FIELD APPLICATIONS OF SOME TENSION RELIEVING PLASTIC TECHNIQUES FOR CUTANEOUS RECONSTRUCTION

Assiut Vet. Med. J. Vol. 52 No. 111 October 2006

Dept. of Surgery, Fac. of Vet. Med., Sadat City; Meinofiya University; Egypt.

FIELD APPLICATIONS OF SOME TENSION RELIEVING PLASTIC TECHNIQUES FOR CUTANEOUS RECONSTRUCTION

(With 7 Figures)

By A.G. ABOU-EL-ELLA (Received at 18/9/2006)

التطبيق الحقلي لبعض تقنيات تخفيف الشد التقويمية لاعادة بناء الجلد

أمل جلال أبو العلا

قد يستمر الشد الغير ملائم في بعض الجروح الجلدية المکتسبة وذلک حتى بعد القيام بالحفر تحت الجلد مما يتعذر معه إغلاق مثل هذه الجروح. وفي هذه الحالات يجب التبصر في استخدام طرق تقويمية إضافية لتخفيف هذا الشد مثل الحز الارتخائي والطرق التقويمية الأخرى. ومن هذا المنطلق کان هدف البحث القاء الضوء على استخدام الحز النقطي وکذلک

کل من التقنية التقويمية على هيئة Z وعلى هيئة V إلى Y في إغلاق وعناية بعض الجروح

الحالات إکلينيکية تعاني من إصابات جراحية بالجلد. وقد تم استخدام الحز الارتخائي النقطي في إغلاق الجروح الجلدية عقب استئصال أورام ليفية متقرحة في منطقة مفصل العرقوب وکذلک عقب استئصال قرحة ناتجة عن ورم للخلايا ألد قلية وأخري خشنه بجوار ماق العين الداخلي في الحمير. وکذلک تم استخدام الحز التقويمي على هيئة Z للمساعدة في غلق الجلد

عقب استئصال قرحتين غير ملتئمتين من الجدار الخارجي الأيسر لمنطقة البطن والصدر في الحمير، علاوة علي استخدام الحز التقويمي علي هيئة V إلى Y لتمکين إحدى الأبقار الهولوشتين من فتح فمها وذلک عقب استئصال رباط ليفي کان يطوق کلا الفکين العلوي والسفلي. ومن خلال هذه الدراسة يمکن القول بأنه عند استخدام هذه التقنيات التقويمية البسيطة أمکن تفادي اندمال الجروح الجلدية بتکوين الأنسجة الليفية الثانوية الغير مستحبة التأثيرها علي وظيفة الجزء المصاب وعلي مظهر الحيوان حيث تم اندمال معطم الجروح في الحالات موضع الدراسة بالاندمال الطبيعي الأول.

SUMMARY

This article will throw the light on the use of mesh expansion technique "punctate relaxing incisions" and sliding flap techniques "Z and V-Y plastic incisions” for management and closure of some clinical surgical skin disorders. Punctate relaxing incisions were performed after excision of ulcerated soft fibroma from the lateral aspect of the hock joint, an

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management. The lesions were unhealed ulcers (three donkeys), soft ulcerated fibromas (two donkeys), ulcerated mastocytoma (one donkey); fibropapilloma (one donkey) and adhesive fibrous band encircling and tying up both jaws in a Holstein dairy cow. Clinical examination and assessment of the affected animals overall health status was performed as a pre-operative evaluation.

All Patients were sedated with intramuscular injection of xylazine 2% in a dose rate of 1.2 mg/kg body weight for donkey and 0.1 mg/kg body weight for the cow. After routine surgical preparation analgesia in most cases was achieved through a field block infiltrations and topical application of Lidocaine 2%. Samples from four cases that showed evidence of neoplastic swellings were taken for histopathological examination at the time of surgery. In all cases wound coapitation was impossible even after undermining of the skin around the wound circumference.

Ulcerated mastocytoma and cutaneous fibroma and fibropapiloma as well as the unhealed ulcers were excised through an elliptical skin incision at the healthy margin away from the lesion. In all cases prior to the use of relaxing incision technique or the sliding flap technique; undermining of the skin around the wound circumference was performed first to a sufficient size as a trial to appose the wound edges.

Punctate relaxing incision technique was applied in five donkeys as described by Bailey et al. (1986). The incisions were started one cm away from the wound edge, 1cm long, and 0.5 cm apart in staggered parallel rows in both sides of the wound.

