Clinical cases of skin surgery

Presentation

Clinical cases of skin surgery

JoaquĂ­n J. Sopena Juncosa

brochure

CliniCal Cases of

skin surgery JoaquĂ­n J. Sopena Juncosa

Joaquín J. Sopena Juncosa

CliniCal Cases of

skin surgery

Clinical cases of skin surgery

Clinical cases of skin surgery

Joaquín J. Sopena Juncosa

Authors: Joaquín J. Sopena Juncosa

and collaborators.

Format: 23 x 29.7 cm.

Number of pages: 208.

Number of images: 550. binding: hardcover.

RETAIL PRICE

83 €

Dr Joaquín J. Sopena has gathered together for that work a

eBook included

remarkable team of national and international specialists in skin surgery in small animals, presenting a versatile work on clinical cases. The book will be structured in a practical and applied manner, aiming at providing a detailed description of each case, including the surgical technique and many pictures and step-bystep series. More than 30 clinical cases on skin surgery that will serve as a guide for every vet in practice confronted for the first time to similar cases.

This publication will be a reference guide for those veterinary surgeons whose intention is to improve clinical management of big wounds requiring one or several surgeries.

Presentation of the book Who has never had to assess the different possibilities for the closure of a wound before making a decision? It is not rare for a veterinary surgeon to have to perform complex techniques to ensure the appropriate closure of a surgical wound. The reasons why these techniques are required are often varied, but they are usually associated with the removal of large masses. In these situations, depending on the wound location, we may encounter serious problems to close the defect that has been created.

There are numerous sources in which we can find answers to our questions, and which will always be part of our collection of reference books. However, situations will always occur that are very specific to our case and more difficult to solve. The details of some techniques are not always accurately reflected, which may cause some problems when performing the procedure and lead to more or less serious complications.

The objective of this book is to answer some of these questions we have all asked ourselves at one time or another.

Based on the experience of all our collaborators, we have elaborated a book that analyses surgical techniques and provides different views, insights, “tips”, approaches that readers may not have considered on previous occasions. All this without forgetting to respect the basic criteria of conventional skin surgery, but with information that only surgeons with years of experience and a lot of training in this field can provide.

In order to achieve this objective, we have gathered renowned professionals with a wide experience in this type of surgical treatment. The path to this book actually started years ago with a work that collected the principles of wound surgery, approached from different points of view and explained with the help of very practical texts (Manejo de heridas y principios de cirugía plástica en pequeños animales, Editorial Servet, 2010). The same approach has been used in this book. To do so, we have worked with most of the collaborators who participated in the elaboration of the previous work, but also with several new, internationally renowned, authors. This way, new views and approaches to the cases are provided.

We have organised this book into four similarly structured sections. After an introduction to the key topic of the section (with general principles to facilitate the understanding of the cases explained further on), a selection of clinical cases are provided to highlight different technical and clinical aspects useful in daily veterinary practice.

The book follows a logical structure; it starts with a chapter dedicated to the wounds that cannot be closed directly and require surgical treatment to prepare the area, debridement and delayed closure. The following chapter describes cases in which skin flaps, which are perhaps the most common plastic surgery technique in veterinary medicine, may be used. The third chapter is dedicated to skin grafts, with a special emphasis on the technique and postoperative period. Finally, we have selected a series of cases in which special techniques have been applied, either because of their complexity (axial pattern flaps, expanders, etc.) or because they are uncommon or less popular (growth factors, vacuum, etc.)

We hope to have achieved the goals we had set, but only the reader, the fellow veterinary surgeon who uses this book will be able to tell us if that is so. Surely there will be some issues left to address, new questions will arise and time will tell us that new approaches or treatments should be considered… who knows, this might be the seed of a third volume.

Joaquín J. Sopena Juncosa

Clinical cases of skin surgery

The author Joaquín J. Sopena Juncosa Graduate and Doctor of Medicine from the University of Zaragoza. Assistant Professor of the Dept. of Animal Medicine and Surgery at CEU Cardenal Herrera University (UCH CEU).

Vice-Deacon of The Faculty of Veterinary Science at UCH CEU.

He is a member of the managing committee for the García Cugat Foundation-UCH CEU, the European Society of Veterinary Trauma and Orthopaedics (ESVOT) and the Spanish Association Small Animal Veterinary Surgeons (AVEPA).

