wet, they are
placed on the wound together with fluid and
replaced before the dressing dries. If used dry, the
dressing is allowed to form a scab on the
wound surface, which will loosen when the wound
surface heals. 
Alginates
Alginate dressings are derived from seaweed and
contain calcium ions. Calcium ions are important
for haemostasis and therefore these dressings can be
used in mildly bleeding wounds. They form a moist
gel by exchanging sodium from wound fluid and
calcium ions from the alginate dressing.22 Alginates
generally have good absorptive properties. They can
be used for highly exudative and infected wounds
(i.e. in the early stages of wound healing). Bacteria
will become trapped in the alginate gel, thereby
decreasing the risk of infection.24 They are not
indicated in minimally exudative wounds because
this might result in dehydration of the wound.24
Foam dressings
Most foam dressings are made of polyurethane and
they are available as sheets and as cavity dressings.
The absorptive capacity and water vapour
permeability differ between foams, but are generally
good. In-situ foams can be used for the treatment of
large cavity wounds and they then prevent
premature closure of the wound.24,83 Foam dressings
keep the wound environment moist, thereby
promoting wound healing, and they are indicated in
the inflammatory as well as in the proliferative
phase of healing.9 They can also be used to deliver
fluid for rehydration or medications.
Polyurethane films
A polyurethane film is a thin film that can be used
as a semi-occlusive layer to create a moist
environment. Water and bacteria cannot permeate
the film, but water vapour can escape. Autolytic
Wound management: a new protocol for dogs and cats40
Hydrocolloids
Hydrocolloids are dressings that stimulate wound
healing by providing a moist environment. They are
interactive dressings that change into a gel when
absorbing fluid and maintain a moist and warm
environment for optimal wound healing. The
amount of exudate that can be absorbed by the
dressing varies depending on the individual
product, but it is often low to moderate.24,78 To
prevent maceration of the surrounding skin, the
dressing should be cut to the shape of the wound.
Hydrocolloid dressings are nonadherent to the
wound surface, but most have an adhesive border
to attach the dressing to healthy skin. Many of the
dressings are impermeable to water as well as to
water vapour and are thus occlusive.24 This protects
the wound against external contamination and
excessive drying. A secondary layer and a tertiary
layer complete the bandage, which has to be
changed every 2–4 days. 
Most research on hydrocolloid dressings is
derived from humans, but a study has recently been
performed on dogs.82 The dressings appeared to be
easy to use, adhesed well and the wounds healed
better than untreated wounds. The granulation
tissue was more regularly organized and the number
of inflammatory cells had decreased. This research
also concluded that the adhesives used in the
dressings were strong and suitable for animal use.
A disadvantage of strong adhesiveness is that
wound contraction is inhibited because the adhesive
bandage counteracts the forces of wound
contraction.17
Hydrocolloids are indicated in the proliferation
phase of wound healing, but hypergranulation
must be monitored.22,79They also have a place in
the debridement phase by creating an environment
for autolytic debridement.22 However, the costs and
benefits should be considered.
Hydrogels
Hydrogels work on the same principle as
hydrocolloids (i.e. they are nonadherent, occlusive
and provide a moist environment). They are placed
on the wound as a gel or as a composite sheet
consisting of a gel adhered to the sheet. The sheets
have to be cut to the shape of the wound to prevent
maceration of the surrounding skin. The amount of
exudate that can be absorbed by the dressing again
depends on the individual product, but is often very
low.22,24 Dressings are normally changed every 3–4
days.
Hydrogels are indicated in wounds free of
infection and excessive necrotic tissue. They can be
used in the debridement phase by creating an
environment for autolytic debridement, but are
debridement is possible under a polyurethane film.24
The absorptive capacity is minimal, therefore
polyurethane films should be used for dry to
minimally exudative wounds. They can also be used
as an occlusive layer over other dressings.24
Petrolatum-impregnated gauzes
Nonadherent gauzes include petrolatum-
impregnated gauzes. The absorptive capacity of
these semi-occlusive dressings is low and fluid can
move through pores in the dressing.24 Therefore,
they should be covered with secondary and tertiary
bandage layers. (Note: Water can move through the
pores, but also bacteria from the environment.24)
Biological dressings
Biological dressings are dressings derived from
natural sources (e.g. porcine small intestinal
submucosa [PSIS], equine amnion dressings, bovine
collagen sheets).9,47 These dressings provide an
exogenous source of collagen, growth factors,
hyaluronic acid, heparin sulphate, chrondroitin
sulphate A and fibronectin.9,47 In addition, they can
act as a scaffold for fibroplasia.9 Because the cost of
biological dressings is high, a primary, nonadherent
dressing, which can be changed more frequently,
can be used to cover biological dressings.24
Advanced techniques
In human medicine, new dressings, topical agents
and techniques are being developed especially for
the treatment of chronic wounds. New techniques
include topical negative pressure (TNP) therapy,
low-level laser therapy, hyperbaric oxygen therapy
and ultrasound therapy. Good results with these
techniques in human practice will possibly lead to
their veterinary use in the future. Some have already
been used in a few veterinary clinical cases. 
Topical negative pressure 
TNP therapy, also known as subatmospheric
pressure therapy or vacuum-assisted therapy, uses
subatmospheric pressure to promote or assist
wound healing and is mainly used in chronic
nonhealing wounds. TNP has multiple proposed
mechanisms of action. The enforcement of negative
pressure on the wound will lead to the removal of
bacteria and excess fluid.84,85 This reduces the risk
of infection and the distance for intercellular
diffusion, thus improving wound oxygenation.84–86
TNP also results in mechanical forces to the
surrounding tissues, which stimulate the local blood
flow in the wound bed, the formation of
granulation tissue and epithelialization.84,85,87,88
A vacuum is created by placing a foam or gauze
dressing on the wound, which is connected by a
tube to a vacuum pump. The gauze and tube are
covered by an adhesive film sheet to provide an
airtight seal. Negative pressure to the wound can
then be applied constantly or intermittently. A
negative pressure of $125 mmHg is recom -
mended.89 Many papers have been published about
TNP in the human literature, and the general
conclusion is that there is a lack of high-level
evidence to support the use of TNP in the treatment
of wounds.84,85,87,88 However, some studies indicate
that TNP therapy has advantages over the use of
moist gauze dressings.87,88
Low-level laser therapy
Low-level laser therapy (LLLT) is a cold laser used
to stimulate wound healing by stimulation of
fibroblast development, acceleration of angio -
genesis, vasodilation and possibly by improving
lymphatic drainage.90,91 This leads to an increase in
granulation tissue formation, an increase in the
formation of new capillaries and possibly a decrease
in swelling.91 Meta-analyses have shown a highly
significant effect of LLLT on wound healing in
humans and horses.92–94 In addition to the
stimulation of collagen formation, there are also
improvements in the time needed for wound
closure, the strength of the wound, the rate of
healing, the number and rate of degranulation of
mast cells, flap survival and analgesia.92,94
Therefore, LLLT stimulates wound healing in the
inflammatory, proliferation and maturation
phases.92,94
Hyperbaric oxygen therapy
Since hypoxia is a common cause for nonhealing,
chronic wounds, hyperbaric oxygen therapy
(HBOT) has been used in the treatment of these
wounds in humans.22 HBOT is considered to be an
adjunctive therapy to standard wound management
and should not replace proper wound
management.95
Patients are placed in a compression chamber
and allowed to breathe 100% oxygen with a
pressure of 2.0–2.5 atmospheres absolute (ATA) for
periods of between 1 and 2 hours, 1–2 times daily.96
The high oxygen concentration allows for complete
saturation of haemoglobin molecules in the
bloodstream and for more oxygen to be dissolved
into the blood.95,96 To achieve local results at the
wound site, the blood supply to the wound has to
be at least partially intact.95 The higher oxygen
tension in blood plasma results in upregulation of
growth factors, downregulation of inflammatory
cytokines, increased fibroblast activation,
angiogenesis, antibacterial effects by stimulation of
leucocytes and enhanced antimicrobial action.95,97
Wound management: a new protocol for dogs and cats 41
In addition to improving oxygen supply to the
tissues, the delivery of nutrients will also be
improved.95,97
Research into the effects of HBOT in human
medicine is limited and application only seems to be
justified when chronic wounds do not respond to
other therapies. There are not many complications
reported, but high oxygen concentrations are
potentially toxic to the lungs and brain.96,97
Ultrasound
Ultrasound is commonly used as a diagnostic tool,
but it can also be used for therapeutic purposes such
as wound healing. The main difference between
diagnostic and therapeutic use of ultrasound is
that the frequency for therapeutic purposes varies
between 1 and 3.3 MHz, whereas the frequency
for diagnostic purposes ranges between 5 and 10
MHz.11,93 Therapeutic ultrasound has thermal and
nonthermal effects, but the main overall effects are
reduction of the inflammatory phase and
promotion of the initial proliferative phase.86,98–101
Ultrasound stimulates cellular recruitment, collagen
synthesis, angiogenesis, wound contraction, fibro -
blasts and macrophages, and fibrinolysis.86,98,101 The
tensile strength of collagen is also increased after
ultrasound treatment.86,101
A protocol for wound management in
dogs and cats
The different options for wound management have
been described in the previous sections. Choosing
which protocol to use depends on effectiveness, cost
and patient benefit. A systematic approach, as
described in Table 4, is recommended for efficient
wound management. 
Step 1: Use a clean room and aseptic
technique
When treating a wound, further contamination and
infection should be prevented. Therefore, patients
with wounds must always be treated in a clean
room and on a clean table. In addition, when
manipulating wounds, (sterile) gloves should be
worn as well as hair nets, face masks and clean
coats. Instruments should be sterilized and the
wound covered with sterile gauze or gel while
clipping the surrounding hair and debriding
necrotic tissue.
Step 2: Obtain a complete medical history
The medical condition of the patient can be
important in selecting a treatment protocol. Some
examples of conditions that influence wound
healing include protein deficiency, anaemia,
inadequate bloodsupply to the wound area,
uraemia and vitamin A or C deficiency.18 Corti-
costeroids or nonsteroidal anti-inflammatory drugs
(NSAIDs) can delay wound healing.18 These factors
must be considered and addressed when dealing
with nonhealing chronic wounds.
Step 3: Obtain information about the cause
and age of the wound
Information about the cause and time of wounding
is important when assessing the level of contami -
nation and the risk of infection. It also influences
the protocol chosen. For example, traumatic
wounds older than 4–6 hours should be considered
to be infected and dealt with as such. 
Step 4: Make a complete assessment of
the wound
A thorough clinical assessment of the wound
provides information about its characteristics and is
necessary for further planning. The following
should be assessed:
• Type of wound.
• Size and depth of the wound.
• Tension of the surrounding skin.
• Phase of wound healing.
• Level of contamination.
• Signs of inflammation.
• Level of exudation.
• Presence of necrotic tissue.
Wound management: a new protocol for dogs and cats42
Table 4. A protocol for wound management in dogs
and cats.
• Use a clean room and aseptic technique.
• Obtain a complete medical history of the patient.
• Obtain information about the cause and age of the
wound.
• Make a complete assessment of the wound.
• Debride necrotic tissue.
• Remove contamination.
• Choose the appropriate method of closure.
• Choose the appropriate dressing.
• Make regular assessments to monitor the progression
of wound healing.
Extra step for chronic or difficult to heal wounds:
• When dealing with chronic wounds not responding to
normal wound management, consider using an
advanced technique.
Wound management: a new protocol for dogs and cats 43
Step 5: Debride necrotic tissue
Debriding necrotic tissue will accelerate the
inflammatory phase of wound healing and the total
healing time will be decreased. The most common
techniques used are surgical and mechanical
debridement. Preferably, all wounds with necrotic
tissue are treated with surgical debridement first.
Autolytic debridement should be considered in a
patient in critical condition with a high anaesthetic
risk, or when there is no clear demarcation line. 
Step 6: Remove contamination
Removal of contamination will reduce the chance of
infection and create better conditions for
uncomplicated wound healing. Physiological
solutions (e.g. sterilized saline or LRS) for pressured
lavage are recommended in all patients. Dilution
of contamination is more important than the
antiseptic or antibacterial properties of the lavage
fluid. Mild antiseptics, such as chlorhexidine,
Dakin’s solution or povidone–iodine solution, can
be considered for more heavily contaminated
wounds, but their potentially toxic effects have to
be taken into consideration. While irrigating, the
spreading of bacteria under the wound edges or into
the wound area must be prevented.
Step 7: Choose the appropriate method
of closure
The different methods of wound closure have been
described earlier in this chapter (Wound closure).
Preferably, all noninfected wounds not containing
necrotic tissue are closed by primary closure. In
infected wounds or wounds containing necrotic
tissue, delayed primary closure, secondary closure
or healing by second intention must be considered.
For example, in patients with a high anaesthetic
risk, small wounds in areas without risk of wound
contracture can be left to heal by second intention.
Wounds that are too large to be closed by suturing,
are not expected to heal completely by second
intention or have a high risk of developing
inappropriate wound contracture can be closed
using tension-relieving techniques, skin grafts or
flaps.
Step 8: Choose the appropriate primary
contact layer
Topical medications and dressings have been
discussed earlier in this chapter (Wound irrigation
and topical medications; Wound dressings and
bandages). There is a wide variety of products, but
most wounds in their inflammatory phase can be
treated with wet-to-dry bandages initially and
glycerol medicated semi-occlusive dressings when
granulation tissue starts to appear. Honey can be
used, after initial wet-to-dry bandages, in heavily
contaminated wounds not responding to the
protocol described above. For selected patients,
other products can be advised. Table 5 (overleaf)
lists most of the available products and their
indications.
Step 9: Regularly reassess the wound
It is important to monitor the progression of healing
by regular assessment of the wound. The choice of
dressings can be adjusted as the wound progresses
through the four phases of healing.
Step 10: Consider using an advanced
technique
When dealing with chronic or nonhealing wounds
not responding to normal wound management, the
use of an advanced technique should be considered.
The techniques discussed earlier in this chapter
(Advanced techniques) are not (yet) commonly used
in veterinary practice, but they are available in some
larger referral centres. Newer techniques, including
TNP therapy, LLLT and HBOT, can be considered.
Staged and multiple surgical debridements followed
by advanced skin reconstruction will allow for
closure of most wounds. 
Cost-effectiveness and patient
and owner benefit
The treatment of large and chronic wounds often
requires special attention, care, time and
commitment of both owner and the treating
veterinarian. Multiple bandage changes lead to high
costs. These costs can be minimized by using the
right wound management protocol, the correct
dressing and bandage change frequency and timely
corrective surgical intervention. As expected, there
will be differences in total costs in dogs and cats
between treatments with traditional saline-impreg -
nated gauze
dressings and modern moisture-retentive dressings,
as has been reported in human and equine
patients.102–104
However, while cost and effectiveness are
important factors, animal and owner comfort
should also be considered. Patient factors to
consider include the discomfort that accompanies
dressing changes. For the owner, factors to consider
include wound odour, leakage of exudate and the
treatment duration associated with the number of
visits to the veterinary clinic. Many of the benefits,
both for the patient and the owner, can be achieved
by applying modern dressings for moist wound
healing.
Conclusion/summary
The options for wound management are so
numerous that it is possible to choose an individual
treatment for every wound and every phase of
wound healing. If optimal wound management is
desired, every wound should be assessed individ -
ually and the treatment adapted regularly to
the information that is gained from the wound
evaluation. After following the 10-step protocol
described above, a well-informed choice can be
made between the available dressings. The modern
moisture-retentive dressings have many benefits
compared with the traditional saline-impregnated
gauzes, but they can currently only be
recommended in chronic wounds, where they
stimulate wound healing more effectively, are more
cost-effective and improve patient and client
comfort.
Wound management: a new protocol for dogs and cats44
Table 5. Topical medications and dressings.
Wound colour Wound type Purpose of treatment Exudate Recommended dressing materials
Black Necrotic wound Remove necrotic tissue ++ Saline gauze†
Alginate
Honey dressing*
Silver dressing*
+ Alginate
Saline gauze†
Hydrogel
Hydrocolloid
Honey dressing
Silver dressing
$ In absence of signs of infection, 
the wound can heal under the scab
Yellow Exudating wound Wound cleaning and ++ Alginate
removal of debris Hydrofibre
Foam
Saline gauze†
+ Alginate
Hydrofibre
Foam
Hydrogel*
Hydrocolloid
Saline gauze†
Green Infected wound Wound cleaning and ++ Antimicrobial gauze dressing†
clear infection Silver dressing†
Honey dressing†
+ Antimicrobial gauze dressing†
Silver dressing†
Honey dressing†
$ Antimicrobial gauze dressing†
Silver dressing
Honey dressing
Red or pink Granulatingor Wound protection ++ Hydrofibre
epithelializing and providing a Foam
wound moist environment + Hydrogel*
to stimulate healing Hydrocolloid*
Hydrofibre
Foam
$ Hydrogel#
++ = wet; + = moist; $ = dry.
†Cover with a secondary absorptive dressing.
*Select one with good absorptive properties or use an absorptive secondary dressing to reduce the number of dressing
changes.
#For rehydration of the wound.
References
1. Hosgood G (2003) Wound repair and specific
tissue response to injury. In: Textbook of
Small Animal Surgery, 3rd edn. (ed D Slatter)
WB Saunders, Philadelphia, pp. 66–86.
2. Dernell WS (2006) Initial wound
management. Vet Clin North Am Small
Anim Pract 36:713–738.
3. Pavletic MM (2010) Atlas of Small Animal
Wound Management and Reconstructive
Surgery, 3rd edn. Wiley–Blackwell, Ames, 
pp. 17–50.
4. Peeters ME, Stolk PWT (2006) Wound
management and first aid. In: The Cutting
Edge: Basic Operating Skills for the
Veterinary Surgeon, 1st edn. (eds
J Kirpensteijn, WR Klein) Roman House
Publishers, London, pp. 97–127.
5. Bohling MW, Henderson RA, Swaim SF et al.
(2004) Cutaneous wound healing in the cat:
a macroscopic description and comparison
with cutaneous wound healing in the dog.
Vet Surg 33:579–587.
6. Bohling MW, Henderson RA, Swaim SF et al.
(2006) Comparison of the role of the
subcutaneous tissues in cutaneous wound
healing in the dog and cat. Vet Surg 35:3–14.
7. Bohling MW, Henderson RA (2006)
Differences in cutaneous wound healing
between dogs and cats. Vet Clin North Am
Small Anim Pract 36:687–692.
8. Swaim SF, Henderson RA (1997) Small
Animal Wound Management, 2nd edn.
Williams & Wilkins, Maryland, pp. 1–12.
9. Hosgood G (2006) Stages of wound healing
and their clinical relevance. Vet Clin North
Am Small Anim Pract 36:667–685.
10. Hedlund CS (2007) Surgery of the
integumentary system. In: Small Animal
Surgery, 3rd edn. (eds TW Fossum, CS
Hedlund, AL Johnson) Mosby Elsevier,
St. Louis, pp. 159–259.
11. Hanks J, Spodnick G (2005) Wound
healing in the veterinary rehabilitation
patient. Vet Clin North Am Small Anim
Pract 35:1453–1471, ix.
12. Swaim SF (1997) Advances in wound
healing in small animal practice: current
status and lines of development. Vet Dermatol
8:249–257.
13. Henry G, Garner WL (2003) Inflammatory
mediators in wound healing. Surg Clin
North Am 83:483–507.
14. Janis JE, Kwon RK, Lalonde DH (2010)
A practical guide to wound healing. Plast
Reconstr Surg 125:230e–244e.
15. Cross KJ, Mustoe TA (2003) Growth factors
in wound healing. Surg Clin North Am
83:531–545, vi.
16. Doughty D (2005) Dressings and more:
guidelines for topical wound management.
Nurs Clin North Am 40:217–231.
17. Swaim SF, Hinkle SH, Bradley DM (2001)
Wound contraction: basic and clinical factors.
Comp Cont Educ Pract Vet 23:20–24.
18. Johnston DE (1990) Wound healing in
skin. Vet Clin North Am Small Anim Pract
20:1–25.
19. Schultz GS, Sibbald RG, Falanga V et al.
(2003) Wound bed preparation: a systematic
approach to wound management. Wound
Rep Reg 11 Suppl 1:S1–28.
20. Amalsadvala T, Swaim SF (2006)
Management of hard-to-heal
wounds. Vet Clin North Am Small
Anim Pract 36:693–711.
21. Taylor GI, Minabe T (1992) The angiosomes
of the mammals and other vertebrates. Plast
Reconstr Surg 89:181–215.
22. Krahwinkel DJ, Boothe HW Jr (2006)
Topical and systemic medications for
wounds.Vet Clin North Am Small Anim Pract
36:739–757.
23. Johnston DE (1990) Care of accidental
wounds. Vet Clin North Am Small Anim
Pract 20:27–46.
24. Campbell BG (2006) Dressings, bandages,
and splints for wound management in dogs
and cats. Vet Clin North Am Small Anim
Pract 36:759–791.
25. Edwards J (2010) Hydrogels and their
potential uses in burn wound management.
Br J Nurs 19:S12, S14–16.
26. Mathews KA, Binnington AG (2002) Wound
management using honey. Comp Cont Educ
Pract Vet 24:53–60.
27. Mathews KA, Binnington AG (2002) Wound
management using sugar. Comp Cont Educ
Pract Vet 24:41–50.
28. Gethin G (2008) Efficacy of honey as
a desloughing agent: overview of current
evidence. EWMA J 8:31–35.
29. Fernandez R, Griffiths R (2008) Water for
wound cleansing. Cochrane Database Syst
Rev 1:CD003861.
30. Moore Z, Cowman S (2008) A systematic
review of wound cleansing for pressure
ulcers. J Clin Nurs 17:1963–1972.
31. Doughty D (1994) A rational approach to
the use of topical antiseptics. J Wound
Ostomy Continence Nurs 21:224–231.
32. Karukonda SRK, Cocoran FT, Boh EE et al.
(2000) The effects of drugs on wound
healing – Part II. Specific classes of drugs
and their effect on healing wounds. Int J
Dermatol 39:321–333.
Wound management: a new protocol for dogs and cats 45
33. Drosou A, Falabella A, Kirsner RS (2003)
Antiseptics on wounds: an area of
controversy. Wounds 15:149–166.
34. Dart AJ, Dowling BA, Smith CL (2005)
Topical treatments in equine wound
management. Vet Clin North Am Equine
Pract 21:77–89, vi–vii.
35. Lee AH, Swaim SF, Yang ST et al. (1984)
Effects of gentamicin solution and cream on
the healing of open wounds. Am J Vet Res
45:1487–1492.
36. Swaim SF (1990) Bandages and topical
agents. Vet Clin North Am Small Anim Pract
20:47–65.
37. White RR, Pitzer KD, Fader RC et al.
(2008) Pharmacokinetics of topical and
intravenous cefazolin in patients with clean
surgical wounds. Plast Reconstr Surg
122:1773–1779.
38. Firoz EF, Firoz BF, Williams JF et al. (2007)
Allergic contact dermatitis to mafenide
acetate: a case series and review of the
literature. J Drugs Dermatol 6:825–828.
39. Bonomo RA, Van Zile PS, Li Q et al. (2007)
Topical triple-antibiotic ointment as a novel
therapeutic choice in wound management
and infection prevention: a practical
perspective. Expert Rev Anti Infect Ther
5:773–782.
40. Fuller FW (2009) The side effects of silver
sulfadiazine. J Burn Care Res 30:464–470.
41. Storm-Versloot MN, Vos CG, Ubbink DT
et al. (2010) Topical silver for preventing
wound infection. Cochrane Database Syst
Rev 3:CD006478.
42. Cooper R (2004) A review of the evidence for
the use of topical antimicrobial agents in
wound care. World Wide Wounds February.
43. Lineaweaver W, McMorris S, Soucy D et al.
(1985) Cellular and bacterial toxicities of
topical antimicrobials. Plast Reconstr Surg
75:394–396.
44. Kramer SA (1999) Effect of povidone–iodine
on wound healing: a review. J Vasc Nurs
17:17–23.
45. Ter Haar G, Klein W (2006) Principles of
asepsis, disinfection and sterilisation. In:
The Cutting Edge: Basic Operating Skills
for the Veterinary Surgeon, 1st edn. (eds
J Kirpensteijn, WR Klein) Roman House
Publishers, London, pp. 14–29.
46. Sanchez IR, Swaim SF, Nusbaum KE et al.
(1998) Effects of chlorhexidine diacetate and
povidone–iodine on wound healing in dogs.
Vet Surg 17:291–295.
47. Fahie MA, Shettko D (2007) Evidence-based
wound management: a systematic review of
therapeutic agents to enhance granulation
and epithelialization. Vet Clin North Am
Small Anim Pract 37:559–577.
48. Sarvis CM (2007) Using antiseptics to manage
infected wounds. Nursing 37:20–21.
49. Hirsch T, Koerber A, Jacobsen et al. (2010)
Evaluation of toxic side-effects of clinically
used skin antiseptics in vitro. J Surg Res
164:344–350.
50. Hirsch T, Limoochi-Deli S, Lahmer A et al.
(2011) Antimicrobial activity of clinically used
antiseptics and wound irrigating agents in
combination with wound dressings. Plast
Reconstr Surg 127:1539–1545.
51. Horrocks A (2006) Prontosan wound
irrigation and gel: management of chronic
wounds. Br J Nurs 15:1222–1228. 49.
52. Ashworth CD, Nelson DR (1990)
Antimicrobial potentiation of irrigation
solutions containing tris-[hydroxymethyl]
aminomethane-EDTA. J Am Vet Med Assoc
197:1513–1514.
53. Fluhr JW, Darlenski R, Surber C (2008)
Glycerol and the skin: holistic approach to
its origin and functions. Br J Dermatol
159:23–34.
54. Saegeman VS, De Vos R, Tebaldi ND et al.
(2007) Flow cytometric viability assessment
and transmission electron microscope
morphological study of bacteria in glycerol.
Microsc Microanal 13:18–29.
55. Moore OA, Smith LA, Campbell F et al.
(2001)Systematic review of the use of honey
as a wound dressing. BMC Complement
Altern Med 1:2.
56. Lusby PE, Coombes A, Wilkinson JM
(2002) Honey: a potent agent for wound
healing? J Wound Ostomy Continence Nurs
29:295–300.
57. Overgaauw PAM, Kirpensteijn J (2005)
Honing bij de behandeling van huidwonden.
Tijdschr Dierg 130:115–116.
58. Ahmed AK, Hoekstra MJ, Hage JJ et al.
(2003) Honey-medicated dressing:
transformation of an ancient remedy into
modern therapy. Ann Plast Surg 50:143–147;
discussion 147–148.
59. Molan PC (2001) Potential of honey in the
treatment of wounds and burns. Am J Clin
Dermatol 2:13–19.
60. Molan PC (2006) The evidence supporting
the use of honey as a wound dressing. Int
J Low Extrem Wounds 5:40–54.
Wound management: a new protocol for dogs and cats46
61. De Rooster H, Declercq J, Van den Bogaert M
(2008) Honing in de wondzorg: mythe of
wetenschap? Deel 1: Literatuuroverzicht.
Vlaams Dierg Tijdschr 78:68–74.
62. De Rooster H, Declercq J, Van den Bogaert M
(2008) Honing in de wondzorg: mythe of
wetenschap? Deel 2: Klinische gevallen bij de
hond. Vlaams Dierg Tijdschr 78:75–80.
63. Swaim SF, Gillette RL (1998) An update on
wound medication and dressings. Comp Cont
Educ Pract Vet 20:1133–1144.
64. Cangul IT, Gul NY, Topal A et al. (2006)
Evaluation of the effects of topical tripeptide-
copper complex and zinc oxide on open-
wound healing in rabbits. Vet Dermatol
17:417–423.
65. Canapp SO Jr, Farese JP, Schultz GS et al.
(2003) The effect of topical tripeptide-copper
complex on healing of ischemic open wounds.
Vet Surg 32:515–523.
66. Lansdown AB, Mirastschijski U, Stubbs N
et al. (2007) Zinc in wound healing:
theoretical, experimental, and clinical aspects.
Wound Rep Regen 15:2–16.
67. Lansdown AB (1993) Influence of zinc
oxide in the closure of open skin wounds.
Int J Cosmet Sci 15:83–85.
68. Agren MS, Ostenfeld U, Kallehave F et al.
(2006) A randomized, double-blind, placebo-
controlled multicenter trial evaluating topical
zinc oxide for acute open wounds following
pilonidal disease excision. Wound Rep Regen
14:526–535.
69. Liptak JM (1997) An overview of the
topical management of wounds. Aust Vet J
75:408–413.
70. Maenthaisong R, Chaiyakunapruk N,
Niruntraporn S et al. (2007) The efficacy
of aloe vera used for burn wound healing:
a systematic review. Burns 33:713–718.
71. Takzare N, Hosseini MJ, Hasanzadeh G et al.
(2009) Influence of aloe vera gel on dermal
wound healing process in rat. Toxicol Mech
Methods 19:73–77.
72. Eshghi F, Hosseinimehr SJ, Rahmani N et al.
(2010) Effects of aloe vera cream on
posthemorrhoidectomy pain and wound
healing: results of a randomized, blind,
placebo-control study. J Altern Complement
Med 16:647–650.
73. Jettanacheawchankit S, Sasithanasate S,
Sangvanich P et al. (2009) Acemannan
stimulates gingival fibroblast proliferation;
expressions of keratinocyte growth factor-1,
vascular endothelial growth factor, and type I
collagen; and wound healing. J Pharmacol
Sci 109:525–531.
74. Thomas DR, Goode PS, LaMaster K et al.
(1998) Acemannan hydrogel dressing versus
saline dressing for pressure ulcers: a
randomized, controlled trial. Adv Wound
Care 11:273–276.
75. Crowe MJ, McNeill RB, Schlemm DJ et al.
(1999) Topical application of yeast extract
accelerates the wound healing of diabetic
mice. J Burn Care Rehabil 20:155–162.
76. Robson MC, Mustoe TA, Hunt TK (1998)
The future of recombinant growth factors in
wound healing. Am J Surg 176:80S–82S.
77. Knighton DR, Ciresi K, Fiegel VD et al.
(1990) Stimulation of repair in chronic,
nonhealing, cutaneous ulcers using platelet-
derived wound healing formula. Surg Gynecol
Obstet 170:56–60.
