Chapter 2

Lumpectomy and Primary Closure

Removal of small benign skin masses is relatively simple. When masses are large or malignant, however, extensive resection may be necessary. Direct closure of large wounds may require tension-relieving techniques such as walking or stent sutures or skin stretchers. When direct closure is not an option, aps, grafts, or other tension-relieving techniques may be necessary (see pp. 1956 and 6770).

Preoperative management
Staging for metastases should be performed in animals with malignant masses. In most animals, this would include three-view thoracic radiographs; in animals with mast cell tumors, abdominal ultrasound is more critical. If preoperative cytology conrms a mast cell tumor, the animal should receive intravenous diphenhydramine before surgical clipping and prepping to reduce mast cell degranulation, and the site should be prepped gently to prevent swelling. Before resection, masses should be measured and local skin tension evaluated to develop a plan for wound closure. If possible, incisions should be made parallel to the lines of tension to facilitate closure. Incision size depends on the type of mass present. Recommended margins for mast cell tumor removal are 2 cm laterally and at least one fascial plane deep. Surgical margins for soft tissue sarcomas should be at least 3 cm in all directions from the palpable tumor to reduce the risk of recurrence; larger margins are recommended for vaccine-induced brosarcomas. Synthetic monolament with absorption time 120 days is often used for subcutaneous closure, since brous tissue around long-lasting suture material may be palpable for months, making postoperative assessment of recurrence more challenging. Size of resection and method of closure should be considered when clipping and positioning the animal. If the surgical procedure is expected to last longer than an hour, prophylactic antibiotics are recommended. For patients undergoing placement of continuous suction drains or infusion catheters at surgery, the site for drain or catheter exit should be planned in advance so that it can be bandaged easily after surgery.

Surgery
In animals with tumors, skin and subcutaneous tissues are usually transected with a blade and scissors to prevent damage to tissue margins. When skin is

17

Surgery of the Skin

incised by radio wave radiosurgery, CO2 laser, or monopolar electrosurgery, char will penetrate the skin biopsies 0.16 to 0.22 mm, and char will extend into the surrounding skin up to 0.26 mm. Elliptical or elongated wounds can be apposed in a linear fashion. The subcutaneous tissues are elevated along the wound margins to facilitate closure. When the resection site is large or irregular, the rst skin suture is placed across the center of the wound to evaluate skin position, and then additional skin sutures are placed across the middle of each remaining half of the incision. Towel clamps can be used to temporarily appose skin margins of wide wounds. Subcutaneous sutures are then placed between the skin sutures or towel clamps to reduce tension before skin closure is completed. Circular wounds (g. 2-1) can be turned into an ellipse and then closed in a linear fashion, or closed in a Y or X shape (g. 2-2). Once again, the central sutures are placed rst to evaluate nal skin position. Tension is greatest in the center of the wound where the tips of the Y or X come together. A buried horizontal mattress suture can be run circumferentially through the subdermal layer to reduce the stress on the skin suture line (g. 2-3). Closure in a Y or X shape may produce skin puckers or folds (dog ears); if these are small, they can be left in place.

Figure 2-1

Circular wound.

Figure 2-2 If skin laxity is sufcient, circular wounds can be closed in a linear manner. For a Y closure, skin at the incision end (arrow) would be pulled toward the center of the defect.

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Lumpectomy and Primary Closure

Figure 2-3 To make a Y-shaped closure, pull the skin edges along one half of the defect together from side to side (thumb forceps) and pull the remaining arc of the skin edge (arrow) centrally. Pull together the subcutaneous tissues at the tips of the Y with a buried purse-string suture before adding the remaining sutures (inset).

Figure 2-4 Stent sutures made with buttons and roll gauze.

Subcutaneous elevation and apposition will reduce tension on skin sutures. To stretch and advance skin before closure, walking sutures can be applied from the wound bed to the subcutaneous tissues under the skin. Besides relieving tension, walking sutures also close dead space and advance the skin margins to allow primary apposition. Dimples in the skin produced by these sutures will usually resolve in 2 to 3 weeks. Walking sutures are not recommended in aps because they damage blood supply and cause local necrosis. They are also contraindicated in infected wounds, thin skin, or areas of motion. Stent sutures reduce tension by spreading pressure out over a large area. The skin is apposed with vertical mattress sutures, with the skin sutures crossing over soft tubing or rolled gauze (g. 2-4). Alternatively, buttons can be sewn 2 to 4 cm from the edges of the wound. Rubber bands, suture, or shing line is wrapped around the buttons to pull them toward midline. Sutures or shing line can be secured with split shot shing weights to allow adjustment of tension (g. 2-5). Padding may be required between the line

19

Surgery of the Skin

Figure 2-5 Secure the ends of an intradermal pattern with split shot shing weights. Increase tension on the closure several times daily by pulling rmly on one end of the suture while placing an additional split shot closer to the wound.