Z-plasty was applied in two donkeys affected with unhealed ulcers at the upper flank and chest wall regions respectively. The Z shaped skin incision was made as described by Pavletic (1993) and started about 2 to 3 cm away from the lesion and the limbs of the Z were equal to the width of the lesion. The angles between the central limb of the Z and the arms were ranged from 50° to 60°

For excision of fibrous band that was tying up both jaws in a Holstein dairy cow; a V-Y plastic incision was performed as the method described by Swaim, and Ralph, (1997).

In all cases a few simple interrupted sutures were placed under the advanced tissues to help close dead space. After final skin plastic repair evaluation at 24 - to 48 hours intervals often continue throughout the entire treatment period.

* Xylaject; 2% Xylazine hydrochloride: ADWIA, 10th of Ramadan City, Egypt. **Debocaine: 2% lidocaine Hydrochloride: El-Nasr Pham. Chem.CO; for Al-Debeiky Pharma, ARE.

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RESULTS

Punctate relaxing incision technique was used for skin wound closure of five donkeys. After excision of a soft fibroma at the lateral and anterior-medial aspect of hock joint in four and six years she donkeys respectively and a fibropapllioma infront of the scapula at left side of the neck in a 7 years old donkey (Fig. 1). The same technique was used also after excision of an ulcerated mastocytoma ulcer and granulating ulcer near the medial canthus of the left eye in a 4 years and 5 years old donkey respectively (Fig. 2). All the lesions were suffered from retarded healing and surgically excised through an elliptical skin incision that extended deeper enough to remove all the infected tissues specially in the case of ulcerated mastocytoma. In such case the lesion was deep and penetrated the nasal cavity; so a rubber drainage tube was fixed to the upper wound lip for flushing and drainages through the nasal opening (Fig. 4 A). The punctate incisions were started about one cm away from the wound edge, 1cm long, and 0.5 cm apart in staggered parallel rows in both sides of the wound (Fig. 3 B). The first row of relaxing incisions was done first and if coapitation failed a second one had been done. A continuous No-0 absorbable intradermal suture is used for closure first (Fig. 3 B&C). The skin is closed with a simple interrupted No-3 non-absorbable skin sutures (Fig. 3 D). The healing process was excellent in three cases from the operated animals. First intension healing took place two weeks postoperatively (Fig. 4 B) and the growing hair nearly covered the operated areas eight weeks later (Fig. 4 C). In case of the two donkeys which operated for fibroma excision from the lateral and anterior-medial aspects of the hock region; disruption of stitches was observed one week postoperatively. The stitches were removed and an immobilization bandage was applied after each dressing and the wound left to heal by second intension (Fig. 4D).

Z-plastic relaxing incision was performed for wound closure after excision of two weeks ulcers at the left flank region (Fig. 5 A) and the left upper part of the chest (Fig. 5 B) of 4 and 5 years old donkeys respectively. Both ulcers were persisted for more than 6 months and didn't respond to topical antiseptics and antibiotics therapy. Surgical excision was performed through an elliptical skin incision that included the weeks rim of the ulcer (Fig. 5 C). The resulted skin defect was closed through a Z-plasty incision that was formed from a central limb, two arms, and two angles where the arms join the central limb. The angles between the arms and central limb was ranged between 50 and 60° and

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all arms were of equal length and nearly equal to the width of the skin defect (Fig. 5 D). After undermining the skin between the Z incision and the lesion it was advanced over the defect, and underlying tacking sutures of No-0 absorbable suture was used to close dead space (Fig. 6A). The tips of the Z-skin flap was sutured first with No-3 nonabsorbable half-buried horizontal mattress sutures then the rest of the Z-plasty defect was fixed into their new position with No-3 nonabsorbable simple interrupted sutures (Fig. 6 B). First intension healing was satisfactory in all cases (Fig. 6 C) and all wounded areas restore cosmetic skin appearance and the growing hair nearly covers the scar formation within eight weeks postoperatively (Fig. 6 D).

V-Y plasty was performed as relaxing technique for removal of a fibrous band that was encircling both jaws in a Holstein dairy cow. The cow was subjected to severe attack of dermatitis of unknown cause that affect most skin of the face (Fig. 7 A). The cow was treated locally and systemically with antibiotics and anti-inflammatory drugs. Eight months latter the cow was unable to open her mouth as a result of the formation of a deep fibrous band that was encircling and tying up both jaws (Fig. 7 B). A bilateral V-shaped skin incisions were made over the area of fibrous tissue formation at the level of both angles of the oral conmisures (Fig. 7 C). A mouth gag was used to help widening of the mouth cavity while undermining and dissection of all the fibrous tissues from the depth of the wound and its circumference. The resultant wound was bigger than the primary one and the V-skin flap was advanced upwardly leaving a wide wounded area not covered by skin (Fig. 7 D). The remaining defect was closed in the shape of Y using No-3 nonabosrbable simple interrupted skin apposition sutures. The operated cow started to open her mouth for prehension of green fodder soon after surgery (Fig. 7 E). Two weeks later first intension healing was achieved with minimal scar tissue formation (Fig. 7 F).

