Enhancing Wound Closure on the Limbs

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Vol.18, No. 8 August 1996

Enhancing WoundClosure on the Limbs

Auburn University

M. Stacie Scardino, DVM Ralph A. Henderson, DVM, MSSteven F. Swaim, DVM, MS Eric R. Wilson, DVM, MS

Planned or traumatic limb wounds that result in loss of tissue or excessive

wound tension are a challenge for the veterinary practitioner. The firstobjective in early management of wounds is to preserve the blood supply

and minimize foreign objects and pathogens so that tissue is suitable for appo-sition and healing. Traumatic wounds call for gentle technique that may in-clude debridement, lavage, and possibly delayed primary closure.

Some wound edges can easily be apposed early after the infliction of thewound. However, the onset of the inflammatory and repair stages of healingmay increase limb circumference, thus making manual apposition of woundedges difficult or impossible. In other fresh wounds, it is obvious that the edges

will never be apposed because of loss of tissue. For these wounds, some form ofskin flap or graft is necessary for reconstruction. Other wounds may initiallyseem large because of primary skin retraction, but skin manipulation revealssufficient skin for closure. This article discusses wounds that fall somewhere inbetween these two categorieswounds that cannot quite be closed.

With proper management of tension, difficult limb wounds may be closedor made smaller to require a smaller flap or graft. Table I presents guidelinesfor the use of various techniques or combinations of techniques. When dealing

with a limb wound under tension, the veterinarian should consider the sim-plest, least invasive, and yet most effective technique first; more involved tech-niques are used as needed. This article and Table I discuss techniques in thegeneral order in which they should be considered for use.

If the skin is pulled too tightly around a wound during wound closure, thecircumferential skin tension (i.e., the biological tourniquet) impairs circula-

tion distal to the wound closure, thus resulting in further swelling.1

If distallimb and paw edema or hypothermia are present, removal or loosening of ten-sion sutures is indicated. A distal limb should not be jeopardized just to close a

wound. Clinical judgment is important in making such assessments.Recently traumatized skin may have a compromised blood supply. Surgical

manipulation should therefore be minimized until circulation improves.2,3

Added insult to an already weakened skin vasculature could result in sloughing.When the integrity of the skin vasculature is questionable, a bandage should beapplied and wound closure delayed for 1 to 3 days.2 If the skin is severely trau-

Continuing Education Article

V

FOCAL POINT

KEY FACTS

I The simplest, least invasive, but

most effective technique for

closure of a limb wound under

tension should be considered

first.

I Skin sutured too tightly around a

leg can cause a biological

tourniquet.

I Onset of inflammatory or repairstages of healing can increase

limb circumference, thus making

it difficult to assess whether

wound edges can be initially

apposed.

I Proper management of tension in

a limb wound results in either

wound closure or reduction of

the size of needed skin grafts or

flaps.

#Simple wound managementtechniques sometimes make skin

grafts or flaps unnecessary.


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Small Animal The Compendium August 1996

TABLE ITension Management Techniques for Closure of Limb Wounds

Techniquea Indications Combinations b

Undermining Wound edges appose or nearly appose

under tension; most beneficial onproximal limb areas

Before:Tension sutures, relaxing incisions,

adjustable horizontal mattress suture (freshwounds)

After:Presutures

Skin-Stretching Sutures

Presutures Wound edges appose or nearly apposeunder tension; lesions (e.g., tumor) wherepostexcision wound closure will be undertension

Before:Undermining, tension sutures,relaxing incisions, adjustable horizontalmattress suture (fresh wounds)

Multiple punctate incisions Wound edges will almostappose undertension

Simultaneous with:Intradermal sutures

After:Presutures; undermining; adjustablehorizontal mattress suture

Adjustable horizontal mattresssutures

Wound edges nearly appose or do notappose under tension (fresh wounds or

wounds in repair stage of healing); in placeof other tension sutures

Before:Relaxing incisions

After:Undermining on fresh wounds;presutures

Far-near-near-far;far-far-near-near

Wound edges appose under tension;wounds with cyclic increases or decreasesin tension with movement (flexionsurfaces, foot pads)