Author of the book Wound management and principles of plastic surgery in small animals (Editorial Servet, 2009) and numerous papers and courses on plastic surgery and the management of large wounds at national and international level.

hkeita/shutterstock.com

His lines of research have focused on surgical techniques and advanced applied therapies in the field of veterinary medicine and experimental surgery. He currently manages the Research Group for Experimental and Applied Veterinary Surgery at UCH CEU. In this field he also works with the García Cugat Foundation for biomedical research. He has supervised 7 doctorate theses and has written over 50 scientific articles in national and international journals.

Collaborators Marc Ardèvol Grau Graduate in Veterinary Medicine from the University of Zaragoza. He currently works at the Hospital Veterinari

and owner of the Clínica Loriguilla Veterinaria (Loriguilla, Valencia). Member of the Research Group for Experimental and Applied Veterinary Surgery at UCH CEU.

Canis (Majorca).

Ángel Díaz-Otero Medina

José María Carrillo Poveda

Graduate in Veterinary Medicine and assistant professor of

Graduate in Veterinary Medicine from the University of Murcia. Doctor in Veterinary Medicine from UCH CEU. Assistant Professor of the Dept. of Animal Medicine and Surgery at UCH CEU. Manager of the Trauma Department at the Clinical Veterinary Hospital at the same university and Head of Surgery at the Global Veterinary Hospital (Puerto de Sagunto, Valencia).

Paula Cava Ten Doctor in Veterinary Medicine from UCH CEU. Assistant Professor of the Dept. of Animal Medicine and Surgery at the same university. She works at the Global Veterinary Hospital (Puerto de Sagunto, Valencia) and the Technology

the Dept. of Animal Pathology at the University of Zaragoza. He practises as a surgeon in a number of veterinary clinics. Specialist in surgery, oncology and minimally invasive procedures. He has worked at the Faculty of Veterinary Science at the University of Turin in Italy.

Juan Manuel Domínguez Pérez Graduate and Doctor of Medicine from the University of Córdoba (UCO). Professor at the Dept. of Animal Medicine and Surgery at the same university. He works at the University of Córdoba Veterinary Hospital. From 2007 to 2013 he was the head of the Department of Small Animal Surgery.

Animal Center (Valencia).

José Andrés Fernández Sarmiento

Déborah Chicharro Alcántara

Graduate and Doctor of Medicine from the University of

Doctor in Veterinary Medicine from UCH CEU. Assistant

Córdoba (UCO). Professor at the Dept. of Animal Medicine and Surgery and staff member at the Small Animal Sur-

Professor of the Dept. of Animal Medicine and Surgery

gery Dept. at the UCO Veterinary Hospital. He has worked

at the same university. Postgraduate in Surgery and

at the University of Glasgow (United Kingdom) and the Sta-

Anaesthesia in Small Animals at the Autonomous Uni-

te University of North Carolina (USA).

versity of Barcelona (UAB). Member of the Research Group for Experimental and Applied Veterinary Surgery at UCH CEU.

Josep de la Fuente Laborda Graduate and Doctor of Veterinary Medicine from the University of Zaragoza and the Autonomous University of Bar-

Belén Cuervo Serrato

celona, respectively. Associate Professor at the UAB. Head

Graduate and Doctor in Veterinary Medicine from UCH

of the Dept. of Trauma and Orthopaedics at the Catalunya

CEU. Assistant Professor of the Dept. of Animal Medici-

Veterinary Hospital (Barcelona). Accredited by AVEPA in

ne and Surgery at the same university. She works at the

Trauma and Orthopaedics.

Global Veterinary Hospital (Puerto de Sagunto, Valencia).

Member of the Research Group for Experimental and Applied Veterinary Surgery at UCH CEU.

Elena Damiá Giménez

Mireia García Roselló Graduate and Doctor of Veterinary Medicine from the Polytechnic University of Valencia. Lead veterinary surgeon at the Veterinary Hospital since 2008. Since Septem-

Graduate and Doctor in Veterinary Medicine from UCH

ber 2013, she has been acting Manager. Currently a mem-

CEU. Assistant Professor of the Dept. of Animal Medicine

ber of the Research Group for Experimental and Applied

and Surgery at the same university. Veterinary surgeon

Veterinary Surgery at UCH CEU.

Clinical cases of skin surgery

Mª Eugenia Lebrero Berna Graduate in Veterinary Medicine from the University of Zaragoza. Specialist in Trauma and Orthopaedic surgery in pets from the Complutense University of Madrid.

