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Use of a Dorsal Cervical Single Pedicle Advancement Flap in 3 Birds With Cranial SkinDefectsAuthor(s) EDWARD J GENTZ DVM MS Dipl ACZM and KATHLEEN A LINN DVM MSSource Journal of Avian Medicine and Surgery 14(1)31-36 2000Published By Association of Avian VeterinariansDOI httpdxdoiorg1016471082-6742(2000)014[0031UOADCS]20CO2URL httpwwwbiooneorgdoifull1016471082-6742282000290145B00313AUOADCS5D20CO3B2

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avms 14 102 Mp 31File 02em

31

Journal of Avian Medicine and Surgery 14(1)31ndash36 2000 2000 by the Association of Avian Veterinarians

Case Reports

Use of a Dorsal Cervical Single Pedicle AdvancementFlap in 3 Birds With Cranial Skin Defects

Edward J Gentz DVM MS Dipl ACZM and Kathleen A Linn DVM MS

Abstract A ring-necked pheasant (Phasianus colchicus) a rock dove (Columba livia) anda red-tailed hawk (Buteo jamaicensis) were each presented with a large soft tissue wound onthe head with exposed skull Each bird was treated with wound debridement removal of necroticbone and grafting of a single pedicle advancement flap from the adjacent dorsal cervical skinWounds in the pheasant and hawk healed without complication In the rock dove the initialflap necrosed but a second single pedicle advancement flap elevated from the dorsal cervicalskin was successful The final result in all 3 birds was complete coverage of the defect withfull-thickness skin In birds use of single pedicle advancement flaps mobilized from dorsalcervical skin may expedite healing of large soft tissue wounds of the head especially when theskull is exposed

Key words skin grafting wound management pedicle flap head wound birds

Introduction

Injuries to the crown of the head can occur inpet captive and free-ranging birds as a result ofcollisions or attacks by other animals12 Althoughsimple soft tissue lacerations often heal without in-tervention injuries that expose the cranium can re-sult in chronic nonhealing wounds12 The presenceof devitalized bone impedes formation of granula-tion tissue and migration of epithelial cells34 In ad-dition skin over the head is firmly attached to theunderlying skull making primary or secondary clo-sure of large wounds difficult once skin edges havebegun to fibrose56 Even when closure is possibletension created by apposing the edges of largewounds can cause eyelid deformation and exposurekeratitis27

Reconstructive techniques can be used to provideepithelial coverage of defects that are difficult orimpossible to close by direct suturing Free skingrafting in which a section of full or partial thick-

From the Department of Clinical Sciences New York StateCollege of Veterinary Medicine Cornell University Ithaca NY14853 USA Present address (Gentz) Wildlife Center of Virgin-ia Waynesboro VA 22980 USA (Linn) Department of Surgi-cal Sciences School of Veterinary Medicine University of Wis-consin Madison WI 53706 USA

ness of dermis and epidermis is detached from adistant donor site and transferred to a wound bedis routinely used in mammals348 and has been re-ported in birds910 Pedicle grafts or flaps aretongues of skin and subcutaneous tissue that are ro-tated or advanced from a donor site to cover a de-fect A portion of a pedicle graft remains continuouswith the donor site to maintain blood supply to thesubdermal plexus within the flap3811 Because oftheir intrinsic blood supply properly designed flapshave a greater chance of remaining viable than dofree grafts especially when the recipient site ispoorly vascularized In addition because pediclegrafts contain full-thickness skin and subcutaneoustissue such grafts can provide normal feather cov-erage if they contain pterylae However the use ofpedicle flaps requires the presence of relativelyloose mobile skin adjacent to the defect A singlepedicle advancement flap was used to close a wingwound in a great horned owl (Bubo virginianus)12

and advancement flaps have been recommended inraptors to reconstruct wounds involving loss of tis-sue on the head2

In this paper we describe the use of a single ped-icle advancement flap in 3 birds By using this tech-nique skin defects over the dorsal cranium were

32 JOURNAL OF AVIAN MEDICINE AND SURGERY

Figure 1 Adult female ring-necked pheasant with a soft tissue wound of the dorsal head that exposes the underlyingskull No wound contracture is present after 3 weeks of conservative wound management

closed without producing excessive tension on sur-rounding facial structures

Case Reports

Case 1

A 112-kg adult female ring-necked pheasant(Phasianus colchicus) from a game farm was pre-sented with head trauma after flying into the side ofits enclosure The bird was alert and responsivewith normal vital signs A full-thickness skinwound measuring 25 25 cm exposed the dorsalcranium (Figure 1) The wound edges were in-flamed and edematous and the exposed skull wasdesiccated The wound was irrigated with 005chlorhexidine acetate solution (Nolvasan solutionFort Dodge Labs Fort Dodge IA USA) and treatedtopically with a polymyxin B sulfatendashbacitracinzincndashneomycin ointment (Neosporin ointmentWarner Wellcome Morris Plains NJ USA) It wasthen covered with a semiocclusive bandage (Tegad-erm 3M Animal Care Products St Paul MNUSA) The pheasant was treated with trimethoprim-sulfamethoxazole (100 mgkg per os [PO] q12hBactrim Roche Nutley NJ USA) for 10 daysWound irrigation was repeated and the dressing re-placed every other day for 3 weeks At 3 weeksthe wound was unchanged in size no granulationtissue was evident and the exposed portion of theskull appeared necrotic Surgery was elected to ex-pedite healing of the wound

The pheasant was premedicated with midazolam(1 mgkg intramuscularly [IM] Versed Roche Nut-ley NJ USA) After 15 minutes it was intubated

and maintained under anesthesia with 25 isoflur-ane An intravenous (IV) catheter was placed in thebirdrsquos right medial metatarsal vein and lactatedRingerrsquos solution was administered throughout the65-minute course of surgery at a rate of 70 mlkghrThe pheasant was placed in sternal recumbencyFeathers surrounding the wound and covering thedorsal aspect of the neck were plucked and the areawas aseptically prepared with 005 chlorhexidineacetate solution and sterile physiologic saline solu-tion The bird was covered with a fenestrated trans-parent adhesive surgical drape (Transparent Surgi-cal Drape Veterinary Specialty Products Boca Ra-ton FL USA)

Skin edges surrounding the wound were debridedand undermined Small rongeurs were used to lift athin layer of devitalized bone from the calvarium atthe caudal aspect of the wound This piece of ne-crotic bone was full thickness of the skull and itsremoval exposed a 05-cm2 area of occipital cortexSkin edges involving the rostral quarter of thewound were apposed in a single interrupted patternwith 4-0 polyglyconate (Maxon Davis and GeckManati Puerto Rico) The remainder of the woundwas closed by using a single pedicle advancementflap developed from the adjacent dorsal cervicalarea Two incisions measuring 35 cm long andspaced 25 cm apart began at the caudal margin ofthe wound and extended caudally along the birdrsquosneck (Figure 2) These incisions diverged distal tothe wound leaving the base of the flap slightly wid-er than its leading edge The skin and associatedsubcutaneous tissues between these incisions wereelevated and the flap was advanced rostrally to cov-

33GENTZ AND LINNmdashPEDICLE ADVANCEMENT FLAP IN 3 BIRDS

Figure 2 A dorsal cervical pedicle advancement flap used in a ring-necked pheasant to cover a soft tissue defect overthe cranium (A) The soft tissue defect present on the dorsum of the head (B) The dotted lines indicate incisions madeto create the advancement flap The skin edges surrounding the initial defect have also been undermined circumferentiallyfor 2ndash3 mm (C) The pedicle flap has been advanced to cover the wound and is sutured in place

er the defect The flap was sutured in place by using4-0 polyglyconate in a simple interrupted pattern(Figure 3)

The graft site was monitored daily and healingprogressed without complications Sutures were re-moved 2 weeks after surgery and the pheasant wasdischarged from the hospital

Case 2

A 026-kg adult rock dove (Columba livia) of un-known sex was presented after being found alongthe roadside The bird was thin and was missingseveral primary feathers The calvarium was ex-posed by a 20 15 cm soft tissue defect on thedorsum of the birdrsquos head The dove was initiallytreated with dexamethasone (4 mgkg IM) and lac-tated Ringerrsquos solution (50 mlkg subcutaneously[SC]) The wound was irrigated with 005 chlor-hexidine acetate solution after which polymyxin Bsulfatendashbacitracin zincndashneomycin ointment was ap-plied A semiocclusive bandage was placed over thewound Trimethoprim-sulfamethoxazole (100 mgkg PO q12h) was administered for 10 days

The wound was irrigated treated with antibioticointment and bandaged daily but the dove fre-quently dislodged the bandage After 10 days be-cause no granulation tissue was evident and the ex-posed calvarium appeared devitalized surgical de-bridement and closure of the wound was elected

