CLINICAL REPORT

Veterinary Surgery
24172-175. 1995

Skin Fold Advancement Flaps for Closing Large Sternal and

Inguinal Wounds in Cats and Dogs

GERALDINE B. HUNT, BVSc, PhD, FACVSC

Skin fold advancement flaps can be created from the elbow and flank folds to close large wounds
in the pectoral and inguinal regions of cats and dogs, respectively. The attachments of the laterally
facing (outer) and medially facing (inner) layers of the skin fold to the adjacent limb are divided
to produce a U-shaped pedicle graft attached to the trunk. This mobilizes skin that can be
advanced over large wounds involving the ventral chest or abdomen, or both. The use of skin
fold advancement flaps enables direct closure of large skin defects without undue tension and
without compromising the mobility of the adjacent limb.
@Copyright 1995 by The American College of Veterinary Surgeons

T HE SKIN and subcutis of the ventral thorax

and abdomen may become involved in disease
processes that require removal of large areas of tissue
two sun-bathing bull terriers. We have subsequently
used this technique in two of a series of five cats with
extensive pyogranulomatous steatitis resulting from
to treat. Examples include advanced pyogranulo- Mycobacterizim smegrnatis infection that were
matous panniculitis resulting from mycobacterial treated by en bloc r e s e ~ t i o nThe
. ~ technique of skin
infection in cats,' inguinal cutaneous squamous cell fold advancement is the subject of this report.
carcinoma of white-coated dogs,2 other neoplasia of
the skin, subcutaneous tissue, mammary glands and SURGICAL TECHNIQUE
lymph nodes, trauma, burns, or abscesses. Although
the skin in these regions is easily mobilized, direct The animal is positioned in dorsal recumbency
closure of large mid-line defects may result in ex- and hair is clipped from the affected area. Depending
cessive tension on the suture line during limb move- on the location of the lesion, hair is also clipped
ment. The flank fold (NAV: plica 1ate1-k)~and elbow from the axial and abaxial surface of both fore or
fold (Fig 1) consist of laterally facing (outer) and hind limbs, to the midantebrachial or midcrural
medially facing (inner) layers of skin, separated by level, respectively. The entire shaved area is prepared
loose connective tissue. Division of their attachment for aseptic surgery and included within the draped
to the limb creates a large U-shaped flap, which may surgical field.
be advanced into adjacent skin defects, allowing The lesion is excised, including subcutaneous fat
tension-free wound closure without compromising and underlying muscle if indicated (Fig 2A and 3A).
limb mobility. Stay sutures are then placed in the edges of mobile
Skin fold advancement flaps were first developed skin on either side of the wound to prevent retraction
by the author to close wounds created by excision beneath the drapes. Advancement flaps are created
of extensive inguinal squamous cell carcinomas in on one or both sides by retracting the elbow fold

From the Department of Veterinary Anatomy, University of Sydney, NSW, Australia.

Address reprint requests to Geraldine B. Hunt, BVSc, PhD, FACVSc, Department of Veterinary Anatomy, The University of
Sydney, NSW 2006, Australia.
@Copyright 1995 by The American College of Veterinary Surgeons
016 1-349919512402-0012$3.00/0

172
 GERALDINE B. HUNT 173

Fig 1. Diagram showing the elbow fold (A) and flank fold (B)
in a domestic cat.

caudally away from the forelimb (Fig 2A, B), or the B

flank fold cranially away from the thigh (Fig 3A, B).
Both the inner (medial) and outer (lateral) layers of
the skin fold are incised along the border of the limb,
and the incision continued dorsally to the point
where the limb joins the trunk (Figs 2A, B, and 3A,
B). The double fold of skin and interposed loose
connective tissue is unfolded with the aid of gentle
dissection to form a large, broad-based, U-shaped
flap that is advanced over the wound. Extensive skin
deficits may be closed by using elbow folds from
each thoracic limb, positioned one in front of the
other over the sternum (Fig 2C). Likewise, two flank
fold advancement flaps can be used side-by-side over
the caudoventral abdomen (Fig 3C). Advancement
flaps may be created from all four limbs to cover C
even more extensive ventral skin defects.
Wounds created by excising the skin folds from
the limbs are closed by directly apposing the medial
and lateral skin edges along the border of the limb,
using a continuous synthetic absorbable suture in
the subcutaneous tissue, and interrupted sutures of
a synthetic nonabsorbable suture in the skin. Once
the skin flaps have been arranged in the wound in
the most appropriate manner, closure proceeds in a
similar fashion. It is advisable to tie the continuous
subcutaneous suture every 6 to 8 cm, then restart it, Fig 2. Diagram showing the use of bilateral elbow fold ad-
to maximize security of wound closure. It is the au- vancement flaps to close a large sternal wound in a cat. (A) After
thor’s preference to insert one or more soft latex en bloc resection of the lesion, both elbow folds are mobilized
drains beneath the skin flaps, exiting at the most by retracting them caudally (arrows). The location of the incision
dividing the elbow fold from its attachments to the limb is in-
dependent points of the wound. These are left in
dicated by the dashed lines. Note that both inner (medial) and
place for 2 to 3 days or until drainage is minimal. outer (lateral) layers of the skin fold are incised, creating a U-
shaped flap that is unfolded and advanced over the defect (B).
DISCUSSION The final result after suturing one flap behind the other is shown
in (C). Asterisks indicate the part of the flap originally situated
Advancement flaps derived from the elbow and at the point of the elbow. Soft latex drains (not labeled) are
flank skin folds allow primary closure of large ventral situated beneath each flap.
174 SKIN FOLD ADVANCEMENT FLAPS