78. Thomas S (2008) Hydrocolloid dressings in
the management of acute wounds: a review
of the literature. Int Wound J 5:602–613.
79. Morgan PW, Binnington AG, Miller CW
et al. (1994) The effect of occlusive and 
semi-occlusive dressings on the healing of
acute full-thickness skin wounds on the
forelimbs of dogs. Vet Surg 23:494–502.
80. Stashak TS, Farstvedt E, Othic A (2004)
Update on wound dressings: indications and
best use. Clin Tech Equine Pract 3:148–163.
81. Lionelli GT, Lawrence WT (2003) Wound
dressings. Surg Clin North Am 83:617–638.
82. Abramo F, Argiolas S, Pisani G et al. (2008)
Effect of a hydrocolloid dressing on first
intention healing surgical wounds in the dog:
a pilot study. Aust Vet J 86:95–99.
83. Turner TD (1997) Interactive dressings used
in the management of human soft tissue
injuries and their potential in veterinary
practice. Vet Dermatol 8:235–242.
84. Ubbink DT, Westerbos SJ, Evans D et al.
(2008) Topical negative pressure for treating
chronic wounds. Cochrane Database Syst
Rev 3:CD001898.
85. Ubbink DT, Westerbos SJ, Nelson EA et al.
(2008) A systematic review of topical negative
pressure therapy for acute and chronic
wounds. Br J Surg 95:685–692.
86. Hess CL, Howard MA, Attinger CE (2003)
A review of mechanical adjuncts in wound
healing: hydrotherapy, ultrasound, negative
pressure therapy, hyperbaric oxygen,
and electrostimulation. Ann Plast Surg
51:210–218.
87. Evans D, Land L (2001) Topical
negative pressure for treating chronic
wounds: a systematic review. Br J Plast
Surg 54:238–242.
Wound management: a new protocol for dogs and cats 47
88. Gregor S, Maegele M, Sauerland S et al.
(2008) Negative pressure wound
therapy: a vacuum of evidence? Arch
Surg 143:189–196.
89. Morykwas MJ, Faler BJ, Pearce DJ et al.
(2001) Effects of varying levels of
subatmospheric pressure on the rate of
granulation tissue formation in
experimental wounds in swine. Ann Plast
Surg 47:547–551.
90. Horwitz LR, Burke TJ, Carnegie D (1999)
Augmentation of wound healing using
monochromatic infrared energy. Exploration
of a new technology for wound management.
Adv Wound Care 12:35–40.
91. Millis DL, Francis D, Adamson C (2005)
Emerging modalities in veterinary
rehabilitation. Vet Clin North Am Small Anim
Pract 35:1335–1355, viii.
92. Enwemeka CS, Parker JC, Dowdy DS et al.
(2004) The efficacy of low-power lasers
in tissue repair and pain control: a meta-
analysis study. Photomed Laser Surg
22:323–329.
93. Van Weeren PR (2006) Physiotherapy. In:
The Cutting Edge: Basic Operating Skills for
the Veterinary Surgeon, 1st edn. (eds
J Kirpensteijn, WR Klein) Roman House
Publishers, London, pp. 230–237.
94. Woodruff LD, Bounkeo JM, Brannon
WM et al. (2004) The efficacy of laser
therapy in wound repair: a meta-analysis
of the literature. Photomed Laser Surg
22:241–247.
95. Juha HA, Niinikoski MD (2004) Clinical
hyperbaric oxygen therapy, wound perfusion,
and transcutaneous oximetry. World J Surg
28:307–311.
96. Kranke P, Bennett M, Roeckl-Wiedmann I
et al. (2004) Hyperbaric oxygen therapy for
chronic wounds. Cochrane Database Syst
Rev 2:CD004123.
97. Roeckl-Wiedmann I, Bennett M, Kranke P
(2005) Systematic review of hyperbaric
oxygen in the management of chronic
wounds. Br J Surg 92:24–32.
98. Dyson M (2000) Ultrasound therapy.
J Equine Vet Science 20:694–695.
99. Taskan I, Ozyazgan I, Tercan M et al. (1997)
A comparative study of the effect of
ultrasound and electrostimulation on
wound healing in rats. Plast Reconstr Surg
100:966–972.
100. ter Haar G (1999) Therapeutic ultrasound.
Eur J Ultrasound 9:3–9.
101. Young SR, Dyson M (1990) Effect of
therapeutic ultrasound on the healing of full-
thickness excised skin lesions. Ultrasonics
28:175–180.
102. Capillas Perez R, Cabre Aguilar V,
Gil Colome AM et al. (2000) Comparison of
the effectiveness and cost of treatment with
humid environment as compared to
traditional cure. Clinical trial on primary
care patients with venous leg ulcers and
pressure ulcers. Rev Enferm 23:17–24.
103. Harding K, Cutting K, Price P (2000) The
cost-effectiveness of wound management
protocols of care. Br J Nurs 9:S6, S8, S10
passim.
104. Xakellis GC, Chrischilles EA (1992)
Hydrocolloid versus saline-gauze dressings
in treating pressure ulcers: a cost-
effectiveness analysis. Arch Phys Med
Rehabil 73:463–469.
Wound management: a new protocol for dogs andcats48
Chapter 3
General reconstructive
techniques
49
Sjef C. Buiks, Marijn van Delden and Jolle Kirpensteijn
• Triangular lesion
• Square lesion
• Bow tie technique
• Walking sutures
• Releasing incisions
• Mesh releasing incisions
• Advancement (U-) flap
• Double advancement or H-flap
• V-Y plasty
• Z-plasty
• Reading man procedure
• Transposition flap
• Interpolation flap
• Rotation flap
General reconstructive techniques50
Procedure
The amount of skin at the edges of the defect is
assessed. The defect is closed as a Y by beginning
at each point and suturing towards the centre 
(18–23).
Reference
Fossum TW, Hedlund CS, Hulse DA et al. (2002)
(eds) Small Animal Surgery, 2nd edn. Mosby,
St. Louis, p. 162.
Triangular lesion
Overview
An irregular-shaped cutaneous defect is converted
into a simpler geometric pattern to facilitate wound
closure. The closure begins at each corner of the
defect and advances towards the centre. It can be
used when sufficient skin is available on all sides of
the defect. Otherwise, rotation flaps or unilateral or
bilateral advancement flaps can be used. If too
much tension is created when the defect is being
closed, excised dog ears may be used as free skin
grafts to cover the remaining defect.
22 The subcutis has now been closed. 23 Interrupted 4-0 nonabsorbable
monofilament sutures are used to close
the skin.
18 A formerly irregular lesion has been
converted into a triangle.
19 The subcutaneous tissue is closed
using 3-0 absorbable monofilament
suture material.
20 Suturing progresses towards the
centre of the lesion.
21 The final subcutaneous suture is put
in place.
18 19 20
21 22 23
General reconstructive techniques 51
Square lesion
Overview
An irregular-shaped cutaneous defect is converted
into a simpler geometric pattern to facilitate wound
closure. The closure begins with suturing at each
corner of the defect and then advancing towards the
centre. A square lesion can be closed using the
technique described below when sufficient skin is
available on all sides of the defect. Otherwise,
rotation flaps or unilateral or bilateral advancement
flaps can be used. If too much tension is created
when the defect is being closed, excised dog ears
may be used as free skin grafts to cover the
remaining defect.
Procedure
The amount of skin at the edges of the defect
is assessed. The defect is closed starting at the
corners of the defect and suturing towards the
centre (24–27).
Reference
Fossum TW, Hedlund CS, Hulse DA et al. (2002)
(eds) Small Animal Surgery, 2nd edn. Mosby,
St. Louis, pp. 162–164.
24 The rectangular defect is slightly converted to a circular
defect due to local tension lines.
25 Interrupted or continous sutures using 3-0 absorbable
monofilament suture material can be used to close the
subcutis.
26 The subcutaneous tissue is closed. 27 The skin is closed with interrupted sutures using 4-0
nonabsorbable monofilament suture material.
24 25
26 27
General reconstructive techniques52
Bow tie technique
Overview
The bow tie technique can be used to close circular
defects where regular skin apposition would result
in large dog ears. This technique depends on the
availability of sufficient skin surrounding the defect.
Two triangles are placed at opposite ends of the
defect with their apex pointing towards the centre
of the defect. The long axis of the defect is situated
on the line of tension. The common axis of the
triangles should be at 30 degrees to the long axis of
the defect. The height of the triangles should equal
the radius of the defect. The corners of the triangles
are then transposed in such a way that the tension
on the long axis is reduced and the defect can be
closed effortlessly.
Procedure
The area around the circular defect is clipped and
shaved in a wide quadrangular shape. The defect
is cleaned if necessary (28). An incision is
made following the predrawn lines and the skin of
the two triangles bluntly undermined (29). The skin
in between the circular defect and the triangles is
then undermined (30). Stay sutures, using 2-0
nonabsorbable monofilament suture material, are
placed to enable the skin to be transposed (31, 32).
After transposing the two sides of the triangles, they
are sutured into position using subcutaneous
sutures of 3-0 monofilament absorbable suture
material (33). The rest of the skin is apposed
by placing a few subcutaneous sutures of 3-0
monofilament absorbable suture material (34). The
skin is closed with interrupted sutures of 4-0
nonabsorbable monofilament suture material (35).
References
Alvarado A (1981) Reciprocal incisions for closure
of circular skin defects. Plast Reconstr Surg
67:482–491.
Fossum TW, Hedlund CS, Hulse DA et al. (2002)
(eds) Small Animal Surgery, 2nd edn. Mosby,
St. Louis, pp. 162–163.
28 Circular defect.
Two triangles, both
with their central
axis at an angle of
30 degrees to the
long axis of the
tension lines, are
drawn with a blue
marker. The height
of the triangles
should equal the
radius of the
circular defect. 
30 The skin
adjacent to the
circular defect is
undermined using
Mayo scissors. 
29 The two
triangles of skin are
removed. 
29
30
28
General reconstructive techniques 53
33 The corners of
the triangles are
sutured into
position.
34 The skin edges
are apposed using
subcutaneous
sutures of 3-0
absorbable
monofilament
suture material. 
31 32
33 34
35 The end result
of the bow tie
reconstruction
technique. 
35
31, 32 The
undermined sides
of the triangles are
dissected and
moved towards
their new position. 
General reconstructive techniques54
Walking sutures
Overview
Walking sutures are used to relieve mild to
moderate tension. They gradually advance skin
from the edge of a wound towards the centre (often
from both sides). Walking sutures are placed
through the underlying fascia at a distance closer to
the centre of the wound than the bite through the
subdermal fascia. 
36 This lesion has too much tension to be closed primarily. 37, 38 The area is gently undermined using scissors.
39, 40 A suture is placed at a distance closer to the centre of
the wound than the bite through the subdermal fascia.
36
39
37
38
40 41
Procedure
Because the lesion has too much tension to be
closed primarily (36) the area is gently undermined
using scissors (37, 38). A suture is placed at a
distance closer to the centre of the wound than
the bite through the subdermal fascia (39, 40). A
sliding knot is used to approximate the flap
(41–44). A second suture is placed at the same level,
but opposite side, of the flap (45) and the pro cedure
is repeated, advancing the skin closer to the edge of
the wound (46–48). Finally, full closure of the
wound is facilitated (49, 50).
General reconstructive techniques 55
41–44 A sliding k not is used to approximate the flap.
44
4342
45 A second suture is placed at the same level, but opposite
side, of the flap.
45
46–48 This procedure is repeated, advancing the skin closer
to the edge of the wound.
46 47
48
49, 50 The procedure is further repeated, facilitating full
closure of the wound.
49
50
Releasing incisions
Overview
An elliptical wound can be closed with releasing
incisions if there is sufficient adjacent skin. The
closure begins by making one or two releasing
incisions parallel to the length of the defect. The
wound is closed first and then the releasing
incision(s) are closed. The tension of the original
wound is dispersed over the releasing incision(s).
Alternatively, the releasing incisions can be allowed
to heal by second intention.
Procedure
The amount of skin at the edges of the defect is
assessed (51) and the positions for the releasing
incisions marked (52). A releasing incision is
marked parallel to the defect and an assessment
General reconstructive techniques56
made as to whether the primary defect can be closed
without tension. If not, a second releasing incision
is made parallel to the first one, but opposite to
the defect. Careful dissection of the bipedicle
skin flap isperformed (53). The defect is closed
by suturing the subcutaneous layer including the
panniculus muscle. The use of 3-0 monofilament,
absorbable suture is preferred (54). The skin is then
closed in an interrupted suture pattern using 
3-0 nonabsorbable suture material (55). After
closure of the defect, both releasing incisions are
closed, if possible (56).
Reference
Pavletic MM (2010) Atlas of Small Animal Wound
Management and Reconstructive Surgery, 3rd edn.
Wiley–Blackwell, Ames, pp. 266–267.
General reconstructive techniques 57
51 An elongated incision can be closed with releasing
incisions if there is abundant skin parallel to the incision.
52 The positions for the releasing incisions are marked.
53 The skin adjacent to the defect is undermined using Mayo
scissors. 
54 The primary defect is closed initially in the middle to
assess if the skin edges are tension free.
55 The centre incision is opposed. 56 The end result after all the incisions have been closed. 
51 52
53 54
55 56
Mesh releasing incisions
Overview
Mesh releasing incisions (or meshing incisions) are
a variation on the releasing incision technique
described above. The skin surrounding the defect is
meshed in an attempt to decrease the skin tension
and allow primary closure of the skin wound. The
procedure is started by careful undermining of the
skin and placing the incisions approximately 1 cm
apart from each other in staggered rows.
Procedure
A wide quadrilateral area around the circular defect
is clipped, shaved and prepared for surgery (57).
The elasticity and the looseness of the skin in the
proximity of the defect is assessed. The sites where
the meshing incisions are to be made are marked
(58) and subsequently incised using a No. 11 scalpel
blade (59). The defect is sutured, leaving the meshed
incisions open for second intention healing (60).
Reference
Pavletic MM (2010) Atlas of Small Animal Wound
Management and Reconstructive Surgery, 3rd edn.
Wiley–Blackwell, Ames, pp. 270 –271.
General reconstructive techniques58
57 A wide area around the circular defect is prepared for
surgery.
59 The marked spots are incised with a No. 11 scalpel blade. 60 The defect is sutured using 4-0 nonabsorbable
monofilament suture material. 
58 The meshing incision sites are marked with a sterile skin
marker.
57 58
59 60
Advancement (U-) flap
Overview
One of the easiest and most versatile flaps used
in veterinary surgery is the advancement (or U-)
flap. A U-flap is a partially detached segment of
skin and subcutaneous tissue. Its viability is based
on maintaining blood circulation through its base
and the subdermal plexus. The rationale behind
this technique is that local skin in an area with a
relative abundance or elasticity is used to close the
primary wound. The secondary wound created can
then be closed in a relatively tension-free fashion.
Procedure
This technique is used (in this case) to close an oval
defect (61). The cutaneous trunci muscle at the edge
of the incision should be noted. The locations of the
two parallel vertical incisions of the U are marked
(62). The two sides of the U-flap are then incised
(63, 64).
General reconstructive techniques 59
61 An oval defect is present. Note the panniculus muscle at
the edge of the skin incision (arrow).
62 The positions for the two vertical incisions are marked.
63, 64 The upper and lower limbs of the U-flap have been incised.
61 62
63 64
The U-flap with the cutaneous trunci muscle
attached is carefully dissected. The edges of the
flap are manipulated using stay sutures (65). The
General reconstructive techniques60
65 The U-flap with the panniculus muscle attached is
carefully dissected.
66, 67 The panniculus muscle at the corners of the U-flap is
sutured to the corners of the defect. 
68 Interrupted sutures are placed. 
65 66
67 68
cutaneous trunci muscle or subcutis at the corners
of the U are sutured to the corners of the defect (66,
67). The skin tension is assessed by placing a couple
General reconstructive techniques 61
69, 70 The layer containing the panniculus muscle is closed in a continuous suture pattern using 3-0 absorbable suture material.
71, 72 The skin is closed with interrupted sutures using 4-0 nonabsorbable monofilament suture material.
69 70
71 72
of interrupted sutures of 3-0 monofilament absorb -
able suture material (68). A continuous suture
pattern is used to close the subcutaneous layer
containing the panniculus muscle (69, 70). The skin
is closed with interrupted sutures of 4-0 non -
absorbable monofilament suture material, starting
at the corners of the defect (71, 72).
General reconstructive techniques62
Double advancement or H-flap
Overview 
An H-flap comprises two advancement (U-) flaps
made in opposite directions.
Procedure
An oval defect is present is this case. The locations
for the two parallel incisions of the H are marked
(73). The two sides of the flap are then incised (74).
The flap, with the cutaneous trunci
muscle attached, is carefully dissected from the
73 One advancement flap has already been incised. Markings
clearly point out the incision lines for extending the U into an
H flap.
74 Both sides of the H-flap have been incised.
wound bed. The edges are manipulated using
stay sutures (75). The cutaneous trunci muscle
at the edges of the H is sutured to the corners of
the defect (76). The skin tension is assessed
by placing a couple of interrupted stay sutures of 
3-0 monofilament absorbable suture material.
A continuous suture pattern is used to close the
subcutaneous layer containing the cutaneous
trunci muscle. The skin is then closed with skin
staples or interrupted sutures of 4-0 nonabsorbable
monofilament suture material (77, 78).
73 74
General reconstructive techniques 63
75 The H-flap with the cutaneous trunci muscle attached is
carefully dissected from the wound bed. 
76 The cutaneous trunci muscle at the edges of the U are
sutured to the corners of the defect.
77 The skin is closed with skin staples or sutures. 78 A double advancement (H-) flap has been used in this dog
to close a defect between the eyes.
75 76
77 78
General reconstructive techniques64
V-Y plasty
Overview
A V-Y plasty is a lengthening procedure used to
relieve tension on a sutured wound. However, the
tension-relieving effect is minimal and this tech -
nique should be reserved for wounds with moderate
tension in areas where there is no skin available for
closure using other methods.
81 The primary defect is sutured.
82, 83 The V incision is closed by apposing the lateral edges,
beginning at the tip.
84 The end result of a V-Y plasty reconstruction is shown.
81 82
83 84
Procedure
An oval defect is present in this case. A V shape is
drawn at least 3 cm from the wound edge (79). Both
sides of the V-flap are then incised (80), the subcutis
undermined and the primary defect is sutured (81).
If necessary, the edges of the wound are carefully
undermined. The incision is closed initially by
apposing the outer edges, beginning at the tip of the
V (82, 83). Closure of the wound is completed by
creating a Y-shaped configuration to the incision
(84).
79 A V shape is drawn at least 3 cm from the edge of the
wound. 
80 The V is incised.
79 80
General reconstructive techniques 65
Z-plasty
Overview
A Z-plasty is used to increase the length of a skin
area (e.g. restrictive scar tissue). A Z-plasty involves
the simultaneous transposition of two equilateral
triangular local flaps. The theoretical amount of
skin lengthening varies with the length of the limbs
of the Z-shaped incision and with the angle between
the limbs.
Procedure
An incision line is marked on the skin parallel to
the direction in which the defect will be closed. This
is the central limb of the Z (85) and it should be
parallel with the line of tension (i.e. perpendicular
to the wound requiring tension relief). The two side
limbs of the Z are drawn on the skin at an angle of
45–60° to the central limb. To guarantee survival
of the skin betweenthe Z and the wound, the
incision should not be made too close to the wound
edge (86). The triangles formed by the Z are
coloured to make the flap clearer (87). The limbs of
the Z are then incised. The corners of the Z are
incised with relatively sharp angles; however,
blunting the angle a little will preserve the blood
supply to the tip (88).
85 The central limb of the Z is drawn perpendicular to the
wound requiring tension relief.
86 The Z limbs are drawn at an angle of 60 degrees to the
central limb.
87 The triangles formed by the Z are coloured in order to
make the plasty clearer.
88 The three limbs of the Z are incised.
85 86
87 88
General reconstructive techniques66
Tension will open up the Z (89). Each triangular
flap is then carefully undermined (90). The position
of the Z before the two triangular flaps are moved
to their new position (91) and the final result of the
Z-plasty after the two flaps have been moved (92)
are shown. The corners of the Z are sutured using
91 The original position of the the triangular parts of Z-
plasty is shown.
92 The final position of the triangular parts of the Z-plasty is
shown.
89 Tension opens up the Z. 90 Each trianglular flap and the skin between the defect and
the Z is undermined using Mayo scissors.
89 90
91 92
General reconstructive techniques 67
3-0 absorbable monofilament suture material (93).
The Z-plasty and the defect are sutured using 4-0
93 The corners of the Z-plasty are sutured.
94, 95 The Z-plasty and the defect are sutured.
93
94 95
nonabsorbable monofilament suture material (94,
95).
96 Illustration showing the reading man surgical procedure.
(A) Circular defect. (B) Determining the direction of the central
limb of the Z-plasty (dotted lines). To obtain a fine scar, this
line should be perpendicular to the relaxed skin tension lines
(RSTL). (C) The central limb of the Z-plasty is drawn as an
imaginary tangential line passing through the margin of the
circular defect. (D, E) Other limbs of Z-plasty are planned with
angles of 45º and 60º according to an unequal Z-plasty
concept. (E) The flap nearest the defect (f1) is used for the
defect closure, and the other flap (f2) is transposed for closure
of the donor site of the first flap with a Z-plasty manoeuver. (F)
The final view after defect closure. (Adapted from Mutaf M,
Sunay M, Bulot Ö (2008) The “Reading Man” procedure: a new
technique for the closure of circular skin defects. Ann Plast Surg
60:420–425.)
General reconstructive techniques68
Reading man procedure
Overview
The reading man procedure can be used in a variety
of ways. It is an effective method of closing a round
defect. Two skin flaps are designed in an unequal Z-
plasty manner. These two flaps provide a maximum
amount of tissue relaxation, which results in
decreased tension (96).
Procedure
The skin tension lines in the area of the defect
are determined. Two parallel lines are drawn
perpendicular to the direction of the skin tension
lines (97). The axis of the Z is placed parallel to the
line of skin tension. The incision should be one-and-
a-half times the diameter of the defect. Lines are
then drawn at an angle of 60º at the end of the
Z and at an angle of 45º at the beginning of the Z
(98). Both flaps are incised and then undermined
using scissors (99). Stay sutures are placed to move
the flaps. The first flap (1) is used to cover the area
of the primary defect and the second flap (2) to
cover the donor area (100, 101). The flaps are
sutured with a continuous subcutaneous pattern
and simple interrupted skin sutures (102, 103).
References
Mutaf M, Sunay M, Bulut Ö (2008) The “Reading
Man” procedure: a new technique for the closure of
circular skin defects. Ann Plast Surg 60:420–425.
96
A B
a
RSTL
a + !
a
C D
E F
60º
f1
f2
45º
60º
f1 f2
General reconstructive techniques 69
100, 101 Stay sutures are placed. Flap 1 is used to cover the area of the primary defect, flap 2 to cover the donor site. 
102, 103 The flap edges are sutured to the defect and the subcutis and skin closed.
100 101
102 103
97 Two parallel lines are drawn in the
direction of the skin tension lines.
98 The outline of the Z is shown. 99 The flaps are incised along the
predrawn lines and they are then
undermined.
97 98 99
f1
f1
f2 f2
General reconstructive techniques70
Transposition flap
Overview
A transposition flap is a local pedicle flap that
transposes skin from an area adjacent to the skin
wound to the defect that is to be closed. The length
of the flap is predetermined and different angles
can be used. The most common angle to the wound
is 90º.
Procedure
The base of the flap should equal the width of the
defect (104, 105) and the length of the flap should
equal the length from the outer pivot point to
the most distant edge of the defect (106, 107). The
donor flap is marked using a sterile marking pen
(108). The flap edges are incised and the flaps lifted
(109, 110). The flap is then transposed into
the defect (111). Finally, the flap is sutured into
place in two layers (112, 113).
References
Fossum TW, Hedlund CS, Hulse DA et al. (2002)
(eds) Small Animal Surgery, 2nd edn. Mosby,
St. Louis, p. 166.
Hedlund CS (2006) Large trunk wounds. Vet Clin
North Am Small Anim Pract 36:847–872.
Pavletic MM (2010) Atlas of Small Animal Wound
Management and Reconstructive Surgery, 3rd edn.
Wiley–Blackwell, Ames, pp. 322–325.
105 The base of the flap, which should equal the width of the
defect, is marked.
106 The length of the flap is measured. It should equal the
length from the outer pivot point to the most distant edge
of the defect.
107 The length of the flap is marked.
104 The width of the defect is measured.
104 105
106 107
General reconstructive techniques 71
111 The flap is transposed into the defect.
112 The flap is sutured to the edges of the wound defect. 113 The end result of a transposition flap reconstruction is
shown.
109 The edges of the flap are incised and the flap is lifted.
110 The flap is lifted from its wound bed.
109
110 111
112 113
108 The complete flap is marked.
108
General reconstructive techniques72
Interpolation flap
Overview
An interpolation flap is a transposition pedicle flap,
traversing an area of normal skin between the
donor site and the recipient site. This flap is similar
to the transposition flap apart from the fact that it
lacks a common border with the wound. The size of
the flap must take into account the width of the
defect and the loss of length that will occur when
the flap is rotated into the defect (114). Because
there is a skin bridge between the flap and the
defect, the subcutaneous tissue on the underside of
the flap is exposed to this bridge and could become
infected. This excess skin is excised after 14 days.
An interpolation flap can be used when there is
insufficient skin adjacent to the defect, but
abundant skin is available in close proximity of the
wound. Alternatively, a single-stage interpolation
flap can be performed with a bridging incision
made between the donor and the recipient sites.
Procedure
Stage 1. The area around the circular defect is
clipped and shaved in a wide quadrilateral area. If
necessary, the defect is debrided. The elasticity and
looseness of the skin in the proximity of the defect
is assessed. The donor flap is marked using a sterile
marking pen. The base of the flap should equal the
width of the defect and the length of the flap should
115 The circular defect has been excised. The donor flap is
outlined in blue. 
115
114 Schematic representation of the interpolation flap. The
base of the flap equals the width of the defect (line 1) and the
length of the flap equals the distance from the outer pivot
point to the most distant edge of the flap (line 2)
114
1
1
2
2
equal the length from the outer pivot point to the
most distant edge of the defect (115). Incisions are
made along the predrawn lines and the donor flap
is undermined, using Metzenbaum scissors,
beginning at the top of the rectangle. Staysutures,
using 2-0 monofilament (non)absorbable suture
material, are placed in the corners of the flap in
order to move it into the recipient site (116). The
flap is sutured into position by placing a few
subcutaneous stitches (117). The donor bed is then
closed (118). The subcutis and skin are sutured
using 3-0 absorbable monofilament suture
materials (119).
General reconstructive techniques 73
119 After suturing the skin, part of the subcutaneous side of
the flap is still accessible (identified by the forceps). 
119
116 The donor flap (which is covering the defect) is ready to
be transposed. 
117 The subcutaneous tissue of the donor flap is sutured to
the recipient site with interrupted sutures. 
118 Note that the segment of the flap overlying the
intervening skin is neither attached to the underlying skin nor
to the defect.
116 117
118
Stage 2. The bridging skin is excised 14 days later
(120). The skin is incised following the blue dotted
line and sutured to the donor and recipient sites
(121–123). (Note: Because the overlying skin
surplus produced in stage 1 of the procedure is
liable to infection, an interpolation flap is in -
frequently used as described and illustrated above.
More commonly, a bridging incision is made or the
flap ends are sutured together (forming a tube) so
that the skin does not touch the underside of the
flap [see Chapter 9, Genicular axial pattern flap].)
References
Fossum TW, Hedlund CS, Hulse DA et al. (2002)
(eds) Small Animal Surgery, 2nd edn. Mosby,
St. Louis, p. 166.
Hedlund CS (2006) Large trunk wounds. Vet Clin
North Am Small Anim Pract 36:847–872.
Pavletic MM (2010) Atlas of Small Animal Wound
Management and Reconstructive Surgery, 3rd edn.
Wiley–Blackwell, Ames, pp. 328–331.
General reconstructive techniques74
121 The superfluous skin is incised and removed.
122 The original lesion and the recipient lesion are now
clearly visible after removal of the bridging skin. 
123 The completed interpolation flap reconstruction is
shown. 
121
122 123
120 The part of the donor flap that will be removed is
outlined.
120
Rotation flap
Overview
A rotation flap is used to cover small, triangular
defects. The flap can be used in any location and is
independent of the size of the triangle. The flap has
a semicircular form and is rotated around a pivot
point. The length of the arc-shaped incision should
be approximately four times the length of the
baseline of the defect. Rotation flaps can be single
or paired. Paired flaps can be used to close wider
defects.
Procedure
The area around the triangular defect is clipped and
shaved (124). A curved incision line is drawn using
a sterile marking pen. The total length of the
semicircular line should be four times the baseline
of the wound. The pivot point is the lower right
corner of the triangle (125). A curved incision is
made and a small piece of the flap is undermined
beginning at the top of the triangle. Stay sutures are
placed in the corner of the flap to facilitate
manipulation of the flap (126). The skin is under -
mined in a stepwise fashion until the flap can be
rotated into the defect with minimal tension (127).
General reconstructive techniques 75
124 A triangular defect is present on the trunk. 125 The arc-shaped incision line is four times the length of
the baseline of the wound. 
126 An arc-shaped incision is made. Two stay sutures are
placed in the corner at the top of the triangle to manipulate
the flap into position. 
127 Half of the skin flap is undermined. In this case this was
sufficient to cover the whole defect without too much tension. 
124 125
126 127
The flap is sutured into position by placing a few
subcutaneous sutures (128). The subcutis is sutured
with a continuous monofilament suture pattern and
the skin with an interrupted monofilament suture
pattern (129).
References
Fossum TW, Hedlund CS, Hulse DA et al. (2002)
(eds) Small Animal Surgery, 2nd edn. Mosby,
St. Louis, pp. 162 and 166.
Hedlund CS (2006) Large trunk wounds. Vet Clin
North Am Small Anim Pract 36:847–872
Pavletic MM (2010) Atlas of Small Animal Wound
Management and Reconstructive Surgery, 3rd edn.
Wiley–Blackwell, Ames, pp. 332–333. 
