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T O day' S Ve T erinary Prac T ice | September/October 2016 | tvpjournal.com P rac T ica L T ec H ni QU e S F r OM TH e na V c in ST i TUT e Peer r eviewed 74 to fasten the flap into its permanent location (Figure 11). a lternatively, some surgeons use small towel clamps to help hold the flap and donor defect edges together while suturing. 3. Once these sutures have loosely positioned the flap, begin closing the hypodermal layer with monofilament absorbable 3-0 or 4-0 suture material in a continuous pattern. c lose the skin with a simple interrupted or simple continuous pattern (my preference) 3-0 or 4-0 monofilament nonabsorbable sutures or with skin staples. 4. Keep the donor defect covered with moistened laparotomy pads until the hypodermis of the flap and defect margins is closed. Undermine the donor skin margins if tension develops while closing the defect. 5. c ontinue closure of the donor defect with hypodermal and skin sutures using the materials mentioned previously (Figure 12). POSTOPERATIVE CARE Bandaging Once surgery is complete, place an e lizabethan collar on the patient and cover the mammary donor region with a stockinette or light bandage (at the surgeon's discretion). i prefer not to bandage the flap after surgery as bandages often "ride up" in the inguinal region, which can cause discomfort and, more important, put pressure on the flap vasculature, compromising perfusion of the flap. Cold Therapy The donor area can be cold-packed for several days after surgery, but i prefer to avoid cold packing the flap region, which can cause vasoconstriction of the subdermal blood supply and compromise the flap. Medical Therapy KEY POINT: e xpect the extensive skin incision and undermining to cause substantial pain post surgery. Therefore, systemic opioids and nonsteroidal anti-inflammatory drugs are administered postoperatively for 24 to 48 hours. a ppropriate orally administered analgesics are given for 5 to 7 days after surgery. Postoperative antibiotic use is limited to patients with signs of wound infection or those in which there was a break in aseptic technique during the surgical procedure. Home Care Owners are instructed to monitor wounds carefully and seek veterinary attention if they notice increasing discomfort, inflammation, or drainage after surgery. Patients should be strictly limited to leash walks, and prohibited from stair climbing, jumping, or running until suture removal at 14 days after surgery. The patient can then gradually increase activity. FIGURE 11. Simple interrupted hypodermal sutures are placed to distribute the tension evenly around the flap and defect margins. FIGURE 12. Healed CSE flap at suture removal 14 days after reconstruction; this is the same dog shown in Figures 7 to 11. FIGURE 13. Patient with a seroma under a right CSE flap, which was used to reconstruct a defect over the cranial stifle and proximal lateral tibia.