The rhomboid flap

22264908_689114241295076_1764003733_nFlorin Cristian Delureanu

DVM, MRCVS

 

 

ABSTRACT

 

In plastic and reconstructive surgery flaps have an important place not only for the aesthetic results obtained but also because they can be used to cover an area without producing tension. The flap mechanism mainly consists of moving a piece of skin from the donor site and moving it to the recipient site (primary defect). The rhomboid flap have a big versatility because can be done anywhere on the surface of the body. Filling small and large wounds with tissue similar in texture, colour and thickness is the ideal objective of the flap. This article describes the surgical approach of two cases, one with an abscess and the other with a benign tumor located at the cutaneous level, both of which are approached by the use of the rhombic flap.

 

 

Introduction

A skin flap represent a partial detachment of a piece of skin and the adjacent subcutaneous tissue with its vascular supply intact. All skin flaps have a pivot point or base. Survival of the skin flap is made by blood circulation through its base during the procedure. From this point of view, it is important that the base of the flap be large enough to prevent necrosis.

Local flaps are based on two types of vascularization: the subdermal plexus or a vein and an artery (figure A; right side- island flap).

Classification of skin flaps is based on blood supply, transfer mode (primary motion), location, composition and configuration (most described in human medicine). Depending on the transfer method, local flaps are classified as follows: -advancement flaps: those who advance forward; -rotational flaps: describe a rotation motion (curvilinear configuration) to the primary defect.

Classification of skin flaps is based on blood supply, transfer mode (primary motion), location, composition and configuration (most described in human medicine).
Depending on the transfer method, local flaps are classified as follows:
-advancement flaps: those who advance forward;
-rotational flaps: describe a rotation motion (curvilinear configuration) to the primary defect.

 

 

The rhombic flap was invented by a human maxilofacila surgeon called Limberg Alexander Aleksandrovich in 1946. By name, the flap has rhomboid shape with two angles of 120 degrees and two angles of 60 degrees. Depending on the primary defect / lesion pattern which require coverage, the flap angles may change. It is often used in reconstructive surgery of the face in humans: eyelid, floor of nose, alar rim and chin defects with good cosmetic results. This skin flap also called Limberg flap is a transposition flap – the elevated skin will have both advancement and rotation movement when is applied over the primary defect.

 

How to design the rhombic flap

 

Whether it is a wound or a tumor, around a defect is drawn a diamond with angles of 120 degrees and 60 degrees as mentioned above. First, the short diagonal that joins the 120 degree angles (BD) must be measured and then extended in the desired direction. The extension (DE) to the outside must have the same length with the short diagonal (BD) and with the sides of the diamond. The next step is to extend another line wich is equal and parallel with the closest side of the diamond (EF). Finally the skin flap is obtained (ADEF).

Figure 1. The sketch of the rhomboid flap.The primary motion of the flap is the motion placed on it to close the primary defect; the secondary motion is the motion placed on the tissue surrounding the primary defect by the flap.

Figure 1. The sketch of the rhomboid flap.The primary motion of the flap is the motion placed on it to close the primary defect; the secondary motion is the motion placed on the tissue surrounding the primary defect by the flap.

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Figure 2. Transferring the flap to the primary defect. The direction of rotation of the flap is indicated by the purple arrow. After rotation in point A dog ear will occur (yellow elipse). During the rotation the flap describes a 120 degree movement. The higher the angle, the dog ears will be more prominent. The secondary defect will be closed following the transfer of point F to the initial position of the D point

 

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Figure 3. The final shape of the rhomboid flap. Point D reached point B, point E reached point C and point F reached point D. A is the only point which maintain the initial position.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

The surgical defect created can be covered with the rhomboid flap from 4 sides (Picture 4).

Figure 4. The variants of flap usage. The best choice is to select the side with the most laxity because in this way the adjacent anatomical structures will not be disturbed. The flap has a mathematical formula in which all sides are made to be equal.

Figure 4. The variants of flap usage. The best choice is to select the side with the most laxity because in this way the adjacent anatomical structures will not be disturbed. The flap has a mathematical formula in which all sides are made to be equal.

 

 

 

 

 

 

 

 

 

Case 1

                  

History

 

Daisy, a six years old female cat of the Maine Coon breed presented with a sebaceous cyst, 2 cm diameter, round shape, locatad on the dorsal lombo-sacral area. The owner says that the cat have a decreased appetite. The pacient was rescued and adopted and was vaccinated just when was young. The cat lives with another 3 cats in the same house, all with the same vaccination status.