The bird was premedicated with midazolam (2

mgkg IM) and glycopyrrolate (001 mgkg IM) in-tubated and maintained on 25 isoflurane Thedove was placed in sternal recumbency and the dor-sal aspect of its head and neck were aseptically pre-pared and draped as described in the pheasant (case1) Rongeurs were used to scrape desiccated bonefrom the surface of the calvarium until a smallamount of hemorrhage was evident Skin edges sur-rounding the defect were debrided and underminedThe rostral skin edges were apposed by using 4-0polyglyconate in a simple interrupted pattern Adorsal cervical single pedicle advancement flap wasdeveloped as described in case 1 In the dove how-ever less subcutaneous tissue was elevated with theskin and the lateral aspects of the flap convergedslightly toward the base The graft was advancedrostrally to cover the defect and was sutured inplace with 4-0 polyglyconate in a simple interruptedpattern After surgery the dove was given lactatedRingerrsquos solution (20 mlkg divided between IV andSC routes) The midazolam was reversed with flu-mazenil (004 mgkg IM Romazicon Hoffman-LaRoche Nutley NJ USA) and the bird was givenbutorphanol (01 mgkg IM Torbutrol Fort DodgeLaboratories Fort Dodge IA USA) for postoper-ative analgesia

Within 8 days after surgery the portion of theflap covering the defect became was necrotic Thebird was anesthetized and prepared for aseptic sur-gery and the necrotic skin covering the defect wasdebrided The wound was irrigated with sterile

34 JOURNAL OF AVIAN MEDICINE AND SURGERY

Figure 3 The pheasant described in Figure 1 after surgical repair of the soft tissue defect over the cranium A dorsalcervical pedicle advancement flap was used

physiologic saline solution and a new single pedi-cle flap was developed from the cervical skin caudalto the original defect To ensure that the base of theflap was broader than its leading edge divergentlateral incisions were created Despite the fact thatthis was the second pedicle graft developed fromthe dorsal cervical skin the flap was easily mobi-lized to cover the defect with very little tension onthe graft The skin flap was sutured in place by us-ing 4-0 polyglyconate in a simple interrupted pat-tern This repair healed without incident and su-tures were removed 2 weeks after surgery The dovewas released 4 days later

Case 3

A 07-kg adult red-tailed hawk (Buteo jamaicen-sis) of unknown sex was presented after beingfound in a field The bird was in thin body condi-tion but it was quiet alert responsive and able toperch A circular depression fracture measuring 8mm in diameterwas e videnti n th epa rietalbo necaudal to the left eye and the wound overlying thisfracture contained feathers bone fragments and ne-crotic soft tissue The caudal aspect of the left orbitwas also fractured and a small amount of clear fluidwas draining from the left globe No metallic ob-jects were evident on skull radiographs Debris wasremoved from the wound and it was irrigated with005 chlorhexidine acetate solution Topical silversulfadiazine ointment (Silvadene Hoechst MarionRoussel Kansas City MO USA) was applied andthe wound was covered with a semiocclusive ban-dage

Results of a complete blood count (CBC) re-

vealed anemia (packed cell volume 26 referencerange 42ndash47) hypoproteinemia (28 gdl refer-ence range 38ndash48 gdl) and leukocytosis (22 600cellsl reference range 6000ndash8000 cellsl) char-acterized by heterophilia (18 800 cellsl [83]reference range 2100ndash2800 cellsl [24ndash46])13

The hawk was treated with 25 dextrosendashhalf-strength lactated Ringerrsquos solution (20 ml by ga-vage q8h for 48h) enrofloxacin (15 mgkg POq12h Baytril Bayer Shawnee Mission KS USA)and a single injection of iron dextran (10 mgkgIM)14 and vitamin B complex (10 mgkg of thiamineSC) Each day for 1 week the wound was irrigatedwith 005 chlorhexidine acetate solution dressedwith silver sulfadiazine ointment and covered witha semiocclusive bandage After 1 week surgical de-bridement and closure was elected to expeditewound healing

After inducing anesthesia with 5 isoflurane ad-ministered by mask the hawk was intubated andmaintained on 25 isoflurane The bird was placedin sternal recumbency and the dorsal aspect of thehead and neck were prepared for aseptic surgeryand draped as described in case 1 Necrotic bonewas debrided from the edges of the defect with ron-geurs Skin edges surrounding the wound were de-brided and undermined and an inverted U-shapedincision with arms 5 cm long and 25 cm apart wasmade immediately caudal to the wound After theskin and associated subcutaneous tissues were ele-vated from underlying muscle the flap was ad-vanced rostrally to cover the defect The graft wassutured to the surrounding skin with 4-0 polyglactin910 (Vicryl Ethicon Somerville NJ USA) in a

35GENTZ AND LINNmdashPEDICLE ADVANCEMENT FLAP IN 3 BIRDS

simple interrupted pattern After surgery the hawkwas treated with lactated Ringerrsquos solution (50 mlkg SC) and butorphanol (01 mgkg IM)

The wound healed without incident and sutureswere removed 14 days after surgery A CBC wasrepeated and results showed that previous hema-tologic abnormalities had resolved Feather cover-age of the head was complete and normal in ap-pearance Because of loss of vision in its left eyethe hawk remained in captivity A year after sur-gery a bony defect remained under the soft tissueon the dorsum of the hawkrsquos head

Discussion

Skin lacerations and abrasions on the head canusually heal without surgical intervention1 In thepheasant (case 1) and dove (case 2) healing by sec-ond intention was delayed because of the presenceof devitalized bone Removal of the necrotic bonemay have expedited healing However debridingthe calvarium exposed brain in the pheasant andpossibly in the hawk (case 3) making immediateclosure of the wound desirable In the dove surgicalrepair of the defect was elected to expedite healing

We chose to use a single pedicle advancementflap in each of these birds for several reasons Be-cause of the size and location of the head woundsclosure by either contraction or direct appositionmight have created sufficient traction on the uppereyelids to affect their function and result in expo-sure keratitis27 The relatively loose mobile skin inthe dorsal cervical area5 adjacent to the woundsmade it feasible to develop local flaps and to avoidthe additional operative time and donor site mor-bidity that would have accompanied harvest of freegrafts To preserve normal feather orientation on thedorsum of the head the flaps were advanced ratherthan rotated into place2 A similar technique usingtwin Z-plasties to create an advancement flap hasbeen used with success in raptors to cover skin de-fects involving the head2 A bipedicle flap whichmakes use of a releasing incision to allow closureof an adjacent defect might have been used in thebirds we describe However this type of flap canhave limited mobility and closure of the donor de-fect by primary intention can be difficult3 In ourexperience single pedicle advancement was simpleto perform and resulted in rapid and uncomplicatedhealing in 2 of the 3 birds in which it was used

Two technical errors probably led to the necrosisof the first flap created in the dove (case 2) Theshallow dissection of subcutaneous tissue in thisflap may have compromised its subdermal plexusand this vascular compromise was likely exacerbat-

ed by the caudal convergence of the lateral incisionsused to define the flap Narrowing the base of a flapdecreases the blood supply available to perfuse thesubdermal plexus311 In areas where the skin is quitemobile an attempt to create parallel side incisionscan result in inadvertent convergence of the sides iflateral tension is applied to the skin for stabilityduring incision To compensate for this tendencyone suggested strategy is to make the lateral inci-sions diverge15 Axial pattern flaps which include adirect cutaneous artery for blood supply can be nar-rowed at the base providing the artery is not com-promised411 To our knowledge use of axial patternflaps has not yet been reported in birds

The presence of devitalized bone was a factorcontributing to delayed healing of the wounds in thepheasant (case 1) and the dove (case 2) Althoughwhen both birds were presented a portion of theskull was already exposed and desiccated we at-tempted to hydrate the wounds to encourage the tis-sue to granulate38 and to prevent bone necrosis Thesemiocclusive dressing used in these birds has beenrecommended to cover wounds that heal by secondintention but an occlusive hydrocolloid dressingmight have been more effective to moisten thewounds7 In the dove the wound dried intermit-tently when the bird dislodged the dressing Sutur-ing the dressing in place or applying a tie-over ban-dage might have been more successful in coveringthe wound However once necrotic tissue was de-brided and the defects were covered with advance-ment flaps wound healing was relatively rapid andresults were functional For this reason flap closurewas elected to expedite healing in the hawk (case3) rather than waiting for the wound to close bysecond intention Because prolonged captivity ofwild birds can lead to an increase in complicationssuch as inappetence foot infections aspergillosisand stress-related death16ndash20 use of skin flaps toclose large head wounds may improve chances fora successful outcome

Dorsal head wounds in birds that are difficult orimpossible to repair by primary intention may healby secondary intention However we recommendthe use of dorsal cervical single pedicle advance-ment flaps in birds to expedite healing

References

1 Harrison GJ Selected surgical procedures In Har-rison GJ Harrison LR eds Clinical Avian Medicineand Surgery Philadelphia PA WB Saunders 1986580ndash581

2 Malley AD Whitbread TJ The integument In Ben-yon PH Forbes NA Harcourt-Brown NH eds Man-ual of Raptors Pigeons and Waterfowl Cheltenham

