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SMALL ANIMALS

CASE REPORT AND CLINICAL REVIEW

Bilateral skin fold rotation–advancement flaps for the closure of


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large lumbosacral wounds in three dogs avj_704 174..179

A Dunn,a* E Buffa,a R Mitchellb and G Huntc

for wound closure,6 may be insufficient to effect tension-free closure


Three dogs were presented for the management of disease pro-
in this area. Axial pattern flaps, or island arterial flaps, based on the
cesses resulting in large skin defects over the dorsal lumbosacral
ventral branch of the deep circumflex iliac artery (DCIA) can be used
region. One had severe dog bite wounds, one had a large burn
sustained from a heating pad and one had a large myxosarcoma in to cover problematic wounds in the dorsal lumbosacral region if this
the region. In each case, the extent and location of the resulting vessel is intact on at least one side.8
skin defect were assessed as factors likely to prevent reconstruction Large dorsal lumbosacral wounds in which the both DCIAs are com-
using simple tension-relieving techniques alone or in combination promised are uncommon, but present a significant management chal-
with established reconstructive techniques, such as axial pattern lenge. Meshed full thickness or partial thickness free grafts can be used
flaps or skin stretching devices. Bilateral skin fold rotation– to cover large trunk wounds;3,9,10 however, a lack of inherent vascular
advancement flaps (SFRAFs) based on the flank folds were mobil- supply, intensive postoperative wound care and inferior cosmetic
ised dorsally and allowed complete wound closure in two dogs and outcome make these techniques a last resort in large trunk wounds.
subtotal closure in the other dog. All wounds healed without major Microvascular anastomosis of full-thickness donor skin to the deep
complications and an acceptable cosmetic outcome was achieved
circumflex iliac artery is feasible;11 however, the need for specialised
in each case. Minor flap debridement was required in two dogs. The
equipment and training in microsurgical techniques limits the avail-
use of bilateral SFRAFs is a useful technique alone or in combination
ability of this technique, with the added problem of closing a large,
with other reconstructive techniques for the closure of large dorsal
full-thickness donor wound.
lumbosacral skin defects when existing techniques are not suffi-
cient. Small flank folds, such as those of obese dogs, may yield Additional techniques allowing coverage of large dorsal lumbosacral
unexpectedly large SFRAFs. wounds with full-thickness skin may be welcomed by the surgeon
faced with extremely large lumbosacral wounds where adjacent skin is
Keywords dogs; flank fold; skin fold advancement flap; skin insufficient for skin stretching, combined with bilateral compromise
reconstruction of DCIAs preventing axial pattern flap use.
Abbreviations DCIA, deep circumflex iliac artery; SFRAFs, skin The purpose of this article is to describe the single session closure of
fold rotation–advancement flaps extensive wounds over the dorsal lumbosacral region in three dogs
Aust Vet J 2011;89:174–179 doi: 10.1111/j.1751-0813.2011.00704.x
with a variation of a previously described reconstructive technique
using flank fold skin (Figure 1).12,13

D
og bite wounds, thermal and electrical burns, and neoplasia
are some of the conditions that may destroy or require sur- Case reports
gical excision of extensive areas of dorsal trunk skin in the
dog.1–4 The general laxity and abundance of trunk skin varies mark- Surgical technique
edly between breeds and individuals;1,2,4 however, the majority of An anal purse string suture was placed. The trunk caudal to the mid-
dorsal trunk wounds can be closed with simple tension-relieving tech- thoracic level, and both hind limbs proximal to the tarsal joints, were
niques.1,2,4,5 If such techniques are insufficient to allow minimal prepared for surgery. Sterile waterproof wraps were placed on the
tension closure, they may be combined with the use of skin-stretching distal limbs and the caudal half of the dog was draped in to the
devices, which mobilise local skin to the surgical site, allowing the surgical field with the dog positioned in sternal recumbency. Prepa-
closure of many large trunk wounds.4,6 ration of the caudal half of the dog removed the need to prepare
additional areas of skin intraoperatively and apply fresh surgical
Wounds over the dorsal lumbosacral region are less amenable to drapes after each re-positioning of the dog, thus reducing the risk of
lateral undermining and advancement, because of the less mobile wound contamination. Tumour excision, wound debridement or
lateral thigh skin, which lacks a panniculus muscle layer.7 Similarly, scar excision were performed on the lumbosacral skin as the case
skin-stretching devices, which rely on a reasonable source of local skin required. The recipient bed was covered with saline-soaked abdomi-
nal sponges and the caudal half of the dog rolled laterally to provide
*Corresponding author: Small Animal Specialist Hospital, 1 Richardson Place, North access to the flank fold. The flank fold attachment at the cranial
Ryde, New South Wales, 2113, Australia; dunnymel@hotmail.com aspect of the thigh was palpated to subjectively estimate the available
a
University of Sydney Veterinary Teaching Hospital, Camden, NSW, Australia
b
North Coast Veterinary Specialists, Tanawha, Queensland, Australia skin for flap formation. A sterile marker was used to mark lines
c
University of Sydney Veterinary Teaching Hospital, Sydney, NSW, Australia along the lateral and medial skin fold attachments to the thigh. The