General Examination

At clinical examination, apart from the wound, dehydration 6%  and a small buccal ulcer behind the last molar on the right mandible were detected. The patient was initially treated with clindamycin and meloxicam for 7 days but no improvement observed. The cyst was infected, with bad smell, partially covered with agglutinated hair and inside soft tissue necrosis was present.

Figure 5. The initial appearance of the wound, 24 hours prior to surgery.

Figure 5. The initial appearance of the wound, 24 hours prior
to surgery.

After inspection, dead space was noticed under the skin around the wound. One day before the surgery we noticed fever (40,1°C) and dehydration 8%. CBC, serum biochemistry and FeLV/FIV test were performed. Neutropenia (0.15 x 109/L, normal range: 1.48 – 10.29) and hyperglobulinemia (57g/L, normal range: 28-51) and decreased ALKP (<10 U/L, normal range: 14-111). IDEXX Snap FeLV/FIV was negative. The cat was hospitalized 24 hours for fluid therapy and i.v. antibiotic (Cefuroxime-Zinacef). After stabilizing the patient the intervention was performed.

 

 

 

Descripting the surgical steps

 

The area was clipped and clorhexidine was used for local antisepsis. Sterile marker was used to draw the rhombic shape around the primary defect.

Figure 6. Appearance of the wound after cleaning. Necrotic tissue and pus was present in the middle of the wound;

Figure 6. Appearance of the wound after cleaning. Necrotic tissue and pus was present in the middle of the wound;

 

 

 

 

 

 

 

 

 

 

Due to the presence of dead spaces   under the skin, the round shape of the primary defect was converted to a rhomboid and the rhombic lines were positioned about 1 cm from the wound margin. In this way the tissue that was not healthy was removed. Identifying the area with the highest laxity is the next step. This was done by pinching the skin around the primary defect. After choosing the appropriate area, the flap that must be transferred was drawn.

The first side of the flap (the extended line outward of the defect) and the second side of the flap (line that is the same length as the first, to the adjacent side of the defect and makes an angle of 60 degrees at the flap apex) were cut and the flap was elevated after undermining

Figure 8. The rhomboid flap is designed. The blue arrow describe the direction in which the flap will be rotated.

Figure 8. The rhomboid flap is designed. The blue arrow describe the direction in which the flap will be rotated.

Figure 9. The primary lesion was excised and the underlying tissues are undermined.

Figure 9. The primary lesion was excised and the underlying tissues are undermined.

Figure 7. The picture illustrates the extension to outside of the short diagonal of the diamond

Figure 7. The picture illustrates the extension to outside of the
short diagonal of the diamond

 

 

 

 

 

 

 

 

 

Skin cuts were made perpendicular with No.10 scalpel blade and and the flap was mobilized with help of Metzenbaum scissors. The surrounding tissues are widely undermined to avoid any tension and the flap is rotated into the recipient site. After rotation, the flap is locked in place by fixing its corners by subcutaneous sutures. The donor site is closed as the flap moves over into the new location. Finally the skin was closed with 4/0 PDX in simple interrupted suture pattern.

Figure 10. Elevation of the flap. Stay suture are used to decrease the risk of flap tip necrosis. This inconvenience usually occurs due to faulty handling during the transfer procedure (usually crushing between fingers).

Figure 10. Elevation of the flap. Stay suture are used to decrease the risk of flap tip necrosis. This inconvenience usually occurs due to faulty handling during the transfer procedure (usually crushing between fingers).

Figure 11. The flap is rotated in the desired place and the first stich is applied on the maximum point of tension. The second and the third stich are placed on the other two corners of the flap (yellow dots).

Figure 11. The flap is rotated in the desired place and the first stich is applied on the maximum point of tension. The second and the third stich are placed on the other two corners of the flap (yellow dots).

Figure 12. Immediate postoperative appearance of the flap. Simple interrupted sutures are used for skin closure

Figure 12. Immediate postoperative appearance of the flap. Simple interrupted sutures are used for skin closure

 

 

 

 

 

 

 

 

 

 

 

 

A common unaesthetic appearance after transposed flap was the “dog ears” at the pivot point. In this situation, dog ear was corrected by excising one triangle along one side of its base.

Figure 13. The aspect of the flap at 48 hours after surgery

Figure 13. The aspect of the flap at 48 hours after surgery

Figure14. The aspect of the flap in the eighth day after surgery. The direction of the hair grow is change because of the rotation.

Figure14. The aspect of the flap in the eighth day after
surgery. The direction of the hair grow is change because of the rotation.