36 JOURNAL OF AVIAN MEDICINE AND SURGERY

British Small Animal Veterinary Association 1996129ndash139

3 Swaim SF Surgery of Traumatized Skin Manage-ment and Reconstruction in the Dog and Cat Phil-adelphia PA WB Saunders 1980

4 Pavletic MM Atlas of Small Animal ReconstructiveSurgery Philadelphia PA JB Lippincott 1993

5 Cooper JE Harrison GJ Dermatology In RitchieBW Harrison GJ Harrison LR eds Avian MedicinePrinciples and Application Lake Worth FL Wing-ers 1994608

6 Coles BH Avian Medicine and Surgery OxfordBlackwell Scientific 1985

7 Altman RB Soft tissue surgical procedures In Alt-man RB Clubb SL Dorrestein GM Quesenberry Keds Avian Medicine and Surgery Philadelphia PAWB Saunders 1997704ndash732

8 Peacock EE Wound Repair 3rd ed PhiladelphiaPA WB Saunders 1984

9 Hannon DE Swaim SF Milton JL et al Full-thick-ness mesh skin grafts in two great horned owls (Bubovirginianus) J Zoo Wildl Med 199324539ndash552

10 Johnson JH Schumacher J McClure SR et al Skingrafting in an ostrich Proc Annu Conf Assoc AvianVet 1993138ndash141

11 Pavletic MM Pedicle grafts In Slatter D ed Text-book of Small Animal Surgery Philadelphia PA WBSaunders 1993295ndash325

12 Hannon DE McGehee NW Weber TD Use of a sin-gle pedicle advancement flap for wound repair in agreat horned owl (Bubo virginianus) Proc AnnuConf Assoc Avian Vet 1995285ndash289

13 Redig PT Laboratory diagnostic procedures hema-tology serum chemistry microbiology In MedicalManagement of Birds of Prey St Paul MN RaptorCenter at the University of Minnesota 199335ndash48

14 Joseph V Preventative health programs for falconrybirds Proc Annu Conf Assoc Avian Vet 1995171ndash178

15 Pavletic MM Skin flaps classification and tech-niques Proc Annu Conf Colo Vet Med Assoc 198950137ndash138

16 Bennett RA Kuzma AB Fracture management inbirds J Zoo Wildl Med 1992235ndash18

17 Bush M James AE Some considerations of practiceof orthopedics in exotic animals J Am Anim HospAssoc 197511587

18 Bush M Montali RJ Novak GR James AE Thehealing of avian fractures a histologic xeroradio-graphic study J Am Anim Hosp Assoc 197612768

19 Rodriguez-Lainz AJ Hird DW Kass PH Brooks DLIncidence and risk factors for bumblefoot (pododer-matitis) in rehabilitated raptors Prev Vet Med 199731175ndash184

20 Jauniax T Coignoul F Pulmonary aspergillosis inBelgian marine birds Ann Med Vet 1994138277ndash281

32 JOURNAL OF AVIAN MEDICINE AND SURGERY

Figure 1 Adult female ring-necked pheasant with a soft tissue wound of the dorsal head that exposes the underlyingskull No wound contracture is present after 3 weeks of conservative wound management

closed without producing excessive tension on sur-rounding facial structures

Case Reports

Case 1

A 112-kg adult female ring-necked pheasant(Phasianus colchicus) from a game farm was pre-sented with head trauma after flying into the side ofits enclosure The bird was alert and responsivewith normal vital signs A full-thickness skinwound measuring 25 25 cm exposed the dorsalcranium (Figure 1) The wound edges were in-flamed and edematous and the exposed skull wasdesiccated The wound was irrigated with 005chlorhexidine acetate solution (Nolvasan solutionFort Dodge Labs Fort Dodge IA USA) and treatedtopically with a polymyxin B sulfatendashbacitracinzincndashneomycin ointment (Neosporin ointmentWarner Wellcome Morris Plains NJ USA) It wasthen covered with a semiocclusive bandage (Tegad-erm 3M Animal Care Products St Paul MNUSA) The pheasant was treated with trimethoprim-sulfamethoxazole (100 mgkg per os [PO] q12hBactrim Roche Nutley NJ USA) for 10 daysWound irrigation was repeated and the dressing re-placed every other day for 3 weeks At 3 weeksthe wound was unchanged in size no granulationtissue was evident and the exposed portion of theskull appeared necrotic Surgery was elected to ex-pedite healing of the wound

The pheasant was premedicated with midazolam(1 mgkg intramuscularly [IM] Versed Roche Nut-ley NJ USA) After 15 minutes it was intubated

and maintained under anesthesia with 25 isoflur-ane An intravenous (IV) catheter was placed in thebirdrsquos right medial metatarsal vein and lactatedRingerrsquos solution was administered throughout the65-minute course of surgery at a rate of 70 mlkghrThe pheasant was placed in sternal recumbencyFeathers surrounding the wound and covering thedorsal aspect of the neck were plucked and the areawas aseptically prepared with 005 chlorhexidineacetate solution and sterile physiologic saline solu-tion The bird was covered with a fenestrated trans-parent adhesive surgical drape (Transparent Surgi-cal Drape Veterinary Specialty Products Boca Ra-ton FL USA)

Skin edges surrounding the wound were debridedand undermined Small rongeurs were used to lift athin layer of devitalized bone from the calvarium atthe caudal aspect of the wound This piece of ne-crotic bone was full thickness of the skull and itsremoval exposed a 05-cm2 area of occipital cortexSkin edges involving the rostral quarter of thewound were apposed in a single interrupted patternwith 4-0 polyglyconate (Maxon Davis and GeckManati Puerto Rico) The remainder of the woundwas closed by using a single pedicle advancementflap developed from the adjacent dorsal cervicalarea Two incisions measuring 35 cm long andspaced 25 cm apart began at the caudal margin ofthe wound and extended caudally along the birdrsquosneck (Figure 2) These incisions diverged distal tothe wound leaving the base of the flap slightly wid-er than its leading edge The skin and associatedsubcutaneous tissues between these incisions wereelevated and the flap was advanced rostrally to cov-

33GENTZ AND LINNmdashPEDICLE ADVANCEMENT FLAP IN 3 BIRDS

Figure 2 A dorsal cervical pedicle advancement flap used in a ring-necked pheasant to cover a soft tissue defect overthe cranium (A) The soft tissue defect present on the dorsum of the head (B) The dotted lines indicate incisions madeto create the advancement flap The skin edges surrounding the initial defect have also been undermined circumferentiallyfor 2ndash3 mm (C) The pedicle flap has been advanced to cover the wound and is sutured in place

er the defect The flap was sutured in place by using4-0 polyglyconate in a simple interrupted pattern(Figure 3)

The graft site was monitored daily and healingprogressed without complications Sutures were re-moved 2 weeks after surgery and the pheasant wasdischarged from the hospital

Case 2

A 026-kg adult rock dove (Columba livia) of un-known sex was presented after being found alongthe roadside The bird was thin and was missingseveral primary feathers The calvarium was ex-posed by a 20 15 cm soft tissue defect on thedorsum of the birdrsquos head The dove was initiallytreated with dexamethasone (4 mgkg IM) and lac-tated Ringerrsquos solution (50 mlkg subcutaneously[SC]) The wound was irrigated with 005 chlor-hexidine acetate solution after which polymyxin Bsulfatendashbacitracin zincndashneomycin ointment was ap-plied A semiocclusive bandage was placed over thewound Trimethoprim-sulfamethoxazole (100 mgkg PO q12h) was administered for 10 days

The wound was irrigated treated with antibioticointment and bandaged daily but the dove fre-quently dislodged the bandage After 10 days be-cause no granulation tissue was evident and the ex-posed calvarium appeared devitalized surgical de-bridement and closure of the wound was elected

The bird was premedicated with midazolam (2

mgkg IM) and glycopyrrolate (001 mgkg IM) in-tubated and maintained on 25 isoflurane Thedove was placed in sternal recumbency and the dor-sal aspect of its head and neck were aseptically pre-pared and draped as described in the pheasant (case1) Rongeurs were used to scrape desiccated bonefrom the surface of the calvarium until a smallamount of hemorrhage was evident Skin edges sur-rounding the defect were debrided and underminedThe rostral skin edges were apposed by using 4-0polyglyconate in a simple interrupted pattern Adorsal cervical single pedicle advancement flap wasdeveloped as described in case 1 In the dove how-ever less subcutaneous tissue was elevated with theskin and the lateral aspects of the flap convergedslightly toward the base The graft was advancedrostrally to cover the defect and was sutured inplace with 4-0 polyglyconate in a simple interruptedpattern After surgery the dove was given lactatedRingerrsquos solution (20 mlkg divided between IV andSC routes) The midazolam was reversed with flu-mazenil (004 mgkg IM Romazicon Hoffman-LaRoche Nutley NJ USA) and the bird was givenbutorphanol (01 mgkg IM Torbutrol Fort DodgeLaboratories Fort Dodge IA USA) for postoper-ative analgesia

Within 8 days after surgery the portion of theflap covering the defect became was necrotic Thebird was anesthetized and prepared for aseptic sur-gery and the necrotic skin covering the defect wasdebrided The wound was irrigated with sterile