© 2011 The Authors


174 Australian Veterinary Journal Volume 89, No 5, May 2011 Australian Veterinary Journal © 2011 Australian Veterinary Association
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b

Figure 1. Diagrammatic representation of bilateral skin fold rotation–advancement flaps for closure of caudodorsal trunk wounds. (a) Lateral skin
incision; A and B are reference points for the following diagrams. (b) The medial skin incision is carried proximally to the inguinal crease. (c) The flank
fold is unfolded and the lateral abdominal skin undermined allowing flap rotation. Direction of flap rotation is indicated by the curved arrow in the
inset diagram. Once rotated, the flap is advanced in the direction of the straight arrows. (d) Thigh wound closure is performed with gentle tension on
the flap (arrows). (e) Wound closure is completed with undermining and advancement of the cranial wound margin (arrows). The flaps may come
together end-on as illustrated; however, care must be taken to avoid placement of this suture line directly along the dorsal spinous processes. Where
flap length permits, a side-to-side closure is preferred.

© 2011 The Authors


Australian Veterinary Journal © 2011 Australian Veterinary Association Australian Veterinary Journal Volume 89, No 5, May 2011 175
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lines converged just proximal to the stifle and care was taken to debrided of devitalised skin and necrotic subcutaneous fat, and
leave sufficient skin medially and laterally to allow donor bed lavaged with sterile saline. Both DCIAs were noted to be thrombosed
closure.12 and non-viable. The resulting defect measured 23 ¥ 20 cm. Open-
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wound management was initiated with wet-to-dry dressings changed


The medial and lateral attachments of the flank fold were incised twice daily for the first 2 days to complete surface debridement.
along the marked lines, with the lateral thigh incision continuing Ongoing open-wound management was favoured over early wound
dorsally as a bridging incision to connect the donor bed to the caudal reconstruction because of the cooperative nature of the dog and the
edge of the recipient bed (Figure 1a). The medial incision extended owners’ desire to avoid surgery. Sterile hydrogel (Solu-Gel; Johnson
proximally to the level of the inguinal crease to allow sufficient release and Johnson Medical, North Ryde, NSW, Australia) covered by a non-
of the flap from the upper limb (Figure 1b). adherent sterile dressing (Melolin; Smith & Nephew Pty Ltd, North
The lateral trunk skin extending from the recipient wound to the flank Ryde, NSW, Australia) and a layer of cotton padding (Combine dress-
fold was carefully undermined deep to the panniculus muscle layer, ing; Smith & Nephew Pty Ltd) were used. Wound dressings were
taking care to preserve any direct cutaneous vessels. Stay sutures were secured with a tie-over dressing4 and dressings were changed every
used to handle the skin edges. The double-layered flank fold was 4 days or sooner if wound fluid strike-through occurred.
unfolded with combined blunt and sharp dissection. The flap was
No appreciable reduction in wound size occurred beyond day 45 of
rotated and advanced on to the recipient bed (Figure 1c). The donor
open-wound management by which time the wound measured 13 ¥
bed was closed in two layers by apposing the medial and lateral edges
11 cm, with a central non-epithelialised area and significant tension in
of the thigh wound while gentle tension was placed on the flap
the surrounding skin (Figure 2). Wound excision was performed on
(Figure 1d). The dog was repositioned and the contralateral flank fold
day 48. Skin edge recoil resulted in an increase in the wound’s dimen-
released and the donor wound closed in an identical manner. Finally,
sion to 16 ¥ 15 cm. Wound closure without significant tension was
the dog was returned to sternal recumbency. The flaps met dorsally
performed using bilateral SFRAFs as described above (Figure 3a, b).
and were apposed either end to end (Figure 1e) or, if flap length
permitted, side to side. Undermining and advancement of the cranial
By day 4 an area of skin necrosis, 0.5 cm diameter, had formed at the
and caudal wound margins assisted in wound closure. Wounds were
junction of the advancement flaps and the caudal wound margin. The
closed in two layers: a continuous intradermal layer of absorbable
necrotic section was allowed to remain in situ, where it formed a hard
suture, such as polydioxanone, and a skin layer of interrupted non-
scab under which epithelialisation had occurred by the time the scab
absorbable suture, such as polypropylene, or skin staples. Fenestrated
lifted off on day 14. The remainder of the wound healed without
drains were placed, the tips extending to dependent positions on the
complication and sutures were removed 14 days after surgery. Hair
cranial thigh. The exit site was chosen so as not to interfere with blood
regrowth with excellent cosmesis was evident at a 4-month postop-
supply to the base of the skin flaps. Drains were attached to closed
erative recheck (Figure 4).
continuous suction devices, and were removed in 2–5 days as dictated
by wound fluid production.