General reconstructive techniques76
128 The rotation flap is sutured into the recipient bed. 
128
129
129 The skin edges are apposed and the skin sutured.
• Introduction
• Background information on avascular and microvascular skin surgery
• Avascular mesh graft
• Microvascular flap transfer
• Conclusion/summary
• References
Chapter 4
Avascular and microvascular
reconstructive techniques
77
Guido Camps and Jolle Kirpensteijn
Introduction
This chapter aims to give a review of the current
techniques being used in the field of avascular and
microvascular flap transfer procedures in veterinary
medicine. Microvascular flap transfer is specialized
surgery that yields many benefits when compared
with fixed flap or avascular graft operations.
Avascular mesh graft transfer techniques for closing
wounds will be described. The background to flap
transfer and its relation to and development into
microvascular free flap transfer is discussed,
followed by a general description of the technique.
A detailed overview of the results of published
scientific articles is provided, with emphasis on the
location of recipient vessels for microvascular free
flap transfers. 
Background information on avascular
and microvascular skin surgery
The act of closing a wound and restoring the skin
has the goal of creating the best conditions to allow
recovery in the shortest amount of time with the
best cosmetic results. This implies that the exposed
lesion needs to be covered completely by functional,
healthy skin. In some wounds the nature of the
lesion or of the surgical procedure makes it
impossible to achieve wound closure with
conventional suturing techniques. The lesion may
simply be too large because so much skin had to be
excised due to the original wounding or too much
skin was lost during the creation of the wound.
When faced with these situations, other solutions
must be explored in order to close the wound
satisfactorily. 
There are two primary options for closing such
wounds: (1) using pedicle flaps, which remain
attached to the skin, or (2) using free grafts,
sometimes referred to as free flaps.1 The use of free
flaps has become more common with the advent of
microvascular surgery, which allows the surgeon to
reconnect the free flap directly to the body’s
circulation, thus ensuring its survivability.
A pedicle flap remains attached to the rest of the
skin via its pedicle and is moved towards the wound
to cover it. This has the advantage that it remains
connected to the body’s circulation. A pedicle flap
can be used to cover large wounds.2 The main
disadvantage, however, is that the surgical
techniques available to the surgeon are limited by
the size of the flap. Problems can arise from
overstretching the flap to cover the wound, thereby
cutting off the blood vessels necessary for sustaining
the flap. Additionally, the procedure must
sometimes involve stretching the flap in a direction
other than how nature intended. This stretching not
only puts pressure on the vessels, it also seems to be
a painful process, specifically in those areas where
skin is sparse and tight due to movement.
In contrast, a free graft (flap) is taken away from
its original site and placed over the wound.
Therefore, it is completely cut off from the body’s
original circulation. Indications for the use of free
flap transfers include a wound beyond the reach of
pedicle flaps or when it is necessary to cover taut,
sparse skin areas that do not have enough
surrounding skin to stretch to cover the wound.
This is usually the case with large distal wounds on
the limbs.3 Healthy granulation tissue or a fresh
wound are required for a successful free flap
transfer procedure.
The process of grafting is in itself not without
risks. The biggest complication in grafting is
infection, which may lead to necrosis ofthe graft
and the recipient site, which in turn leads to
scarring and delayed healing.4 Most problems are
the result of delayed vascularization of the graft
(e.g. due to fluid build-up between the graft and
recipient site). In free graft transplants, three stages
of acceptance (or take) of a graft are recognized:
prior to revascularization, the stage of vascular -
ization, and the stage of final take. In the first stage
only fibrin binds the graft to the site; after 12 hours,
vascularization begins and this is completed after 12
days. Final healing, including contraction, pig -
mentation and innervation, may take up to 18
months.
Complications with conventional free grafts arise
when the graft necrotizes due to insufficient
circulation between the graft and the body’s blood
supply. There are three main causes for problems
with vascularization:3
• Physical movement of the graft can severely
undermine the body’s attempt at
revascularization. As mentioned above, during
the first stage the graft is only stuck to the
recipient site by a fibrin seal. If the graft
moves, it can dislodge this seal and prevent
the development of newly formed vessels or
the connection of vessels to the graft. Free grafts
are often kept as thin as possible to allow fast
revascularization and guarantee the availability
of essential products to survive through diffusion
in the early stages of healing. 
• The second complication is the occurrence of
fluid build-up (e.g. a haematoma) underneath the
graft. Since the recipient site is a wound, it often
keeps bleeding after application of the graft and
a haematoma or seroma can form underneath
the graft and prevent revascularization, which in
turn leads to necrosis of the flap.
• Lastly, due to the initial decreased circulation
underneath the flap, this area will be infiltrated
to a lesser extent by the body’s immune cells.
Because of this, the area can become infected,
which will not only prevent vascularization,
but also compromise the wound bed and the flap
directly, leading to flap death.
Avascular and microvascular reconstructive techniques78
Avascular mesh graft
Overview
A mesh graft is a nonvascularized piece of skin from
a distant and different part of the body that is
transferred to the recipient defect side. Because of
the nonvascularized nature of the graft, extreme
care must be taken in expediting atraumatic
harvesting and attachment of a flap. This is best
facilitated by using two surgical teams. 
Types of mesh grafts
There are two major types of mesh grafts: full-
thickness and partial-thickness. Partial-thickness
mesh grafts are often obtained using electrically
operated mechanical dermatomes, which are
expensive. Grafts can also be obtained manually.
Full-thickness grafts are made using the scalpel
blade as described below. Full-thickness grafts
have the advantage of better cosmetic end
results (especially hair growth). Partial-thickness
grafts have a better chance of survival and the
donor site does not need to be sutured after the
harvesting.
Wound bed preparation
The wound bed must be prepared in such a
way that it will be able to receive the mesh graft
(130, 131). This includes:
• Removing wound fluid, crusts, dead tissue
and possible foreign bodies, thus creating a
healthy granulation tissue bed. This should
be performed in advance of the grafting
procedure.
• Inspecting the epithelial borders and, if
necessary, cleaning up the wound edges
and removing epithelialized tissues.
• Coagulation of any cut blood vessels that
are present.
• Removing the top layer of the granulation
tissue (if necessary).
• The recipient side should be covered with a
saline- or blood-soaked sponge to prevent
dessication while the donor side is being
prepared.
Avascular and microvascular reconstructive techniques 79
130, 131 (130) This cat has a severely necrotic skin wound on its distal limb. (131) The wound is managed appropriately until a
healthy granulation tissue bed has formed.
130 131
Donor side preparation
The donor site should be carefully selected, so the
defect can be closed without tension (132).
Attention should also be directed to the growth
pattern and hair colour to achieve the most
acceptable cosmetic results. An impression is made
of the recipient bed in order to estimate the size of
the donor bed. The graft will expand significantly in
correlation with the number of slits (or meshes) that
are made in the graft, so either a comparable size
wound is made or one slightly smaller. 
Technique
The graft must be kept moistened during the
complete procedure. The site is prepared aseptically
and a marker used to determine the margins of the
graft (133). The skin is then incised along the
marked lines (134). The skin only is elevated from
the wound bed and the panniculus muscle is not
incorporated into the graft. To facilitate removal,
the edges of the graft can be sutured to a roll of
sterilized bandage material (135). The roll is used to
put tension on the graft and lift it up from the donor
bed. As much subcutis as possible is removed from
the graft so that the hair follicles are visible. The
graft is rolled slowly over the bandage material and
attached to the material with a few sutures. The
graft is then detached and freed from the remnants
of subcutaneous fat. A No. 11 blade is used to make
the meshes (slits) in the graft. The distance between
the slits should be less than 1 cm and they are
staggered in alternate rows (136, 137). The graft is
placed as soon as possible on the prepared recipient
side. The edges of the graft are sutured or stapled to
the recipient side (138, 139). Sutures within the
graft are usually not necessary, but in large mesh
grafts a few sutures can be placed inside the graft
edges; these prevent dead space, improve contact
Avascular and microvascular reconstructive techniques80
132 Skin tension is checked at the donor site. 133 A paper template is made of the recipient site to
determine the dimensions of the graft.
134 The harvest site is grafted by incising along the
marked lines.
135 The subcutaneous tissue is removed from the deep
aspect of the graft by careful dissection.
132
134
133
135
Avascular and microvascular reconstructive techniques 81
138, 139 The graft is sutured to the recipient site.
136, 137 The graft is meshed with incisions (slits) that are <1 cm apart and staggered in alternate rows.
140, 141 The donor site is closed primarily.
between graft and bed and decrease seroma
formation. The donor bed is then closed (140, 141).
The use of a nonmeshed graft is discouraged. The
mesh prevents fluid build-up under the graft.
A seroma will significantly decrease the survival
(acceptance) of the graft.
136
138
140 141
139
137
Aftercare
Aftercare is an important aspect of the procedure.
A well-padded, nonadhesive bandage that is able to
absorb excess wound fluid should be applied and
not removed for 3–5 days (142). It must be kept
as clean and dry as possible. In this period,
plasmatic imbibition will take place, which will
nurture the graft, and vessels will be able to
reconnect. After this initial period, very careful
bandage changes will be necessary. The graft will
adhere in 7–14 days and epithelialization of the slits
will take place within a month (143). Cage rest
is essential during the first 10 days. Casts and
splints are only used when other means of
immobilization (e.g. a Robert Jones bandage) are
not possible. Mesh grafts have a 50–90% chance of
survival (144).
Microvascular flap transfer
Overview
In order for the success of a free graft to be less
dependent on the body’s ability to revascularize the
flap, microvascular surgical techniques can be used
that directly connect the flap to the circulatory
system. This combines the circulatory advantage of
pedicle flaps with the possibility of treating wounds
in any location. For this procedure, the free flap is
designed by taking a skin flap with an afferent
and efferent vascular pattern. Specifically, the
vessels that supply and drain theflap are identified,
the flap is freed and placed in the recipient area, and
the vessels are anastomosed to the vessels at the
recipient site. This creates a blood supply to the
graft, independent of the body’s ability to
revascularize the flap through the wound bed.5
General concepts of microvascular flap
transfers
Materials 
An operating microscope with good optics, 9-0 to 11-
0 suturing material, vascular clamps, microscissors,
jeweller’s forceps, ophthalmic needle holders, vessel
dilators and coupling devices are required for
performing microvascular skin flap transfers. In order
to ensure that there are functioning recipient vessels at
the transfer site, an angiography of the recipient area
should be performed. 
Obtaining the flap 
To obtain the flap that will be used in the
procedure, a graft must be harvested from an
appropriate area. The graft must be large enough,
not be in the area undergoing surgery and have a
circulatory system that allows for microvascular
surgery afterwards. Sites commonly used are the
medial side of the thigh and the upper shoulder
area. The lower craniolateral thoracic area can
be used as a harvest place for two specific reasons:
Avascular and microvascular reconstructive techniques82
142–144 A bandage is applied to protect the
meshed wound (142). Follow-up photographs are
shown at 1 month (143) and 6 months (144)
postoperatively, respectively.
142
144
143
it has good hair growth, leading to a more
aesthetically pleasing result, and the skin is
relatively thin, resulting in quick vascularization.3
Other sites and their respective sizes will be covered
in more detail later. 
Preparing the vessels
The vessels within the flap are identified
and prepared using magnification. They should
be clamped and transected in preparation for
reattachment. After the wound site (recipient site)
has been cleaned and prepared for the flap, recipient
vessels are selected. Both vessel ends are prepared for
microvascular anastomosis by irrigation with
heparinized saline. To create actual circulation
within the flap, the artery of the flap is first
anastomosed to an artery of the recipient site. After
this the vein is connected to a vein in the recipient site
with small size nonabsorbable suture material.6
Complications 
The main risk with this procedure is necrosis of the
flap because of faulty circulation. Excluding the
possibility that the anastomosis between the vessels
was badly performed, faulty drainage can be caused
by thrombosis within the flap blocking the
circulation, or it can be due to too much pressure
on the draining vein. A change of flap colour would
be indicative of complications. Anticlotting
medication (e.g. aspirin) can be given to help
prevent a thrombus from forming (Table 6).
Checking the arterial blood flow into the flap can
be achieved with Doppler ultrasound.7 Poor or
occluded drainage of the veins can occur due to
pressure on or kinking of the efferent veins.
An accurate estimation of the appropriate length
of the vein to be used in the flap is essential for
flap survival. It is important to ensure that the
patient cannot damage the newly connected vessels
through postoperative biting or licking of the
wound. It is also important that the site where the
flap was harvested is checked carefully. 
Circulation 
A study in 1973 challenged the contemporary idea
that blood vessels in the skin were more important
for thermoregulation than for nutrient delivery.8
The authors compared human and animal blood
supply to the skin and differentiated between three
types of vessels: segmental, perforator and
cutaneous vessels. Based on the blood supply, skin
flaps can be classified as cutaneous, arterial or
island flaps. The authors found that island flaps
could survive if only their main pedicle vessels
remained intact, as the severance of all other vessels
did not have an adverse effect on flap survival.
Taking this fact into consideration, they performed
successful island flap transfers in pigs by
Avascular and microvascular reconstructive techniques 83
anastomosing the vessels of the island flap via
microvascular surgery.
The first mention of microvascular surgery in
veterinary medicine was in 1986 when cervical
flaps in the dog were successfully performed.9
Certain flaps were found to be successful based
on the superficial cervical vessels supplying blood
to the cervical region. The supplying vessels were
all observed to originate from between the
omotransversarius and trapezius muscles, lying in a
craniodorsal direction towards the cutis. Eight
transfers were performed using the cervical flap and
six of the eight grafts survived. The two graft
failures were caused by decreased circulation, in one
case because of arterial insufficiency and in the
other because of poor venous drainage. Following
these experimental flap transfers, in 1991 the use of
a cervical flap was reported in seven clinical cases,
with a success rate of 100%.12
Table 6. Available antithrombotic medication.
Anti-thrombotic medicine Dosage
Heparin flush6 Heparin saline flush of 
vessel ends before 
anastomosis
Acetylsalicylic acid (ASA)10 0.5 mg/kg (q12h) for 
3–14 days postoperatively
Acetylsalicylic acid (ASA) 2 mg/kg q12h for 4 days 
from day before surgery
Dextran 407 Intraoperative 
administration, 
dosage n/a
Preventing complications
A review of free skin flap transfer by microvascular
anastomosis established five criteria for a successful
skin flap transfer: adequate size, minimal donor site
morbidity, a consistent vascular pedicle, a vascular
diameter of at least 0.5 mm and a minimal vascular
pedicle length of 4.0 cm.10 In cervical flap transfers,
an incision is made in the skin from the top of
the scapula to the cranial point of the shoulder.
The flap, which is located cranial to this incision
on the cervical area, gets its blood from the pedicle,
which can be found via the earlier mentioned
incision. The flap is dependent on the pedicle for its
blood supply for 8–14 days postoperatively. The
critical ischaemia time for the flap is 13 hours
(survival >50% if reperfused). It is important to
counteract the postoperative occlusion as soon as
possible, at least within 4 hours. Acetylsalicylic acid
(ASA) (0.5 mg/kg PO for 3–14 days post surgery)
can be given to prevent clotting in the flap. Flap
transfers are an all-or-nothing procedure; either the
whole flap dies or, hopefully in the majority of
cases, the whole flap survives. 
Donor sites and results
The first large-scale overview of microvascular free
flap transfer results was presented in 1998.7 Case
records from all animals undergoing microvascular
reconstructive procedures at the Western College of
Veterinary Medicine and Michigan State University
were reviewed in the period from 1985 to 1996.
The main variable that was recorded was
flap survival rate. The authors also tried to find
reasons why in specific instances the flap did not
take. The risk factors evaluated were ischaemia
time, institution, surgical experience, experience
of the assistant surgeon, antithrombotic therapy,
anastomosis techniques and flap type. The flap
survival rate reported in this case series was 93%.
No significant relationships between flap survival
and any of the aforementioned risk factors
were observed, with the exception of the experience
of the primary surgeon. The dogs needing
reconstructive surgery used in the study were a
group of mixed gender, breed and size. The most
common indications for surgery included cancer
and car accidents. The vessels of the flap were
anastomosed to the recipient site using both end-to-
end and end-to-side ligation techniques. End-to-side
repairs were favoured when a notable discrepancy
in size between the flap and recipient vessel size was
apparent. The authors noted that the main
intraoperative complication in surviving flaps was
due to poor preparation of the vessel ends before
anastomosis. It is important that the vessel ends are
cleared of adventitial tissue in order to prevent
adventitial tissueprolapsing into the lumen of the
anastomosed vessel. 
Muscle flaps 
An additional result from the above study is
the shift it caused from the use of purely cutaneous
flaps to musculocutaneous flaps or muscle flaps
covered with a (mesh) skin graft. The authors
recommended that muscle is superior to skin in
promoting revascularization of ischaemic wound
beds, thus reducing infection rates and providing a
more rapid initiation of bone healing.
Using muscle tissue in the same manner as a
cutaneous pedicle flap has been described in the
literature.12 The semitendinosus muscle was used
to create a flap to cover a lesion caused by a tibial
fracture. The authors used a muscle flap because of
its healing properties, especially in support of
healing the underlying bone, but they also reported
a partial skin necrosis. Muscle flaps would be of
great interest for use as free flaps for transfer
surgeries.
The use of free muscle flaps has been further
described in another study.13 The rectus abdominis
muscle was used and a cutaneous mesh graft
added. The donor site morbidity and survival of the
rectus abdominis muscle was assessed following
transfer to a medial femorotibial defect in dogs.
First, the dimensions of the abdominis flap were
examined using angiography on flaps harvested
from canine cadavers. In the seven dogs used for
the experiment, the mean length and width of the
excised rectus abdominis muscles were 225 (SD 48)
mm and 55 (SD 6) mm. The muscular transfer
was performed through anastomosis of the caudal
epigastric artery and vein to the saphenous artery
and medial saphenous vein, after which the muscle
was covered with a mesh skin graft. The procedure
was observed to have caused minimal donor site
morbidity. Survival rate of the muscle flap after
microvascular transfer was 100% and angiography
confirmed vascular patency. With the exception of
one partial necrosis, all the skin grafts survived. On
the basis of this, the authors concluded that the
rectus abdominis muscle can be successfully
transferred to a medial femorotibial defect and can
successfully serve as a bed for acute skin grafting.
The authors made special mention of the excellent
aesthetic result of this procedure and attributed
this to the fact that the mesh skin graft can be
rotated so that the grain of the hair is in line
with the coat surrounding the graft. The rectus
abdominis flap is very versatile and can also be used
for other locations (145–148).
Avascular and microvascular reconstructive techniques84
Avascular and microvascular reconstructive techniques 85
145–148 (145) A dog with a large defect in the hard palate
following resection of a melanoma. (146) Following failure
of a local buccal flap, a rectus abdominis muscle was
transferred into the mouth. (147) The anastomosis
post surgery. (148) The surgery resulted in an excellent
outcome. 
Anaesthesiology
Circulation is an important issue when it comes
to flap transfers. A human study, which demon -
strated that lidocaine epidural anaesthesia increased
microcirculatory blood flow in flap transfer
patients, encouraged veterinary applications.
145
147 148
146
One study assessed the effects of epidural
anaesthesia using lidocaine on microcirculatory
blood flow, volume and velocity in free
fasciocutaneous flaps in dogs.14 Ten adult dogs,
weighing 20–25 kg, had an orthotopic transfer
performed with a medial saphenous fascio -
cutaneous free flap (Table 7) by anastomosing the
primary flap vessels back to the medial saphenous
vessels. Blood flow, volume and velocity values in
the flaps were checked throughout the procedure
and compared with the values recorded after
epidural anaesthesia. The values did not change
significantly over time. The only change that did
occur was a reduction in the mean arterial pressure,
which remained below reference values throughout
the whole procedure. The differences between these
results in dogs and humans are attributed to
differences in circulatory build-up between humans
and dogs and cats, as has already been reported.8
The implication of these results is that epidural
anaesthesia with 2% lidocaine is of no direct use in
dogs undergoing microvascular free flap transfer.
Recipient vessels
Two publications gave an overview of access to the
recipient vessels for free flap transfer in the head and
Avascular and microvascular reconstructive techniques86
neck area and on the fore- and hindlimb, common
sites for difficult-to-close wounds.15,16 These studies
were performed with the aim of developing and
evaluating surgical approaches to arteries and veins
that might be used as potential vessels to receive free
tissue transfers. The method for both studies was
similar: the circulatory system of a freshly euthanized
dog was flushed and the cadaver was fixed. After this,
the circulatory system was filled with a mixture of
silicone and barium, and radiographs of the cadaver
were made in order to locate the major arteries and
veins in both the head and neck and the limb areas.
On the basis of a second cadaver, prepared in the
same manner, surgical approaches were developed.
These approaches were further fine-tuned on the basis
of feedback from other surgeons who performed
these approaches on fresh cadavers.
Cervical and cranial recipient vessels
Seven surgical approaches to recipient vessels in the
cervical and cranial area have been suggested.15,16
Infraorbital access 
Artery: infraorbital artery (1–1.5 mm diameter);
vein: superior labial vein (3 mm diameter), or facial
vein (4–5 mm diameter).
Table 7. Microvascular flaps mentioned in veterinary literature.
Location Species Rate of Location of vessels
success
Superficial cervical cutaneous9 Dog 75% The angle formed by the omotransversarius and 
trapezius
Superficial cervical cutaneous7 Dog 90% The angle formed by the omotransversarius and 
trapezius
Medial saphenous fasciocutaneous7 Dog 100% N/A
(149–154)
Caudal superficial epigastric7 Dog 100% N/A
Trapezius7 Dog 100% N/A
Latissimus dorsi7 Dog 50% N/A
Caudal sartorius7 Dog 100% N/A
Trapezius musculocutaneous7 Dog 100% N/A
Saphenous musculocutaneous7 Dog 100% N/A
Cranial abdominal myoperitoneal7 Dog 100% N/A
Footpad7 Dog 100% N/A
Rectus abdominis13 Dog 100% Pudendoepigastric arterial and venous trunks from the
deep femoral artery and vein (in two out of seven dogs 
the vessels sprang directly from deep femoral artery 
and vein)
Lateral thoracic17 Cat 100% Cranially directed external thoracic artery; 1st branch of 
the axillary artery
Avascular and microvascular reconstructive techniques 87
149–154 (149, 150) A large wound is created following excision of a grade 2 mast cell tumour.
(151, 152) The recipient vessels are prepared and a medial saphenous flap anastomosed to repair the defect.
(153) This photograph was taken just before radiation therapy was commenced. (154) This is the area 1 year later. The dog
remained tumour free at the surgical site.
149 150
151 152
153 154
A horizontal incision is made over the
infraorbital foramen, along the long axis of the
infraorbital artery. The levator labii maxillaris
muscle is incised cranial to the superficial
bifurcation of the superior labial vein and facial
vein and retracted to expose the infraorbital artery.
Retracting the skin ventrally exposes the superior
labial vein. Alternatively, the facial vein dorsal to
the superior labial vein can be used. The artery is
more easily isolated because it is devoid of
branches, in contrast to the vein, which contains
many side branches.
Temporal access 
Artery: superficial temporal artery (1.5 mm
diameter); vein: superficial temporal vein
(3 mm diameter) or rostral auricular vein 
(2–2.5 mm diameter).
The platysma muscle is incised via a vertical
incision along the ear canal and the superficial
temporal vein and rostral auricular vein are exposed
next to the parotid salivary gland. A deeper incision
can be made rostral to these veins to expose the
superficial temporal artery. 
Caudal auricular access
Artery: caudal auricularartery (1.5 mm diameter);
vein: caudal auricular vein (2.5–4 mm diameter).
The platysma muscle and subcutaneous tissue are
incised via a vertical incision caudal to the ear
canal, exposing the caudal auricular vein. An
incision is made in the subcutaneous tissue
parallel and about 2 cm caudal to the ear canal,
leading along the caudal border of the parotid
gland. The caudal aspect of the parotid gland is
reflected cranially, exposing the cranial auricular
artery. 
Sublingual access
Artery: lingual artery (3 mm diameter); vein: lingual
vein (4 mm diameter) or sublingual vein (3–4 mm
diameter).
An incision is made along the digastricus muscle
between the mandibular branches, followed by an
incision through the mylohyoid muscle to expose
the lingual vein. After retracting the hypoglossal
nerve passing the hypoglossus muscle, the muscle is
transected and the edges retracted to expose the
lingual artery. The lingual vein is located adjacent to
the lingual artery. The lingual artery is the largest of
the arteries of the head region mentioned, which
makes it relatively easy to locate.
Lateral facial access
Artery: facial artery (1.5 mm diameter); vein: facial
vein (4–6 mm diameter).
An incision is made along the masseter muscle
and the mandibular salivary gland. The facial vein
is exposed as the subcutaneous tissue is dissected.
The facial artery is exposed using a dissection plane
between the masseter and digastricus muscles.
The dissection plane is continued to the level of
the medial aspect of the mandibular salivary gland.
At this point the facial artery is >1 mm in diameter.
Should the facial artery be too small, the lingual
artery is a relatively close alternative. Because of
problems associated with the exposure and size of
the facial artery and the large size of the vein, these
recipient vessels are not considered ideal for free
tissue transfer.
Lateral cervical access
Artery: common carotid artery (7 mm diameter);
vein: external jugular vein (10 mm diameter).
The skin and subcutaneous tissues are retracted
ventrally via an incision parallel and dorsal to the
crest made by the jugular vein in order to expose the
external jugular vein. The brachiocephalicus and
sternomastoidius muscles can be separated in a
lateral to medial direction until the common carotid
artery is exposed. The artery and vein of the free
flap should be anastomosed using an end-to-side
technique, as is always recommended when there is
a relatively large difference in the size of the vessels.
Because of the proximity of the vagosympathetic
and recurrent nerves, this procedure should be
performed carefully. 
Lateral shoulder access
Artery: superficial cervical artery (1.5 mm
diameter); vein: superficial cervical vein (3–4 mm
diameter).
A large incision is made starting just ventral
to the acromion and extending craniodorsally
towards the wing of the atlas. An incision is
made between the omotranversarius and
brachiocephalicus muscles and the muscles are
retracted to expose the superficial cervical artery
and vein within the adventitial tissue. The branches
of the vessels must be ligated to allow them to be
exposed properly.
Forelimb recipient vessels
Six surgical approaches to recipient vessels in the
forelimb have been suggested.16,17
Avascular and microvascular reconstructive techniques88
89
Palmar 
Artery: palmar common digital artery II (no sizes
mentioned); vein: cephalic vein.
An incision is made from the medial aspect of the
accessory carpal pad to the palmaromedial aspect of
the metacarpal pad. The incision is made lateral to
the vein, which lies within the superficial fascia
beneath the skin. The artery can be exposed by
incising the superficial fascia lateral to the cephalic
vein.
Distal antebrachial
Artery: median artery; vein: cephalic vein.
A skin incision is made just caudal and medial to
the cephalic vein. The incision ends at the carpus.
The cephalic vein is exposed by retracting the skin.
The artery is exposed by opening the sheath of the
median neurovascular bundle underneath the flexor
carpi radialis tendon and the superficial digital
flexor tendon. The median artery can be used in an
end-to-end arterial anastomosis as the blood supply
to the distal extremity will be supported by other
arteries. The radial artery could be used as an
alternative in larger breeds. The distal antebrachial
approach should be used in cases where there is
traumatic damage to the palmar vessels. 
Mid-antebrachial
Artery: median artery; vein: cephalic vein.
The cephalic vein is dissected via a skin incision
on the craniomedial aspect of the mid-third of the
antebrachium from superficial fascia beneath
the skin. The flexor muscles are exposed by incising
the deep antebrachial fascia and the median artery
can be found in a neural sheath on or underneath
the cranial aspect of the flexor carpi radialis muscle.
Proximal antebrachial
Artery: median artery; vein: cephalic vein, brachial
vein.
The landmark is the proximal third of the medial
antebrachium. An incision is made on the
craniomedial aspect of the proximal antebrachium,
after which the deep antebrachial fascia is incised
between the pronator teres muscle and the flexor
carpi radialis muscle, separating them to expose the
median artery. For the recipient vein, the brachial or
cephalic veins, which lie in the subcutaneous tissue,
can be used.
Distal humeral
Artery: brachial artery; vein: brachial vein.
Avascular and microvascular reconstructive techniques
The deep brachial fascia can be incised through a
skin incision on the medial aspect of the distal
fourth of the humeral region to expose the brachial
vein along the caudal aspect of the biceps brachii
muscle. The brachial vein can be retracted cranially
to expose the brachial artery. Care must be taken
not to damage essential nerves in the area.
Mid-humeral
Artery: recurrent ulnar artery; vein: recurrent ulnar
vein.
Access is via a skin incision made at the junction
of the middle and distal thirds of the humerus just
cranial to the triceps muscle. The venous branch
from the biceps brachii muscle is ligated and
divided if needed to expose the brachial artery. The
brachial vein is retracted in order to find the
recurrent ulnar artery located beneath. The
recurrent ulnar vein, which is used as the recipient
vein, can be found as it branches off the brachial
vein.
Hindlimb recipient vessels
Twelve surgical approaches to recipient vessels in
the hindlimb have been suggested.16,17
Plantar
Artery: plantar metatarsal artery; vein: medial
branch of the dorsal common digital vein.
Access is via an incision in the plantar and medial
aspect of the metatarsal region from the calcaneus
to the metatarsal pad. The vein can be found
beneath the skin on the dorsomedial aspect of the
second metatarsal bone. The artery can be exposed
by making an incision in the deep fascia along the
medial side of the superficial and deep digital flexor
tendons. The tendons should be retracted laterally
to expose the interosseus group of muscles; the
artery will be found between the first and second
interosseus muscles.
Dorsal tarsal 
Artery: dorsal pedal artery; vein: dorsal common
digital vein or branch thereof.
The dorsal pedal artery can be palpated in the
dorsal tarsal area. An incision in the dorsal aspect
of the tibial tarsal joint is angled slightly medially
towards the junction of the second and third
proximal metatarsal bones. After performing a
sharp dissection medial to the common digital vein
found directly beneath the skin, the short digital
extensor muscles need to be separated to reveal the
dorsal pedal artery.
In some dogs the short digital extensor muscles are
very small and difficult to identify (155–158).
Cranial distal tibial 
Artery: cranial tibial artery; vein: cranial branch of
the medial saphenous vein.