34 JOURNAL OF AVIAN MEDICINE AND SURGERY

Figure 3 The pheasant described in Figure 1 after surgical repair of the soft tissue defect over the cranium A dorsalcervical pedicle advancement flap was used

physiologic saline solution and a new single pedi-cle flap was developed from the cervical skin caudalto the original defect To ensure that the base of theflap was broader than its leading edge divergentlateral incisions were created Despite the fact thatthis was the second pedicle graft developed fromthe dorsal cervical skin the flap was easily mobi-lized to cover the defect with very little tension onthe graft The skin flap was sutured in place by us-ing 4-0 polyglyconate in a simple interrupted pat-tern This repair healed without incident and su-tures were removed 2 weeks after surgery The dovewas released 4 days later

Case 3

A 07-kg adult red-tailed hawk (Buteo jamaicen-sis) of unknown sex was presented after beingfound in a field The bird was in thin body condi-tion but it was quiet alert responsive and able toperch A circular depression fracture measuring 8mm in diameterwas e videnti n th epa rietalbo necaudal to the left eye and the wound overlying thisfracture contained feathers bone fragments and ne-crotic soft tissue The caudal aspect of the left orbitwas also fractured and a small amount of clear fluidwas draining from the left globe No metallic ob-jects were evident on skull radiographs Debris wasremoved from the wound and it was irrigated with005 chlorhexidine acetate solution Topical silversulfadiazine ointment (Silvadene Hoechst MarionRoussel Kansas City MO USA) was applied andthe wound was covered with a semiocclusive ban-dage

Results of a complete blood count (CBC) re-

vealed anemia (packed cell volume 26 referencerange 42ndash47) hypoproteinemia (28 gdl refer-ence range 38ndash48 gdl) and leukocytosis (22 600cellsl reference range 6000ndash8000 cellsl) char-acterized by heterophilia (18 800 cellsl [83]reference range 2100ndash2800 cellsl [24ndash46])13

The hawk was treated with 25 dextrosendashhalf-strength lactated Ringerrsquos solution (20 ml by ga-vage q8h for 48h) enrofloxacin (15 mgkg POq12h Baytril Bayer Shawnee Mission KS USA)and a single injection of iron dextran (10 mgkgIM)14 and vitamin B complex (10 mgkg of thiamineSC) Each day for 1 week the wound was irrigatedwith 005 chlorhexidine acetate solution dressedwith silver sulfadiazine ointment and covered witha semiocclusive bandage After 1 week surgical de-bridement and closure was elected to expeditewound healing

After inducing anesthesia with 5 isoflurane ad-ministered by mask the hawk was intubated andmaintained on 25 isoflurane The bird was placedin sternal recumbency and the dorsal aspect of thehead and neck were prepared for aseptic surgeryand draped as described in case 1 Necrotic bonewas debrided from the edges of the defect with ron-geurs Skin edges surrounding the wound were de-brided and undermined and an inverted U-shapedincision with arms 5 cm long and 25 cm apart wasmade immediately caudal to the wound After theskin and associated subcutaneous tissues were ele-vated from underlying muscle the flap was ad-vanced rostrally to cover the defect The graft wassutured to the surrounding skin with 4-0 polyglactin910 (Vicryl Ethicon Somerville NJ USA) in a

35GENTZ AND LINNmdashPEDICLE ADVANCEMENT FLAP IN 3 BIRDS

simple interrupted pattern After surgery the hawkwas treated with lactated Ringerrsquos solution (50 mlkg SC) and butorphanol (01 mgkg IM)

The wound healed without incident and sutureswere removed 14 days after surgery A CBC wasrepeated and results showed that previous hema-tologic abnormalities had resolved Feather cover-age of the head was complete and normal in ap-pearance Because of loss of vision in its left eyethe hawk remained in captivity A year after sur-gery a bony defect remained under the soft tissueon the dorsum of the hawkrsquos head

Discussion

Skin lacerations and abrasions on the head canusually heal without surgical intervention1 In thepheasant (case 1) and dove (case 2) healing by sec-ond intention was delayed because of the presenceof devitalized bone Removal of the necrotic bonemay have expedited healing However debridingthe calvarium exposed brain in the pheasant andpossibly in the hawk (case 3) making immediateclosure of the wound desirable In the dove surgicalrepair of the defect was elected to expedite healing

We chose to use a single pedicle advancementflap in each of these birds for several reasons Be-cause of the size and location of the head woundsclosure by either contraction or direct appositionmight have created sufficient traction on the uppereyelids to affect their function and result in expo-sure keratitis27 The relatively loose mobile skin inthe dorsal cervical area5 adjacent to the woundsmade it feasible to develop local flaps and to avoidthe additional operative time and donor site mor-bidity that would have accompanied harvest of freegrafts To preserve normal feather orientation on thedorsum of the head the flaps were advanced ratherthan rotated into place2 A similar technique usingtwin Z-plasties to create an advancement flap hasbeen used with success in raptors to cover skin de-fects involving the head2 A bipedicle flap whichmakes use of a releasing incision to allow closureof an adjacent defect might have been used in thebirds we describe However this type of flap canhave limited mobility and closure of the donor de-fect by primary intention can be difficult3 In ourexperience single pedicle advancement was simpleto perform and resulted in rapid and uncomplicatedhealing in 2 of the 3 birds in which it was used

Two technical errors probably led to the necrosisof the first flap created in the dove (case 2) Theshallow dissection of subcutaneous tissue in thisflap may have compromised its subdermal plexusand this vascular compromise was likely exacerbat-

ed by the caudal convergence of the lateral incisionsused to define the flap Narrowing the base of a flapdecreases the blood supply available to perfuse thesubdermal plexus311 In areas where the skin is quitemobile an attempt to create parallel side incisionscan result in inadvertent convergence of the sides iflateral tension is applied to the skin for stabilityduring incision To compensate for this tendencyone suggested strategy is to make the lateral inci-sions diverge15 Axial pattern flaps which include adirect cutaneous artery for blood supply can be nar-rowed at the base providing the artery is not com-promised411 To our knowledge use of axial patternflaps has not yet been reported in birds

The presence of devitalized bone was a factorcontributing to delayed healing of the wounds in thepheasant (case 1) and the dove (case 2) Althoughwhen both birds were presented a portion of theskull was already exposed and desiccated we at-tempted to hydrate the wounds to encourage the tis-sue to granulate38 and to prevent bone necrosis Thesemiocclusive dressing used in these birds has beenrecommended to cover wounds that heal by secondintention but an occlusive hydrocolloid dressingmight have been more effective to moisten thewounds7 In the dove the wound dried intermit-tently when the bird dislodged the dressing Sutur-ing the dressing in place or applying a tie-over ban-dage might have been more successful in coveringthe wound However once necrotic tissue was de-brided and the defects were covered with advance-ment flaps wound healing was relatively rapid andresults were functional For this reason flap closurewas elected to expedite healing in the hawk (case3) rather than waiting for the wound to close bysecond intention Because prolonged captivity ofwild birds can lead to an increase in complicationssuch as inappetence foot infections aspergillosisand stress-related death16ndash20 use of skin flaps toclose large head wounds may improve chances fora successful outcome

Dorsal head wounds in birds that are difficult orimpossible to repair by primary intention may healby secondary intention However we recommendthe use of dorsal cervical single pedicle advance-ment flaps in birds to expedite healing

References

1 Harrison GJ Selected surgical procedures In Har-rison GJ Harrison LR eds Clinical Avian Medicineand Surgery Philadelphia PA WB Saunders 1986580ndash581

2 Malley AD Whitbread TJ The integument In Ben-yon PH Forbes NA Harcourt-Brown NH eds Man-ual of Raptors Pigeons and Waterfowl Cheltenham

36 JOURNAL OF AVIAN MEDICINE AND SURGERY

British Small Animal Veterinary Association 1996129ndash139

3 Swaim SF Surgery of Traumatized Skin Manage-ment and Reconstruction in the Dog and Cat Phil-adelphia PA WB Saunders 1980

4 Pavletic MM Atlas of Small Animal ReconstructiveSurgery Philadelphia PA JB Lippincott 1993

5 Cooper JE Harrison GJ Dermatology In RitchieBW Harrison GJ Harrison LR eds Avian MedicinePrinciples and Application Lake Worth FL Wing-ers 1994608

6 Coles BH Avian Medicine and Surgery OxfordBlackwell Scientific 1985

7 Altman RB Soft tissue surgical procedures In Alt-man RB Clubb SL Dorrestein GM Quesenberry Keds Avian Medicine and Surgery Philadelphia PAWB Saunders 1997704ndash732

8 Peacock EE Wound Repair 3rd ed PhiladelphiaPA WB Saunders 1984

9 Hannon DE Swaim SF Milton JL et al Full-thick-ness mesh skin grafts in two great horned owls (Bubovirginianus) J Zoo Wildl Med 199324539ndash552