Case 1
An obese 9-year-old spayed female Shetland Sheepdog weighing
10.2 kg was presented for management of dog fight wounds sustained
to the trunk 4 days previously. Prior management had consisted of
amoxicillin/clavulanate 12.5 mg/kg twice daily and carprofen 2 mg/kg
once daily.

Hair was clipped from the caudodorsal trunk. An oval-shaped area of


purple to black skin measuring 20 ¥ 17 cm was located dorsally,extend-
ing from the caudal thoracic to the caudal sacral region. The lateral
extents of the wound were the mid-abdominal wall on the right and the
dorsal third of the abdominal wall on the left. There was purulent
discharge from multiple puncture wounds over the region. The skin
had a leathery texture and was starting to slough along a well-
demarcated boundary with healthy skin. Medical management prior to
surgery included a fresh frozen canine plasma (Caniplas; Plasvacc,
Kalbar, Australia) transfusion to address hypoproteinaemia, isotonic
crystalloid fluid therapy and intravenous cephazolin at 22 mg/kg.Anal-
gesia was provided by a transdermal fentanyl patch delivering 50 mg/h
and morphine constant-rate infusion (0.1 mg/kg/h) for the first 12 h.

Anaesthesia was induced with alfaxalone 2 mg/kg IV given 15 min


after premedication with methadone 0.2 mg/kg IV. Anaesthesia was
maintained with isoflurane in oxygen. The wound was sharply Figure 2: Case 1: skin deficit after 48 days of open wound management.

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176 Australian Veterinary Journal Volume 89, No 5, May 2011 Australian Veterinary Journal © 2011 Australian Veterinary Association
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a b

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Figure 3. Case 1: postoperative
appearance. (a) Note that the medial
flank fold skin incision (see Figure 1b)
has extended into the inguinal region,
enabling complete division of the
flank fold from the limb and reducing
the tension on the wound edges
during ambulation. (b) The right skin
fold rotation–advancement flap
(SFRAF) was smaller than the left
because of the extension of the
wound to the level of the right lateral
mid-abdominal wall.

deep margins. The resultant skin defect was 18 ¥ 22 cm, extending


from the mid-lumbar to sacral region with lateral wound margins at
the level of the mid-abdominal wall. The left and right DCIA were
within the resected tissue margins. The wound was closed directly as
described. A 6 ¥ 6 cm defect remained at the most cranial extent of
the defect and was partly closed using a transposition flap from the
dorsal thorax. A small area was left to heal by second intention.
In the week following surgery there was necrosis of the terminal 3 cm of
both advancement flaps, exposing the remnants of the spinous pro-
cesses. Necrotic skin was trimmed and the resultant defect had com-
pletely healed after an additional 2 weeks of open-wound management.
Histopathological examination of the excised tissue confirmed
tumour-free margins. No tumour regrowth occurred during 2 years of
follow up.