Senior veterinary technician at the Small Animal Surgery

Partner and advisor at major veterinary clinics such as the Valencia Sur Veterinary Hospital and the Ejea Veterinary Clinic. Co-author of the collection Surgery in small animal

clinical medicine: surgical images step by step.

Department at the Veterinary Hospital and associate pro-

Monica Rubio Zaragoza

fessor in Animal Medicine and Surgery at the Dept. of Ani-

Graduate in Veterinary Science from the University of Mur-

mal Pathology at the University of Zaragoza.

cia and Doctor from the UCH CEU. Director and Associate Professor at the Department of Animal Medicine and

Juan Manuel Martí Herrero Graduate in Veterinary Medicine from the University of Zaragoza. Holder of a Diploma from the American and European Colleges of Veterinary Surgeons (Dipl. ACVS and Dipl. ECVS).

Surgery at the UCH CEU and Head of the HCV Emergency Department. Member of the Research Group for Experimental and Applied Veterinary Surgery at UCH CEU.

He has worked at veterinary clinics in London and Columbus

Mercedes Sánchez de la Muela

and the State Universities of of North Carolina, Mississippi

Graduate and Doctor of Medicine from the Complutense

and Ohio (USA). Currently a member of Veterinary Surgical

University of Madrid (UCM). Tutor at the Dept. of Animal

Specialists in Chesapeake and Virginia Beach (Virginia).

Medicine and Surgery, Faculty of Veterinary Medicine of

Juan Morgaz Rodríguez Graduate in Veterinary Medicine and tutor of Small Animal Surgery at the Department of Animal Medicine and Surgery at the University of Córdoba. He has worked at

the UZ. Member of the Department of Small Animal Surgery Complutense Veterinary Hospital. Clinical Director of the Cell Therapy Department at the Complutense Veterinary Hospital.

the Gran Sasso Hospital in Milan and at the Universities

Carolina Serrano Casorrán

of Cambridge, Minnesota, North Carolina and Liverpool.

Graduate and Doctor of Veterinary Medicine from the Uni-

Accredited member of the AVEPA Soft Tissue Surgery

versity of Zaragoza. Assistant Tutor in Animal Medicine and

(GECIRA) and holder of GPCert (SAS).

Surgery at the Dept. of Animal Pathology at the same uni-

Ángel Luis Ortillés Gonzalo Graduate in Veterinary Medicine from the University of Zaragoza. He is currently completing his thesis in veteri-

versity. Master in image-guided minimally invasive surgical techniques for biomedical science and Master in Small Animal Clinical Medicine from the University of Zaragoza.

nary ophthalmology. Member of the Ophthalmology at the

Ana Whyte Orozco

University of Zaragoza Veterinary Hospital.

Graduate and Doctor of Veterinary Medicine from the Uni-

Mariluz Ortiz Gómez

versity of Zaragoza. Tutor in Surgical Pathology and Surgery, Faculty of Veterinary Medicine of the same university.

Graduate in Veterinary Medicine from the University of Zara-

University specialist qualification in veterinary dentistry

goza. Postgraduate in Small Animal Clinical Practice. Lead

and maxillofacial surgery from the UCM.

Veterinary Surgeon and Head of the Surgery Department at HCV CEU. Member of the Research Group for Experimental

Eliseo Zuriaga Sanchis

and Applied Veterinary Surgery at UCH CEU.

Doctor in Veterinary Medicine and Assistant Tutor from

José Benito Rodríguez Gómez

UCH CEU. Head of the Dermatology Department at HCV CEU. He currently works in the Global Veterinary Hospital

Graduate and Doctor of Medicine from the Compluten-

and Almenara Veterinary Clinic in addition to practising as

se University of Madrid (UCM). Tutor in Surgical Patholo-

a specialist in a number of clinics in the provinces of Valen-

gy and Surgery, Faculty of Veterinary Medicine of the UZ.

cia and Castellón.

Communication services Web site Online visualisation of the sample chapter.

Presentation brochure in PDF format.