10 Johnson JH Schumacher J McClure SR et al Skingrafting in an ostrich Proc Annu Conf Assoc AvianVet 1993138ndash141

11 Pavletic MM Pedicle grafts In Slatter D ed Text-book of Small Animal Surgery Philadelphia PA WBSaunders 1993295ndash325

12 Hannon DE McGehee NW Weber TD Use of a sin-gle pedicle advancement flap for wound repair in agreat horned owl (Bubo virginianus) Proc AnnuConf Assoc Avian Vet 1995285ndash289

13 Redig PT Laboratory diagnostic procedures hema-tology serum chemistry microbiology In MedicalManagement of Birds of Prey St Paul MN RaptorCenter at the University of Minnesota 199335ndash48

14 Joseph V Preventative health programs for falconrybirds Proc Annu Conf Assoc Avian Vet 1995171ndash178

15 Pavletic MM Skin flaps classification and tech-niques Proc Annu Conf Colo Vet Med Assoc 198950137ndash138

16 Bennett RA Kuzma AB Fracture management inbirds J Zoo Wildl Med 1992235ndash18

17 Bush M James AE Some considerations of practiceof orthopedics in exotic animals J Am Anim HospAssoc 197511587

18 Bush M Montali RJ Novak GR James AE Thehealing of avian fractures a histologic xeroradio-graphic study J Am Anim Hosp Assoc 197612768

19 Rodriguez-Lainz AJ Hird DW Kass PH Brooks DLIncidence and risk factors for bumblefoot (pododer-matitis) in rehabilitated raptors Prev Vet Med 199731175ndash184

20 Jauniax T Coignoul F Pulmonary aspergillosis inBelgian marine birds Ann Med Vet 1994138277ndash281

33GENTZ AND LINNmdashPEDICLE ADVANCEMENT FLAP IN 3 BIRDS

Figure 2 A dorsal cervical pedicle advancement flap used in a ring-necked pheasant to cover a soft tissue defect overthe cranium (A) The soft tissue defect present on the dorsum of the head (B) The dotted lines indicate incisions madeto create the advancement flap The skin edges surrounding the initial defect have also been undermined circumferentiallyfor 2ndash3 mm (C) The pedicle flap has been advanced to cover the wound and is sutured in place

er the defect The flap was sutured in place by using4-0 polyglyconate in a simple interrupted pattern(Figure 3)

The graft site was monitored daily and healingprogressed without complications Sutures were re-moved 2 weeks after surgery and the pheasant wasdischarged from the hospital

Case 2

A 026-kg adult rock dove (Columba livia) of un-known sex was presented after being found alongthe roadside The bird was thin and was missingseveral primary feathers The calvarium was ex-posed by a 20 15 cm soft tissue defect on thedorsum of the birdrsquos head The dove was initiallytreated with dexamethasone (4 mgkg IM) and lac-tated Ringerrsquos solution (50 mlkg subcutaneously[SC]) The wound was irrigated with 005 chlor-hexidine acetate solution after which polymyxin Bsulfatendashbacitracin zincndashneomycin ointment was ap-plied A semiocclusive bandage was placed over thewound Trimethoprim-sulfamethoxazole (100 mgkg PO q12h) was administered for 10 days

The wound was irrigated treated with antibioticointment and bandaged daily but the dove fre-quently dislodged the bandage After 10 days be-cause no granulation tissue was evident and the ex-posed calvarium appeared devitalized surgical de-bridement and closure of the wound was elected

The bird was premedicated with midazolam (2

mgkg IM) and glycopyrrolate (001 mgkg IM) in-tubated and maintained on 25 isoflurane Thedove was placed in sternal recumbency and the dor-sal aspect of its head and neck were aseptically pre-pared and draped as described in the pheasant (case1) Rongeurs were used to scrape desiccated bonefrom the surface of the calvarium until a smallamount of hemorrhage was evident Skin edges sur-rounding the defect were debrided and underminedThe rostral skin edges were apposed by using 4-0polyglyconate in a simple interrupted pattern Adorsal cervical single pedicle advancement flap wasdeveloped as described in case 1 In the dove how-ever less subcutaneous tissue was elevated with theskin and the lateral aspects of the flap convergedslightly toward the base The graft was advancedrostrally to cover the defect and was sutured inplace with 4-0 polyglyconate in a simple interruptedpattern After surgery the dove was given lactatedRingerrsquos solution (20 mlkg divided between IV andSC routes) The midazolam was reversed with flu-mazenil (004 mgkg IM Romazicon Hoffman-LaRoche Nutley NJ USA) and the bird was givenbutorphanol (01 mgkg IM Torbutrol Fort DodgeLaboratories Fort Dodge IA USA) for postoper-ative analgesia

Within 8 days after surgery the portion of theflap covering the defect became was necrotic Thebird was anesthetized and prepared for aseptic sur-gery and the necrotic skin covering the defect wasdebrided The wound was irrigated with sterile

34 JOURNAL OF AVIAN MEDICINE AND SURGERY

Figure 3 The pheasant described in Figure 1 after surgical repair of the soft tissue defect over the cranium A dorsalcervical pedicle advancement flap was used

physiologic saline solution and a new single pedi-cle flap was developed from the cervical skin caudalto the original defect To ensure that the base of theflap was broader than its leading edge divergentlateral incisions were created Despite the fact thatthis was the second pedicle graft developed fromthe dorsal cervical skin the flap was easily mobi-lized to cover the defect with very little tension onthe graft The skin flap was sutured in place by us-ing 4-0 polyglyconate in a simple interrupted pat-tern This repair healed without incident and su-tures were removed 2 weeks after surgery The dovewas released 4 days later

Case 3

A 07-kg adult red-tailed hawk (Buteo jamaicen-sis) of unknown sex was presented after beingfound in a field The bird was in thin body condi-tion but it was quiet alert responsive and able toperch A circular depression fracture measuring 8mm in diameterwas e videnti n th epa rietalbo necaudal to the left eye and the wound overlying thisfracture contained feathers bone fragments and ne-crotic soft tissue The caudal aspect of the left orbitwas also fractured and a small amount of clear fluidwas draining from the left globe No metallic ob-jects were evident on skull radiographs Debris wasremoved from the wound and it was irrigated with005 chlorhexidine acetate solution Topical silversulfadiazine ointment (Silvadene Hoechst MarionRoussel Kansas City MO USA) was applied andthe wound was covered with a semiocclusive ban-dage

Results of a complete blood count (CBC) re-

vealed anemia (packed cell volume 26 referencerange 42ndash47) hypoproteinemia (28 gdl refer-ence range 38ndash48 gdl) and leukocytosis (22 600cellsl reference range 6000ndash8000 cellsl) char-acterized by heterophilia (18 800 cellsl [83]reference range 2100ndash2800 cellsl [24ndash46])13

The hawk was treated with 25 dextrosendashhalf-strength lactated Ringerrsquos solution (20 ml by ga-vage q8h for 48h) enrofloxacin (15 mgkg POq12h Baytril Bayer Shawnee Mission KS USA)and a single injection of iron dextran (10 mgkgIM)14 and vitamin B complex (10 mgkg of thiamineSC) Each day for 1 week the wound was irrigatedwith 005 chlorhexidine acetate solution dressedwith silver sulfadiazine ointment and covered witha semiocclusive bandage After 1 week surgical de-bridement and closure was elected to expeditewound healing

After inducing anesthesia with 5 isoflurane ad-ministered by mask the hawk was intubated andmaintained on 25 isoflurane The bird was placedin sternal recumbency and the dorsal aspect of thehead and neck were prepared for aseptic surgeryand draped as described in case 1 Necrotic bonewas debrided from the edges of the defect with ron-geurs Skin edges surrounding the wound were de-brided and undermined and an inverted U-shapedincision with arms 5 cm long and 25 cm apart wasmade immediately caudal to the wound After theskin and associated subcutaneous tissues were ele-vated from underlying muscle the flap was ad-vanced rostrally to cover the defect The graft wassutured to the surrounding skin with 4-0 polyglactin910 (Vicryl Ethicon Somerville NJ USA) in a

35GENTZ AND LINNmdashPEDICLE ADVANCEMENT FLAP IN 3 BIRDS

simple interrupted pattern After surgery the hawkwas treated with lactated Ringerrsquos solution (50 mlkg SC) and butorphanol (01 mgkg IM)

The wound healed without incident and sutureswere removed 14 days after surgery A CBC wasrepeated and results showed that previous hema-tologic abnormalities had resolved Feather cover-age of the head was complete and normal in ap-pearance Because of loss of vision in its left eyethe hawk remained in captivity A year after sur-gery a bony defect remained under the soft tissueon the dorsum of the hawkrsquos head

Discussion

Skin lacerations and abrasions on the head canusually heal without surgical intervention1 In thepheasant (case 1) and dove (case 2) healing by sec-ond intention was delayed because of the presenceof devitalized bone Removal of the necrotic bonemay have expedited healing However debridingthe calvarium exposed brain in the pheasant andpossibly in the hawk (case 3) making immediateclosure of the wound desirable In the dove surgicalrepair of the defect was elected to expedite healing