Case 3
Figure 4. Case 1: appearance at 4 months after surgery. A 5-year-old female neutered Border Collie dog weighing 21 kg was
presented for management of a non-healing thermal burn wound
over the dorsal lumbosacral region. The burn was sustained from a
heating pad during surgery in dorsal recumbency and had been
Case 2
managed as an open wound for 4 weeks by the referring veterinarian,
An obese 13-year-old male neutered Border Collie weighing 26 kg
by which time the wound measured 18 ¥ 22 cm. Wound closure had
presented with a large subcutaneous mass over the right dorsal
been attempted by using a single pedicle advancement flap from the
lumbosacral region. The dog was otherwise healthy. An incisional
dorsal trunk. By day 10 post-surgery the terminal 50% of the flap had
biopsy yielded a histological diagnosis of myxosarcoma. Magnetic
become non-viable because of a paucity of direct cutaneous vessels
resonance imaging showed the tumour to be situated superficial to
supplying the flap via the subdermal plexus.
the lumbar fascia. No evidence of metastases was discovered on pre-
operative staging, which included haematology, serum biochemistry, After surgical debridement of the failed flap, the skin defect measured
thoracic radiography, abdominal ultrasound and peripheral lymph 25 ¥ 20 cm and neither DCIA was intact.
node aspiration.
Open-wound management with wet-to-dry dressings for 5 days was
The tumour was resected with 3-cm lateral margins. Resection of the followed by wound closure with bilateral SFRAFs. Multiple tension-
superficial lumbodorsal fascia, multifidus lumborum muscles and relieving stab incisions were made in the skin bordering the cranial
dorsal spinous processes of L3–L6 was required to obtain adequate aspect of the wound to facilitate wound closure. Negative pressure

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could not be maintained with a continuous suction device, because of the tail has been described in dogs.19 However, based on the descrip-
the presence of the relieving incisions, so Penrose drains covered with tions of flap dimensions in experimental dogs,20 this technique would
sterile dressing were use to provide wound drainage. Drains were not have allowed wound closure in our cases. A full-thickness, free
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removed 5 days post-surgery. meshed graft combined with an omental pedicle graft has been used to
cover a comparable caudodorsal trunk wound in an obese dog.3 That
A 2 ¥ 2 cm area of skin necrosis was present at the tip of the right flap technique required two major procedures in addition to surgical
by postoperative day 6. It was debrided and re-sutured under general debridement, with 66 days of bandaging after wound reconstruction,
anaesthesia. Further wound healing was uneventful, with all sutures thus showing no advantage over the technique described here. Partial
removed 14 days post-surgery. The cosmetic outcome was considered thickness, meshed free grafts have been used to cover large trunk
excellent at 6-month recheck. defects, but hair growth over both donor and recipient beds is sparse
at best, leading to poor cosmesis compared with techniques that use
Discussion full-thickness skin.9,10
Skin fold flaps based on the flank and axillary folds were initially
Canine skin is abundant, with a high dermal elastin concentration,14
described for the coverage of large ventral trunk defects in dogs and
so healing of skin wounds by contraction and epithelialisation is often
cats,12 and later shown to be useful in the closure of proximal limb and
successful. In the case of large trunk wounds the force of myofibro-
lateral trunk defects.13 The novel dorsal use of bilateral SFRAFs
blast contraction is often equalled by tension in the surrounding skin
allowed the complete closure of substantial dorsal lumbosacral
prior to skin edge apposition, and large unsightly scars that are prone
wounds in cases 1 and 3, and subtotal closure of the wound in case 2.
to trauma and solar dermatitis are common.15 Vacuum-assisted
wound closure has been used to hasten granulation tissue formation A skin fold flap has been used for the closure of a dorsal trunk wound
in large trunk wounds prior to reconstruction16,17 and may have in a cat,13 but in our experience the feline flank folds are of propor-
reduced the period of wound management prior to reconstruction in tionally greater dimensions compared with dogs and, furthermore,
case 1; however, vacuum-assisted wound closure does not replace feline skin is thinner and generally more abundant and elastic than
reconstructive surgery of large wounds. that of the dog, allowing easier closure of comparable wounds such
that advanced trunk skin reconstructive techniques are rarely
Of the many skin closure techniques at the disposal of the surgeon, the required in the cat.21,22
simplest and safest technique that allows wound closure and restora-
tion of function should be chosen. The scale of the skin defects in each A varying degree of flap necrosis was experienced in each dog, with
of the present cases prevented wound closure using simple tension- minor flap debridement required in cases 2 and 3; however, all
relieving techniques such as undermining and advancement with wounds had healed by 3 weeks post-surgery, with dogs 1 and 3 healed
walking sutures.1,2,4,5 Skin-stretching devices in combination with within 2 weeks. Factors contributing to flap necrosis may have
simple tension-relieving techniques are useful for wounds in the tho- included an unacceptably high level of stretching, kinking of the flap
racolumbar region when the pre-surgical assessment of skin elasticity as it crossed the dorsal spinous processes, or compromise of the vas-
suggests there is sufficient local skin.6 In each of the clinical cases cular supply during flap development. The flaps were transferred dor-
described here, a significant portion of the wound was over the ilium sally in relation to their base, so gravity is unlikely to have had a
and sacrum, with taut lateral skin margins, and after careful preopera- significant negative effect on flap survival.23 In fact, elevated flaps may
tive skin tension assessment it was considered that the use of the flank have superior survival compared with dependent flaps, because of the
folds represented the best opportunity for single-session wound improved venous drainage.24
closure. Skin-stretching devices could have been used prior to or after The ventral branch of the DCIA supplies the skin of the lateral thigh
the surgery was performed in these cases and may have facilitated and flank25 and is thought to contribute to the vascular supply of the
complete wound closure and prevented flap tip necrosis in case 2 flank fold.26 In all three cases the DCIAs were not intact, thus smaller
by maximising flap elongation via mechanical creep and stress direct cutaneous branches from the caudal superficial epigastric, inter-
relaxation.6 costal and internal thoracic vessels were the most likely source of
If the ventral branch of the DCIA is intact, unilateral or bilateral axial vascular supply to the subdermal plexus of the SFRAFs.25
pattern flaps or island flaps based on this vessel can be used to close Used in the manner described, the SFRAF acts as a combined advance-
dorsal and lateral wounds in the lumbosacral region;8 however, in ment and rotation flap. The skin forming the flank fold proper does
each of these three cases the DCIAs could not be salvaged either not extend on to the dorsally located recipient bed; rather it is relo-
because of the primary disease process (cases 1 and 3) or because both cated dorsally to cover the caudolateral abdominal wall, allowing skin
DCIAs were within the resected tumour margins (case 2). from the lateral abdomen to be translated dorsally on to the wound
bed. Relocation of the sparsely haired flank fold skin to a more con-
Simultaneous bilateral caudal superficial epigastric axial pattern flaps
spicuous location on the lateral abdomen was cosmetically pleasing in
have been used for wound reconstruction.18 This technique has not
our patients, which were all long-haired breeds. The cosmetic result
been reported for closure of dorsal trunk wounds and although flap
in short-haired dogs may be less than ideal and owners should be
dimensions may have been adequate to permit wound closure, donor
forewarned.
bed closure in the patients described here would not have been pos-
sible without creating extreme tension at the wound reconstruction In addition to bilateral SFRAFs, a transposition flap and partial open
site. An axial pattern flap based on bilateral lateral caudal arteries of wound management (case 2) and multiple relaxing incisions (case 3)