In all cases the treated animals were allowed to put in work one week after removal of skin suture. All wounded areas restore cosmetic skin appearance and the growing hair nearly covers the scar formation within eight weeks postoperatively.

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Fig. 1: Soft cutaneous fibroma at the lateral aspect of the left hock (A) and anterior-medial aspect of the right hock (B) in two different donkeys (arrows).(C) Histopathological section of the lesion reveals bundles of fibrous tissue proliferation. (D) Fibropapilloma at the left side of the neck just infront of the scapula in a 7 years old donkey (arrow).

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Fig. 2: (A) Histopathological section of the same lesion in Fig. 1 D reveals an elevated mass of multiple projections of fibrovascular connective tissue covered by a thick layer of stratified squamous epithelium (H & E X10). (B) Ulcerated mastocytoma at the left side of the face close to the medial canthus in a 4 years old donkey. (C) Histopathological section of the lesion reveals densely packed cords of round cells with central round nucleus, an abundant granular basophilic cytoplasm, and indistinct cell membrane. (D) Granulating unhealed ulcer at the left side of the face near the medial canthus of the eye in a 5 years old donkey (arrow).

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Fig. 3: (A) Left hock region showing a skin defect after excision of the tumor mass, undermining all its circumference and trials to appose wound edges using No-3 non-absorbable tension vertical mattress skin suture (arrows). (B) Left hock region and (C) left side of the face region; showing two rows of punctuate incisions made for relaxing the wound edges (short arrows). Notice the nearly apposed wound edges after placing a simple continous intradermal suture (long arrow). (D) Final skin closure using simple interrupted No-3 silk sutures. Notice the skin expansion leads to widening of the punctuate incisions (arrows).

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Fig. 4: (A) Final skin closure with simple interrupted sutures after excision of the ulcerated mastocytoma lesion. Notice the two rows of punctuate incisions made for relaxing the wound edges (short arrows) and the drainage tube fixed at the upper wound tip (long arrow). (B) The same case three weeks postoperatively showing first intension healing at the main incision site and scar tissue formation filling the areas of the punctuate incisions (arrows). (C) The same case after 8 weeks; notice the growing hair nearly cover all the formed scars (arrows). (D) Second intension healing process at the left hook region six weeks postoperatively (arrow).

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LOR

Fig. 5: Z- plastic technique (A & B) unhealed ulcer at the lateral aspect of the flank region and chest wall in two donkeys respectively (arrows). (C) Skin defect after excision of the lesion and undermining its entire circumference (arrows) (D) Incision of the Z, notice that all limbs of the Z are of equal length and away from the primary lesion by 3 cm (arrows).

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DISCUSSION

Undue tension in some acquired skin wounds may persist even after purposeful undermining. In these cases, additional tension relieving measures may be contemplated, including relaxing incisions or other plastic techniques. The three cutaneous reconstructive techniques used for skin wound closure in the recorded cases were proved to be a suitable means for relieving wound tension and allow wound healing by primary union for cosmetic and functional purposes. The selection of the type of the relieving incision is usually depends upon the extent of wound tension and the presence of sufficient skin in all wound direction to allow the needed extension. Wounds should be closed without undue tension to preserve circulation to the wound margin and minimize the occurrence of traumatic dehiscence (Swaim 1980 and Abou-El-Ella 2005). Recognition of excessive tension requires experience, as does the successful application of methods for its management (Myers 1965). When there is insufficient skin surrounding a wound to allow complete healing by contraction, the central portion of the wound heals by epithelialization. The result is an uncosmetic scar that is delicate and easily traumatized. If epithelialization has resulted in this type of healing, some form of reconstructive surgery should be considered (Fitch and Swaim 1995).

In all treated cases; prior to the performance of any relaxing technique the wound and surrounding skin areas were evaluated to assure adequate blood supply and the presence of enough skin for transposition and advancement. Pavletic (1986) and Swaim and Henderson (1990) recommended the delay of some wound apposition after the skin circulation has improved to withstand wound closure. Hendrix and Baxter (2005) advice that the potential causes for the delay of wound healing such as sequesters foreign bodies and excessive motion should be determined and removed to permit complete wound resolution.