We chose to use a single pedicle advancementflap in each of these birds for several reasons Be-cause of the size and location of the head woundsclosure by either contraction or direct appositionmight have created sufficient traction on the uppereyelids to affect their function and result in expo-sure keratitis27 The relatively loose mobile skin inthe dorsal cervical area5 adjacent to the woundsmade it feasible to develop local flaps and to avoidthe additional operative time and donor site mor-bidity that would have accompanied harvest of freegrafts To preserve normal feather orientation on thedorsum of the head the flaps were advanced ratherthan rotated into place2 A similar technique usingtwin Z-plasties to create an advancement flap hasbeen used with success in raptors to cover skin de-fects involving the head2 A bipedicle flap whichmakes use of a releasing incision to allow closureof an adjacent defect might have been used in thebirds we describe However this type of flap canhave limited mobility and closure of the donor de-fect by primary intention can be difficult3 In ourexperience single pedicle advancement was simpleto perform and resulted in rapid and uncomplicatedhealing in 2 of the 3 birds in which it was used

Two technical errors probably led to the necrosisof the first flap created in the dove (case 2) Theshallow dissection of subcutaneous tissue in thisflap may have compromised its subdermal plexusand this vascular compromise was likely exacerbat-

ed by the caudal convergence of the lateral incisionsused to define the flap Narrowing the base of a flapdecreases the blood supply available to perfuse thesubdermal plexus311 In areas where the skin is quitemobile an attempt to create parallel side incisionscan result in inadvertent convergence of the sides iflateral tension is applied to the skin for stabilityduring incision To compensate for this tendencyone suggested strategy is to make the lateral inci-sions diverge15 Axial pattern flaps which include adirect cutaneous artery for blood supply can be nar-rowed at the base providing the artery is not com-promised411 To our knowledge use of axial patternflaps has not yet been reported in birds

The presence of devitalized bone was a factorcontributing to delayed healing of the wounds in thepheasant (case 1) and the dove (case 2) Althoughwhen both birds were presented a portion of theskull was already exposed and desiccated we at-tempted to hydrate the wounds to encourage the tis-sue to granulate38 and to prevent bone necrosis Thesemiocclusive dressing used in these birds has beenrecommended to cover wounds that heal by secondintention but an occlusive hydrocolloid dressingmight have been more effective to moisten thewounds7 In the dove the wound dried intermit-tently when the bird dislodged the dressing Sutur-ing the dressing in place or applying a tie-over ban-dage might have been more successful in coveringthe wound However once necrotic tissue was de-brided and the defects were covered with advance-ment flaps wound healing was relatively rapid andresults were functional For this reason flap closurewas elected to expedite healing in the hawk (case3) rather than waiting for the wound to close bysecond intention Because prolonged captivity ofwild birds can lead to an increase in complicationssuch as inappetence foot infections aspergillosisand stress-related death16ndash20 use of skin flaps toclose large head wounds may improve chances fora successful outcome

Dorsal head wounds in birds that are difficult orimpossible to repair by primary intention may healby secondary intention However we recommendthe use of dorsal cervical single pedicle advance-ment flaps in birds to expedite healing

References

1 Harrison GJ Selected surgical procedures In Har-rison GJ Harrison LR eds Clinical Avian Medicineand Surgery Philadelphia PA WB Saunders 1986580ndash581

2 Malley AD Whitbread TJ The integument In Ben-yon PH Forbes NA Harcourt-Brown NH eds Man-ual of Raptors Pigeons and Waterfowl Cheltenham

36 JOURNAL OF AVIAN MEDICINE AND SURGERY

British Small Animal Veterinary Association 1996129ndash139

3 Swaim SF Surgery of Traumatized Skin Manage-ment and Reconstruction in the Dog and Cat Phil-adelphia PA WB Saunders 1980

4 Pavletic MM Atlas of Small Animal ReconstructiveSurgery Philadelphia PA JB Lippincott 1993

5 Cooper JE Harrison GJ Dermatology In RitchieBW Harrison GJ Harrison LR eds Avian MedicinePrinciples and Application Lake Worth FL Wing-ers 1994608

6 Coles BH Avian Medicine and Surgery OxfordBlackwell Scientific 1985

7 Altman RB Soft tissue surgical procedures In Alt-man RB Clubb SL Dorrestein GM Quesenberry Keds Avian Medicine and Surgery Philadelphia PAWB Saunders 1997704ndash732

8 Peacock EE Wound Repair 3rd ed PhiladelphiaPA WB Saunders 1984

9 Hannon DE Swaim SF Milton JL et al Full-thick-ness mesh skin grafts in two great horned owls (Bubovirginianus) J Zoo Wildl Med 199324539ndash552

10 Johnson JH Schumacher J McClure SR et al Skingrafting in an ostrich Proc Annu Conf Assoc AvianVet 1993138ndash141

11 Pavletic MM Pedicle grafts In Slatter D ed Text-book of Small Animal Surgery Philadelphia PA WBSaunders 1993295ndash325

12 Hannon DE McGehee NW Weber TD Use of a sin-gle pedicle advancement flap for wound repair in agreat horned owl (Bubo virginianus) Proc AnnuConf Assoc Avian Vet 1995285ndash289

13 Redig PT Laboratory diagnostic procedures hema-tology serum chemistry microbiology In MedicalManagement of Birds of Prey St Paul MN RaptorCenter at the University of Minnesota 199335ndash48

14 Joseph V Preventative health programs for falconrybirds Proc Annu Conf Assoc Avian Vet 1995171ndash178

15 Pavletic MM Skin flaps classification and tech-niques Proc Annu Conf Colo Vet Med Assoc 198950137ndash138

16 Bennett RA Kuzma AB Fracture management inbirds J Zoo Wildl Med 1992235ndash18

17 Bush M James AE Some considerations of practiceof orthopedics in exotic animals J Am Anim HospAssoc 197511587

18 Bush M Montali RJ Novak GR James AE Thehealing of avian fractures a histologic xeroradio-graphic study J Am Anim Hosp Assoc 197612768

19 Rodriguez-Lainz AJ Hird DW Kass PH Brooks DLIncidence and risk factors for bumblefoot (pododer-matitis) in rehabilitated raptors Prev Vet Med 199731175ndash184

20 Jauniax T Coignoul F Pulmonary aspergillosis inBelgian marine birds Ann Med Vet 1994138277ndash281

34 JOURNAL OF AVIAN MEDICINE AND SURGERY

Figure 3 The pheasant described in Figure 1 after surgical repair of the soft tissue defect over the cranium A dorsalcervical pedicle advancement flap was used

physiologic saline solution and a new single pedi-cle flap was developed from the cervical skin caudalto the original defect To ensure that the base of theflap was broader than its leading edge divergentlateral incisions were created Despite the fact thatthis was the second pedicle graft developed fromthe dorsal cervical skin the flap was easily mobi-lized to cover the defect with very little tension onthe graft The skin flap was sutured in place by us-ing 4-0 polyglyconate in a simple interrupted pat-tern This repair healed without incident and su-tures were removed 2 weeks after surgery The dovewas released 4 days later

Case 3

A 07-kg adult red-tailed hawk (Buteo jamaicen-sis) of unknown sex was presented after beingfound in a field The bird was in thin body condi-tion but it was quiet alert responsive and able toperch A circular depression fracture measuring 8mm in diameterwas e videnti n th epa rietalbo necaudal to the left eye and the wound overlying thisfracture contained feathers bone fragments and ne-crotic soft tissue The caudal aspect of the left orbitwas also fractured and a small amount of clear fluidwas draining from the left globe No metallic ob-jects were evident on skull radiographs Debris wasremoved from the wound and it was irrigated with005 chlorhexidine acetate solution Topical silversulfadiazine ointment (Silvadene Hoechst MarionRoussel Kansas City MO USA) was applied andthe wound was covered with a semiocclusive ban-dage

Results of a complete blood count (CBC) re-

vealed anemia (packed cell volume 26 referencerange 42ndash47) hypoproteinemia (28 gdl refer-ence range 38ndash48 gdl) and leukocytosis (22 600cellsl reference range 6000ndash8000 cellsl) char-acterized by heterophilia (18 800 cellsl [83]reference range 2100ndash2800 cellsl [24ndash46])13

The hawk was treated with 25 dextrosendashhalf-strength lactated Ringerrsquos solution (20 ml by ga-vage q8h for 48h) enrofloxacin (15 mgkg POq12h Baytril Bayer Shawnee Mission KS USA)and a single injection of iron dextran (10 mgkgIM)14 and vitamin B complex (10 mgkg of thiamineSC) Each day for 1 week the wound was irrigatedwith 005 chlorhexidine acetate solution dressedwith silver sulfadiazine ointment and covered witha semiocclusive bandage After 1 week surgical de-bridement and closure was elected to expeditewound healing