Author´s CV. Sample chapter compatible with iPad.

www.grupoasis.com/promo/skin_surgery

CliniCal Cases of

skin surgery JoaquĂ­n J. Sopena Juncosa

Table of contents 1. Medical wound management Introduction and techniques Clinical cases Case 1.1 / Postoperative wound dehiscence Case 1.2 / Skin tear in the right chest wall Case 1.3 / Wound in the forearm with conservative management Case 1.4 / Deep tear in the neck

2. Surgery and secondary closure of wounds Introduction and techniques Mandibular degloving injuries Case 2.1 / Complete mandibular degloving injury

Resection of lip tumours Case 2.2 / Labial lymphoma Case 2.3 / Labial plasmacytoma

Wounds caused by drug reactions Case 2.4 / Cutaneous abrasion on forelimbs due to possible reaction to drugs

Wounds from vehicle impact with substance loss, tear wounds and other complications Case 2.5 / Severe injury with substance loss on right hind paw Case 2.6 / Infected wound on left hind limb Case 2.7 / Tear wound in the perianal and perineal region in a female cat Case 2.8 / Tear wound in the perianal and perineal region in a male cat Case 2.9 / Decision on the management of a chronic cervical wound Case 2.10 / Perianal tear wound Case 2.11 / Complicated hind paw wound

3. Skin flaps Introduction and techniques Clinical cases Case 3.1 / Correction of a skin defect in the right forelimb by means of a bipedicle flap Case 3.2 / Plastic surgery in the area of the elbow after a tumour exeresis Case 3.3 / Resolution of an avulsion injury in the limb by means of a single pedicle advancement flap Case 3.4 / Tumour exeresis in the distal region of the forearm Case 3.5 / H-plasty to correct a wound in the right iliac region Case 3.6 / Chronic wound caused by a bite in the back Case 3.7 / Wound caused by an iatrogenic burn

4. Skin grafts Introduction and techniques Clinical cases Case 4.1 / Skin graft in the region of the forearm Case 4.2 / Hit-by-car wound caused complicated by a fracture of the distal physis and malleolus of the tibia Case 4.3 / Wound caused by extravasation of intravenous fluids Case 4.4 / Infected wound in the distal region of the tibia

5. Complex techniques and bioregenerative techniques Introduction and techniques Clinical cases Case 5.1 / Treatment of wounds using a mesh with growth factors Case 5.2 / Single-pedicle, axial-pattern tubed flap after the exeresis of a perianal tumour Case 5.3 / Combination of an axial pattern flap and skin expander in a chest wall wound Case 5.4 / Chronic wound proximal to the elbow Case 5.5 / Wound in the cervical region with muscle tear Case 5.6 / Plastic surgery in a case of malformation of the upper lip Case 5.7 / Episioplasty

6. References

Clinical cases of skin surgery Case 2.2 / Labial lymphoma Airis is a 12-year-old Belgian Shepherd bitch, presenting masses on the lips (Figs. 1 and 2).

The case is referred by the oncology department for adjuvant surgery as part of treatment of lymphoma. As the condition has progressed masses have grownon the lips, which bleed frequently. After discharge, the patient continued with chemotherapy treatment at the oncology department.

36

Fig. 1. Macroscopic appearance of the mass on the

left lip.

Fig. 2. Macroscopic appearance of the mass on the right lip.

Ana Whyte, Carolina Serrano, Ángel Díaz-Otero, Mercedes Sánchez de la Muela

Physical examination The patient was calm, with normal readings, normal cardiac and pulmonary auscultation, a temperature of 38.4 °C and weight 36.6 kg.

Hard, encapsulated masses were observed around lower lips.

Submandibular lymphadenopathy was also observed.

The results of blood tests, ECG and chest X-ray were normal. An oblique X-ray of the mouth was performed to assess the jaw bone.

No signs of disorder were observed, and an intraoral X-ray of the upper jaw showed a loss of alveolar bone caused by periodontal disease at incisor level.

Surgery and secondary closure of wounds / Case 2.2

Surgical technique At the time of surgery, the patient was between cycles of chemotherapy and under treatment with antibiotics (amoxicillin-clavulanic acid) and antiinflammatories (carprofen); this treatment would be of benefit during the postoperative period.

Prior to surgery a full preoperative assessment was completed, checking that the cardiorespiratory parameters were normal.

The surgical field was prepared by shaving the area, surgical lavage and isolation of the area with sterile drapes.

The procedure commenced on the left lip, with a longitudinal incision in the skin from the corner of the lip to the chin at the level of the incisors (Fig. 3), carefully dissecting the subcutaneous tissue and achieving haemostasis using ligatures (one of the anatomical features of the lip is a high level of vascularisation, which in turn aids the healing process) (Fig. 4).