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178 Australian Veterinary Journal Volume 89, No 5, May 2011 Australian Veterinary Journal © 2011 Australian Veterinary Association
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facilitated wound closure. This illustrates that, although SFRAFs 5. Johnston DE. Tension relieving techniques. Vet Clin North Am Small Anim Pract
provide additional skin for caudodorsal trunk wound closure, the 1990;20:67–80.
6. Pavletic MM. Use of an external skin-stretching device for wound closure in
surgeon should be prepared to use additional reconstructive tech- dogs and cats. J Am Vet Med Assoc 2000;217:350.

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3rd edn. Saunders, Philadelphia, 1993;258–384.
The original report of skin fold flaps based on the flank folds suggested 8. Pavletic MM. Canine axial pattern flaps, using the omocervical, thoracodorsal,
that only dogs with well-developed skin folds are appropriate candi- and deep circumflex iliac direct cutaneous arteries. Am J Vet Res 1981;42:391–406.
9. Swaim SF. Principles of Mesh Skin Grafting. Compend Cont Educ Pract Vet
dates for this technique.12 The dogs in cases 1 and 2 were obese with
1982;4:194–200.
poorly developed flank folds; however, of the six flaps created in the 10. Aragon CL, Harvey SE, Allen SW. Partial-thickness skin grafting for large
three patients, all but one flap had sufficient length to cross the dorsal thermal skin wounds in dogs. Compend Cont Educ Pract Vet 2004;26:200–212.
midline while maintaining adequate width, thus we believe the use of 11. Jackson AH, Degner DA, Jackson IT et al. Deep circumflex iliac cutaneous free
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flank folds. Early characterisation of the canine integument found that wounds in cats and dogs. Vet Surg 1995;24:172–175.
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