INDIAN JOURNAL OF VETERINARY AND ANIMAL SCIENCES RESEARCH

(Formerly Tamil Nadu Journal of Veterinary and Animal Sciences)

Vol. 47 July - August 2018 No. 4

Review article
1. CUTANEOUS RECONSTRUCTION 1: TENSION-RELIEVING TECHNIQUES 1371
Bryden J. Stanley

Full length articles

2. EFFECT OF STANDARD TANNIN ON IN VITRO RUMEN METHANE 1379
REDUCTION AND RUMEN FERMENTATION CHARACTERISTICS
A. Bharathidhasan

3. DETECTION OF PESTE DES PETITS RUMINANTS VIRUS ANTIBODIES IN 1392

SERA OF CATTLE
P. Giridharan1 and Y. Krishnamohan Reddy

4. Socio-economic status, husbandry practices followed and 1400

constraints faced by Madras Red sheep farmers in their field
flocks in Kanchipuram district
Haripriya Chappa, S. Meenakshi Sundaram, T. Sivakumar and R.Venkataramanan

5. CARCASS CHARACTERISTICS OF LARGE WHITE YORKSHIRE GROWER 1416

PIGS MAINTAINED UNDER ROOF INSULATION AND WATER FOGGING
SYSTEM DURING SUMMER SEASON
S.Priscilla Rani, Thanga. Thamil Vanan, T.Sivakumar, D.Balasubramanyam
and A.Thennarasu

Short Communications
6. SURGICAL MANAGEMENT OF COMPLETE UTERINE PROLAPSE IN A CAT 1420
Mohamed Shafiuzama, N. Krishnaveni, Mohamed Ali, Gokulakrishnan and
Ravi Sundar George

7. FUNCTIONAL ANALYSIS OF CUMULUS CELLS ASSOCIATED GENES 1422

RELATED TO THE QUALITY OF IN VITRO FERTILIZED CAPRINE EMBRYOS
M. Elanchezhian, S. Gautham, D. Reena, D. Gopikrishnan and A. Palanisammi

8. MORPHOMETRY OF THE MANDIBLE AND UPPER JAW OF THE NATIVE DOGS 1428
OF TIRUNELVELI DISTRICT AND ITS CLINICAL VALUE DURING
REGIONAL ANAESTHESIA
S. Rajathi and S. Muthukrishnan
 Review article
CUTANEOUS RECONSTRUCTION 1:
TENSION-RELIEVING TECHNIQUES
Bryden J. Stanley, BVMS, MACVSc, MVetSc, Diplomate ACVS
Michigan State University, USA

INTRODUCTION SKIN

There are many options for coverage Virgin skin is a relatively thin,
of cutaneous defects in dogs and cats. In bilaminate structure consisting of a very
comparison to horses and humans, our thin epidermis of progressively flattened
small companion animals have the type of epithelial cells, and a strong, thick dermis
skin that can be extensively manipulated (20-30x thicker than epidermis) which
to achieve a robust and enduring closure, contains fibrous, nervous, vascular,
rewarding for both veterinarian and client. lymphatic, follicular and glandular elements.
Whenever a significant reconstructive effort The skin’s main function is protection,
is contemplated, the veterinarian must although it has other roles including
ensure that, thermostatic and immunologic. Skin is
viscoelastic, which means it will have a
1. the owner is committed and invested, tendency to both retract when wounded or
incised, but also to adapt to applied stress
2. the animal can tolerate the proposed forces. We can take advantage of this when
reconstruction, and it comes to relieving tension on the primary
suture line. No wound should be closed by
3. you possess the skill to optimize a simple approximation of wound edges if the
successful outcome. resulting tension will lead to ischemia and
subsequent necrosis of the tissue. Tension-
This review to introduce you to a few
relieving techniques allow local tissues to
of the more commonly utilized tension-
be mobilized to cover a cutaneous defect
relieving techniques used in veterinary
without raising a flap or harvesting a graft.
specialist practice. It is designed to be
Before considering any reconstructive
appropriate for a skilled practitioner, and
closure technique, however, the wound
as such does not include more advanced
must always be managed until the wound
techniques. Not all wounds will be able to
is free of infection, has a good blood supply
be closed by tension-relieving techniques,
and the periwound tissueis healthy.
many will be amenable to these closures and
complications such as wound dehiscence
will be minimized.