The skin is incised on the cranial surface of the
distal aspect of the tibia, lateral to the cranial
branch of the medial saphenous vein. After
dissecting the crural fascia, the long digital extensor
andcranial tibial muscles/tendons are separated.
The cranial tibial neurovascular bundle, which
contains the cranial tibial artery, is exposed. The
cranial branch of the medial saphenous vein can be
exposed after dissecting it from superficial and deep
fascia.
Craniomedial distal tibial
Artery: cranial tibial artery; vein: cranial branch of
the medial saphenous vein.
A skin incision is made over the craniomedial
aspect of the distal tibial region just caudal to the
cranial branch of the medial saphenous vein and the
deep crural fascia is sharply incised. After retracting
the tibialis cranialis muscle, the cranial tibial
neurovascular bundle is dissected from the loose
connective tissue and opened to make the cranial
tibial artery available. The cranial branch of the
medial saphenous vein can be used as the recipient
vein. If the cranial branch of the medial saphenous
vein is too small, as it can be in some smaller dogs,
the lateral saphenous vein can be used. 
Lateral distal tibial
Artery: saphenous artery; vein: lateral saphenous vein.
An incision is made at the level of the distal third
of the tibial region between the lateral saphenous
vein and the caudal branch of the lateral saphenous
vein. A prominent neurovascular bundle can be
palpated along the caudal aspect of the tibia and the
artery exposed. The lateral saphenous vein should
be easily isolated from the subcutaneous tissues.
Caudomedial distal tibial
Artery: caudal branch of the saphenous artery; vein:
caudal branch of the medial saphenous vein or the
cranial branch of the medial saphenous vein.
An incision is made over the distal and medial
aspect of the tibia and the skin is reflected caudally.
The neurovascular bundle can be palpated on the
caudal aspect of the tibia, between the Achilles
tendon and the tibia. The largest of the two veins in
the bundle should be used. If it is still too small, the
cranial branch of the medial saphenous vein can be
used. Because of the distance between the artery and
vein in this approach, they need to be separated in
the pedicle on the flap in order to span the distance. 
Medial femorotibial
Artery: saphenous artery; vein: medial saphenous
vein.
An incision is made over the distal third of the
medial aspect of the femur. The saphenous artery
and medial saphenous vein are found in the areolar
tissue between the caudal head of the sartorius and
gracilis muscles. An incision in the fascia between
the caudal head of the muscles may be necessary. 
Lateral distal femoral
Artery: distal caudal femoral artery; vein: distal
caudal femoral vein.
An incision is made over the cranial border of the
distal aspect of the biceps femoris muscle. The
fascia lata is incised along the cranial border of
the muscle and retracted caudally. The vascular
pedicle entering the distal aspect of the biceps
femoris muscle can be used as the venous and
arterial recipients. This procedure requires
consideration of the effect on the biceps femoris
muscle, part of which may be sacrificed if the blood
supply is lost.
Medial femoral
Artery: femoral artery; vein: femoral vein.
An incision is made in the mid-femoral region
just cranial to the pectineus muscle. The femoral
artery and vein are located just cranial to the
muscle. The fascia along the caudal aspect of
the caudal head of the sartorius muscle is incised
and the muscle is retracted cranially, exposing the
fascial sheath, which surrounds the vessels and
associated femoral nerve. End-to-side anastomosis
of the free flap vessels to the femoral vessels must be
performed because of the large size of these
recipient vessels. 
Medial proximal femoral
Artery: proximal caudal femoral artery; vein:
proximal caudal femoral vein.
In contrast to the medial femoral approach, the
incision is made just caudal to the pectineus muscle
and cranial to the proximal half of the gracilis
muscle. The vessels originate from the proximal
third of the femoral artery and vein corresponding
to the distal aspect of the pectineus muscle.
Inguinal
Artery: caudal superficial epigastric artery; vein:
caudal superficial epigastric vein.
An incision is made craniomedial to the origin of
the pectineus muscle and lateral to the mammary
chain. The mammary tissue is retracted medially
and the fascia surrounding the vaginal tunic is
opened to expose the caudal superficial artery and
vein.
Avascular and microvascular reconstructive techniques90
Proximal lateral femoral
Artery: caudal gluteal artery; vein: caudal gluteal
vein.
A large incision is made over the greater
trochanter along the axis of the femur. After incising
the deep gluteal fascia, the biceps femoris and
superficial gluteal muscles are retracted. The
sacrotuberous ligament is incised and the gluteal
vessels exposed along the ligament. Special care
must be taken to avoid injury to the sciatic nerve
during vessel isolation.
Feline flaps
Though most case reports and research focuses on
free flap procedures in dogs, the use of axial flaps
based on the lateral axial artery in cats has been
studied.16 The mean flap size for a mature, average-
sized cat was found to be 8.7 cm " 15.5 cm. The use
of these flaps was successfully demonstrated in two
clinical cases.
Avascular and microvascular reconstructive techniques 91
155–158 (155–157) A traumatic wound that has received a rectus abdominis free flap and a skin graft over the muscle flap. The
dorsal pedal artery and vein were used for the anastomosis. The skin graft was placed immediately after transfer of the muscle.
(158) The wound 3 weeks postoperative after it had received a skin graft over the rectus abdominis free flap.
155 156
157 158
Conclusion/summary
The advantages of microvascular flap surgery have
been summed up in one study as follows:
‘versatility, reliability, vascularity and the ability to
develop early one-stage corrective procedures for
difficult reconstructive problems’.18 The ability to
provide the flap with a blood supply through
microvascular surgery not only dramatically
increases the survival of flaps, it also indirectly
increases healing of the underlying wound bed
because of this additional beneficial circulation.
However, caution is needed when considering
carrying out microvascular free flap transfers. It
is very important to take note of the fact that
the only significant variable that influences flap
survival is the experience of the surgical team
performing the operation.7 This underlines the
specialized nature of the surgery and the importance
of experience in this field. Additionally, when it
comes to exposing the recipient vessels on the
recipient site, a thorough knowledge of regional
anatomy and a careful and precise surgical
technique are required, not only to find and expose
the vessels correctly so that the procedure can be
performed, but also because incorrect handling of
the recipient vessels may lead to thrombosis in the
anastomosis site at a later point, which can lead to
severe complications.15
Finally, due to the fact that most of the
techniques and anatomical dimensions presented
are based on published studies and reports, which
use only a limited number of animals, anatomical
differences between animals may make it necessary
to deviate from the precise instructions given for the
procedures. This fact may lead to problems when
the techniques are tried, as even within small subject
groups of similarly sized dogs, anatomical
differences often occur. This underlines again the
importance of the surgical team having experience
with microvascular flap transfers. Additionally,
considering the importance of vessel size in these
procedures, it is important to evaluate the fact that
breed differences may require adaptations of the
presented techniques.
Acknowledgements
This chapter is based on a thesis written by
Guido Camps. The authors would like to thank
Dr Dan Degner for critically reviewing the chapter
and providing the photographs.
Avascular and microvascular reconstructive techniques92
References
1. Kirpensteijn J, Klein WR (2006) Woundmanagement and first aid. In: The Cutting
Edge: Basic Operating Skills for the
Veterinary Surgeon, 1st edn. (eds
J Kirpensteijn, WR Klein) Roman House
Publishers, London, p. 125.
2. Hunt GB, Tisdall PLC, Liptak JM et al.
(2001) Skin-fold advancement flaps for
closing large proximal limb and trunk defects
in dogs and cats. Vet Surg 30:440–448.
3. Harari J (2004) (ed) Small Animal Surgery
Secrets. Hanley & Belfus, Philadelphia.
4. Archibald J, Cowley AJ (1974) Plastic
surgery. In: Canine Surgery, 2nd edn.
(ed. J Archibald) American Veterinary
Publications, Santa Barbara, pp. 139–146.
5. Slatter DH (2003) Textbook of Small Animal
Surgery. WB Saunders, Philadelphia. 
6. Fossum TW, Duprey LP (2002)
Microvascular flap transfer. In: Small
Animal Surgery, 2nd edn. (eds TW Fossum,
CS Hedlund, DA Hulse et al) Mosby,
St. Louis, p. 182.
7. Fowler JD, Degner DA, Walshaw R et al.
(1998) Microvascular free tissue transfer:
results in 57 consecutive cases. Vet Surg
27:406–412.
8. Daniel RK, Williams HB (1973) The
free transfer of skin flaps by microvascular
anastomoses: an experimental study and a
reappraisal. Plast Reconstr Surg 52:16–31.
9. Miller CW, Chang P, Bowen V (1986)
Identification and transfer of free cutaneous
flaps by microvascular anastomosis in the
dog. Vet Surg 15:199–204.
10. Miller CW (1990) Free skin flap transfer by
microvascular anastomosis. Vet Clin North
Am Small Anim Pract 20:189–199.
11. Miller CC, Fowler JD, Bowen CVA et al.
(1991) Experimental and clinical free
cutaneous transfers in the dog. Microsurgery
12:113–117.
12. Puerto DA, Aronson LR (2004) Use of a
semitendinosus myocutaneous flap for 
soft-tissue reconstruction of a grade IIIB open
tibial fracture in a dog. Vet Surg 33:629–635.
13. Calfee III EF, Lanz OI, Degner DA et al.
(2002) Microvascular free tissue transfer of
the rectus abdominis muscle in dogs. Vet Surg
31:32–43.
14. Lanz OI, Broadstone RV, Martin RA et al.
(2001) Effects of epidural anesthesia on
microcirculatory blood flow in free medial
saphenous fasciocutaneous flaps in dogs.
Vet Surg 30:374–379.
15. Degner DA, Walshaw R, Fowler JD et al.
(2004) Surgical approaches to recipient vessels
of the head and neck for microvascular free
tissue transfer in dogs. Vet Surg 33:200–208.
16. Degner DA, Walshaw R, Fowler JD et al.
(2005) Surgical approaches to recipient
vessels of the fore- and hindlimbs for
microvascular free tissue transfer in dogs.
Vet Surg 34:297–309.
17. Benzioni H, Shahar R, Yudelevich S et al.
(2009) Lateral thoracic artery axial pattern
flap in cats. Vet Surg 38:112–116.
18. Fowler D (2006) Distal limb and paw
injuries. Vet Clin North Am Small Anim
Pract 36:819–845.
93Avascular and microvascular reconstructive techniques
This page intentionally left blank 
Chapter 5
Reconstructive techniques of
the facial area and head
95
Sjef C. Buiks and Gert ter Haar
• Unilateral modified nasal rotation flap
• Bilateral modified nasal rotation flap
• Full-thickness labial advancement flap (lower lip)
• Full-thickness labial advancement flap (upper lip)
• Full-thickness buccal rotation flap
• Transposition skin flap for upper labial and buccal replacement
• Facial artery axial pattern flap
• Superficial temporal artery axial pattern flap
• Caudal auricular axial pattern flap
• Pedicle flap for pinnal defects
Reconstructive techniques of the facial area and head96
Unilateral modified nasal rotation flap 
Overview
A nasal rotation flap, a local subdermal flap, has
been described for reconstruction of the nasal tip in
humans after removal of local carcinomas. The
authors have modified this flap for use in dogs and
cats, so that it can be used to close wounds of
different sizes and shapes in the rostrodorsal
region of the nose. The following four criteria must
be taken into consideration before the outlines of
the flap are drawn: the type of skull (brachy -
cephalic, mesocephalic or dolichocephalic), the
amount of (excess) skin covering the upper lip, the
location of the defect and the dimensions of the
defect. In the flap description below, the defect is
located dorsally at the bridge of the nose with the
rostral border contacting the caudal part of the
nasal plane. Larger defects can be closed using this
unilateral technique or using bilateral flaps. The
procedure results in a good cosmetic appearance of
the wound without excess tension in the donor and
recipient sites. The procedure can be further
modified to include part of the dorsal nasal plane
tissue in the raised flap to aid in reconstruction of
lateral nasal plane defects (159, 160).
Procedure
A line is drawn starting at the rostral part of the
defect, along the border of the tip of the nose and
continuing laterally in an arch shape to meet the
alar groove (161). To avoid dog ears on closure and
to minimize scar formation, a triangle is formed
around the distal part of the crescent-shaped line
that is going to be excised (162). The flap area is
then automatically outlined by the caudal part of
the triangle and the medial part of the defect. To
avoid a second dog ear on closure, two converging
lines are drawn on the contralateral side of the nose,
with the broadest part meeting the caudolateral part
of the defect. The skin is incised along the predrawn
lines and the two triangular-shaped skin areas are
excised (163, 164). The flap area is undermined to
facilitate advancement of the flap to the tip of the
nose (165). One stay suture (using 2-0 absorbable
monofilament suture material) only is used to
manoeuvre the flap. The flap is transposed into the
defect (166, 167) and the subcutaneous tissue of the
flap is attached to the adjacent subcutaneous tissue
in an interrupted or continuous suture pattern using
3-0 absorbable monofilament suture material (168,
169). The skin is then routinely closed (170,171).
Reference
Smadja J (2007) Crescentic nasojugal flap for nasal
tip reconstruction. Dermatol Surg 33:76–81.
Ter Haar G, Buiks SC, Kirpensteijn. Cosmetic
reconstruction of a nasal plane and rostral nasal
skin defect using a modified nasal rotation flap in a
dog. Vet Surg, in press.
159, 160 Unilateral modified nasal rotation
flap. (159) The red lines represent the
incision lines for creation of the flap
(marked with asterisk) and excision of
Burrow’s triangles (blue, arrows), for closure
of a laterodorsal nasal defect (orange with
red lines). (160) After excision of Burrow’s
triangles and undermining of the local skin
flap (asterisk), the flap is rotated and
sutured into position, yielding a cosmetic
closure.
159 160
* *
Reconstructive techniques of the facial area and head 97
164 Lateral view of the flap area. 165 The flap area has been
undermined ready for rostromedial
advancement.
166 The tip of the flap should easily
reach the contralateral tip of the nose.
167 Lateral view of the flap transposed
into position. 
168 The subcutaneous tissue of the
flap is sutured to the adjacent
subcutaneous tissue. 
169 Lateral view of the flap with the
subcutaneous tissues apposed.
170 Closure of the skin, dorsal view.
Note the absence of dog ears.
171 Left lateral view after skin closure
and flap completion. 
162 Lateral view of
the flap area. The
triangle will be
excised to avoid a
dog ear on closure.
163 Both redundant skin triangles have
been excised.
161 162
163 164 165
166 167 168
169 170 171
161 Dorsal view on
the surgery site. The
shaded area will be
removed to create
the defect.
Reconstructive techniques of the facial area and head98
Bilateral modified nasal rotation flap
Overview
Bilateral use of a modified nasal rotation flap allows
for closure of larger defects of the skin of the rostral
nose in dogs and cats without creating the
asymmetry that usually results from advancing a
large amount of local tissue in this area. The same
criteria as described for the unilateral technique (see
p.96) must be taken into consideration before the
outlines of the flap are drawn. 
There are two variations of the bilateral flap
technique:
• Performing the techniquebilaterally exactly
as described for the unilateral technique
allows for closure of relatively long, but not
very wide, defects where both flaps meet in
the midline.
• For closing defects that are relatively short but
wide, the flaps can be advanced and
undermined further so that they cross the
midline. One side can be used to close the more
rostral part of the defect, while the second part
is used to close the caudal part (172, 173).
Procedure
The incision lines needed to create the bilateral
nasal rotation flaps are outlined using the same
method as for the unilateral procedure (174). The
predrawn lines are then incised and the two
triangle-shaped skin areas are excised (175). After
placing tag sutures in both flaps, they are
undermined to facilitate advancement of the skin
over the bridge of the nose (176). The flaps are
undermined until they can be rotated into place
without tension. Both crescentic defects are then
filled (177). In order to avoid necrosis of the end of
the flap, the ends can be trimmed with scissors or a
scalpel (178). The subcutaneous tissue (179) and
the skin (180) are closed routinely.
Reference
Smadja J (2007) Crescentic nasojugal flap for nasal
tip reconstruction. Dermatol Surg 33:76–81.
172,173 Bilateral modified nasal rotation flap. (172) The red lines represent the
incision lines for creation of two rotation flaps (A + B) after excision of Burrow’s
triangles (blue, arrows) to close a large oval dorsal nasal midline defect (orange). (173)
The two raised flaps are rotated into position to fill the defect. Note that after rotation
of the flaps and closure, the formation of dog ears is prevented by the previous
excision of Burrow’s triangles.
174172 173
174 The excision area of the defect
and the incision and excision lines of
the bilateral crescentic nasojugal flaps
are outlined with blue ink. 
Reconstructive techniques of the facial area and head 99
175 The defect has been excised, as well as the triangles of
skin necessary to rotate the bilateral flap into the defect. 
176 Stay sutures are placed in both flaps to aid undermining
of the tissues and rotation into the defect. 
177 Both flaps have been rotated into position. In case of
relatively short but wide defects, the flaps are rotated to fill
the rostral and caudal part of the defect. 
178 The pointed ends of the flap are trimmed. 
179 The flaps are sutured in place starting with closure of the
subcutis in an interrupted suture pattern. 
180 The completed bilateral modified nasal rotation flap after
closure of the skin with interrupted nonabsorbable sutures
is shown. 
175 176
177 178
179 180
Reconstructive techniques of the facial area and head100
Full-thickness labial advancement flap
(lower lip)
Overview
This technique is used to close rostral defects of the
lower lip. The inferior labial artery and vein provide
the blood supply to the lower lip and should be
preserved. The lower lip is easier to mobilize than
the upper lip. As a result, the skin incision required
for rostral advancement is only a few centimetres,
even in large defects. 
Procedure
A full-thickness labial excision of the tumour (in
this case), with clear margins, is performed (181). A
skin incision of variable length is created to advance
the lower lip rostrally (182). The mucosa of the
lower lip is incised a few millimetres from the
gingival border (183). The flap is undermined and
elevated while preserving the vessels to the desired
length. Rostral traction is applied to the lower lip in
order to close the defect without tension (184). The
mucosal incision is closed in either an interrupted or
continuous pattern using absorbable monofilament
suture material (185, 186). The submucosa/subcutis
is closed with interrupted sutures using absorbable
monofilament suture material. If necessary, a
Penrose drain is used to control dead space
(187). The skin is sutured with nonabsorbable
monofilament suture material (188).
181 Full-thickness labial excision of a tumour of the lower lip
has been performed. 
182 A skin incision is made caudally from the caudoventral
aspect of the wound. 
References
Degner DA (2007) Facial reconstructive surgery.
Clin Tech Small Anim Pract 22:82–88.
Pavletic MM (1990) Reconstructive surgery of the
lips and cheek. Vet Clin North Am Small Anim
Pract 20:201–226.
Pavletic MM (2010) Atlas of Small Animal Wound
Management and Reconstructive Surgery, 3rd edn.
Wiley–Blackwell, Ames, pp.456–457.
181 182
Reconstructive techniques of the facial area and head 101
183 A full-thickness flap is created by undermining the tissue
while preserving a 2 mm strip of mucosa on the gingival
border to facilitate suturing at a later stage.
184 Rostral tension is applied to the flap to determine the
appropriate size. 
185 The mucosa is sutured first with a stay suture, starting
rostrally.
186 The suturing of the mucosa has been completed. 
187 Closure of the subcutis has been performed with
absorbable monofilament suture material. 
188 The skin has been sutured with nonabsorbable
monofilament suture material. 
183 184
185 186
187 188
Reconstructive techniques of the facial area and head102
Full-thickness labial advancement flap
(upper lip)
Overview
A labial advancement flap entails complete
elevation of the entire thickness of the upper lip to
maximize its advancement into rostral labial
defects. The blood supply is dependent on the
superior labial artery and vein. This flap is
especially suitable for defects involving the rostral
third of the upper lip. When necessary, the flap can
be combined with partial maxillectomy. Retraction
of the flap can cause unilateral distortion
of the nasal planum, but this usually subsides over
1–2 weeks.
Procedure
A full-thickness rectangular excision of the tumour
of the upper lip (in this case) is performed and a
skin incision drawn in the caudal upper lip to
allow for advancement of the lip over the desired
length (189). The upper lip is incised down to
the mucosa. A 5 mm strip of mucosa should be
left along the gingival border (190). The flap is
carefully dissected and advanced rostrally without
compromising the blood supply at the base of
the flap (191). A wedge-shaped area is trimmed
from the rostral border of the flap so that the entire
flap conforms more accurately to the curvature
of the opposing labial margin (192). The mucosa is
closed with absorbable sutures in a simple
interrupted pattern (193, 194). The skin is closed
with interrupted sutures using nonabsorbable
monofilament suture material (195).
References
Degner DA (2007) Facial reconstructive surgery.
Clin Tech Small Anim Pract 22:82–88.
Pavletic MM (1990) Reconstructive surgery of the
lips and cheek. Vet Clin North Am Small Anim
Pract 20:201–226.
Pavletic MM (2010) Atlas of Small Animal Wound
Management and Reconstructive Surgery, 3rd edn.
Wiley–Blackwell, Ames, pp. 454–455.
189 A full-thickness rectangular excision of a tumour of the
rostral upper lip has been performed. The labial advancement
flap has been outlined with blue ink.
190 The flap is incised down to the mucosa.
189 190
Reconstructive techniques of the facial area and head 103
191 The flap is undermined until advancement can be done
without tension.
192 Part of the rostral border of the flap is trimmed to allow
for better cosmesis.
193 Closure of the mucosal surface is started. 194 Closure of the mucosal surface is completed.
195 The skin is closed in a simple interrupted pattern with
nonabsorbable suture material.
191 192
193 194
195
Reconstructive techniques of the facial area and head104
Full-thickness buccal rotation flap
Overview
A full-thickness buccal rotation flap is a variation of
the labial advancement flap. It is primarily indicated
after resection of large parts of the upper lip. The
buccal rotation technique will advance the labial
commissure rostrally, which may result in mild
facial asymmetry.
Procedure
Lip tumours should be removed with wide margins
and wounds debrided (196). The remaining caudal
labial marginand cheek can now be grasped,
rotated and stretched rostrally towards the
rostrodorsal defect with a suture (197, 198).
A portion of the lip margin of the rotation flap is
trimmed before apposition to the skin of the rostral
lip (199). The respective skin borders of the flap can
now be apposed to the remaining labial margin
(200, 201). The oral mucosa is closed in an
interrupted or continuous suture pattern (202) and
the skin is apposed with interrupted sutures (203).
References
Degner DA (2007) Facial reconstructive surgery.
Clin Tech Small Anim Pract 22:82–88.
Pavletic MM (1990) Reconstructive surgery of the
lips and cheek. Vet Clin North Am Small Anim
Pract 20:201–226.
Pavletic MM (2010) Atlas of Small Animal Wound
Management and Reconstructive Surgery, 3rd edn.
Wiley–Blackwell, Ames, pp. 458–459.
196 Full-thickness resection of a tumor has been carried out,
resulting in a large rectangular defect. 
197 A suture is placed in the caudal labial margin to help
rotate and advance the flap towards the dorsorostral part of
the defect.
196 197
Reconstructive techniques of the facial area and head 105
198 After tightening the suture, an estimation of the amount
of lip border that has to be trimmed can be made.
199 A portion of the lip margin is trimmed with scissors or
a scalpel.
200 The first step in closure is apposing the remaining labial
borders. 
201 The first skin suture is tightened, after which the
remainder of the defect is closed. 
203 The end result after closing the subcutis in a continuous
pattern and closing the skin with interrupted sutures is shown. 
202 The oral mucosa is closed with interrupted sutures,
starting ventrally. The ventral part of the closed Y-defect is
shown. The remainder of the defect is closed in a similar
manner. 
198 199
200 201
202 203
Reconstructive techniques of the facial area and head106
Transposition skin flap for upper labial
and buccal replacement
Overview
Skin flap replacement of the lip and upper cheek,
based on a facial artery axial pattern flap (see p.
108) is only recommended when the defect is too
large to be closed by other techniques. While the
skin serves as an adequate replacement for the oral
mucosa, flaps using oral mucosa are preferable
whenever possible.
Procedure
A wide resection using 75% of the upper
lip and adjacent cheek is performed (204).
A transposition flap is outlined on the cheek
adjacent to the defect. The width of the flap should
be approximately twice the width of the defect,
since part of the flap will be used to replace the
mucosal defect. The base of the flap is aligned with
the lower buccal edge of the defect (205). The skin
portion of the flap is incised and then carefully
undermined beneath the panniculus muscle to the
level of the base of the flap near the defect (206).
The dorsal border of the flap is sutured to the
remaining mucosa of the upper lip in a simple
interrupted pattern with absorbable suture material
(207). The skin flap is folded onto itself and the
subcutaneous/submucosal tissues are sutured with
interrupted absorbable monofilament material
(over a Penrose drain when necessary) (208, 209).
The skin is apposed with interrupted sutures (210).
References
Pavletic MM (1990) Reconstructive surgery of the
lips and cheek. Vet Clin North Am Small Anim
Pract 20:201–226.
Pavletic MM (2010) Atlas of Small Animal Wound
Management and Reconstructive Surgery, 3rd edn.
Wiley–Blackwell, Ames, pp. 468–469.
204 A full-thickness resection of the upper lip and adjacent
cheek has been performed.
205 A transposition flap is outlined on the skin with blue ink.
204 205
Reconstructive techniques of the facial area and head 107
206 The skin flap is undermined towards the base of the flap
at the level of the defect.
207 The replacement flap has been sutured to the remaining
upper lip mucosa. 
208 The skin flap is folded onto itself. 209 The subcutaneous and submucosal tissues have been
apposed. 
210 The skin has been closed in an interrupted pattern with
nonabsorbable suture material. 
206 207
208 209
210
Reconstructive techniques of the facial area and head108
Facial artery axial pattern flap
Overview
A facial artery axial pattern flap can be used to
cover defects involving the rostral and lateral nasal
regions and the maxilla. The base of the flap is
located at the commissure of the lip and is therefore
perfused by the superior and inferior labial arteries.
A cutaneous branch of the angularis artery runs
between the superior and inferior labial arteries and
meets the cutaneous branches of the masseteric
artery and the transverse facial artery at the dorsal
extent of the flap. The caudal border of the flap is
defined by the lateral aspect of the first cervical
vertebra (atlas). Sufficient skin is usually harvested
if the flap is extended to the level of the vertical ear
canal. This also reduces the risk of necrosis of the
tip of the flap. The lateral borders of the flap are the
caudal mandible ventrally and the ventral aspect of
the zygomatic arch dorsally. In the cat, the viability
of an axial pattern flap based on the facial artery,
with similar dimensions to the flap, has recently
been demonstrated (211, 212).
Procedure
The outline of the flap is drawn using the following
landmarks: the lateral aspect of the atlas, the ventral
margin of the caudal mandible and the ventral
aspect of the zygomatic arch (213). The skin is
incised as outlined and then undermined (214). The
flap is transposed into the defect (215).
The remaining labial mucosa is attached to the
maxillary gingiva in either an interrupted or
continuous pattern using absorbable monofilament
suture material (216). The subcutis of the most
distal corners of the flap is sutured to the
subcutaneous tissue of its new location using
absorbable interrupted sutures (217). The
remaining subcutaneous tissue is then sutured
(218). A Penrose drain can be used if needed. The
skin is closed routinely using nonabsorbable
monofilament suture material (219).
References
Milgram J, Weiser M, Kelmer E et al. (2011) Axial
pattern flap based on a cutaneous branch of the
facial artery in cats. Vet Surg 40:347–351.
Pavletic MM (1990) Reconstructive surgery of the
lips and cheek. Vet Clin North Am Small Anim
Pract 20:201–226.
Pavletic MM (2010) Atlas of Small Animal Wound
Management and Reconstructive Surgery, 3rd edn.
Wiley–Blackwell, Ames, pp. 468–469.
Yates G, Landon B, Edwards G (2008) Investigation
and clinical application of a novel axial pattern flap
for nasal and facial reconstruction in the dog. Aust
Vet J 85:113–118.
211, 212 Schematic
representation of the facial
artery axial pattern flap. The
coloured part of the dog
depicts the estimated area that
can be reached by the flap.
212211
Reconstructive techniques of the facial area and head 109
213 The boundaries of the axial pattern flap are drawn. 214 The flap is incised along the dotted outline.
215 The flap is rotated into position. 216 The labial mucosa is attached to the gingiva.
217 The primary closure of the subcutaneous tissue has been
performed.
218 The flap is sutured to its new location with interrupted
sutures using absorbable suture material.
219 A lateral view following closure of the skin.
213 214
215 216
217 218
219
Reconstructive techniques of the facial area and head110
Superficial temporal artery axial
pattern flap
Overview
This axial pattern flap has been described for use in
both dogs and cats. The vascular supply consists of
a cutaneous branch of the superficial temporal
artery. The subdermal plexus that lies both
superficial and deep to the frontal muscle is
incorporated into the flap. The flap is used to cover
defects involving the maxilla and the maxillofacial
area. The anatomical boundary of the base of the
flap is determined by the lateral orbital rim. The
width of the flap is limited rostrally by the eye and
caudally by the ear, therefore the width of the flap
is equal to the length of the zygomatic arch. In
brachycephalic breeds, the amount of skinthat can
be harvested is limited. The length of the flap is
limited to the dorsal orbital rim of the contralateral
eye. Extending the flap beyond this point has been
shown to result in necrosis of the distal end of the
flap (220, 221).
Procedure
Two parallel lines are drawn to outline the width of
the flap according to its boundaries. The base of the
flap is located at the level of the dorsal orbital rim.
This can be extended if a longer flap is needed to
cover a more rostral defect. After the lines have
been extended (if necessary) to the dorsal orbital
rim of the contralateral eye, they are connected in a
straight line (222). The flap is incised and bluntly
dissected from the underlying tissue, underneath the
frontal muscle (223). The flap is then transposed
onto the site of the defect using stay sutures. If
tension is excessive, the most rostral incision of the
flap above the eye can be extended (224). The flap
is sutured to the periosteum on the midpoint of the
convex side of the flap. This technique prevents
there being an abundance of skin on the concave
side of the flap covering the eye (225). Alternatively,
the dog ear can be removed using a Burrow’s
triangle (see H-plasty, p.118). The subcutaneous
tissues of the flap and the donor site are closed in an
interrupted or continuous pattern using absorbable
monofilament suture material (226). The skin of the
flap and the donor site are closed routinely with
interrupted sutures using nonabsorbable
monofilament suture material (227).