The mass is then approached through the labial mucosa, making an incision parallel to the previous one (Fig. 5). It is then resected until fully removed (Fig. 6).

37

Fig. 3. Longitudinal incision in the skin, covering the entire mass.

Fig. 4. Dissection of the subcutaneous tissue and detail of the cutaneous vascularisation after ligature.

Fig. 5. Detail of the incision and dissection of the labial mucosa on the internal aspect.

Fig. 6. Exeresis of the mass and the resulting wound.

Clinical cases of skin surgery

The wound was closed using 3/0 glyconate monofilament sutures, firstly closing the subcutaneous tissue with single stitches, followed by a continuous intradermal suture. In order to distribute the tension lines evenly and avoid the incorrect apposition of the wound edges, this suturing was done in two stages, firstly from the chin to the posterior part of the canine tooth and secondly, from this point to the corner of the lip (Figs. 7 and 8).

Fig. 7. Intradermal suture of the anterior portion.

38

Fig. 8. Completed suture.

On the lower right lip two areas were affected, separated by healthy tissue, one more distal, reaching from the corner of the lip to underneath of the third premolar, and another further forward, extending from the first premolar to the second incisor (Fig. 9).

Fig. 9. Macroscopic appearance of the right side.

Surgery and secondary closure of wounds / Case 2.2

The surgery was performed independently following the same procedure as above on the opposite side (Figs. 10 and 11).

The pathologic diagnosis of the masses removed was a diffuse large cell lymphoma.

Postoperative antibiotic and antiinflammatory treatment was continued for 10 days, treating the suture area with chlorhexidine twice daily. The use of an Elizabethan collar was advised.

Evolution The patient progressed well, and was discharged 20 days after surgery, referred back to the oncology department (Fig. 12).

39

Fig. 10. Caudal mass resected and sutured defect, start of exeresis of the mass in

Fig. 11. Completed suture.

the cranial portion.

a

Fig. 12. Appearance of the area 20 days post surgery. Left side (a) and right side (b).

b

Clinical cases of skin surgery Case 2.3 / Labial plasmacytoma The patient is an 11-year-old male Yorkshire Terrier called Toy. This referred case initially presented inflammation of the lips with infection, for which antibiotic treatment was prescribed for 15 days (amoxicillin-clavulanic acid). After the inflammation was controlled, a nodule was observed. A fine-needle biopsy (FNA) was performed, revealing a malignant round cell oral tumour. The patient was then referred to us for surgical resection.

40

Fig. 1. Appearance of the lower left lip (after biopsy) with alterations to normal morphology. The arrow shows the location of the mass.

Surgical technique A wedge-shape incision was made in the skin, creating an equilateral triangle measuring 3 cm on each side, the base of which was the free edge of the lip. This covered the area of the lesion from the posterior side of the inferior canine tooth to just before the corner of the lip (Fig. 2).

Fig. 2. Approach to the external aspect via a wedgeshaped incision.

Ana Whyte, Carolina Serrano, Ángel Díaz-Otero, Mercedes Sánchez de la Muela

Physical examination The dog was calm, with normal readings, normal cardiac and pulmonary auscultation, a temperature of 37.1 °C and a weight of 4.2 kg.

No submandibular lymphadenopathy was palpated.

The results of blood tests, ECG and chest X-ray were normal.

A round mass on the left inferior lip close to the corner was observed. It was encapsulated, with a hard consistency, measuring approximately 1 cm (Fig. 1).

The surgical field was prepared by shaving the area, surgical lavage and isolation of the area with sterile drapes.

Surgery and secondary closure of wounds / Case 2.3

The dissection of the subcutaneous tissue on the external aspect was performed, applying haemostasis of the vessels using ligature (Fig. 3). An incision was then made on the internal mucosa of the lip, longitudinal to the labial edge, and the entire tumour was resected (Fig. 4 and 5).

Fig. 3. Appearance of the dissection of the subcutaneous tissue.

41

Fig. 4. Approach from the internal aspect of the lip.

Fig. 5. Appearance of the wound created after removal of the tumour.

Clinical cases of skin surgery

Several single stitches were initially placed in the subcutaneous tissue close to the edge of the lip to close the wound edges correctly and the wound was then closed from the inside using 4/0 glyconate monofilament suture material, in a simple continuous pattern, with a reinforcing knot (Fig. 6).