Before:Relaxing incisions

After:Undermining; presutures;intradermal sutures

Relaxing Incisions

Simple relaxing Wound edges will almostappose undertension; provides coverage for vital limbstructures (e.g., tendons, ligaments, nerves,and vessels)

Before:Just before tension sutures

After:Presutures; undermining; adjustablehorizontal mattress suture

Z-plasty Wound edges will almostappose under

tension; skin is available in one directionfor transposition to a perpendiculardirection for wound closureusuallyupper limb wounds

Before:Just before intradermal sutures

After:Presutures; undermining; horizontalmattress sutures

Tension Sutures

Intradermal Wound edges appose under tension;patient is likely to molest the wound; inplace of other skin sutures; under casts orsplints where timed suture removal isimpractical

Before:Other tension sutures; relaxingsutures

After:Undermining; presutures

aThe main tension-management techniques (undermining, skin-stretching sutures, tension sutures, and relaxing incisions) are listed inthe order in which they should be considered when one is dealing with tension wound closure on a limb.bThe combinations are procedures that could be used in concert with other tension-management techniques. These are generalguidelines; however, clinical judgment should be used when deciding on needs for any particular wound.

Vertical mattress Wound edges appose under tension Before:Relaxing incisions

After:Undermining; presutures;intradermal sutures


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matized, it may be necessaryto delay surgical manipula-tion to allow edema toresolve before the skin circu-lation has improved suffi-ciently to withstand wound

closure. Clinical judgment isimportant in assessing thestatus of the skin circulationprior to wound closure.

UNDERMININGUndermining the skin ad-

jacent to a wound is thesimplest procedure for re-lieving tension when directsuturing results in too muchtension during wound ap-position. Undermining frees

the skin from underlyingtissue, thereby allowing thefull elastic potential of theskin to be used as the skin isstretched to cover a wound.1,2

Because of the small amountof skin on the limbs, under-mining usually provides limited skin for reconstruction.It is probably most beneficial on the proximal portionof the limbs, where there is more skin.

Undermining can be used in an attempt to gain asmuch skin as possible for wound closure. It should beconsidered when wound edges can be apposed or al-most apposed with tension. In fresh wounds, under-mining can be used before tension sutures, relaxing in-cisions, or adjustable horizontal mattress sutures. It canalso be used after presutures.

The skin of the limbs should be undermined in theloose areolar fascia deep to the dermis.13 Blunt-tippedMetzenbaum scissors are almost universally used forundermining skin. Alternately opening and closing thescissor blades allows separation of the loose areolar con-nective tissue.2,3 For meticulous dissection around spe-cific structures, sharp-sharp scissors are preferred. Thepoints engage the connective tissue with much less ap-

plied pressure, and the blades (when opened) bluntlyseparate the tissue.2 Sharp undermining may be per-formed by snipping the subcutaneous tissue with scis-sor blades as they move throughout the tissue or bycutting the subcutaneous tissue with a scalpel blade.1,2

SKIN-STRETCHING AND TENSION SUTURESSuture techniques may be used to relieve tension by

gradually stretching the skin around a wound so that it

can be apposed or nearly ap-posed. Such suturing tech-niques include presuturesand adjustable horizontalmattress sutures. Tensionsutures are usually thought

of as sutures that incorpo-rate a larger quantity of skinand are able to overcomedistraction forces at the

wound edges. Suture pat-terns commonly used toovercome tension includefar-near-near-far, far-far-near-near, and vertical mat-tress sutures.

Skin-Stretching SuturesPresutures

Presutures are placed be-fore the wound is debridedor a lesion (e.g., a tumor) isexcised. Presutures resemblea Lembert suture with biteson either side of the lesion.