References
Fahie MA, Smith MM (1997) Axial pattern flap
based on the superficial temporal artery in cats: an
experimental study. Vet Surg 26:86–89.
Fahie MA, Smith MM (1999) Axial pattern flap
based on the cutaneous branch of the superficial
temporal artery in dogs: an experimental study and
case report. Vet Surg 28:141–147.
Fahie MA, Smith BJ, Ballard JB et al. (1998)
Regional peripheral vascular supply based on the
superficial temporal artery in dogs and cats. Anat
Histol Embryol 27:205–208.
Hedlund CS (2002) Surgery of the integument. In:
Small Animal Surgery, 2nd edn. (eds TW Fossum,
CS Hedlund, DA Hulse et al.) Mosby, St. Louis,
pp. 134–228.
Pavletic MM (2010) Atlas of Small Animal Wound
Management and Reconstructive Surgery, 3rd edn.
Wiley–Blackwell, Ames, pp. 398–399.
Reconstructive techniques of the facial area and head 111
220, 221 Schematic
representation of the
superficial temporal artery axial
pattern flap. The coloured part
of the dog depicts the
estimated area that can be
reached by the flap.
222 A dorsal view of the defect and
the borders of the flap.
223 After incising the flap, a bridge has
automatically been created between
the defect and the donor site.
224 Tension in the flap is assessed by
rotating the flap into the defect.
225 In order to prevent the creation of
dog ears and abundant skin in the
orbital region of the eye, the flap is
sutured to the periosteum. 
226 The subcutis is closed to relieve
tension using absorbable monofilament
material.
227 The final appearance of the
reconstructed defect after routine
skin closure is shown.
220 221
222 223 224
225 226 227
Reconstructive techniques of the facial area and head112
Caudal auricular axial pattern flap
Overview
The caudal auricular axial pattern flap, also known
as the platysma myocutaneous flap, is used to
reconstruct defects in the neck and caudodorsal part
of the skull. The flap can be extended rostrally to
cover defects in the dorsal orbital area. This flap is
also used to cover defects ventral to the orbit and
after eye enucleation. The base of the flap is centred
over the lateral wing of the first cervical vertebra
(atlas). The branches of the caudal auricular artery
and vein are directed caudodorsally. The caudal
auricular artery is located approximately 1 cm
caudal to the base of the scutiform cartilage of the
auricle (228–230).
Procedure
With the animal in lateral recumbency, the scapula
should be positioned perpendicular to the trunk.
This can be done by extending the forelimb and
securing it to the table if necessary. The width of the
flap should correspond to the width of the defect.
Two parallel lines are drawn beginning just ventral
of the base of the ear and extending to the cranial
aspect of the scapula. The distance between the lines
determines the width of the flap (231, 232). The
flap is then positioned in the mid-section of
the cervical region. The two lines are connected at
the level of the scapula (232). A defect is created by
removing a tumour or debriding a wound (233).
The skin flap is incised along the predrawn lines
(234). The skin is then undermined and elevated,
taking care to preserve the cutaneous vessels that
enter the flap between the vertical ear canal and the
wing of the atlas. The skin should be undermined
deep to the platysma muscle (sphincter colli
superficialis). A bridging incision is used to connect
the donor and recipient sites (235). The flap is
rotated dorsally and rostrally into the defect (236).
The flap is then sutured into place in two layers and
the donor site is closed using two layers. Absorbable
monofilament suture material should be used for
the subcutis and nonabsorbable mono filament
suture material or skin staples for the skin (237,
238).
References
Hedlund CS (2002) Surgery of the integument.
In: Small Animal Surgery, 2nd edn. (eds
TW Fossum, CS Hedlund, DA Hulse et al.) Mosby,
St. Louis, pp. 134–228.
Pavletic MM (2010) Atlas of Small Animal Wound
Management and Reconstructive Surgery, 3rd edn.
Wiley–Blackwell, Ames, pp. 396–397.
Pope ER (2006) Head and facial wounds in dogs
and cats. Vet Clin North Am Small Anim Pract
36:793–817.
Smith MM, Payne JT, Moon ML et al. (1991) Axial
pattern flap based on the caudal auricular artery in
dogs. Am J Vet Res 52:922–925.
Stiles J, Townsend W, Willis M et al. (2003) Use of
a caudal auricular axial pattern flap in three cats
and one dog following orbital exenteration. Vet
Ophthalmol 6:121–126.
228–230 Schematic
representation of the
caudal auricular artery
axial pattern flap. The
coloured part of the dog
depicts the estimated area
that can be reached by the
flap.
228 230229
Reconstructive techniques of the facial area and head 113
231 A dorsal view of the outlined defect (shaded area). 232 Outline of the flap in the mid-section of the cervical
region.
233 A defect has been created. 234 The borders of the flap have been incised.
231 232
233 234
237 The subcutaneous tissues of the flap are sutured to the
subcutis of the recipient site. 
238 The subcutaneous tissues of the donor and recipient
sites have been closed over a Penrose drain. The skin has been
closed using staples. 
237 238
235 After undermining the flap, a bridging incision is made. 236 The flap is rotated into the defect.
235 236
Reconstructive techniques of the facial area and head114
Pedicle flap for pinnal defects
Overview
This is a distant flap used to reconstruct defects on the
convex side of the pinna. Full-thickness defects and/or
defects on the concave side can be reconstructed using
different techniques. Healing by second intention is
the first option. The second option is to sever the
pedicle flap created for coverage of the convex side
from the donor site at its base. A second pedicle
flap from the dorsal part of the head can then be
sutured onto the concave side of the defect. The third
option is to incise the base of the pedicle flap created
for coverage of the convex side so that it can be folded
over the caudal rim of the pinna. It is subsequently
sutured in place on the concave side of the pinna.
Vascular obstruction and necrosis are more likely to
occur using the latter technique. The second
technique is described below.
Procedure
The pinna with the defect is placed against the
donor site (i.e. the lateral aspect of the neck) (239).
An incision is made in the donor site to match the
shape of the pinnal defect. The incisions are
extended approximately 5 mm to 1 cm and the flap
is undermined (240). The flap is sutured to the skinon the convex surface of the pinna using interrupted
sutures of nonabsorbable monofilament suture
material (241). A nonadherent bandage is used to
cover the wound and ear. The bandage should be
changed regularly for 10–14 days. The flap is then
incised at its base (242). The sutures are removed
and the steps described above are repeated 10–14
days after the initial procedure to cover the defect
on the concave surface of the ear. The donor site
will now be the dorsum of the head (243, 244). The
bandage is changed regularly, the sutures removed
239 A full-thickness defect of the left pinna is shown. 240 The flap outline matches the boundaries of the defect.
The incisions are extended for 5 mm on the skin of the neck.
241 After undermining the flap, it is sutured to the skin of the
pinna.
242 The flap is cut at its base and the sutures are removed
after 10–14 days.
239 240
241 242
Reconstructive techniques of the facial area and head 115
after 10–14 days and the flap incised at its base
(245). The donor site is closed routinely (246).
References
Fossum TW (2007) Surgery of the ear. In: Small
Animal Surgery, 3rd edn. (eds TW Fossum,
CS Hedlund, AL Johnson et al.) Mosby Elsevier,
St. Louis, pp. 289–316.
Henderson RA, Horne R (2003) Pinna. In:
Textbook of Small Animal Surgery, 3rd edn.
(ed D Slatter) WB Saunders, Philadelphia, 
pp. 1737–1746.
Pavletic MM (2010) Atlas of Small Animal Wound
Management and Reconstructive Surgery, 3rd edn.
Wiley–Blackwell, Ames, pp. 666–667.
Swaim SF, Henderson RA (1997) Small Animal
Wound Management, 2nd edn. Williams &
Wilkins, Philadelphia, pp. 143–275.
243 The second flap is outlined on the dorsum of the head. 244 The flap is sutured to the concave side of the pinna, on
top of the former flap.
245 The flap is incised at its base after 10–14 days. 246 Closure of the donor site is shown.
243 244
245 246
This page intentionally left blank 
• H-plasty
• Z-plasty
• Semicircular skin flap
• Rhomboid flap
• Modified cross lid flap
• Lip-to-eye mucocutaneous subdermal plexus rotating flap
• Superficial temporal artery axial pattern flap for reconstruction of the
upper eyelid
• Entropion repair and the arrowhead method for correction of lateral
canthal entropion involving the upper and lower eyelid
• Stades technique for correction of upper eyelid entropion/trichiasis
• Munger–Carter flap adaptation of the Kuhnt–Szymanowski/Fox–Smith
procedure for correction of lower eyelid ectropion and macroblepharon
in dogs
117
Chapter 6
Reconstructive techniques of
the eyelids
Rick F. Sanchez 
techniques such as autologous conjunctival trans -
plants, pedicles or autologous buccal mucosal trans -
plants are also performed. 
Procedure
The patient is positioned in sternal recumbency with
the head slightly elevated and turned to give good
exposure of the surgical field. The lesion to be
removed is highlighted in the skin of the lower eyelid
using blue ink (247). The lesion is then excised,
creating a large, full-thickness eyelid defect (248).
The incision path for the H-plasty consists of two
slightly diverging lines that extend from the ventral
118
H-plasty
Overview
This is a relatively simple technique that can be used
to reconstruct a very large portion of the upper or
lower eyelid, including parts of the lateral canthus.
Superficial eyelid defects or full-thickness defects
may be reconstructed using this technique. Recon -
struction of large defects of the upper eyelid may
result in impairment of the blink response. In
addition, as peripheral skin is used, trichiasis is a
potential complication. When repairing large full-
thickness defects, the surgeon must remember that
no conjunctival lining is provided unless additional
247 The lesion to be removed is shown in blue ink on the
lower eyelid.
249 The incision for the H-plasty is shown in blue ink. 
248 The lesion is removed, creating a large full-thickness
defect.
250 The Burrow’s triangles of skin are removed from each
side of the incision path.
Reconstructive techniques of the eyelids
247 248
249 250
sides of the defect for a length approximately one
and a half times the length of the defect. Two
Burrow’s triangles are incorporated into each in -
cision line, with the point of each triangle being
away from the incision line. The side of the triangle
that runs along the incision line is at least the same
length as the distance the flap must travel to cover
the defect (249). The triangles are removed and the
flap is dissected with care from the tissues below
using scissors. The surgeon should ensure that the
flap is capable of moving freely and will cover the
defect with no tension (250–252). The flap is
secured into position by placing sutures in the angles
created by the collapsed triangles and also half way
along the main vertical incision of the graft.
Positioning of the graft should allow for at least 1
mm of graft to protrude from the eyelid margin into
the inter palpebral fissure (253). The flap is now
secured at the palpebral edge in two layers. First, a
suture of absorbable material is placed in the
subcutaneous plane with a buried knot. The first
bite (as shown in 254) is taken in the right side of the
graft as it travels in a proximal to distal direction.
The needle is then redirected to engage the opposite
side of the wound and create a bite that travels in the
opposite direction. 
119
253 The first sutures are placed in the skin.
252 The graft covers the defect without tension.251 The flap should move easily.
251 252
253
254 The first deep bite is taken in the graft side in order to
create a buried knot.
254
Reconstructive techniques of the eyelids
This creates a loop of suture that places the knot in
the proximal part of the incision path away from
the surface. A more detailed view can be seen under
Z-plasty (266–279) and in the diagrams provided
in the section on the rhomboid flap (285, 286).
Before closure, the surgeon must ensure that 1
mm of grafted tissue will protrude into the inter -
palpebral aperture, over the eye. Once the knot is
tied, the long end of the suture material may be
used to close the sub cutaneous layer with a simple
continuous pattern that is extended to where the
surgeon placed the first skin suture. At this point a
second buried knot is created and the suture is cut
(255). A full description of how this is done can be
found under Z-plasty (p. 121). The surgeon must
ensure that the buried knot does not protrude into
the space between the eyelid and the eye or onto
the skin surface. In thin eyelids it may not be
possible to close the subcutaneous layer separately
from the cutaneous layer. The skin near the eyelid
edge is then sutured in a simple continuous or
simple interrupted suture pattern using absorbable
suture material and the remainder of the surgical
wound is closed with simple interrupted sutures of
nonabsorbable suture material (256, 257).
References
Stades F, Gelatt K (2007) Eyelid surgery. In:
Veterinary Ophthalmology, 4th edn. (ed K Gelatt)
Blackwell Publishing, Ames, pp. 563–617. 
van der Woerdt A (2004) Adnexal surgery in dogs
and cats. Vet Ophthalmol 7:284–90.
120
255 The second bite is taken in the opposite side of the
wound.
256 The skin is sutured in a simple interrupted pattern using
nonabsorbable suture material.
257 The free edge of the graft should protrude
approximately 1 mm into the interpalpebral fissure.
255
256 257
Reconstructive techniques of the eyelids
Z-plasty
Overview
This sliding flap technique is very useful for the
reconstruction of defects of the lateral aspect of
the upper or lower eyelid and, therefore, part of the
lateral canthus. It is a simple and elegant technique
that ensures repair of a relatively large defect with
minimal wound tension. As with other sliding graft
techniques, trichiasis may result. 
Procedure
The patient is positioned in sternal recumbency
with the head slightly elevated and turned to give
good exposure of the surgical field. The lesion to be
removed is highlightedin the skin using blue ink
(258). The lesion is then excised, creating a large,
full-thickness eyelid defect (259). Carefully planned
Burrow’s triangles are marked on the skin with blue
ink (260). One triangle is positioned next to the
lateral canthus and the other is posi tioned in the
uppermost corner of the defect to be closed. The
upper triangle is positioned so that the angle in
contact with the main incision line is pointing
ventrally and the triangle in the lateral canthus is
positioned so that the angle that contacts the main
incision line is pointing dorsally. 
121
258 The lesion to be removed is marked in blue ink. 
259 The lesion is excised, creating a full-thickness defect. 260 Burrow´s triangles are carefully planned as shown.
259
258
260
Reconstructive techniques of the eyelids
The planned triangle path is incised with a scalpel
and then removed with scissors (261, 262). The skin
to be advanced should be carefully undermined
with scissors so that the graft encounters little
resistance when sliding into the wound. The graft is
moved in such a way that both Burrow’s triangles
are closed (263). The first skin sutures help relieve
any tension left in the tissue, which should be
minimal, and they are placed in the centre of each
122
263 After careful tissue dissection, the defect should close
easily and with minimal wound tension.
264 Skin sutures are placed in the middle of each incision line
on either side of the eyelids. 
261 Incisions are made into the skin following the planned
outline.
262 The incised triangles are removed.
incision line on either side of each eyelid. This
should ensure that the edge of the graft that
recreates the eyelid margin is protruding into the
interpalpebral aperture over the eye for at least 1
mm to allow for graft shrinkage. The distal part of
each of the incision lines may be closed after this
(264, 265). The subcutaneous layer of the recreated
eyelid margin is sutured next using absorbable
suture material. The needle bites are placed so that
261 262
263 264
Reconstructive techniques of the eyelids
123
the knot is buried within the skin. As this is a
‘holding’ suture, it must include the tarsal plate
whenever possible. The first needle bite is placed
into the upper eyelid. It travels parallel to the skin
surface, starting 3 mm into the wound, goes
through the tarsal plate and exits near the eyelid
margin. The needle is then redirected into the
advanced skin graft, entering 1 mm away from the
edge of the graft; this ensures that the grafted
skin will protrude 1 mm into the palpebral aperture.
The needle then travels parallel to the skin and
exits 3 mm from the incision line (266–268). The
suture loop thus formed allows for a buried knot
to be created once the suture is tied. After this, the
long end of the suture material may be used to close
the subcutaneous layer with a simple continuous
pattern that is extended to where the first skin
suture was placed. 
267 The needle is directed onto the other side of the wound,
ensuring that it enters the graft 1 mm away from its edge
and exits 3 mm from the wound.
268 The suture forms a loop that creates a buried knot
when tied.
265 The distal part of each incision line can be closed at
this stage.
266 Creation of a buried knot. A first bite is taken into the
upper eyelid 3 mm from the wound and exiting next to the
edge of the eyelid. The needle must travel parallel to the skin
and into the tarsal plate.
265 266
268267
Reconstructive techniques of the eyelids
At this point a second buried knot is created and the
suture is cut. The surgeon must ensure that buried
knots never protrude into the space between the
eyelid and the eye or onto the skin surface. In thin
eyelids it may not be possible to close the
subcutaneous layer separately from the cutaneous
layer (269, 270). The skin near the eyelid edge is
then sutured using a simple continuous or simple
interrupted suture pattern of absorbable material,
and the remainder of the surgical wound is closed
with simple interrupted sutures of nonabsorbable
material (271). Absorbable multifilament suture
material is preferred when in close proximity to the
eye be cause of the softer nature of the ends of the
sutures.
The wound of the lower eyelid margin is closed
in a similar manner. The first bite is taken into the
eyelid side of the wound. It travels from 3 mm from
the wound margin, through the tarsal plate, parallel
to the skin, and exits close to the edge of the eyelid.
The needle is then redirected into the edge of the
graft. It enters 1 mm away from the graft’s edge;
124
271 The remainder of the skin incision is closed with simple
interrupted sutures. Absorbable multifilament suture material
is preferred when in close proximity to the eye due to the
softer nature of the suture ends.
272 A first bite is taken into the lower eyelid 3 mm into the
wound and exiting next to the edge of the eyelid. The needle
must travel parallel to the skin and into the tarsal plate.
269 Only the short end of the suture is cut, leaving the long
end available to close the subcutaneous layer. 
270 A buried knot is tied and the suture is cut.
269 270
271 272
Reconstructive techniques of the eyelids
this ensures that the grafted skin will protrude
1 mm into the palpebral aperture. The needle then
travels parallel to the skin and exits 3 mm from the
incision line (272, 273). The resulting suture loop
allows for a buried knot to be created once the
suture is tied. After this, the long end of the suture
material may be used to close the subcutaneous
layer separately from the cutaneous layer, as was
done with the upper eyelid, provided the eyelid
thickness allows for a two-layer closure (274, 275).
The skin near the eyelid edge is then sutured using
a simple interrupted suture pattern of absorbable
material and the remainder of the surgical wound is
closed in a similar manner with nonabsorbable
material (276).
References
Stades F, Gelatt K (2007) Eyelid surgery. In:
Veterinary Ophthalmology, 4th edn. (ed K Gelatt)
Blackwell Publishing, Ames, pp. 563–617. 
van der Woerdt A (2004) Adnexal surgery in dogs
and cats. Vet Ophthalmol 7:284–290.
125
275 Only the short end of the suture is cut, leaving the long
end available to close the subcutaneous layer. 
276 The remainder of the skin incision is closed with simple
interrupted sutures. Absorbable multifilament suture material
is preferred when in close proximity to the eye due to the
softer nature of the suture ends.
273 The needle is directed onto the other side of the wound,
ensuring it enters the graft 1 mm away from its edge and
exits 3 mm into the wound.
274 The suture forms a loop that creates a buried knot
when tied.
273 274
275 276
Reconstructive techniques of the eyelids
Semicircular skin flap 
Overview
This is a relatively challenging technique that
uses both rotation and sliding of skin. It may be
used to repair defects of the upper or lower
eyelids that are between 30% and 60% of the eyelid
length; however, reconstruction of large defects of
the upper eyelid may result in some impairment of
the blink response. In addition, as peripheral skin
is used, trichiasis is a potential complication. The
radius of the circular incision should be twice the
length of the defect to be closed and the flap should
always rotate from a lateral to a medial direction.
To facilitate movement of the flap, a Burrow’s
triangle is removed from the distal end of the
incision and the flap is undermined with care.
Procedure
The patient is positioned in sternal recumbency
with the head slightly elevated and turned to give
good exposure of the surgical field. A curved
incision with a radius that is twice the size of the
defect is planned starting at the apex of the triangle.
The incision outline extends to the facial skin lateral
to the lesion (277). A Burrow’s triangle is excised at
the end of the incision to allow the skin and
orbicularis oculi muscle flap to slide medially once
the flap has been undermined(278). The flap is
undermined and then rotated medially into the
defect. The wound created by the excision of the
Burrow’s triangle should close with minimal ten -
sion, while the corner of the triangle at the end of
the extended curved incision collapses to meet the
other side of the wound (279). The first suture is
placed at this point of collapse. A second suture is
then placed one-third of the way between the
first suture and the eyelid margin, followed by a
third suture, which is placed two-thirds of the
way to the eyelid margin. These sutures should
relieve any residual flap tension while at the same
time allowing the new eyelid margin to protrude 
1–2 mm into the palpebral aperture to compensate
for flap shrinkage (280). The eyelid margin is
sutured using an internal buried knot in the shape
of an inverted vertical mattress suture. The needle
is introduced into the flap side 5 mm from the
wound’s edge and exits 1 mm away from the edge
of the graft before crossing over onto the eyelid,
where it enters just below the eyelid edge and exits
4 mm into the wound so as to mirror the opposite
suture path (281). The suture is tied and the long
end used to suture the muscle–stroma–conjunctival
layers at either side of the wound up to the area
where the third skin suture was placed (282). The
subcutis in between the initial skin sutures is
sutured, if necessary, with absorbable material. The
rest of the skin is closed with simple interrupted
absorbable sutures (283, 284).
References
Pellicane CP, Meek LA, Brooks DE et al. (1994)
Eyelid reconstruction in five dogs by the
semicircular flap technique. Vet Comp Ophthalmol
4:93–103.
Stades F, Gelatt K (2007) Eyelid surgery. In:
Veterinary Ophthalmology, 4th edn. (ed K Gelatt)
Blackwell Publishing, Ames, pp. 563–617.
126
277 The outline of the incision for the semicircular flap,
starting at the ventral edge of a defect of the lower eyelid and
ending in a Burrow’s triangle, is shown. 
278 The incision has been made and the Burrow’s triangle
excised in preparation for undermining of the flap.
277
278
Reconstructive techniques of the eyelids
127
279 The flap is rotated medially and the Burrow’s triangle
collapses in the process.
280 The placement of the first three skin sutures is shown.
This minimizes any residual tension on the flap prior to sutur -
ing its edge onto the eyelid margin.
281 An inverted vertical mattress suture is used to appose
the flap to the eyelid edge, which closes the defect.
282 The long end of the suture is used to complete the deep
layer closure with a simple continuous suture pattern.
283 The subcutaneous tissues of the donor and recipient site
are apposed if needed with interrupted sutures placed
between the first three skin sutures.
284 The skin is closed routinely.
279 280
281
284283
282
Reconstructive techniques of the eyelids
RHOMBOID FLAP
Overview
This technique has been described in humans to
reconstruct skin defects near or directly involving
the medial canthus. Skin in this region is adhered to
the underlying tissues, making flaps much less
mobile. The method described in this book has been
modified to involve the medial canthus and recon -
struct the upper punctum after it has been removed
during mass resection. It also makes use of a tarsal
plate suture (285) and a figure-of-eight suture
(286). Reconstruction of the upper punctum is not
necessary if the lower punctum is still intact. A
simpler version of the technique may be used if
a mass is removed from the medial canthal region
without involvement of the medial canthus.
Procedure
The patient is positioned in sternal recumbency
with the head slightly elevated and turned to give
good exposure of the surgical field. The lesion to be
removed is outlined in the skin of the medial
canthus using blue ink (287). This is later excised,
creating a large, full-thickness, medial canthal
defect. However, prior to mass removal, the
surgeon must first cannulate the upper punctum
128
using a large diameter nonabsorbable suture that is
then passed through the canaliculus into the
nasolacrimal duct until it exits the nose (288). (For
details on how this is sutured onto the alar fold see
Superficial temporary artery axial pattern flap,
p. 139.) The suture is left in place for 3 weeks, when
re-epithelialization around the suture will have oc -
curred and it can then be removed. The path of the
incision is planned so that it creates a flap that takes
the shape of the dorsolateral quarter of a rhomboid
located medial to the lesion (289). The width of the
flap is slightly larger than the width of the defect
and its length should at least equal the distance
from the dorsalmost aspect of the lesion to just
over its mid-point. Once the flap has been created it
should be freed from the underlying tissues with
gentle dissection so that it can be moved onto the
defect (290). The secondary defect created in the
bed of the flap is closed by direct apposition of
skin (291). Skin sutures are then placed at every
angle of the incision line, except in the medial
canthal area, which must be reconstructed (292).
The medial canthus is closed by placing a ‘holding’
suture (i.e. one that travels through the tarsal plate)
with a buried knot, followed by a holding and
appositional figure-of-eight suture pattern (293).
286
286 Figure-of-eight suture. This suturing technique may be
used on its own or, when indicated, in addition to the tarsal
plate suture. It provides perfect alignment of the wound
edges and it positions the knot on the skin’s surface, away
from the eye. The long piece of the suture may be used to
close the skin surface with a single interrupted suture.
285 Tarsal plate suture or
buried knot. The purpose of this
suturing technique is the crea -
tion of a buried knot using a
vertical mattress suture pattern.
The long end of the suture knot
is then used for suturing the
subcutaneous skin in a simple
continuous pattern. When this
technique is used in the eyelid margin, it is referred to as a tarsal plate suture because the suture travels through this structure.
Depending on the reconstruction, a figure-of-eight suture is sometimes used on the skin surface in addition to a tarsal plate suture
(as shown on the right side of the diagram).
Reconstructive techniques of the eyelids
a a'
b b'
a = a' = 1–2mm
b = b' = 3–4mm
Tarsal plate
285
Tarsal plate suture
with buried knot
ExternalAll internal
129
290 Incisions
are made into
the skin
following the
predrawn
outline and the
flap is gently
dissected from
the underlying
tissues.
288 The lesion
is excised, full-
thickness, after
passing a large
diameter
nonabsorbable
suture through
the upper punc -
tum and then
through the
nasolacrimal
duct until it exits
via the nasal
ostium.
287 The lesion
to be removed
is marked in
blue ink.
291 The donor
site is closed by
simple
apposition of
the skin edges.
292 The
incision is
closed first by
placing
nonabsorbable
sutures at every
angle, except
for the medial
canthus. 
289 The flap is
carefully
planned to
create the
dorsolateral
quarter of a
rhomboid
medial to the
lesion, as
shown.
287 288
289 290
291 292
Reconstructive techniques of the eyelids
293 The
medial canthus
is closed in two
layers with non -
absorbable sut -
ure material.
The first suture
travels through
the tarsal plate.
This offers
tissue holding
power and has
a buried knot.
293
This double closure ensures wound integrity and
minimizes the risk of wound dehiscence. The
surgeon must ensure that the suture does not
damage the nasolacrimal duct or canaliculi of the
upper or lower eyelid as it travels through the
canthal tissue.
The figure-of-eight suture pattern (286) is tech -
nically demanding because each half of the suture
must be an exact mirror image of the other to avoid
appositional defects. The needle is first inserted into
the lower eyelid skin, approximately 4 mm away
from its edge, and it exits at the subcutaneous level
into the defect. The needle then crosses over onto
the other side ofthe defect, entering the upper
eyelid through the subcutaneous tissues, approxi -
mately 2 mm from the eyelid margin, and exiting
near to or through a meibomian gland opening 1–2
mm away from the edge of the wound. At this point
the needle crosses over to the lower eyelid by
entering through or next to a meibomian gland, also
1–2 mm away from the edge of the wound. The
needle exits through the subcutaneous tissue of the
lower eyelid into the wound approximately 2 mm
from the eyelid margin. The needle then crosses the
wound one last time to enter the upper eyelid
subcutaneously approximately 4 mm from the
eyelid margin and exiting through the skin of the
eyelid. This pattern results in a symmetrical loop of
tissue, which rests over the flat section of the edge
of the eyelid where the openings of the meibomian
gland openings are situated. Two pieces of suture
cross over each other in symmetry within the
wound and the suture ends, exit either side of the
wound through the skin, mirroring each other, and
allow the suture knot to be tied on the surface of the
skin away from the eye (294). The remainder of the
skin is then closed with nonabsorbable suture
material ensuring that the suture ends do not reach
the ocular surface (295). The cannulated suture that
is left in place to reconstruct the upper canaliculus
and punctum is removed after approximately 3
weeks once re-epithelialization of these structures
around the suture has occurred.
References
Blanchard GL, Keller WF (1976) The rhomboid
flap for the repair of extensive ocular adnexal
defects. J Am Anim Hosp Assoc 12:576–580.
Hoffmann A, Blocker T, Dubielzig R et al. (2005)
Feline periocular nerve sheath tumors: a case series.
Vet Ophthalmol 8:153–158.
Ng SG, Inkster CF, Leatherbarrow B (2001) The
rhomboid flap in medial canthal reconstruction.
Br J Ophthalmol 85:556–559.
Teske SA (1998) The modified rhomboid
transposition flap in periocular reconstruction.
Ophthalmic Plast Reconstr 14:360–366.
130
294 The
second suture
is in a figure-
of-eight
pattern. This is
designed to
anchor at the
tarsal plate
while
achieving
symmetrical
tissue
apposition. 
295 The
remainder of
the skin is
closed with
interrupted
sutures
making sure
that suture
ends do not
contact the
eye.
294
295
Reconstructive techniques of the eyelids
Modified cross lid flap
Overview
This technically demanding two-stage technique
was originally described by Mustarde in 1971 for
use in humans. It was later modified by Munger and
Gourley to repair upper eyelid defects of up to 75%
of the length of the eyelid in dogs and cats, allowing
for a rotating flap containing the lower eyelid to
recreate the upper eyelid while preserving the lat eral
and medial canthi. The transposed pedicle is given
time to heal within the upper eyelid and then it is
transected. This is followed by repair of the defect
created in the lower eyelid using an H-plasty. A
further modification is described below where
the H-plasty is performed during the first stage
with the aim of decreasing the overall wound
tension between stages one and two. Instead of an
H-plasty, the surgeon may also perform a lip-to-eye
mucocutaneous subdermal plexus rotating flap.
This technique is described later (p. 134) and it has
been reported in the veterinary literature for use in
dogs and cats. The eye must be kept hydrated, using
a viscous tear preparation and antibiotic drops or
ointment, during the time between the two surgical
stages as eyelid function will be compromised and
corneal lesions could develop. Hydration is also
likely to help reduce the formation of adhesions
between the flap and the H-plasty during this time.