Figure 2-6 Skin-stretching device. The elastic bands have been temporarily tightened to demonstrate the stretching effects (arrows) on the skin. Once the skin has been cleaned, bandage dressings will be placed over the wound bed before securing the elastic bands to the Velcro dorsally. This dog underwent a caudal supercial epigastric ap (180 rotation) to cover a burn wound on the hip.

and incision, particularly in convex areas, to prevent damage to underlying skin. If left in place for long periods, stent sutures can cause necrosis of the attachment sites, particularly when tubing or buttons are used; therefore, they are often removed within 2 to 3 days of placement. Skin can be stretched before or after lumpectomy with tie-over bandages or elastic skin stretchers (g. 2-6). Skin stretching devices are made with Velcro self-adherent pads, 1-inch-wide sewing elastic, and cyanoacrylate (superglue). The hair is clipped and the skin is cleaned with soap and alcohol and allowed to dry completely. Several pads are glued at least 5 to 10 cm from the margins on either side of the wound, using the hook portion of the pad. Application of a thin layer of superglue to the contact surface of the pad improves adhesion to the skin. The pile surface of the elastic bands will secure the elastic to the hooks on the pads. A dressing is placed under the bands if a wound or incision is present. Initially the elastic bands should be under moderate tension; tension is increased every 6 to 8 hours to stretch the skin. In most patients, skin is stretched signicantly in 4 days, with the greatest gains in the rst 48 to 72 hours. When no longer needed, pads can be removed by peeling them off the skin or using a glue solvent.

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Surgical technique: lumpectomy

1. With a sterile ruler and marking pen, measure and draw appropriate margins around the mass. 2. Make an incision through the skin and subcutaneous tissues along the marked line (g. 2-7). 3. If a mast cell tumor is present, continue dissection at least one fascial plane below the tumor. For soft tissue sarcomas, remove wider margins (g. 2-8). 4. Place a suture full thickness through the fascia, subcutis, and skin to hold the layers together and to mark the cranial or dorsal edge of the resection.

Lumpectomy and Primary Closure

Figure 2-7 Incise the skin at least 2 cm around the margin of a mast cell tumor and at least 3 cm around the margin of a sarcoma. In this dog, the skin was incised 5 cm lateral to the mass (inner purple circle), which was previously diagnosed as a brosarcoma.

Figure 2-8 Dissect at least one fascial plane below mast cell tumors, if possible, and at least 3 cm below brosarcomas. In this dog the dorsal spinous processes were removed along with the adjacent muscle.

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Surgery of the Skin

Figure 2-9 Close fascia with interrupted sutures if under tension.

5. Place two full-thickness sutures along a second edge of the resected tissues, 90 degrees from the rst suture, so that orientation of the mass will be marked (note these suture placements on the histology submission form). 6. Using sharp and blunt dissection, remove the mass. Cauterize or ligate associated blood vessels. 7. If possible, appose any incised fascial or muscle edges with interrupted or continuous sutures of 2-0 or 3-0 rapidly absorbable material (g. 2-9). 8. Carefully undermine the skin margins with blunt and sharp dissection at the level of the loose areolar fascia or deep to the panniculus. Leave any direct cutaneous vessels intact. Large wounds may require undermining for 8 to 14 cm laterally along the skin margin. 9. Place a continuous suction drain as needed, exiting the drain through healthy skin at a site that will be easily covered with a bandage (e.g., away from the prepuce or anus). 10. To stretch the skin toward the midline of the defect and secure it in place, insert subcutaneous walking sutures with 3-0 or 4-0 rapidly absorbable suture (g. 2-10). a. Near the junction of the elevated skin base and subcutis, take a bite of subdermal fascia or deep dermal tissue in the skin parallel to the direction of advancement. b. Take a bite in the wound bed a few centimeters closer to the wound center than the skin bite, and tie the suture. In some animals, the rst row of walking sutures may need to be preplaced before tying. c. Continue to place several walking sutures in a row, spacing them at least 3 cm apart, and placing as few sutures as possible.

d. Repeat the process on the opposite side of the incision.