The wounded areas in the treated cases were located in different body areas such as; the limb, close to the medial canthus of the eye, close to the mouth commissaries and at the lateral aspect of the body wall. The healing processes at these areas were retarded as a result of excessive mobility or mechanical interferences. The retardation of the healing process was attributed to excessive granulation tissue and infections in case of distal extremity wounds and ulcers (Blackford et al., 1991), heavy load and bad quality saddle in case of back wounds in

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donkeys (Koriem 2001), and reactive process in case of mastocytoma (London et al. 2001). Reconstructive and grafting techniques were indicated by Jacobs, et al. (1984) to overcome the slower and complicated healing of the skin lesions of the limbs.

The punctate relaxing incisions were used in areas having a minimal skin allowed for wound covering as close to the medial canthus of the eye or at the lateral and anterior-medial aspects of the hock region. So that the length of the punctate incisions used was not exceeded one cm to allow maximum skin elasticity for coverage and minimize the size of the resulted scars. The same finding was also noticed by Vig (1985) and Bailey et al. (1986) and they recommended the breaking up of the large relaxing incision into many small incisions for more cosmetic appearance and faster healing.

A single row of punctate incisions one each side of the wound margins was done first; then the wound was evaluated for presence of tension. If undue tension persists another rows were performed as needed to minimize vascular compression. Swaim (1990) and (1993); Swaim and Henderson (1990); Swaim and Scardino (1993); and Pavletic (1993) find that the chance of damaging the skin vasculature and causing necrosis are increased when more punctate incisions made than necessary.

The healing process after application of the relaxing incision was superb at the face and neck region while, stitches were pulled out through the tissues at the hock regions one week postoperatively. The stitches were removed and the wound left to heal by second intension with application of an immobilization bandage but excessive scar was observed at the center of the wound. The same complication was observed by Jacobs et al. (1984) and he attributed the scar formation to the absence of the cutaneous musculature underlying the integument in the limbs, which affords the skin considerable mobility. This mobility contributes to impressive second intension healing with minimal scarring in the upper body of the horse than in the limbs. Houlton and Edwards (1995) attempted suturing of wounds even in cases where sloughing is anticipated. They explained that in such cases an inevitable limited amount of primary union will take place, leaving less tissue to heal by granulation.

The Z-plasty technique was found suitable to be used at the lateral aspect of the body wall after excisions of weak ulcers from the upper flank and chest areas as there were enough skin permits the flaps of the Z-plasty to be transposed and lie in their new position. Swaim

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(1980) and (1993) and Vig MM (1992) advised the surgeon to manipulate the skin around the wound to ensure that there will be sufficient skin in one direction to allow the needed relaxation in the perpendicular direction before using a Z-plasty as a relaxing incision.

All the limbs of the Z-plasty were of equal length as mentioned by Swaim, and Ralph (1997), while the angles between the arms and central limbs were approximately ranged from 50 to 60°. The central arm after final wound closure was rounded and elongated toward the original wound as mentioned by Swaim and Ralph, (1997) and Pavletic (1993).

The V-to-Y plasty technique was helpful for relieving fibrous tissue adhesion that was encircling both jaws of a Holstein dairy cow. Although the operated cow was not able to open its mouth as in normal range but she was able to feed green fodders normally. Hickman (1995) indicated the use of the same technique for relieving minor tension in small areas.

From the present study we can concluded that the use of mesh expansion technique "punctate relaxing incisions" and sliding flap techniques "Z and V-Y plastic incisions” not only avoids the undue lengthy process of healing by granulation but also the subsequent unsightly scarring. The enhancement of the healing process was attributed by Bennett (1988) and Fitch and Swaim (1995) to the occlusion of the wound that improves humidity and preventing formation of a scab and increases the rate of epithelialization. Moreover, the scars lifted after application of the relaxing incisions in the recorded cases were small and nearly covered by the growing hair within eight weeks. Houlton and Edwards (1995) explained that second intension healing of wide skin wounds are often leave a wide scar, devoid of hair, which gradually contracts giving rise to unhealthy contraction lines. Bailey, et al. (1986) attributed the considerable success of the relaxing incisions in the horse than in human to the hair coverage of the horse usually conceals most associated scars.

Veterinary practitioners should be familiar with these least invasive reconstructive and effective skin relaxing incisions to allow complete wound healing after excision of some cutaneous tumors, unhealed large ulcers, and relieving wound tension to allow primary union healing.

ACKNOWLEDGMENT We thank Prof. Dr. S. El-Balal; Head of Pathology Department and Dean of the Fac. Vet. Med. Sadat City, Meinofyia University; for his assistance in the histopathological section of the present work.

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