Procedure
The patient is positioned in sternal recumbency with
the head slightly elevated and turned to give good
exposure of the surgical field. The lesion to be
removed is marked in the skin of the central upper
eyelid using blue ink (296). The lesion is then
excised, creating a large, full-thickness eyelid defect
(297). The dimensions of the flap that will be created
from the lower eyelid are carefully planned (298,
299). The pivoting point of the flap will ensure a
direct blood supply exists until the transposed eyelid
heals into the defect in the upper eyelid, which will
act immediately as a source of blood for the most
distal aspects of the flap. 
131
296 The lesion to be removed is marked in blue ink.
298 The flap outline is planned with its pivot point located
medially.
297 The lesion is excised, creating a full-thickness defect.
299 Incisions are made into the skin following the
planned outline.
296 297
298 299
Reconstructive techniques of the eyelids
The pivot point of the flap must be small enough to
allow for rotation, but large enough to allow for the
flap to maintain a direct blood supply. The eyelid is
transposed with its conjunctival tissue, which also
maintains its own blood supply via the pivot point.
The lateral aspects of the flap are sutured to the
medial aspect of the upper eyelid defect, starting with
a deep conjunctival suture of absorbable suture
material and a buried knot (the knot ends are facing
the tissue and not the eye) (300). Suturing is
continued from medial to lateral in a simple
continuous suture pattern using the long end of the
thread (301). The two eyelid edges are apposed
medially. This junction is best apposed using a figure-
of-eight suture pattern, (see Rhomboid flap, p. 128)
(302). The remainder of the skin wound is closed in
a simple interrupted pattern using nonabsorbable
suture material (303).
The resulting defect of the lower eyelid is then
closed with an H-plasty (304, 305). Alternatively,
a lip-to-eye mucocutaneous subdermal plexus
rotating flap can be used. The latter ensures a
cosmetic, trichiasis-free, mucosa-lined eyelid repair,
although it is more time consuming and technically
more demanding. By 2 weeks, the flap should have
healed into the upper eyelid defect and the skin
sutures may be removed. If adhesions have formed
between the flap and the H-plasty, they must be cut.
At this stage the pivot point of the flap can be
transected and the medial edge of the lower eyelid
transposed to the upper eyelid, where it becomes the
lateral edge of the upper eyelid. This requires that
part of the lateral section of the transposed flap is
broken down and redundant flap tissue is removed
to accommodate the new lateral eyelid edge. In
addition, the small wound created in the lower
medial eyelid, where the pivot of the graft was
transected, is incorporated into the H-plasty
(306, 307).
References
Esson D (2001) A modification of the Mustardé
technique for the surgical repair of a large feline
eyelid coloboma. Vet Ophthalmol 4:159–160.
Munger RJ, Gourley IM (1981) Cross lid flap for
repair of large upper eyelid defects. J Am Vet Med
Assoc 178:45–48.
Mustardé JC (1971) Surgical treatment of
malignant tumors of the upper lid. Chir Plastica
1:25–33.
132
300 The lateral conjunctiva of the transposed eyelid is
sutured to the medial conjunctiva of the upper eyelid defect.
301 The long end of the knot is used to suture the rest of the
conjunctival tissue in a simple continuous pattern.
300 301
Reconstructive techniques of the eyelids
133
302 The medial edge of the upper eyelid is sutured to the
transposed eyelid edge of the graft in a figure-of-eight
pattern using absorbable suture material. 
303 The skin is sutured with simple interrupted, absorbable
sutures.
306 The pivot point of the transposed flap is clipped and the
flap is adapted before it is resutured. This results in a small
defect in the medial aspect of the H-plasty, which is also
sutured.
307 The end result is a cosmetic and anatomically correct
upper eyelid with a conjunctival lining and a recreated
lower eyelid.
304 The defect created in the lower eyelid is closed using an
H-plasty (shown). A lip-to-eye subdermal plexus rotating flap
may also be used for this purpose.
305 The finished H-plasty is shown. The transposed flap is
allowed to heal for 2 weeks.
302 303
304 305
306 307
Reconstructivetechniques of the eyelids
Lip-to-eye mucocutaneous subdermal
plexus rotating flap
Overview
This one-step technique is used to reconstruct
lesions of the lower eyelid in dogs by creating a
rotating mucocutaneous subdermal plexus flap that
contains the edge of the upper lip and its underlying
mucosa. In cats it has been used in combination
with the Mustardé technique for repair of upper
eyelid agenesis, and a modification of this technique
has also been used in cats to reconstruct the upper
and lower lateral eyelid and lateral canthus using
the lateral upper and lower lip and commissure. The
use of lip tissue provides a soft, continuous,
trichiasis-free eyelid margin as well as a mucosal
surface for the recreated eyelid. 
134
Procedure
The patient is positioned in sternal or lateral
recumbency with the head slightly elevated and
turned to give good exposure of the surgical field.
This includes the mucosal surface of the lip section
that is to be transposed. The lesion to be removed
is marked in the skin of the lower eyelid using blue
ink (308). The lesion is then excised, creating a
large, full-thickness eyelid defect (309). The shape
and size of the full-thickness lip flap is planned by
creating two slightly converging incision lines at a
45° angle to an imaginary line that bisects the
medial and lateral canthi (310). The position of the
caudal incision of the graft is such that it points to
the base of the ear. The distance between the rostral
and caudal incisions is slightly larger at the base of
309 The lesion is excised, creating a full-thickness eyelid
defect.
308 The lesion to be removed is marked in blue ink.
308 309
Reconstructive techniques of the eyelids
the graft than at the edge of the lip, and the width
of the graft at the lip is 1–2 mm larger than the
width of the defect to be closed. The flap margins
are then incised. A full-thickness incision must be
made only at the edge of the lip and through 2–3 cm
of skin containing buccal mucosa; the rest of the
incision is made only through skin and not into the
buccal cavity (311, 312). The mucosal side of the
flap must then be incised to separate it from the rest
of the mucosal surface within the oral cavity (313)
135
313 The mucosal side of the flap is incised parallel to the
edge of the lip.
312 The flap is elevated to expose the mucosal side.
310 Two skin incisions, which converge slightly towards the
lip, are created.
311 Full-thickness incisions are made at the edge of the lip
only and through the skin into the buccal cavity for 2–3 cm.
The remainder of the incision path is through skin only.
310 311
312 313
Reconstructive techniques of the eyelids
315 A
bridging
incision is
planned that
spans the
distance
between the
most rostral
aspect of the
base of the
flap and the
centre of the
defect in the
lower eyelid. 
314 The flap
is gently
undermined
taking care not
to damage the
subdermal
plexus.
This will create a pedicle that contains a 2–3 cm
mucosal surface at the tip. The graft is then gently
undermined to its base while taking great care to
preserve the subdermal plexus (314). A flap-
bridging incision is then performed from the rostral
base of the pedicle to the centre of the lower eyelid
defect (315, 316). The flap is sutured into the defect
in two separate layers. The first layer uses
absorbable suture material to join the conjunctiva
at each of the two edges of the eyelid wound to
the corresponding mucosa either side of the tip of
the pedicle. Suture knots should remain buried
within the tissue so that they do not protrude into
the newly created conjunctival sac, where they
could easily damage the ocular surface (317–319).
The lip is sutured in two layers, with care being
taken to ensure that the knots of the absorbable
sutures placed internally do not protrude into the
buccal cavity (320), and the skin is sutured in a
simple interrupted pattern using nonabsorbable
suture material (321).
136
314 315
Reconstructive techniques of the eyelids
316 The
bridging
incision
is made.
137
317 The
conjunctiva is
sutured to the
transposed
mucosa of the
pedicle.
318 Simple
interrupted
sutures with
buried knots
using
absorbable
suture material
are placed.
319 The lateral
side is sutured,
followed by the
medial side. 
320 The lip is
sutured in two
layers.
321 The skin is
closed with
simple
interrupted
sutures using
nonabsorbable
suture material. 
316 317
318 319
320 321
Reconstructive techniques of the eyelids
The area close to the eye is sutured in a figure-of-
eight pattern (see Rhomboid flap, p. 128) using
absorbable suture material and the rest of the skin
is closed in a simple interrupted pattern using the
same material (322–325).
References
Esson D (2001) A modification of the Mustardé
technique for the surgical repair of a large feline
eyelid coloboma. Vet Ophthalmol 4:159–160.
Pavletic MM, Lawrence AN, Confer AW (1982)
Mucocutaneous subdermal plexus flap from the lip
for lower eyelid restoration in the dog. J Am Vet
Med Assoc 180:921–926.
Whittaker CJ, Wilkie DA, Simpson DJ et al.
(2010) Lip commissure to eyelid transposition for
repair of feline eyelid agenesis. Vet Ophthalmol
13:173–178.
138
322 The edge
of the wound is
closed in a
figure-of-eight
pattern using
absorb able
suture material.
Closure may
also include a
previously
placed internal
stitch with a
buried knot.
323 The skin
in the vicinity
of the figure-of-
eight is
closed in a
simple contin -
uous pattern
using absorb -
able suture
material that is
obtained from
the long end of
the figure-of-
eight suture
knot. 
324 The
closure is
cosmetic and
should ensure
that no knots
are too long
and in contact
with the eye. 
325 A smooth
eyelid edge
with a mucosal
side is finally
created.
322 323
324 325
Reconstructive techniques of the eyelids
Superficial temporal artery axial
pattern flap for reconstruction of the
upper eyelid
Overview
This technically demanding surgery has been
described for the reconstruction of the medial
canthus and part of the upper eyelid of a dog with
a mast cell tumour that required wide excision
margins, which included the upper punctum. The
technique was developed as an alternative to
enucleation, which would have been necessary
to avoid secondary surface ocular problems due to
overexposure. Caudal auricular axial pattern flaps
and an axial pattern flap based on a cutaneous
branch of the facial artery (see Chapter 5) have also
been described in the veterinary literature, where
facial skin reconstruction is required following
orbital exenteration (removal of the eye, the adnexa
and the orbital contents) to treat eyelid tumours. 
Procedure
The patient is positioned in sternal recumbency
with the head slightly elevated and turned to give
good exposure of the surgical field. The lesion to be
removed is highlighted in the skin of the medial
upper eyelid and canthus using blue ink (326). The
lesion is then excised, creating a large, full-thickness
eyelid and canthal defect that can be reconstructed
using a superficial temporal artery axial pattern
flap. Prior to removal of the mass, the upper
punctum is cannulated with a large diameter
nonabsorbable suture. This is passed through the
canaliculus and nasolacrimal duct until it exits
through the nasal ostium in the distal nasal cavity
(327). As the suture exits the nose it is sutured to
the skin close to the alar fold. The suture is left in
place for 2 weeks until a new punctum is formed via
re-epithelialization. The lesion is then excised,
creating a large full-thickness eyelid and canthal
defect that can be reconstructed using a superficial
temporal artery axial patten flap. Careful dissection
around the nasolacrimal duct is performed using a
blade with a sharp end (e.g. No. 11 Parker blade)
(328).
139
327 The upper punctum has been cannulated with a large
diameter absorbable suture that travels through the
nasolacrimal duct and exits through the ostium located in
the distal nasal passage.
326 A lesion in the medial canthus, as well as the dissection
marginaround it and the proposed graft pedicle, are shown.
326
327
Reconstructive techniques of the eyelids
328 Careful dissection is undertaken around the cannulated
nasolacrimal duct to avoid damaging the duct. 
328
The full-thickness resection of eyelid includes its
conjunctival lining. The conjunctiva that covers the
palpebral part of the exposed third eyelid is also
removed with the exception of a horizontal strip of
conjunctiva that is left intact along the third eyelid
margin (329). The rest of the third eyelid is left
intact. Once the mass is removed with the required
tissue margins, a large defect results (330). This
must be closed to avoid desiccation of the ocular
surface.
A superficial temporal artery axial flap is planned
to cover the defect. The graft in the surgery described
here originates from the right side of the head, as it is
to be rotated into a defect in the left side. The
140
331 The predrawn outline of the pedicle is incised with a
scalpel blade.
332 The graft is carefully undermined. 
329 The eyelid resection includes the conjunctival lining and
a strip of conjunctiva is all that is left along the edge of the
third eyelid. 
330 The size of the defect created is shown. Exposure of the
ocular surface results.
329
331
330
332
Reconstructive techniques of the eyelids
predrawn outline of the pedicle is incised and the
graft undermined with gentle dissection (331, 332).
The graft should cover the defect with no tension
prior to suturing (333). The cut edge of the
horizontal strip of conjunctiva on the palpebral side
of the third eyelid is sutured onto the edge of the
graft medially (334). This ensures that the graft
contains a soft mucosal side with which to contact
the globe. As the pedicle is sutured onto the
underlying tissues in its new position, a Penrose drain
is placed under it to help collect the fluid that is likely
to build-up in the postoperative period (335). The
drain exits the skin from a location ventral to the
surgical field and it is removed on day 3 or 4 post
surgery. 
141
333 The graft is laid onto the defect without any tension prior
to suturing.
334 The third eyelid is sutured onto the graft medially. 335 A Penrose drain is placed under the graft.
333
334 335
Reconstructive techniques of the eyelids
The skin over the head is advanced to bring it
closer to the pedicle. The subcutaneous tissue layer is
sutured in a simple interrupted pattern with
absorbable suture material (336) and the skin is
closed in a simple interrupted pattern with
nonabsorbable suture material (337). The suture that
passes through the nasolacrimal duct is sutured onto
the skin next to the alar fold (338). The other end of
the suture is secured to the skin in a position that
allows a new punctum to form via re-
epithelialization in the space between the third eyelid
and the graft (339, 340).
References
Jacobi S, Stanley BJ, Petersen-Jones S et al. (2008)
Use of an axial pattern flap and nictitans to
reconstruct medial eyelids and canthus in a dog. Vet
Ophthalmol 11:395–400
Milgram J, Weiser M, Kelmer E et al. (2011) Axial
pattern flap based on a cutaneous branch of the
facial artery in cats. Vet Surg 40:347–351.
Stiles J, Townsend W, Willis M et al. (2003) Use of
a caudal auricular axial pattern flap in three cats
and one dog following orbital exenteration. Vet
Ophthalmol 6:121–126.
142
337 The skin is closed with simple interrupted sutures.
337
Reconstructive techniques of the eyelids
336 The subcutaneous layer of the graft is sutured to the
underlying tissues and the subcutaneous layer of the skin
around it. 
336
143
339 The other end of the suture lies between the
third eyelid and the graft and it is sutured to the
external skin. 
338 The suture that has passed through the
nasolacrimal duct and exited via the nasal
ostium is sutured onto the skin near the alar
fold. The exit point of the Penrose drain is also
seen in this image. 
340 The graft, Penrose drain and nasolacrimal duct suture as
viewed from above.
338
339
340
Reconstructive techniques of the eyelids
Entropion repair and the arrowhead
method for correction of lateral canthal
entropion involving the upper
and lower eyelid
Overview
All entropion correction techniques are based on
the Celsus–Hotz method, a skin–orbicularis oculi
muscle excision that is performed only 2 mm away
from the eyelid margin with the aim of everting the
entropion and redirecting the skin and its hairs
away from the ocular surface. The first incision
follows the eyelid margin and extends 1–2 mm
away from the area that requires correction. The
second incision starts and ends at the same point,
but curves away from the initial incision during its
course. The maximum distance between the two
incisions will be determined by the amount of
eversion that is required to correct the entropion.
This may be done by one of several methods (e.g. by
pinching the skin until the desired everting effect is
achieved, which is commonly referred to as the
'pinch method'). It is important that the calculation
is performed in the conscious patient, prior to
anaesthesia and after the instillation of a topical
anaesthetic, so as to minimize the effect of eyelid
spasm due to corneal irritation. The Celsus–Hotz
technique has been modified to suit different parts
of the eyelid margin. This is the case with the
arrowhead method, which is used to repair the
lateral canthal entropion typically seen in asso -
ciation with lateral upper and lower eyelid
entropion in Shar-Peis and other broad-headed
breeds.
Procedure
The patient is positioned in sternal recumbency with
the head slightly elevated and turned to give good
exposure of the surgical field. In the case described
here there is lateral canthal entropion with extension
into the lateral upper and lower eyelids (341). The
incision paths are outlined (342). The innermost path
is situated 2 mm away from the eyelid margin and
starts 1 mm medial to the most central section of the
entropic upper and lower eyelids. It continues along
the eyelid margins until the two incision paths meet
near the lateral canthus. The outermost path of the
incision courses from the same starting point as the
innermost path and ends 4–6 mm lateral to the
lateral canthus. The outer path curves away from the
inner path and the width of the curve is pre -
determined by the pinch method, which shows the
degree of correction required to evert the eyelid
margin. The skin and orbicularis oculi muscle are
incised as planned and the skin–orbicularis oculi
section located between the incisions is removed
(343, 344). The resulting surgical wound is sutured
in a single layer of simple interrupted sutures. The
first suture is placed at the lateral canthus (345). A
layer of sutures is then placed at the medial end of the
incision path of the upper and lower eyelids. This is
followed by a second layer of sutures placed 1–2 mm
away from the lateral canthal suture (346). At this
point, another layer of sutures is placed between the
first two, bisecting the surgical wound. The principle
of bisection is followed until the entire surgical
wound is closed with single interrupted sutures
spaced 1–2 mm apart (347, 348).
Reference
Stades F, Gelatt K (2007) Eyelid surgery. In:
Veterinary Ophthalmology, 4th edn. (ed K Gelatt)
Blackwell Publishing, Ames, pp. 563–617. 
144 Reconstructive techniques of the eyelids
145
343 The skin incision is shown as it wraps around the lateral
eyelid margin of the right eye of this dog.
344 The island of skin and the orbicularis oculi muscle are
excised. 
347 Further sutures are placed between the first two layers of
sutures, bisecting the surgical wound.
348 The skin suturing of the arrowhead entropion repair is
shown near completion. 
345 Suturing of the wound starts with a simple interrupted
suture in the lateral canthus.
346 Sutures are placed at the lateral and medial ends of the
incision paths of the upper and lower eyelid.
343 344
345 346
347 348
Reconstructive techniques of theeyelids
341 A lateral canthal entropion, which extends into the upper
and lower lateral eyelids of the right eye, is shown.
342 The incision paths for the arrowhead entropion
correction of the lateral canthus and lateral upper and lower
eyelid are shown.
341 342
Stades technique for correction of
upper eyelid entropion/trichiasis
Overview
This technique was originally described by Frans
Stades in 1987 to treat upper eyelid entropion/
trichiasis in dogs with a large amount of facial skin
and heavy ears. These dogs are predisposed to
progressive drooping of the facial skin and upper
eyelid, which loses contact with the eye and
becomes entropic. This procedure describes the
removal of the row of upper cilia and adjacent skin
hairs from the upper eyelid edge, everting it in the
process and avoiding further hairs from growing
along its edge. This problem typically affects
Cocker Spaniels, Clumber Spaniels, Bloodhounds
and other dogs with similar facial characteristics.
The technique addresses neither the progressive
droop of the skin, which will continue over the life
of the animal, nor the lower eyelid, which may also
have central ectropion with lateral entropion. In
addition, it does not shorten the palpebral length,
which often exceeds the average of 33 mm found in
most medium and large breed dogs by 7 mm or
more. Additional techniques and modifications are
required to solve these problems. In cases of
macropalpebral fissure, this author has previously
modified the Stades procedure successfully by
adding a central wedge resection that shortens the
length of the upper eyelid. Other techniques range
from shortening the lower eyelid via a skin wedge
resection to the recently reviewed V-to-Y procedure,
which is specifically designed to correct lower eyelid
ectropion, medial and lateral canthoplasties and
reduce the interpalpebral fissure length in one step,
and rhitidectomy procedures, which reduce the
amount of excess (face-lift) skin on the head. 
Procedure
The patient is positioned in sternal or lateral
recumbency with the head slightly elevated and
turned to give good exposure of the surgical field.
The surgical landmarks are marked with blue ink
(349). A large section of skin is removed from the
upper eyelid. The dorsalmost aspect of the incision
path is determined by carefully positioning the
blunt end of an instrument inside the dorsal
conjunctival fornix. Externally, and just above it,
the upper eyelid usually creates a fold. The
lateralmost part of the skin excision ends
approximately 2 mm lateral to the lateral canthus
and extends medially just beyond the point where
upper eyelid cilia do not grow in the dog; this is
approximately the medial fourth of the upper
eyelid. The first incision is made along the upper
eyelid by inserting a pointed blade, such as a No. 11
Bard-Parker, parallel to the eyelid margin and only
1 mm away from it (350, 351). The eyelid must be
kept under tension by stretching it manually or with
an instrument. The meibomian glands should not be
damaged in the process if possible, while the blade
146
349 The surgical landmarks for the skin excision of the Stades
procedure are shown, including the position of the upper
conjunctival fornix.
350 A pointed scalpel blade is introduced perpendicular to
the tensed eyelid margin.
349 350
Reconstructive techniques of the eyelids
must be deep enough to excise the hair follicles that
give rise to the upper eyelid cilia and the skin hairs
adjacent to them. This may be difficult as hair
follicles often lie in very close proximity to the
meibomian glands. If any hair follicles are identified
in an area 4 mm wide above the eyelid margin, they
should be destroyed with a gentle scrape using the
scalpel blade (352). A second incision is then made
perpendicular to the eyelid skin and starting and
ending at the same point. The course of the second
incision curves dorsally until it reaches the
dorsalmost surgical landmark as described above
(353). The island of skin inside the incision path
is undermined and excised (354). The dorsal edge of
the skin wound may be undermined so as to free it
for approximately 5 mm. This allows the edge to be
moved and sutured to an area approximately 4 mm
above the eyelid margin, immediately along the
147
353 The line of the second incision is shown as it curves
dorsally.
354 The skin above the upper eyelid is undermined and
excised. 
352 Residual hair follicles in the wound area above the eyelid
margin are destroyed with gentle scraping.
352
353 354
351 The incision extends from 2 mm lateral to the lateral
canthus to the medial fourth of the upper eyelid. 
351
Reconstructive techniques of the eyelids
dorsal edge of the tarsal plate, which contains the
meibomian glands, and without causing exces sive
eyelid eversion (355). Simple interrupted sutures are
placed 1–2 mm apart to secure the skin edge to its
new location. Alternatively, they may be spaced
approximately 3–4 mm apart, followed by a simple
continuous suture pattern. The resulting strip of
hairless tissue between the eyelid edge and the skin
edge is allowed to heal by granulation tissue (356).
References
Donaldson D, Smith KM, Shaw SC et al. (2005)
Surgical management of cicatricial ectropion
following dermatophaties in two dogs. Vet
Ophthalmol 8:361–366.
Stades FC (1987) A new method for the correction
of upper eyelid entropion-trichiasis: operation
method. J Am Anim Hosp Assoc 23:603–606.
Stades FC, Boevé MH (1987) Surgical correction
of upper eyelid entropion-trichiasis: results and
follow up for 65 eyes. J Am Anim Hosp Assoc
23:607–610.
Stades FC, Boevé MH, van der Woerdt A (1992)
Palpebral fissure length in the dog and cat. Prog Vet
Compar Ophthalmol 2:155–161.
148
355 The dorsal skin wound is undermined by 5 mm or less to
assist in moving the skin edge to a location 4 mm dorsal to
the eyelid edge.
355
356 The result after suturing is a strip of hairless tissue that
heals by granulation tissue.
356
Reconstructive techniques of the eyelids
Munger–Carter flap adaptation of the
Kuhnt–Szymanowski/Fox–Smith
procedure for correction of lower
eyelid ectropion and macroblepharon
in dogs
Overview
The technique was originally developed for use in
humans by Kuhnt–Szymanowski and was later
modified by Blaskovic, who avoided splitting the
eyelid edge and damaging the meibomian glands.
It underwent further adaptations by Fox and
Smith and was described for use in dogs by Munger
and Carter in 1984 to correct what the authors
described as atonic entropion. The technique
shortens the lower eyelid by incorporating a
wedge resection under a skin flap. It results in
correction of central lower eyelid ectropion and
the accompanying medial and lateral entropion and
it lifts the lateral canthus. It may be complemented
by an upper eyelid wedge resection for reduction of
the upper eyelid length and in selected cases by the
Stades procedure, which may be further modified
by incorporating a wedge resection in its centre.
Procedure
The patient is positioned in sternal recumbency
with the head slightly elevated and turned to give
good exposure of the surgical field. The incision
path courses along, and 2 mm away, from the lower
eyelid margin. It extends from an area 2 mm medial
to the central eyelid ectropion and extends 10 mm
lateral and 4 mm dorsal to the lateral canthus to
descend from that point (357). This creates a
triangular flap of skin, which is carefully
undermined and reflected downwards (358).
149
357 The incision path is shown coursing along the lower
eyelid margin and extending from the central eyelid to an area
dorsolateral to the lateral canthus before descending. 
358 The triangular flap of skin is shown reflected downwards
and exposing the eyelid edge and eyelid stroma in
preparation for the next step.
357 358
Reconstructive techniques of the eyelids
A full-thickness wedge of lower eyelid edge and
eyelid stroma, muscle and conjunctiva, equal to the
amount of eyelid shortening that is desired, is
excised (359,360). This is closed with a 
figure-of-eight suture pattern (see Rhomboid flap)
(361, 362). The long end of the suture is used to
close the wedge resection at the level of the eyelid
stroma (which also approximates the wound edges
at the level of the conjunctiva) using a simple
continuous suture pattern (363, 364). The flap of
skin becomes oversized by an amount equal to the
amount of skin removed in the wedge resection. The
flap is then equally shortened before being sutured
back onto the skin (365, 366). The first simple
interrupted skin suture is placed in the apex of the
triangle situated lateral to and slightly above the
lateral canthus. To complete the closure the rest of
the sutures are placed along the edge of the wound
approximately 1 mm apart (367).
References
Munger RJ, Carter JD (1984) A further
modification of the Kuhnt–Szymanowski procedure
for correction of atonic entropion in dogs. J Am
Anim Hosp Assoc 20:651–656.
Stades F, Gelatt K (2007) Eyelid surgery. In:
Veterinary Ophthalmology, 4th edn. (ed K Gelatt)
Blackwell Publishing, Ames, pp. 563–617.
359, 360 A full-thickness wedge is excised from the eyelid margin in order to reduce the length of the lower eyelid by the desired
amount. 
359 360
362
361, 362 A figure-of-eight suture pattern is used to close the defect created by the wedge resection.
361
Reconstructive techniques of the eyelids150
Reconstructive techniques of the eyelids 151
363, 364 The long end of the suture is used to complete the closure of the wedge resection with a simple continuous suture
pattern.
363 364
365, 366 The oversized flap of skin is reduced in size by an amount equal to the amount of skin removed in the wedge resection. 
365 366
367 Sutures are placed along the edge of the wound
approximately 1 mm apart and starting at the apex of the
triangle lateral to the lateral canthus. 
367
This page intentionally left blank 
Chapter 7
Reconstructive techniques
of the neck and trunk
153
Marijn van Delden, Sjef C. Buiks and Gert ter Haar
• Omocervical axial pattern flap
• Thoracodorsal axial pattern flap
• Cranial superficial epigastric axial pattern flap 
• Cutaneous trunci myocutaneous flap
• Latissimus dorsi myocutaneous flap
• External abdominal oblique muscle flap
• Tensor fascia lata flap
• Episioplasty
• Scrotal flap
• Tail flap/lateral caudal axial pattern flap
Omocervical axial pattern flap
Overview
An omocervical axial pattern flap can be used for
closing large skin defects of the face, neck, head,
ear, shoulder and axilla. This axial pattern flap is
based on the superficial cervical branch of the
omocervical artery and vein. Both the artery and
vein enter the skin cranial to the shoulder at the
level of the prescapular lymph node and the cranial
shoulder depression, and run dorsally just cranial
to the scapula. The boundaries of the flap are the
acromion of the scapula ventrally, the spine of the
scapula caudally and a line parallel to the caudal
border cranially. The caudal border should be
approximately twice the distance from the spine of
the scapula to the prescapular lymph node. The
distal border of the flap is the dorsal midline;
however, it may extend over to the contralateral
shoulder region. The omocervical axial pattern flap
is a versatile flap that can be rotated in numerous
directions (368, 369).
Procedure
The animal is positioned in lateral recumbency with
the forelimb in a relaxed position, perpendicular to
the trunk. A line is drawn over the spine of the
scapula; this will be the caudal border of the flap.
The outline of the cranial incision is parallel to the
caudal border and equals the distance from the
prescapular lymph node to the caudal incision
outline (370). The flap can be extended if necessary
to the dorsal midline and to the contralateral
scapulohumeral joint. The opposite omocervical
direct cutaneous artery and vein must be ligated and
divided. The flap is undermined below the level of
the sphincter colli superficialis muscle, starting at
the distal part of the flap. Stay sutures are placed in
order to rotate the flap from the donor site into the
skin defect in the neck and to ensure no tension will
be present on the flap after suturing (371). It is
important to ensure that the vessels are not
damaged or occluded while undermining and
rotating the flap (372). A bridging incision is made
in the skin between the flap and the defect (373).
The flap is rotated into the defect and the
subcutaneous tissues are sutured (over a Penrose
drain, if needed) in an interrupted pattern using
absorbable monofilament suture material (374). The
skin is apposed with interrupted sutures using 4-0
nonabsorbable suture material or staples (375).
Reconstructive techniques of the neck and trunk154
368, 369 Schematic representation of the omocervical axial pattern flap. The coloured part of
the dog depicts the estimated area that can be reached by the flap.
368 369
Reconstructive techniques of the neck and trunk 155
370 A large defect is created in the neck. The head is on the
right side of the photograph. The ventral side of the dog is at
the bottom of the picture. The outline of the omocervical axial
pattern flap is drawn on the skin. 
371 After undermining the flap, it is rotated into position. 
372 The base of the flap, with the superficial cervical branch
of the omocervical artery, is shown.
374 The flap is rotated into the recipient site and the
subcutaneous tissues are sutured in place. A Penrose drain
is placed.
373 Before suturing the flap into position, a bridging incision
is made between the flap and the defect. 
375 The end result of an omocervical axial pattern flap
procedure is shown. The skin has been closed using staples.
370 371
372 373
374 375
An example of an omocervical axial pattern flap for
closure of a large defect as the result of tumour
excision around the ear base of a cat is shown
(376–379).
References
Degner DA (2007) Facial reconstructive surgery.