 Figure 15. Seventeen days post surgery. The stiches were removed after ten days. No complicatios were encountered. Is very difficult to distinguish the change of the hair growth direction


Figure 15. Seventeen days post surgery. The stiches were removed after ten days. No complicatios were encountered. Is very difficult to distinguish the change of the hair growth direction

 

 

 

 

 

 

 

 

 

 

 

 

Case 2

 

History

 

Coco, a mix breed male dog, three years old was brought to the clinic because a lump was identified on the skin. Owner reports that the mass was seen some days ago and does not believe it has increased significantly. Also says it makes itching and that the dog often scratch there and bleeds. This was the owner’s only concern.

 

General examination

 

No abnormalities were detected after clinical examination except the lump. With a cauliflower aspect, the lump had a small base of implantation and 1,2/1,4 cm in diameter. After palpation of the skin around, no pain or local temperature were identified. FNA and blood tests were recommended before surgery and histopathological examination after. The owner declined for financial reasons the FNA and blood test but accepted the histopathological examination. In this situation, a two centimeter safety margin clearance was decided.

 

Surgical approach

 

            Surgical steps along with flap drawing were described above except for asepsis. In this case  iodine povidone was used.

Figure 16. The mass is identified on the left scapular area after clipping; local asepsis was made.

Figure 16. The mass is identified on the left scapular area after clipping; local asepsis was made.

Figure 17. The diamond is designed around the mass; The mid-third skin of the cranial chest was chosen for transfer

Figure 17. The diamond is designed around the mass; The mid-third skin of the cranial chest was chosen for transfer

Figure 18. Sectioning on contour lines.Control of bleeding is done by hemostat forceps

Figure 18. Sectioning on contour lines.Control of bleeding is done by hemostat forceps

 

 

 

 

 

 

 

 

 

Figure 19. The final aspect of the flap; the skin is closed with 3/0 PGA in simple interrupted pattern.

Figure 19. The final aspect of the flap; the skin is closed with 3/0 PGA in simple interrupted pattern.

 

 

 

 

 

 

 

 

Histopathological result

               Description: Cutaneous/ subcutaneous mass composed of  chistic masses well delimited by a cheratinized multilayered epithelium with epithelial cells with squamous differentiation oxifiles, mixed with abundant, granular and amorphous keratin; multifocal with the tendency of confluence, inflammatory infiltration with neutrophils, macrophages and epithelial cells is observed. Malignant neoplastic cells are not present in the examined sections.

 

               Interpretation: Benign follicular tumor – pilomatrixoma with associated granulomatous inflammatory process.

 

Figure 20. Wiev of the flap 4 days after surgery; small necrosis was noticed on the tip of the flap (green arrow).

Figure 20. Wiev of the flap 4 days after surgery; small necrosis was noticed on the tip of the flap (green arrow).

Figure 21. The aspect of the flap 23 days after surgery; the hair was cut to facilitate flap view. Small crusts are present on the tip of the flap and on the pivot point (blue arrows).Notice the cosmetic scar lines (yellow arrows).

Figure 21. The aspect of the flap 23 days after surgery; the hair was cut to facilitate flap view. Small crusts are present on the tip of the flap and on the pivot point (blue arrows).Notice the cosmetic scar lines (yellow arrows).

 

 

 

 

 

 

 

 

 

 

Common complication of the flap

 

  • Hematoma;
  • Bleeding;
  • Flap necrosis;
  • Secondary infection.

 

Short indications for proper surgical procedure

 

  • The sides of the rhomboid must have the same length;
  • The sides of the flap must must have the same length;
  • Depending on the shape of the primary lesion, the diamond angles may vary in degrees;
  • Any defect in rhombic shape shows 4 variants in which it can be covered.
  • The lowest laxity region should be chosen and as far as possible so as not to alter anatomical plans.

 

 

Annual Congress of Romanian Feline Medicine Society and 3rd Anniversary Vets on The Balkans

1455057_1385809371666592_1582061359_nOn 24-25th of May 2018 in Bucharest, Romania, held 6th edition of annual congress of Romanian Society of Feline Medicine.
Vets on The Balkans was part of the congress to celebrate 3th birthday. It was an initiative organised by SRMF and Vets on The Balkans and 7 veterianrians from the region came to present their clinical cases, as they do in the journal in general.35970301_10217274258237800_7836393764011638784_n

The veterinarians who attend were:

36063836_10217274259037820_8158738992381034496_nDr Elli Kalemntazki from Greece. She is a graduate the Faculty of Veterinary Medicine of Aristotle University in Greece and held postgraduate degree in Public Health from The National School of Public Health in Athens, Greece. She is also Profesional Coach accreditated by the International Coach Federation since 2010 and a Certified Practicioner of Neuro Linguistic programming since 2012. Her subject was “Management of communications with clients”.