When placed several hoursbefore excision or debridement, the presutures stretchthe skin, thus reducing the tension necessary to close the

wound.47 Presuturing is based on the skins biomechani-cal properties (creep and stress relaxation), which allowskin held under tension to gradually stretch beyond itsinherent extensibility.46,8 This technique is particularlyuseful on the distal limbs, where the use of walkingsutures to overcome tension could result in encroach-ment on the superficial vital structures in the area (i.e.,vessels, nerves, and tendons).7

Presutures are indicated when wound edges can beapposed or almost apposed with tension. This techniquecan also be used in fresh wounds before undermining orbefore tension sutures, relaxing incisions, or adjustablehorizontal mattress sutures are used. Signs of impairedcirculation (i.e., edema or hypothermia) distal to thepresutures indicates that final wound closure may pro-duce a biological tourniquet. In such cases, gradual ap-

plication of tension by an adjustable horizontal mattresssuture may be indicated to stretch the skin. As an alter-native, the other tension closure techniques described inthis article may be indicated for wound closure.

Tranquilization and local analgesia are usually suffi-cient for placing presutures. Using 2-0 or 3-0 nonab-sorbable suture material, the surgeon places suture bitesin the skin 2 to 5 cm on either side of the lesion andexerts tension on adjacent skin (Figure 1A and 1B).

The Compendium August 1996 Small Animal

C R E E P I S T R E S S R E L A X A T I O N I I N H E R E N T E X T E N S I B I L I T Y

Figure 1Presutures. (Aand B) The day before surgery, theskin adjacent to the lesion is sutured over the lesion using aLembert suture pattern. (C) The following day, the presu-tures are removed and the lesion is excised. (D) The resultingdefect or wound is closed using the stretched skin madeavailable by the presutures.


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The direction of the stretch is chosen according to theanticipated direction of least tension.6 The steep arc ofthe circumference of the limb of some small animalsmay interfere with the tightening of presutures.

Experiments on swine show that 40% less force is re-quired to close a presutured wound than is required fora control wound.4 Another study performed on horsesshowed that a prolonged period (24 to 30 hours) ofpresuturing resulted in moderate edema that necessitat-ed undermining. When presutures were placed for only


D I R E C T I O N O F L E A S T T E N S I O N I E D E M A I U N D E R M I N I N G

Figure 2A

Figure 2 Adjustable horizontal mattress suture. (A) Thislimb wound in the repair stage of healing will eventually heal

without a graft or flap. An adjustable horizontal mattress su-ture will be used to enhance wound contraction. (B) Place-ment: a half-buried horizontal mattress suture starts the su-ture at one end. The suture is then advanced as anintradermal horizontal mattress suture with each bite slightlyadvanced. On the final bite, the needle is passed through theentire thickness of the skin and through a hole in a sterilebutton. After the wound edges are advanced as far as possi-ble, two split shots are used to hold the suture tight (see in-set). (C) Tightening: the suture is grasped with forceps andgently pulled. The split shots are pulled away from the but-ton as the wound edges advance closer together. New splitshots will be applied over the button. (D) After 7 days, thesuture has resulted in almost complete wound apposition.

Figure 2C

Figure 2D

Figure 2B


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When adjustable horizon-tal mattress sutures are usedearly in wound manage-ment, resolution of edema

will enhance the amount ofadvancement of wound

edges. Skin-edge advance-ment is greatest during thefirst 2 to 3 days because ofinherent elasticity. Whenthe wound edges are ap-posed or when they have ad-vanced to their limit (i.e.,tension does not result infurther wound edge ad-vancement), the suture is re-moved. Wound edges canoften be advanced into ap-position or near-apposition

in a short time (Figure 2D).The suture may be loos-

ened if the surgeon believesthat it is too tight (e.g., ifthere were signs of impairedcirculation distal to the

wound). The weights wouldbe removed and moved far-ther away from the button.

A modified placement canbe done by placing the fish-ing weightbutton appara-tus at both ends of thesuture, thus permitting tight-ening from both ends. Thistechnique is helpful for clos-ing long wounds becausethe suture material slipsthrough tissue less the fur-ther it is from the where thepull is applied. Thus, pull-ing at each end of the woundtends to distribute tensionmore evenly along the wound.