Clin Tech Small Anim Pract 22:82–88.
Hedlund CS (2007) Surgery of the integumentary
system. In: Small Animal Surgery, 3rd edn. (eds
TW Fossum, CS Hedlund, AL Johnson et al.)
Mosby Elsevier, St. Louis, p. 212.
Pavletic MM (2010) Atlas of Small Animal Wound
Management and Reconstructive Surgery, 3rd edn.
Wiley–Blackwell, Ames, pp. 374–375.
Pope ER (2006) Head and facial wounds in dogs
and cats. Vet Clin North Am Small Anim Pract
36:793–817.
Thoracodorsal axial pattern flap
Overview
Thoracodorsal axial pattern flaps can be used to
cover defects involving the shoulder, forelimb,
elbow, axilla and thorax. This flap is based on
the cutaneous branch of the thoracodorsal artery
and associated vein. The moderately sized
thoracodorsal cutaneous artery branches in a dorsal
direction behind the scapula. If a long flap is
required, it may be necessary to divide the opposite
cutaneous branch of the thoracodorsal artery
and vein. The cranial boundary of the flap is the
spine of the scapula. The caudal boundary is
the skin parallel to the cranial incision, equal to the
distance from the cranial incision to the caudal
shoulder depression. The incisions are extended
dorsally as far as the dorsal midline, but they can be
extended to the contralateral side. Alternatively, a
Reconstructive techniques of the neck and trunk156
376 377
376 A cat with a large mass caudoventral to the right ear
canal is shown. An omocervical axial pattern flap is outlined.
377 The mass has been resected and the flap harvested.
378 379
378 The flap has been sutured in place. The result
immediately after surgery is shown.
379 Ten days after surgery and suture removal.
383 The outline of the thoracodorsal axial pattern flap, the
course of the vasculature and the defect are drawn on the
skin. The head is on the left side of the photograph. The
ventral side of the dog is at the bottom of the picture. 
384 The defect has been created and the skin incisions for
the thoracodorsal axial pattern flap have been made. 
157Reconstructive techniques of the neckand trunk
380–382 Schematic representation of the thoracodorsal axial pattern flap. The coloured part of the dog depicts the estimated
area that can be reached by the flap.
380
383 384
381 382
standard peninsular or hockey-stick shaped
configuration can be created, depending on the
location and size of the defect (380–382).
Procedure
The animal is positioned in lateral recumbency with
the forelimb in a relaxed position, perpendicular
to the trunk. A line is drawn over the spine of the
scapula; this will be the cranial border of the flap.
The line of the caudal incision is parallel to the
cranial border and equals the distance from the
cranial border to the caudal shoulder depression
(383). The flap can be extended if necessary to
the dorsal midline and to the contralateral site or in
a hockey-stick shaped configuration. The skin is
incised along the borders of the flap (384).
The flap is undermined below the level of the
cutaneous trunci muscle, starting at the distal part
of the flap.
While undermining and rotating the flap, it is
important to make sure that the vessels are not
damaged or occluded (385, 386). A bridging
incision is made in the skin between the flap and
the defect (387). The flap is rotated into the defect
and the subcutaneous tissues of the flap are sutured
to the subcutaneous tissue of the recipient site (over
a Penrose drain, if needed) in an interrupted pattern
using absorbable monofilament suture material
(388). The subcutaneous tissues of the donor
site are closed using absorbable monofilament
suture material (389). The skin is apposed with
interrupted sutures using 4-0 nonabsorbable
suture material or staples (390). An example of
a thoracodorsal axial pattern flap for closure
of a large thoracic wall defect in a dog is shown
(391–394).
References
Degner DA (2007) Facial reconstructive surgery.
Clin Tech Small Anim Pract 22:82–88.
Hedlund CS (2007) Surgery of the integumentary
system. In: Small Animal Surgery, 3rd edn. (eds
TW Fossum, CS Hedlund, AL Johnson et al.)
Mosby Elsevier, St. Louis, pp. 212–213.
Pavletic MM (2010) Atlas of Small Animal Wound
Management and Reconstructive Surgery, 3rd edn.
Wiley–Blackwell, Ames, pp. 376–377.
Pope ER (2006) Head and facial wounds in dogs
and cats. Vet Clin North Am Small Anim Pract
36:793–817.
Reconstructive techniques of the neck and trunk158
387 Before suturing the flap into position, a bridging incision
is made between the flap and the defect. 
388 The flap is rotated into the recipient site and the
subcutaneous tissues of the flap are sutured in place.
A Penrose drain has been placed.
387 388
385 The flap is undermined beneath the cutaneous trunci
muscle. 
386 The flap is undermined to the level of its base near the
origin of the thoracodorsal artery and vein. 
385 386
Reconstructive techniques of the neck and trunk 159
389 The subcutaneous tissues of the donor site are apposed
using absorbable monofilament suture material.
390 The end result of a thoracodorsal axial pattern flap
procedure is shown. The skin has been sutured in an
interrupted pattern using nonabsorbable suture material.
389 390
391 392
391 Dog in left lateral recumbency with a large defect of the
skin and subcutis in the lateral thoracic region. The head is on
the right side of the photograph.
392 After approximation of the muscles, a large
thoracodorsal axial pattern flap with hockey-stick
configuration has been raised and rotated into position.
393 394
393 The flap has been sutured into position and the
subcutaneous tissues and skin have been approximated.
Penrose drains are placed.
394 Three days after surgery, the Penrose drains are
removed.
Reconstructive techniques of the neck and trunk160
incision. The flap can be either peninsular or island
in design (395, 396).
Procedure
The animal is placed in dorsal recumbency with the
forelimbs extended cranially. The flap is outlined
with the base of the flap located just lateral to the
xyphoid process. The medial incision is outlined in
the ventral midline and the lateral incision is placed
at a distance equal to the distance from the nipples
to the midline. The caudal limit is preferably the
fourth mammary gland (397). The skin is then
incised according to the predrawn outline (398).
The flap is undermined using scissors, starting from
the midline and extending to the lateral aspect of
the flap, beneath the panniculus and
supramammarius muscles. The cranial epigastric
artery and vein should be preserved during flap
dissection and harvesting (399, 400). Stay sutures
are inserted into the caudal border of the flap to
enable nontraumatic rotation of the flap into the
defect. The vessels must not be kinked or occluded
when rotating the flap (401). The flap is sutured
into the recipient site by placing a few subcutaneous
interrupted sutures of monofilament absorbable
suture material. 
Cranial superficial epigastric
axial pattern flap 
Overview
A cranial superficial epigastric axial pattern flap can
be used to close large sternal skin wounds after
tumour resection or injury. The flap is based on the
cranial superficial epigastric artery. Although there
are some anatomical variations, the artery and vein
are most commonly located in the hypogastric area,
caudal to the ventral border of the costal arch and
medial to the xyphoid process. Because the vessels
are shorter, this flap is smaller and less versatile
than the caudal superficial epigastric axial pattern
flap. Depending on the size of the patient, the base
of the flap is located in the region of the cranial
epigastric vessel, entering the skin lateral to the
abdominal midline and a few centimetres caudal to
the cartilaginous border of the ventral thorax. The
flap may include mammary glands two, three, four
and, possibly, five. In males, the end of the flap must
be cranial to the prepuce to enable closure of the
donor site and minimize the risk of necrosis of
the flap. The midline of the abdomen serves as the
central border of the flap, whereas the distance
from the midline to the mammary nipples serves as
the reference for measurement for the lateral
395, 396 Schematic representation of the cranial superficial epigastric axial pattern flap. The coloured part of the dog depicts the
estimated area that can be reached by the flap.
395 396
Reconstructive techniques of the neck and trunk 161
397 A large sternal defect has been created and the superficial
cranial epigastric axial pattern flap has been outlined. The head
of the dog is located to the right side of the photograph. 
398 Skin incisions have been made following the predrawn
outline of the flap. 
397 398
399 Stay sutures have been placed after the flap has been
undermined beneath the panniculus and supramammarius
muscles.
400 Care has been taken to ensure that the vessels have not
been damaged during the undermining and that they were
not kinked or occluded when the flap was rotated. 
399 400
401 The flap is rotated into the defect with the help of stay
sutures. 
401
Reconstructive techniques of the neck and trunk162
The subcutis of the donor site can be closed in an
interrupted pattern using absorbable monofilament
suture material. When necessary, walking sutures
can be used to move the skin over the donor site
defect (402). All the subcutaneous tissues are
apposed in an interrupted pattern using
monofilament absorbable suture material (403).
The skin of the donor and recipient sites is closed
using nonabsorbable monofilament suture material
or staples (404).
References
Hedlund CS (2006) Large trunk wounds. Vet Clin
North Am Small Anim Pract 36:847–872.
Hedlund CS (2007) Surgery of the integumentary
system. In: Small Animal Surgery, 3rd edn. (eds
TW Fossum, CS Hedlund, AL Johnson et al.)
Mosby Elsevier, St. Louis, p. 214.
Pavletic MM (2010) Atlas of Small Animal Wound
Management and Reconstructive Surgery, 3rd edn.
Wiley–Blackwell, Ames, pp.384–385.
Cutaneous trunci myocutaneous flap
Overview
A cutaneous trunci flap is a compound flap
consisting of three layers:skin, subcutaneous fat and
the cutaneous trunci muscle. It can be used to close
defects on the trunk as well as large wounds on the
forelimb. The thoracodorsal axial pattern flap and
lattisimus dorsi myocutaneous flap are harvested
from the same area. The thoracodorsal axial pattern
flap and the cutaneous trunci myocutaneous flap are
better suited for skin defects, whereas the latissimus
dorsi myocutaneous flap is better suited for thoracic
wall defects where simultaneous reconstruction of
the chest with muscle and skin are required. The
landmarks for the cutaneous trunci myocutaneous
flap are the ventral border of the acromion, the
caudal border of the triceps muscle, the head of the
13th rib and the axillary fold. The dorsal flap border
is drawn from a point ventral to the acromion and
caudal to the border of the triceps muscle, towards
the last rib. The ventral border is parallel to
402 Walking sutures have been placed in the fascia of the
body wall and the subdermal fascia to assist in closure of the
donor site. 
403 The subcutaneous tissues in the donor and recipient sites
have been apposed. 
404 The skin has been closed using staples. 
402
403 404
Reconstructive techniques of the neck and trunk 163
is made, starting at the ventral border of the
outlined flap and extending through the cutaneous
trunci muscle (409). The rest of the flap is incised
through the skin, subcutis and cutaneous trunci
muscle and then undermined, starting at the dorsal
aspect of the flap deep to the cutaneous trunci
muscle and continuing towards the base of the flap.
the dorsal border, starting in the axillary skin fold
(405–407).
Procedure
The patient is positioned in lateral recumbency with
the forelimb in a relaxed position. The outline of
the flap is drawn in the donor area using the
landmarks described above (408). A skin incision
405–407 Schematic representation of the cutaneous trunci
myocutaneous flap. The coloured part of the dog depicts the
estimated area that can be reached by the flap.
405
406 407
408 A defect has been created on the forelimb and the
borders of the cutaneous trunci myocutaneous flap have been
outlined. 
408
409 The ventral border of the flap has been incised. The
cutaneous trunci muscle is gently undermined using scissors.
409
Reconstructive techniques of the neck and trunk164
413 A bridging incision has been made between the donor
and recipient sites. 
413
410 After the flap has been dissected through the skin, the
subcutis and the cutaneous trunci muscle, it can be lifted and
undermined with the help of stay sutures. 
410
411 The flap has been dissected beneath the cutaneous
trunci muscle and towards its base. 
411
412 The flap is rotated into the defect in order to evaluate its
size and the location of the bridging incision. 
412
subcutaneous tissues of the flap are sutured to the
subcutis of the recipient site using absorbable
monofilament suture material. The cutaneous
trunci layer and the subcutis of the donor site
are closed in two separate layers in either an
interrupted or continuous pattern using absorbable
monofilament suture material (415, 416). The skin
is closed routinely using staples or nonabsorbable
monofilament suture material (417).
Monofilament suture material stay sutures are
placed to enable atraumatic manipulation of the
flap (410, 411). The flap is then rotated into the
defect on the forelimb to make sure it is the correct
size and that it can be sutured in place without
tension (412). A bridging incision is performed
between the donor and recipient sites and the flap
is transposed into the defect (413, 414). A Penrose
drain is placed if indicated and the donor and
recipient sites are closed. The muscle and
Reconstructive techniques of the neck and trunk 165
416 The subcutaneous tissues and muscle of the flap are
sutured to the subcutis of the defect. The cutaneous trunci
muscle and the subcutaneous tissues of the donor site are
closed separately. 
417 The skin of both the donor and the recipient site is
closed in an interrupted pattern using staples or
nonabsorbable monofilament suture material. 
415 A Penrose drain has been inserted into the donor site
underneath the muscle layer.
References
Hedlund CS (2006) Large trunk wounds. Vet Clin
North Am Small Anim Pract 36:847–872.
Pavletic MM (2010) Atlas of Small Animal Wound
Management and Reconstructive Surgery, 3rd edn.
Wiley–Blackwell, Ames, pp. 492–493.
Pavletic MM, Kostolich M, Koblik P et al. (1987)
A comparison of the cutaneous trunci myocutaneous
flap and latissimus dorsi myocutaneous flap in the
dog. Vet Surg 16:283–293.
414 The flap has been transposed into the defect and is
ready for suturing. 
414 415
416 417
Reconstructive techniques of the neck and trunk166
These branches also penetrate the muscle surface
towards the cutaneous trunci muscle and the skin.
The most prominent intercostal artery is the branch
that emerges from the 5th intercostal space and
enters the latissimus dorsi muscle. This artery is
responsible for much of the perfusion of the middle
part of the muscle. Intercostal arteries also supply
segmental branches to the dorsal portion of the
latissimus dorsi muscle and overlying cutaneous
trunci muscle. The landmarks for the latissimus
dorsi myocutaneous flap are the ventral border of
the acromion, the caudal border of the triceps
muscle, the head of the 13th rib and the axillary skin
fold (418–420).
Latissimus dorsi myocutaneous flap
Overview
A latissimus dorsi flap can be used to close large
thoracic defects, abdominal wall defects and wounds
on the elbow. The thickness of this flap is very useful
where there is a lack of granulation tissue in an area
(e.g. the elbow region) or when thoracic wall recon -
structions are required. The latissimus dorsi muscle
originates from the thoracolumbar fascia of the
thoracic and lumbar spinous processes and from
muscular attachments to the last two or three ribs.
The insertion of the latissimus dorsi is on the major
teres tuberosity of the humerus. The dorsal and
ventral portions of the muscle are supplied by the
thoracodorsal artery and by branches from the
intercostal arteries emerging from the chest wall.
418–420 Schematic representation of the latissimus dorsi myocutaneous flap. The coloured part of the dog depicts the estimated
area that can be reached by the flap.
418 419 420
Reconstructive techniques of the neck and trunk 167
424 Dissection deep to the latissimus dorsi muscle is
continued until the thoracodorsal artery is encountered. 
Procedure
The patient is positioned in lateral recumbency
with the forelimb in a relaxed position. The outline
of the donor flap is drawn according to the
landmarks described above (421). A skin incision is
made, starting at the ventral border of the outlined
flap and extending through the cutaneous trunci
muscle (422). The incision is extended to the
421 A defect on the forelimb has been created and the
latissimus dorsi myocutaneous flap dimensions have been
outlined. 
422 The ventral border of the flap has been incised. After
incision of the skin and subcutis, the incision has to be
deepened through the cutaneous trunci muscle and latissimus
dorsi muscle. 
423 The latissimus dorsi muscle is undermined using scissors. 
421 422
423 424
underlying latissimus dorsi muscle using a scalpel or
scissors. The remainder of the flap is incised
through the skin, subcutis, cutaneous trunci muscle
and latissimus dorsi muscle and then undermined,
starting at the dorsal aspect of the flap deep to the
latissimus dorsi muscle (423). The flap is further
undermined towards its base with the help of stay
sutures of monofilament suture material (424).
Reconstructive techniques of the neck and trunk168
While undermining the muscle, the branches of
the intercostal arteries are isolated, ligated and
divided deep to the latissimus dorsi muscle. The
thoracodorsal artery is identified and preserved
just caudal to the border of the triceps muscle at
the caudal shoulder depression(425). The flap is
rotated into position taking care not to damage or
occlude the thoracodorsal artery. The size of the
flap and the location for the bridging incision are
then assessed (426). A bridging incision is made
between the donor and the recipient site (427). The
flap is secured by suturing the latissimus dorsi
muscle to the subcutaneous tissues of the defect
(over a Penrose drain if required) in an interrupted
pattern using absorbable monofilament suture
material (428). The donor site is closed in three
layers. The latissimus dorsi muscle is sutured first
in an interrupted or continuous pattern using
absorbable monofilament suture material (over a
Penrose drain if required). The subcutaneous tissues
are then apposed using absorbable monofilament
suture material (429). The skin is closed with
nonabsorbable monofilament suture material or
staples (430).
425 The thoracodorsal artery is visible where it enters the
latissimus dorsi muscle just caudal to the border of the
triceps muscle. 
426 Stay sutures are used to rotate the flap from the donor
site to the recipient site. 
427 A bridging incision has been made from the donor site
to the recipient site. 
428 The flap is sutured into the recipient bed and a Penrose
drain is placed. 
425 426
427 428
Reconstructive techniques of the neck and trunk 169
References
Halfacree ZJ, Baines SJ, Lipscomb VJ et al. (2007)
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. Vet Surg 36:587–592.
Hedlund CS (2006) Large trunk wounds. Vet Clin
North Am Small Anim Pract 36:847–872.
Monnet E, Rooney MB, Chachques JC (2003)
In-vitro evaluation of the distribution of blood
flow within a canine bipedicled latissimus dorsi
muscle flap. Am J Vet Res 64:1255–1259.
Pavletic MM (2010) Atlas of Small Animal Wound
Management and Reconstructive Surgery, 3rd edn.
Wiley–Blackwell, Ames, pp.494–495.
Pavletic MM, Kostolich M, Koblik P et al. (1987)
A comparison of the cutaneous trunci myocutaneous
flap and latissimus dorsi myocutaneous flap in the
dog. Vet Surg 16:283–293.
429 Closure of the donor site. The latissimus dorsi muscle
and the subcutis have been closed in separate layers.
430 The skin of the donor and recipient sites has been closed
using staples. 
429 430
Reconstructive techniques of the neck and trunk170
External abdominal oblique muscle
flap
Overview
An external abdominal oblique muscle flap can be
used to close full-thickness wall defects in the
abdominal or caudal thoracic wall. Because of
its elasticity and pliability, this muscle flap is
sufficiently large to cover defects as large as
10 " 10 cm in medium-sized dogs. The oblique
abdominal muscle consists of two parts: the costal
part, which arises from the fifth to the 13th rib,
and the lumbar part, which arises from the 13th rib
to the thoracolumbar fascia. The aponeurosis of the
muscle inserts on the linea alba and its fibres
are directed caudoventrally. The neurovascular
pedicle is comprised of branches of the cranial
abdominal artery, the cranial hypogastric nerve and
a satellite vein. This pedicle must be preserved
when a lumbar external abdominal muscle flap is
pivoted into the thoracic or abdominal wall defect
(431, 432).
431, 432 Schematic representation of the external abdominal oblique muscle flap. The coloured part of the dog depicts the
estimated area that can be reached by the flap.
431 432
Reconstructive techniques of the neck and trunk 171
Procedure
The patient is positioned in lateral recumbency
(right lateral recumbency in this example) with both
limbs in a relaxed position. The paracostal skin
incision, from the level of the epaxial muscles to
the ventral midline, 5.0 cm caudal to the 13th rib, is
outlined (433). The skin is incised and then
undermined between the incision and the defect (in
this case in the caudal thoracic region at the level
of the 11th and 12th rib) (434). The fascial edges
of the external abdominal oblique muscle are
identified and divided ventrally from the linea alba
and caudally at the level of the skin incision. The
muscle is undermined, preserving the neurovascular
pedicle, and the flap is transposed to the adjacent
defect (435). In order to rotate the flap into the
defect and determine an appropriate place for all
the sutures, the two free corners of the flap are
sutured first (temporarily) cranially into the defect.
The base of the flap is then sutured to the
caudal corners of the defect (436). Subsequently,
the two cranial sutures are removed and the flap
is rotated caudally to expose the inner side of the
flap.
433 The dog is positioned in right lateral recumbency. The
head of the dog is to the right and the ventral side of the dog
is at the top of the photograph. A defect has been created in
the caudal thoracic region including partial removal of the
11th and 12th ribs. The liver can be seen in the defect. The
paracostal incision line for harvesting the external abdominal
oblique muscle flap is outlined.
434 After the skin has been incised, it is undermined, using
scissors, from the starting point of the incision to the
surgical wound. 
435 The part of the muscle designated to close the defect is
separated caudally and ventrally from the lumbar part of the
muscle and transposed into the defect.
436 The muscle flap is temporarily sutured in place in the
defect. 
433 434
435 436
Reconstructive techniques of the neck and trunk172
Next, the transversus abdominal muscle is located
(437). The inner fascial surface of the external
abdominal oblique muscle is sutured to
the transversus abdominal muscle. This layer is
closed using interrupted mattress sutures or in
a continuous pattern. Apposing these two muscle
layers is important in preventing postoperative
abdominal herniation (438). The flap is pulled
cranially again and sutured into position in an
interrupted pattern using absorbable monofilament
suture material. After closing the abdominal wall
defect, the subcutis of the donor and recipient
sites are sutured with absorbable monofilament
suture material (439). The skin is closed routinely
with nonabsorbable monofilament suture material
or staples (440).
References
Hedlund CS (2006) Large trunk wounds. Vet Clin
North Am Small Anim Pract 36:847–872.
Pavletic MM (2010) Atlas of Small Animal Wound
Management and Reconstructive Surgery, 3rd edn.
Wiley–Blackwell, Ames. pp. 496–497.
437 The muscle flap is folded caudally to expose the
transverse abdominal muscle. 
439 The flap is sutured into position and the subcutaneous
tissues are partly apposed. 
438 The transverse abdominal and external abdominal
oblique muscles have been sutured using a continuous
suture pattern. 
440 The skin has been closed routinely using the technique
described in Chapter 3 (p. 51)
437 438
439 440
Reconstructive techniques of the neck and trunk 173
Tensor fascia lata flap
Overview
A tensor fascia lata flap can be used to close full-
thickness wall defects in the abdominal wall or
to cover chronic wounds of the pelvic region.
Because of its elasticity and versatility, this
musculocutaneous flap is an efficient option for
repair of abdominal wounds requiring both soft
tissue and fascia. The technique has been used
successfully in human reconstructive surgery. The
tensor fascia lata is part of the gluteus muscle
group and its blood supply is derived from the
lateral circumflex femoral artery, which is a branch
of the femoral artery (441–443).
Procedure
The dog is placed in lateral recumbency, assuring
access to the caudal abdominal area and the entire
hindlimb (444). An outline of the flap is drawn.
The anatomical landmarks for this flap are the
greater trochanter dorsally, the stifle ventrally, the
biceps femoris muscle caudally and the sartorius
muscle cranially. The caudal border of the flap is
located in the groove between the superficial
biceps femoris and the deep vastus lateralis
muscles. The cranial border is parallel to the
caudalborder, located in the groove between the
tensor fascia lata and the sartorius muscles (445).
444 The animal is positioned in right lateral recumbency. The
head of dog is to the left side of the photograph and the left
hindlimb at the top. A defect in the abdominal wall has been
created. 
441–443 Schematic representation of the tensor fascia
lata flap. The coloured part of the dog depicts the
estimated area that can be reached by the flap.
445 The dimensions of the tensor fascia lata flap are outlined
and the caudal skin incision has been made. The top asterisk
depicts the greater trochanter while the bottom one depicts
the stifle.
444
445
441
442 443
*
*
Reconstructive techniques of the neck and trunk174
The incision is extended through the skin, the
subcutaneous tissue and the deep fascia. The
tensor fascia lata is undermined starting at the
distal end of the flap and progressing towards the
proximal part of the flap. Stay sutures are placed
(446). A bridging incision is made between the
donor site and the recipient site (447). In order to
rotate and secure the flap into the defect, the two
distal corners of the flap are sutured into the defect
first (448). The rectus abdominis muscle is located
in the dorsocaudal wall of the defect and the flap
is sutured to the two dorsocaudal corners of the
defect. The two cranial sutures can now be
removed and the flap turned caudally to allow for
visualization of its inner side (449). The inner side
of the fascia lata flap is sutured to the rectus
abdominis muscle in an interrupted pattern using
absorbable monofilament suture material (450).
The flap is sutured into the defect in an interrupted
pattern using absorbable monofilament suture
material (451). The subcutis of the flap is apposed
to the defect in a continuous or interrupted
pattern using absorbable monofilament suture
material (over a Penrose drain if required). The
subcutaneous tissues of the donor side are
closed routinely (452). The skin of the donor
and recipient sites is closed in an interrupted
pattern using nonabsorbable monofilament suture
material (453).
References
Demirseren ME, Gokrem S, Ozdemir OM et al.
(2003) Hatchet-shaped tensor fascia lata
musculocutaneous flap for the coverage of
trochanteric pressure sores: a new modification.
Ann Plast Surg 51:419–422.
Josvay J, Sashegyi M, Kelemen P et al. (2006) A
modified tensor fascia lata musculofasciocutaneous
flap for the coverage of trochanteric pressure sores.
J Plast Reconstr Aesthet Surg 59:137–141.
Paletta CE, Freedman B, Shehadi SI (1989) The
VY tensor fasciae latae musculocutaneous flap.
Plast Reconstr Surg 83:852–7; discussion 858.
446 The tensor fascia lata flap is being harvested with the
help of stay sutures. The vastus lateralis and sartorius muscles
are visible. 
447 The flap is rotated into the defect in order to determine
the location of the bridging incision. 
446 447
Reconstructive techniques of the neck and trunk 175
450 The fascia lata muscle at the dorsocaudal border of the
defect is sutured to the rectus abdominis muscle with
interrupted sutures. 
451 The fascia lata flap is sutured into the defect. 
452 The subcutaneous tissues of the donor and recipient
sites have been apposed over a Penrose drain. 
453 The skin of both the recipient and donor sites is closed
routinely. 
450 451
452 453
449 After removing the cranioventral sutures, the flap is
turned caudally to expose the inside.
448 The two cranioventral corners of the flap are sutured in
place first in order to determine the location of the sutures for
the dorsocaudal corners of the flap. 
448 449
Reconstructive techniques of the neck and trunk176
Episioplasty
Overview
Perivulvular dermatitis, as a result of excessive skin
folds around the vulva, can be treated with an
episioplasty or a vulvoplasty. This technique can
also be used as a preventive measure. If severe pyo -
derma is present, it should be treated medically
before surgery is performed. Depending on the
curvature of the folds, a ventral, dorsal or combined
episioplasty can be performed.
Procedure
The animal is placed in ventral recumbency. The
amount of skin that can be resected is assessed by
grasping the skin folds. Two crescent-shaped lines,
which begin near the ventral vulvar commissure
and converge dorsally, encircling the vulva, are
drawn. The largest amount of skin will be removed
dorsally (454). The two lines are incised and the
ellipse of redundant skin removed. Excess
subcutaneous tissue is also removed (455). The
subcutis is closed using interrupted absorbable
monofilament sutures with buried knots. The
initial sutures are placed in the 3, 9 and 12 o’clock
positions. The result of the resection can then be
evaluated. If the folds persist, more skin can be
excised along the outer margin of the resection
(456). When enough skin has been excised, the
subcutis is closed in an interrupted pattern using
absorbable monofilament suture material (457).
The skin is closed routinely in an interrupted
pattern using nonabsorbable monofilament suture
material (458, 459).
References
Hedlund CS (2007) Surgery of the integumentary
system. In: Small Animal Surgery, 3rd edn. (eds
TW Fossum, CS Hedlund, AL Johnson et al.)
Mosby Elsevier, St. Louis, p. 245.
Hedlund CS (2007) Surgery of the reproductive and
genital systems. In: Small Animal Surgery, 3rd edn.
(eds TW Fossum, CS Hedlund, AL Johnson et al.)
Mosby Elsevier, St. Louis, pp. 721–723.
Reconstructive techniques of the neck and trunk 177
458 The skin has been closed in an interrupted pattern using
nonabsorbable monofilament suture material.
459 A bitch with a healed episioplasty is shown.
458 459
454 The patient is positioned in ventral recumbency. The
anus is situated dorsally, out of view. After assessing the
amount of skin that can be harvested, two converging lines
are drawn. 
455 The excess perivulvular skin has been excised. 
454 455
456 The subcutaneous tissues are apposed using
monofilament absorbable suture material. The initial sutures
are placed in the 3, 9 and 12 o’clock positions. 
457 Closure of the subcutis has been completed.
456 457
Reconstructive techniques of the neck and trunk178
Scrotal flap
Overview
A scrotal flap is a local subdermal flap that is easy
to prepare and can be used to cover large defects
in the perineal area or the caudal and medial aspect
of the thigh. The scrotal skin is thin and has a
greater elasticity than truncal skin. This is because
of the dartos layer beneath the scrotal skin, which
consists of smooth muscle, collagen and elastic
fibres. Perineal branches of the external pudendal
and cremaster artery supply the scrotum with
blood. A prescrotal castration is performed in intact
male dogs prior to reconstruction of the defect.
A scrotal flap procedure can be performed in
previously castrated dogs, but the remaining scrotal
skin is less pliable.
Procedure
The dog is positioned in dorsal recumbency with
the hindlimbs positioned cranially and spread wide
(460). A routine prescrotal castration is performed.
The prescrotal incision is closed routinely (as
performed here) or it is incorporated into the base
of the flap (461). The skin is incised at the base of
the scrotum craniolaterally, so that the base of the
flap is on the opposite side of the defect. The scrotal
skin is then dissected by separating the tunica dartos
and abdominal fascia, and stay sutures are placed
(462). Before closing the defect, the hindlimbs are
adducted to minimize the tension on the defect and
the skin flap. The limbs are directed slightly cranially
and dorsally. The subcutaneous tissue of the scrotal
flap is sutured to the subcutis of the defect in an
interrupted suture pattern using absorbable
monofilament suture material (463). The skin is
closed routinely in an interrupted pattern using
nonabsorbable monofilament suture material (464).