Ind. J. Vet. & Anim. Sci. Res., 47 (4) 1371-1378, July - Aug, 2018 1371
 Bryden

TENSION LINES Strong Subcutaneous Sutures

All portions of a dog’s skin are not We should never underestimate the
equally pliable in different directions. contribution of a strong subcutaneous suture
Tension lines in the skin of a dog are formed line. It can significantly reduce tension on
by the predominant pull of the fibrous the skin sutures of the primary suture line
tissue within the skin. The skin tension by redistributing the tension onto 2 layers.
Ensure that the bites are taken in the fibrous
lines in dogs (especially those with tighter
layer of the hypodermis, which is stronger.
skin) should be considered when making
Subcutaneous sutures can be interrupted
an incision and when closing a defect. One
or continuous – use interrupted in areas
of the best ways of assessing the amount that may be susceptible to dehiscence.
of tension when closing a wound is to Following a good subcutaneous layer, the
manipulate the edges several ways into skin edges should be almost touching, thus
apposition, then carefully ascertain if the allowing the fine skin sutures to concentrate
tension is within physiological limits, and on apposition rather than tension relief.
in which direction the suture line should
run to have the least amount of tension. TENSION-RELIEVING SUTURES
As a rule, closing the wound parallel to
tension lines will place less tension on the Stent & Bolster Sutures
sutures, minimize puckering and “dog ear” Stent sutures are usually in the form
formation, and reduce the incidence of of vertical mattress sutures, supported with
“biological tourniquet”. some form of bolster to prevent the suture
cutting into the skin. These sutures are
TECHNIQUES COMMON TO usually pre-placed deep into the tissues, at
ALL TENSION RELIEVING some distance from the wound edges. The
PROCEDURES padding material beneath the suture loops
must be soft and extend the length of the
Undermining wound, or be short lengths under each
suture. Wide Penrose drains or bolsters
Undermining is the use of scissors
of bandage roll are ideal, buttons are not
or a scalpel to separate the skin from
(they do not disperse the tension widely
underlying tissue. This allows the full
enough, and can cause pressure necrosis
elastic potential of the skin to be utilised to underneath the button). Once the stent
cover a wound. On areas of the body that sutures are placed, the primary suture line is
have a panniculus carnosus muscle (e.g., closed in two layers, then the stent sutures
cutaneous trunci, platysma), undermining snugged down as necessary. Stent sutures
should be performed deep to the muscle, to should be removed on the 3rd or 4th day
preserve the deep subdermal plexus. When post-operatively, once stress relaxation of
undermining, the surgeon should try to the skin has occurred. Note that these stent
preserve any direct cutaneous vessels that sutures should NOT be horizontal mattress
supply the skin. sutures – these can compromise blood flow
to the wound edge.

1372 Ind. J. Vet. & Anim. Sci. Res., 47 (4) 1371-1378, July - Aug, 2018
 Cutaneous reconstruction......

Stent Sutures
Walking Sutures with minimal resulting tension. Final skin
closure is then accomplished with routine
Walking sutures are interrupted subcutaneous and skin sutures. If walking
sutures of 2-0 or 3-0 absorbable suture sutures are correctly placed, i.e., with the
material (with a swaged needle), placed bite taken through the dermis, the overlying
from the deeper portion of the dermis to skin will appear dimpled at that point. Be
the underlying fascia. They are generally careful not to penetrate the skin with the
used following undermining and serve to walking sutures, as this may introduce
spread the tension evenly across the skin, contamination and lead to subcutaneous
away from the edges. Walking sutures are infection. This technique is easier to perform
placed in staggered rows on both sides in dogs with a thick dermis, and may not be
of the wound, moving the skin across the appropriate to cats and thin-skinned dogs.
defect and allowing it to meet in the middle

N.B. Although walking sutures reduce tension on the primary suture line, they can
be transiently uncomfortable, and can also compromise the vascular supply to the skin (so
be careful in flaps). In addition, increased suture material in the wound is not desirable in
contaminated wounds. The skin dimpling is a temporary cosmetic problem.

Ind. J. Vet. & Anim. Sci. Res., 47 (4) 1371-1378, July - Aug, 2018 1373
 Bryden

FNNF and FFNN Sutures refer to entry or exit distance from the
primary suture line. Both FNNF and FFNN
These sutures are indicated for closure sutures are placed in the order that their
of wounds with just a little bit of increased names indicate. The “far-far” component
tension, or in which tension on the wound provides tension relief, while the “near-near”
edges cyclically increases and decreases component is appositional. All entrance and
during movement, e.g., a flexion surface or exit points of these sutures are linear, and
lacerated paw pad. Far-near-near-far and placedmeticulously perpendicular to the
far-far-near-near sutures are combinations skin edges.
of tension and approximating sutures, and