illary area may fail to heal by primary intention

because of excessive tension during ambulation. De-
hiscence is particularly undesirable after excision of
infectious or neoplastic lesions, because it may be
difficult to determine whether wound breakdown
was caused by recurrence of the original disease pro-
cess or unsatisfactory wound healing per se.
The advancement flap described here is a sub-
dermal plexus flap,5deriving its blood supply from
terminal branches of direct cutaneous arteries. The
surgeon must ensure that the pedicle left after di-
viding the flap from its attachment to the limb is
not unduly narrow. This has not been a problem
in the cases treated thus far; however, the potential
for compromising flap viability in this manner
should be appreciated. There are no definite
guidelines regarding length-to-width ratios of sub-
dermal plexus flaps because the circulation differs
r e g i ~ n a l l yHowever,
.~ previous work suggests that
the length-to-width ratio should be restricted to
less than 2: 1 .6
The amount of skin created by mobilizing the el-
bow or flank folds is usually substantial. This type
of flap differs from the caudal superficial epigastric
axial pattern flap because it is based lateral to the
inguinal canal and does not use the ventral abdom-
inal skin. Creation of advancement flaps from all
four skin folds allows coverage of most of the ventral
C midline in the cat, although such a procedure has
c
__.c - not yet been performed by this author in a clinical
case. Although flaps illustrated in this article were
based laterally, preliminary studies show that it is
also possible to create medially based flaps to cover
skin defects of the lateral body wall (Hunt et al, un-
published observations).
Fig 3. Diagram showing the use of bilateral flank fold ad- The elbow and flank folds allow a wide range of
vancement flaps to close a large inguinal wound in a cat. Flank limb motion to occur. However, their obliteration
folds are mobilized (A) by retracting them cranially (arrows) and does not result in appreciable limb dysfunction or
dividing the attachments of the inner and outer layers of skin to dis~omfort.~ The two cats so treated retained the
the proximal thigh (dashed lines). The unfolded flaps (B) are
advanced medially to lie side-by-side over the defect. Note the
ability to run, jump, and climb normally after sur-
inguinal fat in the wound; this would be excised in cases of my- g e r ~The. ~ profile of the animal’s torso and limbs is
cobacterial panniculitis. (C) Final result after bilateral flank fold altered by this procedure, but once hair regrowth
advancement. Asterisks indicate the region of the flap originally over the surgical site is complete the abnormality is
situated near the stifle. Note the presence of a soft latex drain not obvious (Fig 4).
beneath each flap.
The efficacy of this new advancement flap tech-
nique is dependent on the presence of well-developed
wounds without undue tension and without com- skin folds. It is therefore useful for all cats but not
promising limb mobility. If sutured in a conven- all dogs. There is no limitation with the caudal flap
tional manner, large wounds in the inguinal and ax- in male dogs, as the skin harvested is remote from
 GERALDINE B. H U N T 175

the region of the prepuce and scrotum. In animals

with poorly developed flank folds, axial pattern flaps
based on the caudal superficial epigastric or deep
circumflex iliac arteries may provide an alternate
means of closing large wounds in these region^.^-^
ACKNOWLEDGMENT
I would like to acknowledge Bozena Jantulik for her
excellent artwork, Associate Professor Christopher R.
Bellenger who suggested the idea from which the tech-
nique was developed, and Dr Richard Malik for assistance
with the manuscript.

REFERENCES
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infections of the skin, in August JR (ed): Consultations
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ditions of the epithelial region, in Madewell BR, Theilen
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Fig 4. Photograph of a cat 16 weeks after removal of an ex- taneous arteries. Am J Vet Res 42:391-406, 1981
tensive mycobacterial pyogranuloma from the inguinal region. 9. Remedios AM, Bauer MS, Bowen CV: Thoracodorsal and
The skin deficit was closed using bilateral flank fold advancement caudal superficial epigastric axial pattern flaps in cats. Vet
flaps. Surg 18:380-385, 1989