References
Hedlund CS (2007) Surgery of the integumentary
system. In: Small Animal Surgery, 3rd edn. (eds
TW Fossum, CS Hedlund, AL Johnson et al.)Mosby Elsevier, St. Louis, pp. 159–259.
Matera JM, Tatarunas AC, Fantoni DT et al.
(2004) Use of the scrotum as a transposition flap
for closure of surgical wounds in three dogs. Vet
Surg 33:99–101.
Reconstructive techniques of the neck and trunk 179
464 The skin has been closed routinely. 
464
463 The hindlimbs have been partially adducted and the
subcutaneous tissue apposed over a Penrose drain. 
460 The animal is positioned in dorsal recumbency for
prescrotal castration prior to harvesting a scrotal flap.
461 The dog has been castrated and a large defect on the
medial right thigh has been created. The craniolateral incision
for creation of the scrotal flap is shown. 
462 After dissection of the scrotal skin, the flap is advanced
into the defect using stay sutures. 
460 461
462 463
Reconstructive techniques of the neck and trunk180
Tail flap/lateral caudal axial pattern
flap
Overview
A tail flap (or lateral caudal axial pattern flap) can
be used to close large caudodorsal trunk defects and
skin wounds in the perineal region and hindlimbs.
To use the flap, amputation of the tail is necessary.
The skin of the proximal cranial 75% of the flap
can be used to reduce the possibility of distal flap
necrosis. A dorsal midline incision along the length
of the tail is used to cover dorsocaudal defects and
a ventral midline skin incision is used to cover
defects of the perineum and proximal hindlimb. Tail
flaps are based on the lateral caudal arteries, which
arise from the caudal gluteal arteries. They are
located in the subcutaneous tissue of the tail, lateral
and ventral to the transverse processes of the caudal
vertebrae in the proximal region. In the distal part
of the tail, the vessels travel dorsal to the transverse
processes (465–467).
Procedure
The dog is positioned in ventral recumbency. An
outline of the incision line for the flap is made
(468). A dorsal median skin incision is made from
the tail base to the tip of the tail (469). The
subcutaneous tissue around the tail vertebrae is
dissected, taking care to preserve the right and left
lateral caudal arteries and veins (470). Once the tail
is completely freed from surrounding subcutaneous
tissues, the tail is amputated at the caudal second or
third intervertebral space (471– 473).
Approximately 75% of the skin flap is preserved by
amputating the distal part of the tail with overlying
skin (474, 475). Stay sutures are placed in the tip of
the flap. 
465–468 Schematic representation of the lateral caudal axial pattern flap. The coloured part of the dog depicts the estimated area
that can be reached by the flap.
465 466 467
Reconstructive techniques of the neck and trunk 181
470 The subcutaneous tissues are dissected from the tail
vertebrae. 
471 The skin of the entire tail has been dissected and the
right and left lateral caudal arteries and veins have been
preserved. 
472 The tail is amputated at the second intervertebral space. 473 Completion of the proximal tail amputation at the level
of the second intervertebral space. 
469 Dorsal view of the back and tail of a dog with the incision
line for the tail flap outlined. A defect has been created on the
caudal back of the dog. 
470 The dorsal median skin has been incised.
468 469
470 471
472 473
475 The distal part of the tail is removed together with the
overlying skin. 
475
474 The distal part of the tail is amputated.
474
The flap is then rotated into position in order to
determine an accurate flap length (476). A bridging
incision is made between the donor site and the
recipient site (477). The flap is rotated into the
defect and the subcutaneous tissues are apposed in
an interrupted pattern using absorbable
monofilament suture material (478). The skin is
closed with interrupted sutures of nonabsorbable
suture material or staples (479).
References
Hedlund CS (2006) Large trunk wounds. Vet Clin
North Am Small Anim Pract 36:847–872.
Pavletic MM (2010) Atlas of Small Animal Wound
Management and Reconstructive Surgery, 3rd edn.
Wiley–Blackwell, Ames. pp. 400–401.
Saifzadeh S, Hobbenaghi R, Noorabadi M (2005)
Axial pattern flap based on the lateral caudal
arteries of the tail in the dog: an experimental study.
Vet Surg 34:509–513.
476 The flap is rotated into the defect with the help of stay
sutures. The appropriate length of flap and the location of the
bridging incision are determined.
477 A bridging incision between the donor and recipient
sites has been made. 
478 The subcutaneous tissues have been apposed. 
479 The skin has been closed routinely. 
476
477
478
479
182 Reconstructive techniques of the neck and trunk
• Lateral thoracic artery axial pattern flap
• Superficial brachial axial pattern flap
• Axillary (forelimb) fold flap
• Flexor carpi ulnaris muscle flap 
• Phalangeal fillet (digit I or dewclaw [P-I])
• Phalangeal fillet (digits II–IV)
• Fusion podoplasty
• Segmental pad transfer
Chapter 8
Reconstructive techniques
of the forelimb
183
Sjef C. Buiks, Tjitte Reijntjes and Jolle Kirpensteijn
Lateral thoracic artery axial pattern
flap
Overview
A lateral thoracic artery axial pattern flap is
mainly used for defects involving the elbow region,
but it also has potential for other difficult wounds
within its arc of rotation. The flap is based on the
lateral thoracic artery and vein. The lateral thor -
acic artery is the second branch of the axillary
artery and is directed caudally and runs deep to the
axillary lymph node. The same artery also branches
off to the deep pectoral muscle and the latissimus
dorsi muscle. The lateral thoracic artery has
multiple superficial branches. This network of
blood vessels in the subcutaneous tissue supplies
the skin dorsal and ventral to the main trunk of the
artery and reaches from the midline ventrally to
the mid-thorax dorsally. The anatomical position
of the lateral thoracic artery is comparable in dogs
and cats, but in dogs the artery supplies the skin of
the ventral and lateral body wall up to the caudal
aspect of the eigth rib, whereas in cats it supplies the
skin as caudally as the last rib. The point where the
lateral artery becomes superficial is the centre of
the flap. This point (caudal to the triceps muscle
and adjacent to the dorsal border of the deep
pectoral muscle) can be palpated. The landmarks
for the flap are the midline ventrally and dorsally
a line parallel to the ventral border at a distance
that equals the distance from the centre of the flap
to the ventral border. The caudal border is the eigth
rib in dogs and the 13th rib in cats. A smaller size
flap can be created to minimize skin flap necrosis
(480, 481).
Procedure
The patient is placed in lateral recumbency with the
forelimb in a relaxed position. In this case a large
defect has been created in the elbow region (482).
The outline of the lateral thoracic artery flap is
184
480, 481 Schematic representation of the lateral thoracic
artery axial pattern flap. The coloured part of the dog depicts
the estimated area that can be reached by the flap.
Reconstructive techniques of the forelimb
482 A defect has been created on the right forelimb. 
482480 481
Reconstructive techniques of the forelimb 185
483 The lateral thoracic artery axial pattern flap has been
outlined on the skin. The ventral margin can be extended to
the midline if necessary.
484 After incising the skin and undermining the flap, a
bridging incision has been made and the flap rotated into
the defect.
485 The subcutaneous tissues of the flap, recipient site and
donor site have been apposed using absorbable
monofilament suture material. 
486 The skin has been closed in an interrupted pattern using
nonabsorbable monofilament suture material.
drawn in the donor area using the landmarks
described above (483). A skin incision is made,
starting at the ventral border of the outlined flap.
The flap is then undermined, starting dorsally
and working towards the cranioventral base of the
flap. Stay sutures are placed in the corners of the
flap to helprotate it into the defect on the forelimb
(484). The subcutaneous tissues of the flap are
apposed to the edges of the defect using absorbable
monofilament suture material. The subcutis of the
donor site is closed in a continuous or interrupted
pattern (over a Penrose drain when needed) using
absorbable monofilament suture material (485).
The skin is closed using staples or simple inter -
rupted sutures of nonabsorbable suture material
(486).
References
Benzioni H, Shahar R, Yudelevich S et al. (2009)
Lateral thoracic artery axial pattern flap in cats. Vet
Surg 38:112–116.
Pavletic MM (2010) Atlas of Small Animal Wound
Management and Reconstructive Surgery, 3rd edn.
Wiley–Blackwell, Ames. pp. 378–379.
483 484
485 486
Superficial brachial axial pattern flap
Overview
This axial pattern flap is used to cover antebrachial
wounds and defects involving the elbow. A
cutaneous branch of the superficial brachial artery
supplies the craniomedial antebrachium. The
cephalic vein runs on the lateral side of this vessel
(487–489).
Procedure
The dog is positioned in dorsal recumbency. The
forelimb should be extended so that the elbow
joint is not flexed. The donor site, which consists
of skin on the scapulohumeral joint, the cranial
humerus and the elbow, is clipped and aseptically
prepared. The flap area is cleaned and sterilized
using routine procedures. If necessary, the defect
is debrided. A flap should always be placed on a
healthy granulation bed or fresh tissue. Epithelium
from the wound edges is removed if necessary. Two
parallel lines are drawn from the elbow joint to the
greater tubercle of the humerus. The distance
between the two lines corresponds with the width of
the defect. It is important to ensure that the site can
be closed without creating too much tension. The
flap is progressively tapered as it approaches the
greater tubercle. The length of flap required is
determined by measuring from the pivot point bet -
ween the defect and the flap (490). Incisions
are made following the predrawn lines from the
end to the base of the flap. The flap is then elevated
and rotated laterally into the defect. If the flap is
not long enough to cover the defect, it can be
elongated by incising its base (491). A bridging
incision is made to facilitate rotation of the flap.
It also lengthens the flap (492). Stay sutures are
used to manoeuvre the flap (493).
Reconstructive techniques of the forelimb186
487–489 Schematic representation of the superficial brachial
artery axial pattern flap. The coloured part of the dog depicts
the estimated area that can be reached by the flap.
487 488
489
Reconstructive techniques of the forelimb 187
490 Dorsal view of
the defect and the
donor site. Note the
pivot point (arrow).
491 The flap is
assessed to determine
if it is of the correct
length. 
492 A bridging
incision is made to
facilitate rotation of
the flap.
493 The flap is rotated
with the help of stay
sutures so that it covers
the defect.
490 491
492 493
The flap is partially sutured into place with 3-0
absorbable monofilament sutures at critical
landmarks (494). The flap is then fully sutured into
place with interrupted or continuous sutures of
absorbable monofilament suture material for the
subcutis and interrupted sutures of nonabsorbable
monofilament suture material for the skin. If
necessary a drain can be placed, which exits the
wound at its most distal point. The donor site is
closed with interrupted or continuous sutures
of absorbable monofilament suture for the subcutis
and interrupted sutures of nonabsorbable mono -
filament material for the skin (495).
References
Done SH, Goody PC, Evans SA et al. (1996) (eds)
Color Atlas of Veterinary Anatomy. Volume 3: the
Dog and Cat. Mosby, St. Louis, p. 4.33 (fig. 4.56).
Dyce KM, Sack WO, Wensing CJG (1996)
Textbook of Veterinary Anatomy. WB Saunders,
Philadelphia, p. 461.
Fossum TW, Hedlund CS, Hulse DA et al. (2002)
(eds) Small Animal Surgery, 2nd edn. Mosby,
St. Louis, p. 171.
Pavletic MM (2010) Atlas of Small Animal Wound
Management and Reconstructive Surgery, 3rd edn.
Wiley–Blackwell, Ames, pp. 380–382.
Straw R (2007) Reconstructive surgery in veterinary
cancer treatment. In: Proceedings of the World
Small Animal Veterinary Association Congress,
Sydney.
Reconstructive techniques of the forelimb188
495 A dorsal view of
the closed defect and
donor site is shown.
494 The flap has
been partially attached
to the defect with
sutures placed at the
base of the defect.
494
495
Axillary (forelimb) fold flap
Overview
An axillary fold flap is used for the closure of
wounds on the lateral and ventral aspect of the
thorax (496, 497).
Procedure
The dog is positioned in lateral recumbency,
making sure that the donor site and the defect
site are easily accessible. When suturing the flap
onto the defect, the dog can either be kept in
lateral recumbency while the forelimb is extended
abaxially or be placed in dorsal recumbency
(498, 499). The donor site and defect are clipped
and aseptically prepared. This includes the trunk at
the base of the limb, the shoulder area and the
proximal part of the forelimb. The distal part of
the limb is covered with a sterile bandage. The
defect is debrided if necessary. A flap should always
be placed on a healthy granulation bed or fresh
tissue. The dimensions of the defect and the
amount of skin that can be harvested to cover the
defect are assessed. This can be done by grasping
the loose skin from the body wall to the elbow.
Reconstructive techniques of the forelimb 189
498 Medial view of the site where the defect will be created.
Note the forelimb is stretched abaxially.
499 The amount of skin needed is being assessed.
498 499
496, 497 Schematic representation of the axillary (forelimb)
fold flap. The coloured part of the dog depicts the estimated
area that can be reached by the flap.
496 497
Harvesting too much skin will result in excessive
tension on closure of the donor site. Flexing and
extending the elbow while elevating the skin will
outline the outer boundaries of loose skin (500).
Two lines are drawn outlining the flap; one line is
drawn on the medial aspect of the skin covering
the humerus, the other on the lateral side. The
lines are connected distally by a crescent-shaped
line. The width of the flap should correspond to the
width of the defect. Ideally, the width should be
approximately 50% of the length of the flap. The
base of the flap has to be sufficiently wide to allow
perfusion via the subdermal plexus (501, 502). The
skin is then incised along the marked lines (503).
The flap is undermined so that it can be elevated
from the triceps. Stay sutures using absorbable
monofilament suture material are placed at the
distal end of the flap so that it can be transposed
into the defect (504). Before the flap is secured in
place, the distance that has been created is spanned
by rotating the flap medially. The proximal tip of
skin and the skin at the far side of the former
flap base is apposed with a single suture (505). The
flap is attached to the recipient bed using two
interrupted subcutaneous sutures (506). The flap
is then further sutured to the subcutis using
absorbable monofilament suture material; if
necessary, walk ing sutures and a Penrose drain can
be used (507). The skin is closed with interrupted
sutures using nonabsorbable monofilament suture
material (508).
Reconstructive techniques of the forelimb190
502 Lateral view of the donor site. The caudal part of the
defect can be seen.
502
501 Caudal view of the site of the procedure. The limb is now
stretched forward.
501
500 The defect has been created.
500
Reconstructive techniques of the forelimb 191
507 The flap has been sutured to the subcutis of the defect. 508 The skin of the flap and the surrounding tissue have
been apposed.
504 The flap has been transposed into the defect.
506 The flap has been partially attached.505 The gap has been spanned with a single suture apposing
the proximal tip of skin and the skin at the far sideof the
former flap base.
504
505 506
507 508
503 An incision has been made on the lateral aspect of the
donor flap.
503
The donor site is closed in two layers: the sub -
cutaneous layer with interrupted or continuous
sutures using absorbable monofilament suture mat -
erial and the cutaneous layer with interrupted
sutures using nonabsorbable monofilament suture
material (509–511). The final result of this flap
procedure is shown in a dog with a lesion near the
elbow (512, 513).
References
Fossum TW, Hedlund CS, Hulse DA et al. (2002)
(eds) Small Animal Surgery, 2nd edn. Mosby,
St. Louis, pp. 166–167.
Reconstructive techniques of the forelimb192
512, 513 An axillary fold flap
has been performed on a dog
with a defect on its forearm.
512 513
509 The donor site has been closed in
two layers.
510 Medial view of the completed
procedure. Note that the dog ear on the
elbow has not yet been excised.
511 Lateral view of the transposed flap
and the donor site.
509 510 511
Hunt GB (1995) Skin fold advancement flaps for
closing large sternal and inguinal wounds in cats
and dogs. Vet Surg 24:172–175.
Hunt GB, Tisdall PLC, Liptak JM et al. (2001) Skin
fold advancement flaps for closing large proximal
limb and trunk defects in dogs and cats. Vet Surg
30:440–448.
Pavletic MM (2010) Atlas of Small Animal Wound
Management and Reconstructive Surgery, 3rd edn.
Wiley–Blackwell, Ames, pp. 334–335.
Reconstructive techniques of the forelimb 193
Flexor carpi ulnaris muscle flap
Overview
A flexor carpi ulnaris muscle flap involves the
humeral head of the flexor carpi ulnaris. It is used in
cases of chronic wounds involving the antebrachial,
carpal and metacarpal areas. The origin of the
muscle is the medial humeral epicondyl and its
insertion is the accessory carpal bone. In this way,
the flexor carpi ulnaris flexes the carpus. The
humeral head of the flexor carpi ulnaris muscle is
vascularized by the caudal interosseous artery,
which enters the muscle at the distal tendon
(514–516).
Procedure
The dog is positioned in lateral recumbency. The
donor site, including the elbow and carpus, is
clipped. The flap area is then cleaned and
aseptically prepared using routine procedures. The
defect is debrided if necessary. The flap should
always be placed on a healthy granulation bed or
fresh tissue. Epithelium is removed from the wound
edges if necessary. A sterile glove can be used to
cover the paw (517). An incision is made along the
caudolateral aspect of the antebrachium, starting
below the elbow and extending distally to 2 cm
distal to the accessory carpal bone (518).
514–516 Schematic representation of the flexor carpi ulnaris
muscle flap. The coloured part of the dog depicts the
estimated area that can be reached by the flap.
514 515 516
517 Dorsolateral view of the site of the defect and the upper
forelimb.
518 An incision has been made along the caudolateral aspect
of the antebrachium. 
517 518
The ante brachial and carpal fascia are incised in
order to expose the humeral head of the flexor carpi
ulnaris (519, 520). The ulnar head of the flexor
carpi ulnaris is transected at its distal tendon to
expose the humeral head (521). The humeral head
of the flexor carpi ulnaris muscle can be identified
between the ulnaris lateralis muscle laterally and the
ulnar head of the flexor carpi ulnaris muscle
caudally (522). After blunt dissection of the fascial
attachments of the humeral head, the flexor carpi
ulnaris muscle is transected between its proximal
and middle parts (523). A bridging incision is made
between the donor site and the recipient site and the
muscle is then rotated into the wound (524).
The flap is sutured into the defect with interrupted
or continuous sutures of absorbable monofilament
suture material. If the flap is to be closed using
adjacent skin, the skin is undermined and walking
sutures may be placed in the subcutaneous tissue to
facilitate closure (525, 526). The ulnar tendon is
attached to its head with interrupted sutures or a
specific tendon suture pattern using absorbable
monofilament suture material (527, 528). A drain
can be placed if needed. If the muscle flap cannot
be covered by skin, a wet bandage is placed over the
surface of the muscle. After 2 weeks, granulation
tissue will have formed and the wound can be
closed primarily with a free skin graft.
References
Chambers JN, Purinton PT, Allen SW et al. (1998)
Flexor carpi ulnaris (humeral head) muscle flap
for reconstruction of distal forelimb injuries in
two dogs. Vet Surg 27:342.
Done SH, Goody PC, Evans SA et al. (1996) (eds)
Color Atlas of Veterinary Anatomy. Volume 3: the
Dog and Cat. Mosby, St Louis, p. 4.28 (fig. 4.47).
Dyce KM, Sack WO, Wensing CJG (1996)
Textbook of Veterinary Anatomy. WB Saunders,
Philadelphia, p. 86.
Fossum TW, Hedlund CS, Hulse DA et al. (2002)
(eds) Small Animal Surgery, 2nd edn. Mosby,
St. Louis, pp. 178–179.
Szentimrey D (1998) Principles of reconstructive
surgery for the tumor patient. Clin Tech Small
Anim Pract 13:70–76.
Reconstructive techniques of the forelimb194
519 After incising the skin, the fascia is exposed.
520 View of the ulnar head of the flexor carpi ulnaris muscle
after incision of the fascia.
521 Transection of the distal tendon of the ulnar head of
the flexor carpi ulnaris muscle.
519
520 521
Reconstructive techniques of the forelimb 195
522 Dissection of the humeral head of flexor carpi ulnaris
muscle.
523 Transection of the humeral head of the flexor carpi
ulnaris muscle between the proximal and middle third of
the muscle.
524 The site of the defect is connected to the flap area with
a bridging incision.
522 523
524
527 Interrupted sutures are used to attach the ulnar tendon
to its head.
528 The skin has been closed using nonabsorbable
monofilament suture material.
525 The flap is rotated into the defect.
526 Walking sutures may be necessary to facilitate
approximation of the subcutis.
525
526 527
528
Phalangeal fillet (digit I or dewclaw [P-
i])
Overview
Wounds on the dorsal aspect of the carpal and
metacarpal region can be covered using local ad -
vancement flaps or a flexor carpi ulnaris muscle
flap. Small wounds distal to the carpus on the
palmar or lateral aspect of the claw can be covered
with a phalangeal fillet flap using the skin of the
thumb (P-1) (529–531).
Procedure
The dog is positioned in lateral recumbency to
allow access to the medial aspect of the affected
limb. The distal part of the limb is clipped. The flap
area is cleaned and aseptically prepared using
routine procedures. The defect is debrided if
necessary. The flap should be placed on a healthy
granulation bed or fresh tissue. Epithelium, if any, is
removed from the wound edges (532). A No. 11
scalpel blade is used to make a circular incision
around the base of the nail (533–535).
Reconstructive techniques of the forelimb196
532 Medial view of the defect.
533 A circular incision is made around the nail bed.
529–531 Schematic representation of the phalangeal filet (P-
I) flap. The coloured part of the dog depicts the estimated area
that can be reached by the flap.
532
533
530 531529
534 The skin around the nail has been incised.
534
Reconstructive techniques of the forelimb 197
The skin of the thumb is incised along the predrawn
lines (536, 537). The nail is then carefully dissected.
The artery and vein that supply the thumb are
ligated using absorbable monofilament suture
material, or they can be cauterized. The phalanx
and the metacarpal bone are removed (538).
535 The borders of the flap have been drawn.
538 The donor area is shown after removal of the thumb.
536 The first incision has been made.
537 The thumb is dislocated and amputated.
535 536
537 538
The caudolateral dotted line is incised and a
bridging incision made to facilitate rotation of the
flap into the area of the defect (539). The flap is
rotated into the defect (540). The subcutis of the
flap is sutured with interrupted or continuous
sutures using absorbable monofilament suturematerial (541, 542). The skin is closed with
interrupted sutures using nonabsorbable
monofilament suture material (543).
References
Bradley DM, Shealy PM, Swaim SF (1993) Meshed
skin graft and phalangeal fillet for paw salvage: a
case report. J Am Anim Hosp Assoc 29:427–433.
Done SH, Goody PC, Evans SA et al. (1996) (eds)
Color Atlas of Veterinary Anatomy. Volume 3: the
Dog and Cat. Mosby, St Louis, p. 4.41 (fig. 4.73).
Dyce KM, Sack WO, Wensing CJG (1996) (eds)
Textbook of Veterinary Anatomy. WB Saunders,
Philadelphia, pp. 79, 462–463.
Fossum TW, Hedlund CS, Hulse DA et al. (2002)
(eds) Small Animal Surgery, 2nd edn. Mosby,
St. Louis, pp. 206–208.
Slatter D (2003) Textbook of Small Animal Surgery,
Volume 2. WB Saunders, Philadelphia, p. 1987.
Swaim SF, Henderson RA (1997) (eds) Small
Animal Wound Management, 2nd edn. Williams &
Wilkins, Philadelphia, pp. 342, 352.
Reconstructive techniques of the forelimb198
Reconstructive techniques of the forelimb 199
542 The subcutis has been apposed.
543 The skin has been closed.
540 The flap is being rotated into the defect.
541 The flap is sutured into the defect.
540
541 542
543
539 The caudolateral line has been incised and a bridging
incision made.
539
Phalangeal fillet (Digits II–IV)
Overview
Phalangeal fillets are used to close defects of the
phalanges and paws. They can be used to cover de -
fects on the other phalanges or on the dorsum of the
paw.
Procedure
The animal is positioned in lateral recumbency.
The medial and lateral aspects of the distal limb
and the area around the toes and the defect are
clipped. The affected area is carefully cleaned and
debrided and an assessment made of which pha lanx
needs to be removed (544). An incision is made on
the dorsal aspect of the paw, in the skin between the
two toes, from proximal to distal. It is then
extended to the plantar aspect of the digit (545,
546). The dorsal vasculature is ligated (547). The
proximal phalangeal bone (phalanx I) and tendons
are then removed. The bones in the digit are re -
moved by careful dissection as close to the bones as
possible (548–550). Next, the distal phalanx and
the nail (phalanx III) are removed (551) and, finally,
the middle phalangeal bone (phalanx II) and
tendons are excised (552) .
Reconstructive techniques of the forelimb200
544 The area of the defect has been
cleaned and debrided.
545, 546 An incision has been made on the dorsal aspect of the paw (545) and
extended to the plantar aspect of the digit (546).
547 The vasculature is ligated. 
547
544
545 546
Reconstructive techniques of the forelimb 201
548–550 The proximal phalangeal bone (phalanx I) and tendons are removed. The bones in the digit are removed by careful
dissection as close to the bones as possible. 
548 549 550
551, 552 The distal phalanx and the nail (phalanx III) are removed (551) and the
middle phalangeal bone (phalanx II) is excised (552).
551 552
The flap is trimmed to the appropriate size
(553–555). The flap is kept in one piece in order to
cover the dorsum of the paw. The flap is sutured
using a few sutures of absorbable monofilament
suture material in the subcutis (556–558). The
subcutis is closed in a continuous pattern using
absorbable suture material and the skin is closed in
an interrupted pattern using nonabsorbable
monofilament suture material (559, 560).
References
Barclay CG, Fowler JD, Basher AW (1987) Use of
the carpal pad to salvage the forelimb in a dog and
cat: an alternative to total limb amputation. J Am
Anim Hosp Assoc 23:527–532.
Basher AWP, Fowler JD, Bowen CVA et al. (1990)
Microneurovascular free digital pad transfer in the
dog. Vet Surg 19:226–231.
Demetriou JL, Shales JC, Hamilton MH et al.
(1990) Reconstruction of a nonhealing lick
granuloma in a dog using a phalangeal fillet
technique. J Am Anim Hosp Assoc 43:288–291.
Fowler D (2006) Distal limb and paw injuries.
Vet Clin North Am Small Anim Pract 36:819–845.
Gourley IM (1978) Neurovascular island flap for
treatment of trophic metacarpal pad ulcer in the
dog. J Am Vet Med Assoc 14:119–125.
Pavletic MM (2010) Atlas of Small Animal Wound
Management and Reconstructive Surgery, 3rd edn.
Wiley–Blackwell, Ames, pp. 538–545.
Swaim FS, Garret PD (1985) Foot salvage
techniques in dogs and cats: options, do’s and
don’ts. J Am Anim Hosp Assoc 21:511–519.
Swaim SF, Henderson RA (1997) (eds) Small
Animal Wound Management, 2nd edn. Williams &
Wilkins, Philadelphia, pp. 342–346.
Reconstructive techniques of the forelimb202
553 The flap is trimmed. 555 An overview of the flap is shown.
553 554 555
554 A bridging incision is made at the
distal end of the flap.
Reconstructive techniques of the forelimb 203
559 The skin is closed with
nonabsorbable monofilament suture
material. 
560 The closed skin is shown.
559 560
556–558 The flap is sutured into the defect.
556 557 558
Fusion podoplasty
Overview
Fusion podoplasty is recommended in cases of
severe pododermatitis that are not responsive to
medical treatment. All the skin between the toes
and pads is removed and the toes and pads are sut -
ured together to form one ‘foot’. 
Reconstructive techniques of the forelimb204
Procedure
The animal is positioned in lateral recumbency.
The distal limb is clipped and shaved. The skin
between the digits should be clipped carefully.
The distal paw is cleaned and aseptically prepared
using routine procedures. A line is drawn on the
skin between the digits to mark which portion
should be removed (561, 562). The portion of skin
to be removed on the abaxial sides of the third and
fourth digits is shorter than on the axial side (563).
A line is then drawn to mark the portion of the
skin that has to be removed on the palmar side,
between the digital pads and the metatarsal/
metacarpal pad (564). The skin between the digits
is then removed (565–567) and the skin on the
plantar aspect of the paw is also removed (568,
569).
561, 562 The portion of skin that is to be removed has been
marked. A piece of skin as long as the adjacent digit should be
removed.
563 The outline of the skin between digits three and four is
shown.
561
562 563
Reconstructive techniques of the forelimb 205
567 All the skin on the dorsal side of the paw has
now been removed.
569 The foot is shown after all the skin has been removed.568 All the skin on the plantar side of the paw has been
removed.
565 The skin between digits two and three has been
removed.
566 The skin between digits three and four has also been
removed.
565
566 567
568 569
564 The plantar outline of the skin to be removed is shown. 
564
The digital pads and the metatarsal/metacarpal
pad are sutured together using absorbable
monofilament suture material (570–572). The
subcutis is closed on the dorsal aspect of the paw
in a continuous pattern using absorbable mono -
filament suture material. The skin on the dorsum
of the paw is closed in an interrupted suture
pattern (573). Placement of a drain is not
necessary with this procedure.
References
Fowler D (2006) Distal limb and paw injuries. Vet
Clin North Am Small Anim. Pract 36:819–845.
Gregory C, Gourley IM (1990) Use of flap and or
grafts for repair of skin defects of the distal limb of
the dog and cat. Prob Vet Med 2:424–432.
Pavletic MM (2010) Atlas of Small Animal Wound
Management and Reconstructive Surgery, 3rd edn.
Wiley–Blackwell, Ames, pp. 538–545.
Swaim FS, Garret PD (1985) Foot salvage
techniques in dogs and cats: options, do’s and
don’ts. J Am Anim Hosp Assoc 21:511–519.
Swaim SF, Henderson RA (1997) (eds) Small
Animal Wound Management, 2nd edn. Williams &
Wilkins, Philadelphia, pp. 364–369.
Reconstructive techniques of the forelimb206
570, 571 The second digital pad (570) and the fifth digital pad (571) have been sutured onto the metacarpal pad.
573 The skin on the dorsum of the paw has been closed
using an interrupted suture pattern.
572 All the pads have now been sutured together.
570 571
572 573
Reconstructive techniques of the forelimb 207
Segmental pad transfer
Overview

Mais conteúdos dessa disciplina