Far-Far-Near-Near Suture Far-Near-Near-Far Suture

SKIN STRETCHING TECHNIQUES large defect, even one that may require a
flap. This valuable yet underused technique
Mechanical creep is a phenomenon of takes advantage of the previously mentioned
the skin’s viscoelasticity that allows it to phenomena of mechanical creep and stress
elongate under constant short-term loading. relaxation over the 24 to 72 hours before
Within the extracellular matrix of the loaded definitive wound closure. Pretensioning
dermis, the convoluted superhelices of the sutures are placed to influence an existing
coiled triple helix collagen fibers readily wound; presuturing refers to sutures that
straighten and realign in a more parallel are placed to have an effect on an area of
orientation under load, releasing water planned excision. The technique works
molecules and increasing skin viscosity. particularly well in truncal and proximal
The delicate elastic fibers, also in the limb regions of dogs and cats, because of
extracellular matrix, become fractured and their weak hypodermal attachments. It can
lose their elasticity. Thus, over time, the also be effective around the hock joint,
skin will elongate (mechanical creep) and antebrachium, and carpus in some animals.
lose its tendency to recoil when the load is Pretensioning can be used when the surgeon
removed (stress relaxation). can only achieve partial closure because of
Pretensioning concern for biological tourniquet formation.
When contemplating pretensioning or
Pretensioning is a valuable tool to presuturing, it is essential that the periwound
consider when contemplating closure of a tissues are healthy.

1374 Ind. J. Vet. & Anim. Sci. Res., 47 (4) 1371-1378, July - Aug, 2018
 Cutaneous reconstruction......

There are several different ways of loading tension has dissipated because of
performing pretensioning and presuturing: stress relaxation. The suture line can be
gently loaded again, gradually drawing the
• Insertion of a simple continuous skin edges closer. Periodic loading can be
suture line through skin and performed every 8, 12, or 24 hours over 2
superficial hypodermis of the to 3 days, by which time even quite large
wound edges with 2-0 or 0 defects can often be approximated directly.
nonabsorbable monofilament It is always surprising how much skin can
suture material: be ‘persuaded’ to close over a few days.

At time of definitive closure, the

pretensioning sutures are removed
completely, and the area is prepared for
surgery. Closure is still performed in two
layers but requires minimal undermining
and minimal disruption of the granulating
tissue bed (which contributes to the
contraction process).
• Using a continuous horizontal
intradermal running pattern Pre-suturingz
around the edges of the wound
using 3-0 or 2-0 nonabsorbable Presuturinginvolves insertion of
monofilament suture material sutures through the skin in a Lembert
secured through a button at both fashion, plicating the intact skin over an
ends. This technique is best suited area of planned excision. This is generally
to skin with a thick and healthy performed 24-48 hours before surgery,
dermis. This suture pattern can tightened once or twice over that time, then
be left in for longer than the usual removed immediately prior to surgery.
72 hours, acquiring a degree of Post-tensioning
biological creep.
Externally applied skin stretching
The sutures are tightened to the devices such as Velcro pads can be
point of mild and tolerable tension on the very effectively used postoperatively to
skin, one that is not likely to cause suture minimize incisional tension. This technique
“cut-out” or great discomfort. Slippage of is particularly useful if the surgeon becomes
suture material can be avoided through the concerned about the tension on the incision
application of a lead split shot compressed after the wound has been closed.Velcro
over the suture ends. The area is then pads are glued to the skin and Velcro straps
protected for 8, 12 or 24 hours and then applied to relieve the load on the skin on
reassessed. At that time, the sutures will either side of the incision.
be noticeably looser because the initial

Ind. J. Vet. & Anim. Sci. Res., 47 (4) 1371-1378, July - Aug, 2018 1375
 Bryden

Acute (Intra-operative) Skin Stretching healing period of several days, the device is
expanded by 10-15% of final volume every
Intraoperative skin expansion takes the 2 or 3 days until final volume is achieved.
opportunity to obtain some degree of stress During expansion, subcutaneous fat
relaxation and limited mechanical creep decreases, dermal thickness decreases, and
during the surgical procedure. By loading epidermal proliferation occurs. A dense,
the skin edges following undermining, fibrous capsule forms over the implant, thus
adequate tension relief on the primary the skin is not as pliable or elastic as normal
suture line may be obtained. The skin can skin. Skin perfusion is enhanced, however.
be loaded using skin hooks, towel clamps Following completion of the expansion
or stay sutures to provide constant tension period, the addition of a static maintaining
on the undermined skin for 30 – 45 minutes. period following expansion appears to
This technique will not obtain the same improve the quality of the expanded skin.
degree of stress relaxation as pretensioning
over several days, and may not even provide TENSION-RELIEVING
any advantage over simply undermining, INCISIONS
but can be useful when positioning loose-
skinned animals. Mesh Expansion
Chronic Skin Expansion Mesh expansion, or multiple punctate
relaxing incisions are small (1cm, 1/2 inch),
The use of skin expanders has been parallel, staggered incisions made in the
reported intermittently but consistently in skin adjacent to the wound to relieve the
the veterinary literature. This technique tension associated with wound closure.
is worth mentioning because in certain This technique is particularly useful to
situations where skin loss is significant relieve tension associated with wound
(e.g., severe burns), this may be the only closure in the extremities below the elbow
technique that will enable robust, full and stifle, the ear, and tail, but can also
thickness re-coverage. Skin expansion is be used on proximal limb and trunk. The
not suited to acutely traumatized skin and skin around the wound is undermined,
is usually undertaken as part of a delayed or and tension on the wound edges assessed.
staged reconstructive effort. The technique If tension is considered unacceptable for
takes advantage of the phenomenon of closure, an initial row of 1cm stab incisions
‘biological creep’, which is defined as is created, using a #15 or #11 scalpel blade,
the creation of new dermal and epidermal 1cm away from the wound edge with 1 cm
components following prolonged constant space between each incision. Tension on
loading. An inflatable or expandable the wound edges is reassessed, to decide if
silicone elastomer device of predetermined further rows are required. Depending on the
volume (e.g., 100 mls) is surgically or amount of tension, one, few, or many rows
endoscopically placed in the subcutaneous may be placed. Rows should be staggered
tissues of pliable skin adjacent to an (i.e., offset from each other) and 1cm space
existing or proposed defect. After an initial allowed between the rows. A limb can be