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Lumpectomy and Primary Closure

Figure 2-10 To place walking sutures, take a bite of the subcutaneous tissues close to the base of the elevated skin, then take a bite of the wound bed fascia closer to midline (inset). The resultant suture will pull the skin closer to midline.

Figure 2-11 Excise large dog ears by transecting them at their base with scissors or a blade.

e.

Place additional staggered rows of walking sutures successively closer to the skin margin, with the wound bed bites closer to midline than the skin bites so that the skin is stretched toward midline as it is tacked in place.

11. 12. 13. 14.

For large defects or those under tension, temporarily place towel clamps across the wound to appose the skin edges (g. 2-2; see also g. 7-14). Appose the subcutaneous fat with simple interrupted or simple continuous sutures of 3-0 rapidly absorbable material. Excise large dog ears by cutting across the elevated tissue several mm above its base with sharp scissors or a blade (g. 2-11). Appose the skin with staples or simple interrupted or cruciate sutures of 3-0 nylon (g. 2-12). If towel clamps were not used to temporarily close the wound, place the rst skin suture across the center of the

23

Surgery of the Skin

Figure 2-12 Final appearance. Note how recruitment of skin from the ank fold resulted in exposure of unclipped areas (arrow). These areas were kept covered with additional drapes until skin closure was complete; however, a wider prep is preferable.

Figure 2-13 Stent sutures. Place wide mattress sutures through short pieces of tubing (inset, top drawing) or over (inset, bottom drawing) longer pieces of tubing lateral to the incision line to spread out tension. Remove stent sutures in 2 to 3 days.

wound to appose the skin. If skin position is acceptable, place a skin suture across the widest part of each half of the wound, then ll in the gaps. Interrupted buried intradermal sutures can also be placed before skin sutures to further reduce tension. 15. For added relief of tension along the skin closure, place temporary stent sutures using a mattress pattern (g. 2-13). a. Place a piece of pliable tubing or a tightly rolled gauze along each side of the incision line.

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b. Take a simple interrupted bite across the incision line (near-near) 1 to 1.5 cm from the skin edges, medial to the tubing or gauze. c. Reversing the direction of the needles take a wider bite of skin back across the incision line (far-far) just lateral to the tubing or gauze so the material is included within the suture loop.

Lumpectomy and Primary Closure

d. Tie the suture over the material rmly enough to release tension on the skin closure without crushing the skin under the material. e. Alternatively, take a bite under and across the incision, through a piece of tubing or button, back across under and across the incision, and through a second button or piece of tubing.

16.

If tension is excessive, consider a Z-plasty (pp. 3840), single or multiple punctate relaxing incisions (p. 41), or additional stent sutures.

Postoperative considerations
The subcutaneous surface and cut edge of the mass should be marked with blue or green ink and allowed to dry before placing the tissues in formalin. This will allow the pathologist to evaluate margins during histologic examination. Elizabethan collars and exercise restriction are recommended, particularly in wounds with tension. Bandages may be required to protect drain exit sites or reduce mobility. Postoperative analgesics are critical in patients with walking sutures or wounds under tension. If needed, a three-way stopcock can be attached to the tubing of a continuous suction drain to allow infusion of local anesthetics for 2 to 3 days. In animals undergoing mast cell tumor resection, skin sutures are left in place for 3 weeks, since healing is prolonged. Administration of antineoplastic agents or high dose corticosteroids should be delayed until the wound is healed enough for suture removal. Common complications after mass removal include seroma or hematoma formation, dehiscence, infection, or tumor recurrence from incomplete resection. Seroma formation and dehiscence are common in dogs after mast cell tumor resection because of local tissue reaction and delayed healing. Walking sutures may disrupt blood supply to advanced skin, and stent sutures may cause ischemia under the devices. When skin stretchers are used, improperly applied adhesive pads may loosen prematurely.

Bibliography
Amalsadvala T and Swaim S: Management of hard-to-heal wounds. Vet Clin Small Anim Pract 2006;36:693711. Fulcher RP et al: Evaluation of a two-centimeter lateral surgical margin for excision of grade I and grade II cutaneous mast cell tumors in dogs. J Am Vet Med Assoc 2006;228:210215. Hedlund CS: Large trunk wounds. Vet Clin N Am Small Anim Pract 2006;36:847 872. Pavletic MM: Use of external skin-stretching device for wound closure in dogs and cats. J Am Vet Med Assoc 2000;217:350354. Silverman EB et al: Histologic comparison of canine skin biopsies collected using monopolar electrosurgery, CO2 laser, radiowave radiosurgery, skin biopsy punch, and scalpel. Vet Surg 2007;36:5056.

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