Tension SuturesIntradermal SuturesThe terms intradermal su-

ture and subcuticular sutureare often used interchange-ably to describe suturesplaced either in the lower portion of the dermis or inthe area of the dermis that blends into the subcutis.2,9

By definition, however, intradermal sutures are placed

in the dermis and subcutic-ular sutures are placed un-der the dermis, in the sub-cutaneous tissue.9,10

Intradermal sutures areoften used when wound

edges can appose but withtension. They reduce the ten-sion across the wound mar-gin before skin sutures areplaced5,9,11 or can be used inlieu of skin sutures. Intrader-mal sutures also help preventthe widening of scars after re-moval of sutures if a nonab-sorbable suture material isused.1,2,11 If nonabsorbablematerial is to be used inlight-skinned animals, an

undyed material is preferredso that the sutures will not bevisible through the skin.

Intradermal sutures maybe combined with simpleskin apposition techniques orother tension-relieving tech-niques.2,5 They may be usedafter undermining or presu-tures and before other ten-sion sutures are placed or re-laxing incisions are made. Inaddition, intradermal tensionsutures are much less pronethan other types of tensionsuture to injury inflicted bythe patient.2,9 These suturesshould be considered whenthe patient may molest the

wound. Intradermal suturesare also preferred in lieu ofskin sutures under casts orappliances, when timed re-moval of sutures may be im-practical.

When used for woundclosure on the distal limbs(where tension is a definitefactor), an effort is made toensure that these tension su-tures are placed in the der-

mis rather than in the subcutis. If the skin is too thinfor the entire suture to be placed intradermally, a com-bined pattern beginning in the subcuticular zone, en-


S U B C U T I C U L A R I S U T U R E I U N D Y E D M A T E R I A L I C A S T S

Figure 5Vertical mattress suture. When used for tension re-lief, vertical mattress sutures are placed away from the skinedge. Soft latex rubber tubing is placed under the sutures toserve as stents.

Figure 6Simple relaxing incision. (A) The distance (B)be-tween the original wound and the relaxing incision shouldequal the width (A) of the original wound. (B) When theoriginal wound is closed, the relaxing incision will be as largeas the original wound was before closure. (C) When two re-laxing incisions are used, the distance (B)between the origi-

nal wound and each relaxing incision should equal the width(A)of the original wound. (D) After the original wound isclosed, each of the two relaxing incisions will equal half ofthe width of the original wound.


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tering the dermis, and exit-ing at the subcuticular zonecan be substituted. Thesesutures are placed with 3-0or smaller absorbable suturematerial in a continuous

pattern, with the needlepassing horizontally witheach suture bite4 (Figure 3).The pattern is the same asthat used for an adjustablehorizontal mattress suture.

Far-Near-Near-Farand Far-Far-Near-NearSutures

Far-near-near-far and far-far-near-near sutures pro-vide both tension relief and

apposition.1,2,5,10,11 Far-near-near-far and far-far-near-near sutures are particularly good for closing wounds in

which tension increases or decreases cyclically duringmovement (e.g., a flexion surface or a lacerated footpad).2 These sutures can be used by themselves or afterundermining, presutures, or intradermal sutures. Theyshould be considered before relaxing incisions are con-sidered.

These sutures are usually placed with 2-0 to 4-0 non-absorbable suture material in the order that their namesimply, with each bite being taken on the opposite site ofthe wound. Thefarcomponent acts as a tension suture,

while the nearcomponent holds wound edges in apposi-tion1,2,5,10,12 (Figure 4). When these sutures are used, ex-cessive tightening should be avoided to prevent suture-line inversion, which could impair healing.1,2,5,10,12

Vertical MattressSutures

When placed at a distance from the wound margins,vertical mattress sutures serve as tension sutures.1,10 Theycould be used alone or after undermining, presutures, orintradermal sutures. They should be considered beforerelaxing incisions are considered. Because of their con-

figuration, vertical mattress sutures do not tend to inter-fere with circulation as much as horizontal mattress su-tures do; however, these sutures concentrate tension onthe skin near the wound edges, where pressure could bemost detrimental to wound healing.1,2,13 When used fortension, they may be removed 3 to 4 days after place-ment.