Dr Mila Bobadova is graduate the Faculty of Veterinary Medicine of University of Foresty in Sofia , Bulgaria. She is head manager of „ Dobro Hrumvane” veterinary clinics in Bulgaria. Mila paricipate ESAVS Dermatology courses.Her subject was „ Dermatolgy Puzzle”.

Dr Zoran Loncar from Serbia. Workin as full time Doctor of Veterinary Medicine Regional refferal veterinarian in Neurology and Orthopedic field. Member of ECVN, ESVOT, SCIVAC, SITOT, AO-Active member, jounior speaker. Author of sciantific publications. Clinical research surgeon. I can say the she showed 40 % of the pathology in cats through the point of view of Neurology.33399188_2115310181818038_3422930777036292096_n

Dr Daniela Drumea from Romania. Veterinary doctor, Dr. Daniela Luciana Drumea graduated the University of Veterinary Medicine in Bucharest, promotion 2014. Became a member of the non-stop veterinary clinic Tazy Vet in 2011, working as a veterinary assistant during her student years. Her passion and ambition to learn as much as possible about veterinary dermatology and the ongoing training at numerous national and international congresses and workshops led to the experienced and dedicated doctor that she is today.

Dr Bianca Bofan, PhD student, veterinarian in Centru de endoscopie si chirurgie minim invasive in Bucharest, Romania. Stgrongly involved in respiratory pathology in dogs and cats. Her subject was Interventional Treatment of Nasopharyngeal Stenosis- different approach on 2 cats.

Dr Constantin Ifteme, the head manager of Centru de endoscopie si chirurgie minim invasive in Bucharest, Romania. Member of VES&VIRIES,speaker, owner and manager of Vet Traing Center in Bucharest, Romania. His subject was Esophageal stricture-it is not always easy.

36046878_10217274257677786_6946097079919837184_nDr Luba Gancheva, owner of Vets on The Balkans presented dermatology case from Bulgaria, managed together with romanian vet Dr Rares Capitan, as a great job between balkans vets. Because we strongly believe that hand by hand we all be better.
On 24th as a precongress course, she present the difference between veterinary medicine between Romania and Bulgaria. Both countries has what to learn and in that way will be more easy and fast. The motto of the journal is „ Sharing is Caring”. 25 veterinarians participated the workshop.34193737_1704022103007044_964561530542620672_n

The organization of the Congress was in high professional level and more than 200 veterinarians attended.

We would like to express our gratitude to SRMF and Dr Tache Epure and Dr Valentin Nicolae for the opportunity to be part of it and to share these moments together.

See you next year on th 7th edition!33585435_1925558754173638_2662456110895595520_n

SAVAB Congress 2018 and how Balkans were part of it!

congrestasVets on the Balkans has got 2 free registrations with accommodation from SAVAB (Small Animal Veterinary Association of Belgium) this year. It was a huge gesture to our region and our journal. They support the willing and desire of the veterianrians from East Europe to grow and improve their knowledge.

 

 

‘ The CATalogue’ cats, cats and more cats,  in Wemmel ( near to Brussels) was on 9th to 10th of March this year.

They had as speakers: Hans Kooistra, Gerry Polton, Penny Watson, Pascale Smets , Sara Van Cauwelaert .

bdr

bty

 

 

 

 

 

 

 

 

 

One of the vets, Dr Yordan Yordanov, who was able to be there, share with us:

 

 

“I am grateful for the opportunity to visit the Belgian congress for small animals, I am extremely impressed by the high level of lectures, the hospitality of the organizers Anne Kriegel, Bob Prossmasms and Mark Vanghelwell, and the good organization of the event. I’ve made many new acquaintances, and I hope other colleagues like me will discover the benefits of SAVAB.”

 

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After something like this we are strongly believe that hand by hands we all be better and we live in a wonderful world. We would like to express our gratitude to SAVAB for such a great opportunity and you should know that you are big part of our Balkan family!

 

THANK YOU SAVAB and Dr Ann Criel!!!banner catalogue

Dermatophytosis (Ringworm)

stef artMarina-Ştefania Stroe, DVM

Romania

History

Dog, yorkshire terrier, F, 6 years old, spayed, vaccinated, dewormed and with fleas and ticks treatment done, 2 kg. She has been scratched for 2 weeks. A new cat was brought home three weeks ago. The cat present areas of alopecia on the tail.