Fig. 6. Start of continuous suturing from the inside, after placing of single apposition sutures.

42

Once complete, the defect was closed externally using two sets of sutures, subcutaneously with 4/0 glyconate monofilament and cutaneously with 3/0 nylon, using simple interrupted sutures in both cases (Fig. 7).

The pathologic diagnosis of the mass removed was oral plasmocytoma.

Postoperative care included soft diet, antibiotic treatment (amoxicillin-clavulanic acid), mucoadhesive gel on the oral mucosa, iodine on the cutaneous sutures and Elizabethan collar.

Fig. 7. External cutaneous suture.

Evolution Patient recovery was satisfactory. Sutures were removed 7 days after surgery (Fig. 8).

Fig. 8. Removal of cutaneous sutures 7 days after surgery.

Surgery and secondary closure of wounds / Wounds caused by drug reactions

Wounds caused by drug reactions

Josep de la Fuente Laborda

Introduction The administration of intravenous drugs and the maintenance of permeable airways for several days require correct management.

Hospitalised patients must be monitored to prevent possible local conditions, both vascular (phlebitis), cutaneous and subcutaneous (leaking of fluid, local subcutaneous reactions, necrosis, etc.).

The careful placing of peripheral venous lines, correct management and hygiene, maintenance for the correct time and regular checking of intravenous line patency will prevent many of these complications.

In patients due to be hospitalised for long periods or requiring large amounts of fluids, it is advisable to fit a central venous line, as it allows larger flows of fluid and is a safer option for prolonged periods.

In case of fluid leakage, it is important to detect this early, and to know what substances have leaked. This allows local action to be taken where necessary, applying products to minimise the effect of the leakage. Where this is not possible, serious and complex situations may be encountered such as the one described in Case 2.4 (see next page).

43

Clinical cases of skin surgery Case 2.4 / Cutaneous abrasion on forelimbs due to possible reaction to drugs This case shows a 9-month-old Breton Spaniel called Luna, presenting a cutaneous abrasion due to a possible drug allergy.

44

Fig. 1. Cutaneous necrosis on the forelimbs due to a possible allergic drug reaction.

Fig. 2. The lesion extended to the underside of the thorax.

Josep de la Fuente Laborda

Clinical record The patient was admitted urgently with an acute case of haemorrhagic gastroenteritis compatible with an infectious disease. After completing the necessary laboratory tests, a diagnosis of parvovirus was given, and treatment started with antibiotics, NSAIDs, fluid replacement, plasma and intravenous feeding. After three days she began to present a widespread oedema over both forelimbs, developing cutaneous necrosis in just four days (Figs. 1 and 2).

Surgery and secondary closure of wounds / Case 2.4

Figs. 3 and 4. Appearance of granulation tissue 18 days after cutaneous necrosis.

45

Wound management From that moment a daily wound dressing regime is started, using sterile physiological saline, physical debridement, epithelisation ointment, sterile moist dressings and bandages, in addition to the necessary analgesia (fentanyl patches), antiinflammatories (carprofen) and antibiotics (marbofloxacin). After 18 days, sufficient granulation tissue had formed to proceed with the necessary skin surgery (Figs. 3 and 4). However, as it was observed that the wound was improving daily, surgery was delayed until day 60, which is when the wound no longer showed signs of evolution (Fig. 5).

Fig. 5. Appearance 60 days after cutaneous necrosis.

Clinical cases of skin surgery

Surgical technique In order to treat the wounds on the left forelimb, all scar tissue was removed (Fig. 6) and primary closure of the wound performed (Fig. 7). On the right forelimb there were two distinct areas: one with moderate epithelisation, treated by re-dressing daily using moist epithelisation dressings, and another with both areas of no epithelisation tissue and highly fibrotic scar tissue, compromising elbow mobility (Fig. 8), which was treated surgically.

Fig. 6. Removal of scar tissue from the left forelimb.

46

Fig. 7. Primary closure of the wound.

Fig. 8. Appearance of the right forelimb, showing areas with moderate epithelisation tissue and areas of no epithelisation and highly fibrotic scar tissue.

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Servet works with the most renowned national and international authors to include the topics most demanded by veterinary surgeons in its catalogue. In addition to its own works, Servet also prepares books for companies and the main multinational companies in the sector are among its clients.

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