The tension required to close some wounds wouldcause the suture to tear the skin. In these cases, stents of

rubber tubing or buttonsmay be placed under the su-tures.1,2,5 Soft latex rubbertubing is preferred because itis more comfortable for theanimal (Figure 5). When us-

ing such devices, the veteri-narian should observe thewound daily because thepressure from the device maycause ischemic necrosis ofthe skin under the sutures.

A continuous subcuticu-lar suture and simple inter-rupted skin sutures may becombined with the verticalmattress sutures to providefinal skin-edge apposi-tion.2,5,10,12 Nonabsorbable

2-0 or 3-0 monofilamentsuture material is usually

used for these sutures. When used for tension relief,vertical mattress sutures should be placed before othersutures rather than after the skin is closed. This orderhelps ensure that none of the underlying superficial ves-sels, nerves, or tendons on the distal limb are incorpo-rated into the sutures.

RELAXING INCISIONSIn general, relaxing incisions are indicated when the

wound edges are close to being apposed but the sur-geon believes that apposition with tension suturescould produce enough tension to impair circulation.Examples include wounds for which presutures and ad-

justable horizontal mattress sutures have already beenused without complete wound closure. Several forms ofrelaxing incisions can be used with the aforementionedtension-management techniques.

Simple Relaxing Incisions A simple relaxing incision is made parallel and adja-

cent to the wound, with intervening skin being used for wound closure. Thus, these incisions involve creatingwounds to close woundswhich may cause the surgeon

and the pet owner some concern. The surgeon maytherefore want to consider trying presutures, undermin-ing, or an adjustable horizontal mattress suture first. If

wound edges will almost appose with tension, a simplerelaxing incision may be made prior to placement of ten-sion sutures.

Some wounds expose tendons, ligaments, nerves,and vessels. Such exposure justifies primary closure

with the aid of a relaxing incision in exchange for a de-

The Compendium August 1996 Small Animal

S T E N T S I R U B B E R T U B I N G I B U T T O N S I E X P O S E D T I S S U E

Figure 7Multiple punctate relaxing incisions. (A) If the skinedges do not appose as a continuous intradermal suture isplaced, multiple punctate relaxing incisions are made 1 cmfrom the wound edge, 1 cm long and 0.5 cm apart in stag-gered, parallel rows. They may be placed bilaterally. (B)Once apposed, the skin edges are sutured routinely. (FromSwaim SF, Henderson RA (eds): Small Animal Wound Man-agement. Philadelphia, Lea & Febiger, 1990, p 105. Modified

with permission.)


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fect in a relatively unobtrusive location. If the incisionis in healthy skin, it usually heals uneventfully.1,2,5,11,13

Because the amount of skin available for wound closureis limited on the limbs, the wound should be watched

during healing to ensure that a bio-logical tourniquet does not resultfrom contraction and epithelializa-tion.

When making the incision, the sur-geon should ensure that the width ofskin between the relaxing incision andthe wound is equal to the width of the

wound. After undermining the skinbetween the wound and the incision,the bipedicle flap of skin is advancedover the wound1,2,5,11,13 (Figure 6A and6B). When only one relaxing incisionis used, the defect remaining after clo-sure of the original wound is about aslarge as the original wound. When re-laxing incisions are created on bothsides of a wound, the width of eachflap (distance of incision from wound)should equal the widest part of the de-fect. Closure results in two smaller de-fects that are allowed to heal as open

wounds5,8 (Figure 6C and 6D).

Multiple Punctate RelaxingIncisions

Multiple punctate relaxing inci-sions are small parallel staggered inci-

sions made in the skin adjacent to a wound to releasetension in wound closure.2,5,7,13,14 Multiple punctate re-laxing incisions break up the relaxing incision intomany small incisions that are more cosmetic and heal


B I O L O G I C A L T O U R N I Q U E T I B I P E D I C L E F L A P I W I D T H O F D E F E C T

Figure 8Z-plasty. (A) An open wound on the craniolateral aspect of the proximalforelimb. (B) Pinching skin proximal to the lesion proximodistally reveals insuffi-cient laxity. (C) Pinching skin craniocaudally reveals sufficient skin laxity. (D) Z-

plasty designed adjacent to the wound to move skin from craniocaudal plane to theproximodistal plane for wound closure. (E) Wound closed using Z-plasty proximallyand multiple punctate incisions distally.

