The importance and versatility of skin is often overlooked. It is taken for granted that when a skin lump is removed, the skin edges will just be sutured back together with ease. Sometimes this is not the case and imaginative ways need to be employed to bring the skin back together with no tension. Wounds under tension are destined to break down.
Rosie presented to us with a large tennis ball sized tumour on her elbow. In order to remove the tumour in its entirety, and additionally get clear margins, a large amount of skin had to be removed from the area. Technically, the excision of the tumour and overlying skin is straight forward. The challenge begins when trying to close the wound. When skin is cut it naturally retracts making the defect even larger. With large defects on the limbs it is simply impossible to bring the edges together, there would be far too much tension and the wound would pull apart and breakdown.
One way to reduce tension is to pre stretch the skin prior to surgery using, believe it or not, Velcro! Velcro dots can be stuck to the skin on either side of the anticipated wound and drawn together using a Velcro strip. Although ingenious, in Rosie’s case the wound was too big even with lots of pre-stretching. Instead we used a more advanced technique. A thoraco dorsal skin flap is a procedure whereby skin over the shoulder blade is cut in such a way as to preserve its blood supply and then rotated 180 degrees downwards to cover the defect on the elbow. The resultant wound over the shoulder blade can be closed quite easily as the skin in this area is much more mobile and can be brought together with very little tension. The flap is sutured over the elbow wound, closing it nicely with no tension.
After her thoraco dorsal skin flap surgery, Rosie awoke free from cancer and with an elbow that can be flexed and used as normal. Had it not been for the development of this technique, Rosie would have faced limb amputation or months of wound dressing and cleaning with the real possibility of infection and set back.
Rosie is fully recovered and jumping for joy!