After inducing anesthesia with 5 isoflurane ad-ministered by mask the hawk was intubated andmaintained on 25 isoflurane The bird was placedin sternal recumbency and the dorsal aspect of thehead and neck were prepared for aseptic surgeryand draped as described in case 1 Necrotic bonewas debrided from the edges of the defect with ron-geurs Skin edges surrounding the wound were de-brided and undermined and an inverted U-shapedincision with arms 5 cm long and 25 cm apart wasmade immediately caudal to the wound After theskin and associated subcutaneous tissues were ele-vated from underlying muscle the flap was ad-vanced rostrally to cover the defect The graft wassutured to the surrounding skin with 4-0 polyglactin910 (Vicryl Ethicon Somerville NJ USA) in a

35GENTZ AND LINNmdashPEDICLE ADVANCEMENT FLAP IN 3 BIRDS

simple interrupted pattern After surgery the hawkwas treated with lactated Ringerrsquos solution (50 mlkg SC) and butorphanol (01 mgkg IM)

The wound healed without incident and sutureswere removed 14 days after surgery A CBC wasrepeated and results showed that previous hema-tologic abnormalities had resolved Feather cover-age of the head was complete and normal in ap-pearance Because of loss of vision in its left eyethe hawk remained in captivity A year after sur-gery a bony defect remained under the soft tissueon the dorsum of the hawkrsquos head

Discussion

Skin lacerations and abrasions on the head canusually heal without surgical intervention1 In thepheasant (case 1) and dove (case 2) healing by sec-ond intention was delayed because of the presenceof devitalized bone Removal of the necrotic bonemay have expedited healing However debridingthe calvarium exposed brain in the pheasant andpossibly in the hawk (case 3) making immediateclosure of the wound desirable In the dove surgicalrepair of the defect was elected to expedite healing

We chose to use a single pedicle advancementflap in each of these birds for several reasons Be-cause of the size and location of the head woundsclosure by either contraction or direct appositionmight have created sufficient traction on the uppereyelids to affect their function and result in expo-sure keratitis27 The relatively loose mobile skin inthe dorsal cervical area5 adjacent to the woundsmade it feasible to develop local flaps and to avoidthe additional operative time and donor site mor-bidity that would have accompanied harvest of freegrafts To preserve normal feather orientation on thedorsum of the head the flaps were advanced ratherthan rotated into place2 A similar technique usingtwin Z-plasties to create an advancement flap hasbeen used with success in raptors to cover skin de-fects involving the head2 A bipedicle flap whichmakes use of a releasing incision to allow closureof an adjacent defect might have been used in thebirds we describe However this type of flap canhave limited mobility and closure of the donor de-fect by primary intention can be difficult3 In ourexperience single pedicle advancement was simpleto perform and resulted in rapid and uncomplicatedhealing in 2 of the 3 birds in which it was used

Two technical errors probably led to the necrosisof the first flap created in the dove (case 2) Theshallow dissection of subcutaneous tissue in thisflap may have compromised its subdermal plexusand this vascular compromise was likely exacerbat-

ed by the caudal convergence of the lateral incisionsused to define the flap Narrowing the base of a flapdecreases the blood supply available to perfuse thesubdermal plexus311 In areas where the skin is quitemobile an attempt to create parallel side incisionscan result in inadvertent convergence of the sides iflateral tension is applied to the skin for stabilityduring incision To compensate for this tendencyone suggested strategy is to make the lateral inci-sions diverge15 Axial pattern flaps which include adirect cutaneous artery for blood supply can be nar-rowed at the base providing the artery is not com-promised411 To our knowledge use of axial patternflaps has not yet been reported in birds

The presence of devitalized bone was a factorcontributing to delayed healing of the wounds in thepheasant (case 1) and the dove (case 2) Althoughwhen both birds were presented a portion of theskull was already exposed and desiccated we at-tempted to hydrate the wounds to encourage the tis-sue to granulate38 and to prevent bone necrosis Thesemiocclusive dressing used in these birds has beenrecommended to cover wounds that heal by secondintention but an occlusive hydrocolloid dressingmight have been more effective to moisten thewounds7 In the dove the wound dried intermit-tently when the bird dislodged the dressing Sutur-ing the dressing in place or applying a tie-over ban-dage might have been more successful in coveringthe wound However once necrotic tissue was de-brided and the defects were covered with advance-ment flaps wound healing was relatively rapid andresults were functional For this reason flap closurewas elected to expedite healing in the hawk (case3) rather than waiting for the wound to close bysecond intention Because prolonged captivity ofwild birds can lead to an increase in complicationssuch as inappetence foot infections aspergillosisand stress-related death16ndash20 use of skin flaps toclose large head wounds may improve chances fora successful outcome

Dorsal head wounds in birds that are difficult orimpossible to repair by primary intention may healby secondary intention However we recommendthe use of dorsal cervical single pedicle advance-ment flaps in birds to expedite healing

References

1 Harrison GJ Selected surgical procedures In Har-rison GJ Harrison LR eds Clinical Avian Medicineand Surgery Philadelphia PA WB Saunders 1986580ndash581

2 Malley AD Whitbread TJ The integument In Ben-yon PH Forbes NA Harcourt-Brown NH eds Man-ual of Raptors Pigeons and Waterfowl Cheltenham

36 JOURNAL OF AVIAN MEDICINE AND SURGERY

British Small Animal Veterinary Association 1996129ndash139

3 Swaim SF Surgery of Traumatized Skin Manage-ment and Reconstruction in the Dog and Cat Phil-adelphia PA WB Saunders 1980

4 Pavletic MM Atlas of Small Animal ReconstructiveSurgery Philadelphia PA JB Lippincott 1993

5 Cooper JE Harrison GJ Dermatology In RitchieBW Harrison GJ Harrison LR eds Avian MedicinePrinciples and Application Lake Worth FL Wing-ers 1994608

6 Coles BH Avian Medicine and Surgery OxfordBlackwell Scientific 1985

7 Altman RB Soft tissue surgical procedures In Alt-man RB Clubb SL Dorrestein GM Quesenberry Keds Avian Medicine and Surgery Philadelphia PAWB Saunders 1997704ndash732

8 Peacock EE Wound Repair 3rd ed PhiladelphiaPA WB Saunders 1984

9 Hannon DE Swaim SF Milton JL et al Full-thick-ness mesh skin grafts in two great horned owls (Bubovirginianus) J Zoo Wildl Med 199324539ndash552

10 Johnson JH Schumacher J McClure SR et al Skingrafting in an ostrich Proc Annu Conf Assoc AvianVet 1993138ndash141

11 Pavletic MM Pedicle grafts In Slatter D ed Text-book of Small Animal Surgery Philadelphia PA WBSaunders 1993295ndash325

12 Hannon DE McGehee NW Weber TD Use of a sin-gle pedicle advancement flap for wound repair in agreat horned owl (Bubo virginianus) Proc AnnuConf Assoc Avian Vet 1995285ndash289

13 Redig PT Laboratory diagnostic procedures hema-tology serum chemistry microbiology In MedicalManagement of Birds of Prey St Paul MN RaptorCenter at the University of Minnesota 199335ndash48

14 Joseph V Preventative health programs for falconrybirds Proc Annu Conf Assoc Avian Vet 1995171ndash178

15 Pavletic MM Skin flaps classification and tech-niques Proc Annu Conf Colo Vet Med Assoc 198950137ndash138

16 Bennett RA Kuzma AB Fracture management inbirds J Zoo Wildl Med 1992235ndash18

17 Bush M James AE Some considerations of practiceof orthopedics in exotic animals J Am Anim HospAssoc 197511587

18 Bush M Montali RJ Novak GR James AE Thehealing of avian fractures a histologic xeroradio-graphic study J Am Anim Hosp Assoc 197612768

19 Rodriguez-Lainz AJ Hird DW Kass PH Brooks DLIncidence and risk factors for bumblefoot (pododer-matitis) in rehabilitated raptors Prev Vet Med 199731175ndash184

20 Jauniax T Coignoul F Pulmonary aspergillosis inBelgian marine birds Ann Med Vet 1994138277ndash281

35GENTZ AND LINNmdashPEDICLE ADVANCEMENT FLAP IN 3 BIRDS

simple interrupted pattern After surgery the hawkwas treated with lactated Ringerrsquos solution (50 mlkg SC) and butorphanol (01 mgkg IM)

The wound healed without incident and sutureswere removed 14 days after surgery A CBC wasrepeated and results showed that previous hema-tologic abnormalities had resolved Feather cover-age of the head was complete and normal in ap-pearance Because of loss of vision in its left eyethe hawk remained in captivity A year after sur-gery a bony defect remained under the soft tissueon the dorsum of the hawkrsquos head

Discussion

Skin lacerations and abrasions on the head canusually heal without surgical intervention1 In thepheasant (case 1) and dove (case 2) healing by sec-ond intention was delayed because of the presenceof devitalized bone Removal of the necrotic bonemay have expedited healing However debridingthe calvarium exposed brain in the pheasant andpossibly in the hawk (case 3) making immediateclosure of the wound desirable In the dove surgicalrepair of the defect was elected to expedite healing