Figure 8A Figure 8B Figure 8C

Figure 8D Figure 8E


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faster than one large relaxing incision and are usuallymore acceptable to the animals owner.2,7,14 However,they may not provide as much relaxation as is attained

with one large relaxing incision.4,15,16As with simple re-laxing incisions, the surgeon may want to try presu-tures, undermining, or an adjustable horizontal mat-tress suture before using multiple punctate relaxingincisions.

A study evaluating the extent (width) of the skin de-fect (in relation to the circumference of the leg) thatcould be closed using multiple punctate relaxing inci-sions showed healing to be very cosmetic in those de-fects that comprised one fourth of the circumference ofthe limb. Healing was satisfactory but less cosmetic

when the defect was two sevenths of the limb circum-ference. When the defect was one third of the limb cir-cumference, healing was complete but cosmetic appear-ance was poor.15

The incisions are usually 1 cm from the wound edge,1 cm long, and 0.5 cm apart in staggered parallel rows.

A continuous absorbable intradermal suture is placed.If the skin edges do not appose as the suture is placedand tightened (or if they appose with tension), punc-

tate relaxing incisions are made in the skin adjacent tothe wound edges on both sides of the wound.2,7,16 Onceapposed, the skin is sutured routinely (Figure 7).

Another technique for performing the procedure in-volves placing the continuous intradermal absorbablesuture along the length of the wound but not tighten-ing or tying it at one end. While tension is held on thefree end of the suture, hemostats are placed under aloop of suture near its origin and lifted. If the skin

edges do not appose, punctate incisions are made bilat-erally in the area of tension. The hemostats are placedunder another loop of suture, and the procedure is re-peated until the wound is closed along its entirelength.2,7,13

No more punctate incisions should be made than arenecessary to allow wound closure without tension.2,7

The larger the relaxing incisions and the more incisionsthat are made, the greater the skin relaxation; however,the chance of damaging the skin vasculature and caus-ing necrosis also increases.2,7,13,14

Z-PlastyZ-plasty is the transposition of two interdigitating

triangular flaps of skin; it allows a gain in length or re-laxation in one direction due to shortening of the skinin the opposite direction.1,2,5 Before using a Z-plasty asa relaxing incision, the surgeon should manipulate theskin around the wound to ensure that there will be suf-ficient skin in one direction to allow the needed relax-ation in the perpendicular direction1,2,5,17 (Figure 8Athrough 8C).

Theoretically, if all limbs of the Z-plasty are of equal

length and the angles are at 60, there should be a 75%gain in length as the flaps are transposed.2,5,13,17 Howev-er, the actual gain from a Z-plasty is determined by theskin and scar tissue where it is performed.5,13,17 Again,the surgeon may want to try presutures, undermining,or an adjustable horizontal mattress suture before usinga Z-plasty relaxing incision.

When a Z-plasty is used as a relaxing incision, all ofthe limbs of the Z should be of equal length; 60 angles


A P P O S I T I O N I C O S M E S I S I S K I N V A S C U L A T U R E

Figure 9Z-plasty. (A) AZ-plasty with all three limbs of equal length and 60 angles is made adjacent to the defect, with the cen-tral limb of the Z in the direction of needed relaxation. (B) The flaps of the Z and skin between the Z-plasty and the wound areundermined. (C) The wound is closed. The flaps of the Z-plasty tend to realign themselves as the wound is closed. (D) TheZ-plasty is sutured using half-buried horizontal mattress sutures for the flap tips. The central limb of the Z-plasty is now alignedperpendicular to its original direction.


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2. Swaim SF, Henderson RA: Management of skin tension, inSwaim SF, Henderson RA (eds): Small Animal Wound Man-agement. Philadelphia, Lea & Febiger, 1990, pp 87106.

