I. Minor/Moderate Skin Tension Management Options

A. Definition: Able to close wound with forceps, or skin edges can be apposed by pushing adjacent skin edges together without excessive difficulty.

B. Identification of skin tension lines

1.  Closure of linear wounds without dog-ear formation

2.  Minimizing skin tension across suture line

C. Methods of minor/moderate skin tension relief

1.  Body positioning

2.  Subcuticular suture pattern

3.  Undermining skin edges

4.  Walking sutures

5.  Retention sutures/stents

6.  Relaxing/release incisions

7.  Z-plasty

8.  W-plasty technique

9.  V-Y plasty

D. Decision-making factors

1.  Tension lines

2.  Skin defect configuration (flap vs. linear incision)

3.  Vital structures in area- functional or cosmetic problem result?

4.  Vascular supply of skin (axial vessel nearby?)

5.  Viability of surrounding skin (trauma, radiation damage?)

6.  Location of defect, "mechanically important" area (elbow, etc.)

7.  Amount and direction of tension relief?

II. Larger Defects, Major Skin Tension Management Options

A. Definition: Unable to close skin without undue difficulty; closure results in distortion of important anatomic structure.

B. Method of closing major defects

1.  Local random subdermal flaps (local transfer of small to large amounts of skin, cosmesis important)

a.  Single pedicle advancement

b.  Bipedicle advancement

c.  Rotational flap

d.  Transpositional flap

e.  Interpolation flap

2.  Axial pattern flaps (ensure vascular supply, transfer large amounts of skin to more distant areas compared to subdermal flaps, cosmesis important)

a.  Omocervical

b.  Thoracodorsal

c.  Deep circumflex iliac (dorsal, ventral branch)

d.  Caudal superficial epigastric

e.  Cranial superficial epigastric

f.  Brachial

g.  Genicular

h.  Caudal auricular

i.  Reverse saphenous

j.  Superficial temporal

k.  Caudal auricular

3.  Distant flaps (motion areas, recipient bed not ideal, cosmesis important)

a.  Direct (hinge of pouch flaps)

b.  Indirect (tubed pedicle flaps)

4.  Myocutaneous flaps (large en bloc excision, severe trauma-loss of body wall)

a.  Latissimus dorsi MC flap

b.  Cutaneous trunci MC flap

5.  Muscle flaps (cavity defect, improve vascular supply of area)

a.  Latissimus dorsi muscle

b.  External abdominal oblique

c.  Caudal sartorius muscle

d.  Cranial sartorius muscle

6.  Free Grafts (recipient bed healthy, minimal motion, cosmesis not very important)

a.  Punch/pinch grafts

b.  Strip grafts

c.  Stamp grafts

d.  Sheet grafts

e.  Mesh grafts

7.  Decision-making factors

a.  Site of defect

b.  Shape of defect

c.  Size of defect

d.  Amount and health of neighboring skin

e.  Cosmesis

f.  Body defect repair also required

g.  Recruitment of blood supply important

C. Strategy of choice of wound reconstruction

1.  Available skin to borrow locally? Yes

a.  Defects distal to elbow, stifle or tail base--no local flaps

b.  Defects in neck, truncal, or abdominal area--local or axial pattern

2.  Distance of defect away from area from which to borrow skin

a.  Large defects to be covered from distant area--axial pattern

b.  Smaller defects close to donor area--local

3.  Available skin to borrow locally? No

a.  Distant flap technique

b.  Graft

4.  Need to recruit blood supply?

a.  Yes, distant flap

b.  No, graft

5.  Wound bed conditions?

a.  Contaminated, exudative, poor vascularity, distant flap

b.  Clean, good vascularity, graft

6.  Need for mechanically durable surface?

a.  Yes, distant flap, pad transfer

b.  No, pinch, seed, mesh graft

7.  Need for skin and body wall reconstruction?

a.  Yes, myocutaneous flap

b.  No, skin flap, graft