We chose to use a single pedicle advancementflap in each of these birds for several reasons Be-cause of the size and location of the head woundsclosure by either contraction or direct appositionmight have created sufficient traction on the uppereyelids to affect their function and result in expo-sure keratitis27 The relatively loose mobile skin inthe dorsal cervical area5 adjacent to the woundsmade it feasible to develop local flaps and to avoidthe additional operative time and donor site mor-bidity that would have accompanied harvest of freegrafts To preserve normal feather orientation on thedorsum of the head the flaps were advanced ratherthan rotated into place2 A similar technique usingtwin Z-plasties to create an advancement flap hasbeen used with success in raptors to cover skin de-fects involving the head2 A bipedicle flap whichmakes use of a releasing incision to allow closureof an adjacent defect might have been used in thebirds we describe However this type of flap canhave limited mobility and closure of the donor de-fect by primary intention can be difficult3 In ourexperience single pedicle advancement was simpleto perform and resulted in rapid and uncomplicatedhealing in 2 of the 3 birds in which it was used

Two technical errors probably led to the necrosisof the first flap created in the dove (case 2) Theshallow dissection of subcutaneous tissue in thisflap may have compromised its subdermal plexusand this vascular compromise was likely exacerbat-

ed by the caudal convergence of the lateral incisionsused to define the flap Narrowing the base of a flapdecreases the blood supply available to perfuse thesubdermal plexus311 In areas where the skin is quitemobile an attempt to create parallel side incisionscan result in inadvertent convergence of the sides iflateral tension is applied to the skin for stabilityduring incision To compensate for this tendencyone suggested strategy is to make the lateral inci-sions diverge15 Axial pattern flaps which include adirect cutaneous artery for blood supply can be nar-rowed at the base providing the artery is not com-promised411 To our knowledge use of axial patternflaps has not yet been reported in birds

The presence of devitalized bone was a factorcontributing to delayed healing of the wounds in thepheasant (case 1) and the dove (case 2) Althoughwhen both birds were presented a portion of theskull was already exposed and desiccated we at-tempted to hydrate the wounds to encourage the tis-sue to granulate38 and to prevent bone necrosis Thesemiocclusive dressing used in these birds has beenrecommended to cover wounds that heal by secondintention but an occlusive hydrocolloid dressingmight have been more effective to moisten thewounds7 In the dove the wound dried intermit-tently when the bird dislodged the dressing Sutur-ing the dressing in place or applying a tie-over ban-dage might have been more successful in coveringthe wound However once necrotic tissue was de-brided and the defects were covered with advance-ment flaps wound healing was relatively rapid andresults were functional For this reason flap closurewas elected to expedite healing in the hawk (case3) rather than waiting for the wound to close bysecond intention Because prolonged captivity ofwild birds can lead to an increase in complicationssuch as inappetence foot infections aspergillosisand stress-related death16ndash20 use of skin flaps toclose large head wounds may improve chances fora successful outcome

Dorsal head wounds in birds that are difficult orimpossible to repair by primary intention may healby secondary intention However we recommendthe use of dorsal cervical single pedicle advance-ment flaps in birds to expedite healing

References

1 Harrison GJ Selected surgical procedures In Har-rison GJ Harrison LR eds Clinical Avian Medicineand Surgery Philadelphia PA WB Saunders 1986580ndash581

2 Malley AD Whitbread TJ The integument In Ben-yon PH Forbes NA Harcourt-Brown NH eds Man-ual of Raptors Pigeons and Waterfowl Cheltenham

36 JOURNAL OF AVIAN MEDICINE AND SURGERY

British Small Animal Veterinary Association 1996129ndash139

3 Swaim SF Surgery of Traumatized Skin Manage-ment and Reconstruction in the Dog and Cat Phil-adelphia PA WB Saunders 1980

4 Pavletic MM Atlas of Small Animal ReconstructiveSurgery Philadelphia PA JB Lippincott 1993

5 Cooper JE Harrison GJ Dermatology In RitchieBW Harrison GJ Harrison LR eds Avian MedicinePrinciples and Application Lake Worth FL Wing-ers 1994608

6 Coles BH Avian Medicine and Surgery OxfordBlackwell Scientific 1985

7 Altman RB Soft tissue surgical procedures In Alt-man RB Clubb SL Dorrestein GM Quesenberry Keds Avian Medicine and Surgery Philadelphia PAWB Saunders 1997704ndash732

8 Peacock EE Wound Repair 3rd ed PhiladelphiaPA WB Saunders 1984

9 Hannon DE Swaim SF Milton JL et al Full-thick-ness mesh skin grafts in two great horned owls (Bubovirginianus) J Zoo Wildl Med 199324539ndash552

10 Johnson JH Schumacher J McClure SR et al Skingrafting in an ostrich Proc Annu Conf Assoc AvianVet 1993138ndash141

11 Pavletic MM Pedicle grafts In Slatter D ed Text-book of Small Animal Surgery Philadelphia PA WBSaunders 1993295ndash325

12 Hannon DE McGehee NW Weber TD Use of a sin-gle pedicle advancement flap for wound repair in agreat horned owl (Bubo virginianus) Proc AnnuConf Assoc Avian Vet 1995285ndash289

13 Redig PT Laboratory diagnostic procedures hema-tology serum chemistry microbiology In MedicalManagement of Birds of Prey St Paul MN RaptorCenter at the University of Minnesota 199335ndash48

14 Joseph V Preventative health programs for falconrybirds Proc Annu Conf Assoc Avian Vet 1995171ndash178

15 Pavletic MM Skin flaps classification and tech-niques Proc Annu Conf Colo Vet Med Assoc 198950137ndash138

16 Bennett RA Kuzma AB Fracture management inbirds J Zoo Wildl Med 1992235ndash18

17 Bush M James AE Some considerations of practiceof orthopedics in exotic animals J Am Anim HospAssoc 197511587

18 Bush M Montali RJ Novak GR James AE Thehealing of avian fractures a histologic xeroradio-graphic study J Am Anim Hosp Assoc 197612768

19 Rodriguez-Lainz AJ Hird DW Kass PH Brooks DLIncidence and risk factors for bumblefoot (pododer-matitis) in rehabilitated raptors Prev Vet Med 199731175ndash184

20 Jauniax T Coignoul F Pulmonary aspergillosis inBelgian marine birds Ann Med Vet 1994138277ndash281

36 JOURNAL OF AVIAN MEDICINE AND SURGERY

British Small Animal Veterinary Association 1996129ndash139

3 Swaim SF Surgery of Traumatized Skin Manage-ment and Reconstruction in the Dog and Cat Phil-adelphia PA WB Saunders 1980

4 Pavletic MM Atlas of Small Animal ReconstructiveSurgery Philadelphia PA JB Lippincott 1993

5 Cooper JE Harrison GJ Dermatology In RitchieBW Harrison GJ Harrison LR eds Avian MedicinePrinciples and Application Lake Worth FL Wing-ers 1994608

6 Coles BH Avian Medicine and Surgery OxfordBlackwell Scientific 1985

7 Altman RB Soft tissue surgical procedures In Alt-man RB Clubb SL Dorrestein GM Quesenberry Keds Avian Medicine and Surgery Philadelphia PAWB Saunders 1997704ndash732

8 Peacock EE Wound Repair 3rd ed PhiladelphiaPA WB Saunders 1984

9 Hannon DE Swaim SF Milton JL et al Full-thick-ness mesh skin grafts in two great horned owls (Bubovirginianus) J Zoo Wildl Med 199324539ndash552

10 Johnson JH Schumacher J McClure SR et al Skingrafting in an ostrich Proc Annu Conf Assoc AvianVet 1993138ndash141

11 Pavletic MM Pedicle grafts In Slatter D ed Text-book of Small Animal Surgery Philadelphia PA WBSaunders 1993295ndash325

12 Hannon DE McGehee NW Weber TD Use of a sin-gle pedicle advancement flap for wound repair in agreat horned owl (Bubo virginianus) Proc AnnuConf Assoc Avian Vet 1995285ndash289

13 Redig PT Laboratory diagnostic procedures hema-tology serum chemistry microbiology In MedicalManagement of Birds of Prey St Paul MN RaptorCenter at the University of Minnesota 199335ndash48

14 Joseph V Preventative health programs for falconrybirds Proc Annu Conf Assoc Avian Vet 1995171ndash178

15 Pavletic MM Skin flaps classification and tech-niques Proc Annu Conf Colo Vet Med Assoc 198950137ndash138

16 Bennett RA Kuzma AB Fracture management inbirds J Zoo Wildl Med 1992235ndash18

17 Bush M James AE Some considerations of practiceof orthopedics in exotic animals J Am Anim HospAssoc 197511587

18 Bush M Montali RJ Novak GR James AE Thehealing of avian fractures a histologic xeroradio-graphic study J Am Anim Hosp Assoc 197612768

19 Rodriguez-Lainz AJ Hird DW Kass PH Brooks DLIncidence and risk factors for bumblefoot (pododer-matitis) in rehabilitated raptors Prev Vet Med 199731175ndash184

20 Jauniax T Coignoul F Pulmonary aspergillosis inBelgian marine birds Ann Med Vet 1994138277ndash281