3. Pavletic MM: Undermining for repair of large skin defects insmall animals. Mod Vet Pract67:1320, 1986.

4. Liang MD, Briggs P, Heckler FR, Futrell J: PresuturingAnew technique for closing large skin defects: Clinical and ex-

perimental studies. Plast Reconstr Surg81(5):694702, 1988.5. Swaim SF: Principles of plastic and reconstructive surgery, inSlatter DH (ed): Textbook of Small Animal Surgery, ed 2.Philadelphia, WB Saunders Co, 1993, pp 280294.

6. Harrison IW: Presuturing as a means of reducing skin ten-sion in excisional biopsy wounds in four horses. Cornell Vet81:351356, 1991.

7. Swaim SF, Scardino MS: Selected paw and distal limb sal-vage and reconstructive surgery techniques, in Bojrab MJ(ed): Current Techniques in Small Animal Surgery, ed 4. Bal-timore, Williams & Wilkins, in press.

8. Bigbie R, Shealy P, Moll D, Gragg D: Presuturing as an aidin the closure of skin defects created by surgical excision.Proc AAEP:613624, 1990.

9. Smeak DD: Buried continuous intradermal suture closure.Compend Contin Educ Pract Vet14(7):907919, 1992.

10. Stashak TS: Selection of suture materials and suture patternsfor wound closure, in Stashak TS (ed): Equine Wound Man-agement. Philadelphia, Lea & Febiger, 1991, pp 5269.

11. Johnston DE: Tension-relieving techniques. Vet Clin NorthAm Small Anim Pract20:6780, 1990.

12. Stashak TS: Reconstructive surgery in the horse.JAVMA170:143149, 1977.

13. Pavletic MM: Tension-relieving techniques, in Pavletic MM(ed): Atlas of Small Animal Reconstructive Surgery. Philadel-phia, JB Lippincott Co, 1993, pp 146182.

14. Swaim SF: Wound management of the distal limbs andpaws. Vet Med Rep2:128139, 1990.

15. Vig MM: Management of integumentary wounds of extrem-ities in dogs: An experimental study. JAAHA21:187192,1985.

16. Swaim SF: Paw salvage and reconstruction techniques fordogs and cats. Proc AAHA 58th Annu Meet:182187, 1991.

17. Vig MM: Management of experimental wounds of the ex-tremities in dogs with Z-plasty.JAAHA28:553559, 1992.

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T A C K I N G S U T U R E S I D E A D S P A C E I I N T R A D E R M A L S U T U R E

are made adjacent to the defect, with the central limbof the Z in the direction in which relaxation is need-ed1,2,5,13,17 (Figures 8D and 9A). After the Z is incised,its flaps and the skin between the Z and the wound areundermined (Figure 9B).

The original wound should be closed before the

Z-plasty. Tacking sutures may be used to help closedead space between the Z-plasty and the wound, if nec-essary.1,2,5 Depending on the amount of tension associ-ated with closure, simple interrupted 3-0 nonab-sorbable skin sutures may be sufficient by themselves,or they may be used in conjunction with a continuous3-0 absorbable intradermal suture if tension is a factor.

As the wound is closed, the flaps of the Z-plasty tendto transpose themselves and lie in their new positionfor final suturing (Figure 9C). The Z-plasty defect isthen sutured using half-buried horizontal mattress su-tures to suture the tips of the flaps in place.1,2 If theprocedure has been performed correctly, the central

limb of the Zwill be aligned perpendicular to its origi-nal direction (i.e., it will be parallel to the long axis ofthe wound (Figures 8E and 9D).

About the AuthorsDrs. Scardino and Swaim are affiliated with the Scott-

Ritchey Research Center and Drs. Swaim, Henderson,

and Wilson with the Department of Small Animal Surgery

and Medicine, College of Veterinary Medicine, Auburn

University, Alabama. Dr. Henderson is a Diplomate of the

American College of Veterinary Surgeons.

REFERENCES1. Swaim SF: Management of skin tension in dermal surgery.

Compend Contin Educ Pract Vet2(10):758766, 1980.

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Enhancing Wound Closure on the Limbs