1376 Ind. J. Vet. & Anim. Sci. Res., 47 (4) 1371-1378, July - Aug, 2018
 Cutaneous reconstruction......

undermined and meshed circumferentially Simple Relaxing Incision

if necessary.
A simple relaxing incision, which
is also called a bipedicle flap, is a useful
tension-relieving option in several
situations, including closing a defect near
an orifice to prevent distortion, covering
vital structures such as exposed joints,
tendons, nerves, and orthopedic implants. It
can also be used to close a chronic wound
where edges are scarred and nonpliable, as
it can mobilize adjacent, more elastic skin.
An incision is created parallel to the long
axis of the defect with the width of the skin
bridge (or bipedicle flap) being equivalent
to the width of the wound, and the length
of the relaxing incision no longer than the
length of the defect. The surgeon should
keep in mind that if the length to width
When meshing the skin, it is prudent
ratio of the bipedicle flap exceeds 4:1,
to have a support under the skin, such as
vascular supply to the central skin bridge
a sterile tongue depressor or gauze. This
may become compromised. The bipedicle
controls mesh placement and prevents
flap is undermined and advanced into the
inadvertent laceration of underlying
defect, which can then be closed without
muscles or vessels. Following mesh
tension. The relaxing incision can allowed
expansion and primary suture line closure,
to heal by second intention, or closed
a non-adherent, semi-occlusive dressing
with or without tension sutures. Although
and bandage are applied until the meshes
this procedure creates a new wound (the
are epithelialized, in approximately 7 days.
relaxing incision), generally this incision is
When the mesh expansion is substantial,
in a less critical area, in healthy, pliable skin,
the meshed skin may appear compromised
and not challenging to address. Bilateral
(red-purple discoloration) for several days,
relaxing incisions, (i.e., one on either side
but healing and final outcomes are usually
of the wound) can be performed in areas
excellent. The surgeon should be careful,
that permit, and are especially useful when
however, not to make the individual mesh
closing a chronic, fibrotic wound.
incisions too large, as this can cause
vascular compromise to the meshed skin.
Mesh expansion of skin flaps are not
recommended as they will compromise the
circulation through the dermis.

Ind. J. Vet. & Anim. Sci. Res., 47 (4) 1371-1378, July - Aug, 2018 1377
 Bryden

V to Y-Plasty incision is made in the skin adjacent to

the defect, with the point of the chevron
Similar to a simple relaxing incision, away from the defect. The skin between
the V-Y plasty provides a flap of skin that the chevron and the defect is undermined
can be advanced into a defect or provide and advanced over the defect. The resultant
tension relief adjacent to an orifice. The new defect (with the appearance of an open
procedure is indicated for closing defects chevron) is then closed in the shape of a
that are chronic and surrounded by inelastic ‘Y’. Suturing commences at the arms of the
skin, and closing wounds near structures Y and continues until tension is apparent to
that would be distorted by closure under the surgeon. The remaining open defect is
tension, such as the eye. A chevron-shaped closed to form the stem of the Y.

Although we have discussed a fair negative pressure wound therapy. With

number of techniques, there are more some cutaneous defects, however, there
procedures available to relieve tension on is a point where simple tension relief on
the primary suture line. Once you have the primary wound edges will still not be
become adept at these discussed above, adequate to achieve closure. To close these
your skills can be further honed to include large defects, we must look to development
other techniques such as Z-plasties, of a cutaneous pedicle graft (skin flap) or
M-plasties, O-to-S closures and incisional harvesting a free skin graft.

1378 Ind. J. Vet. & Anim. Sci. Res., 47 (4) 1371-1378, July - Aug, 2018