 

WhatsApp Image 2017-09-03 at 15.41.53

fig 1

Circumscribed lesions on the shoulder (Fig. 1) and on ventral cervical region (Fig. 3), areas of round shaped alopecia with erythema, scaling.

Remaining hairs may appear broken off.

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fig 2

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fig 3

Positive Wood’s lamp examination – apple green glow associated with the root of each hair (Fig. 2)

Matt fur examined with Wood’s lamp:

auricular pavilion (Fig. 4) and cervical ventral (Fig. 5) positive, fluorescent hairs.

WhatsApp Image 2017-09-03 at 15.41.49

fig 4

Picture1

fig 5

A true dermatophyte infection reveals an apple green fluorescence on the roots of the hair.

 

Diagnosis

Picture2

Fig. 6: Microscopic examination – hair with modified structure of medulla and cortex.

Dermatophytosis (Ringworm)

Other differentials (ex. demodicosis, superficial pyoderma).

Wood’s lamp examination: typical yellowish-green fluorescent hair shafts that can be given by Microsporum canis strains; only Microsporum canis fluoresces and in only about half of cases. The Wood’s lamp is useful in establishing a tentative diagnosis of dermatophytosis in dogs and cats but false-negative and false-positive results are common. Definitive diagnosis is established by DTM culture.

Trichogram: misshapen hair shafts infiltrated with hyphae and arthrospores.

Deep skin scraped: negative

Treatment

Topical antifungal treatment applied on whole body twice a week, for 6-8 weeks until the result of the DTM culture is negative. Bathing are recommended to be done with shampoo containing chlorhexidine and an antifungal (ex ketoconazole) after the animal has been clipped. Ointment containing clotrimazole applied locally in thin layer, daily.

Environment: Decontamination measures in the house, where the animal stood (changed and washed carpets, bedding, beds, pillows), taking all measures to remove spores.

Supplements based on Omega 3 and Omega 6, which will help reduce pruritus and inflammation.

Prognosis

The prognosis is good. However, it should not be forgotten that dermatophytosis is a contagious disease that can be transmitted to other animals and humans.

Cervical Herniated Disc in dog

timisoaraDR FODOR LUCIAN HAPPY PET, TIMISOARA ROMANIA

Introduction

 

Disc herniation is a neurological disorder that is characterized by slipping nucleus pulposus outside of the space between the bodies of two vertebrae, the clinical appearance of intense pain in the area. Practical part or whole kernel pulposus (soft area of ​​the intervertebral disc) herniates through a weakened area of ​​the intervertebral disc annulus. Disc herniation can occur at any level of the spine, but the two most common sites are the lumbar and cervical. To establish a diagnosis of certainty indicated imaging studies: x-rays, CT, MRI, myelography. Nuclear magnetic resonance (NMR) is much more appropriate than CT in diagnosing pathologies of the spine. The obtained images are three-dimensional and thus very well both visualization column and nerve roots, and can determine the disease itself. Currently, MRI is the imaging method for diagnosing first intention herniated disk and can even be used in patients who have no clinical symptoms.

 

Case report

 

A 4 years old male, boxer weighting 24kg was present to us, after 14 days of tetraplegia; the debut being 6 months ago when it started difficult and heavy lifting from the bottom, neck pain when the steroid anti-inflammatory drug was administrated, the symptoms were resolved;  14 days ago tetraplegia was installed.

 

Clinical Examination

The animal presents a normal body temperature, its respiratory and cardiac frequency is within normal values, biochemical parameters and blood results is not modified. Neurological tests point out the tetraplegia, with persistence of profound sensibility and the absence of superficial sensibility. After neurological examination were also present: abolished patellar reflexes, flexor reflex abolished, tibial reflex abolished, absence correctional reaction, panicular reflex abolished , anal reflex present globe bladder.

 

Additional Examinations

fig 1

fig 1

fig 2

fig 2

An MRI was done at the Telescan, Timisoara, which pointed out a extrusion of the intervertebral C2-C3 (fig. 1/2).

 

 

Diagnosis:

Cervical Herniated Disc C2-C3

 

 

Treatment:

 

  • Surgical Procedure

 

Surgical technique: ventral corpectomy, herniated disc extraction.

The dogs were anesthetized with a mixture of ketamine and xylazine (10 mg/kg and 15 mg/kg i. m.), Propofol (2 mg/kg) and artificially ventilated by a respirator with oxygen and monitored.

fig 3

fig 3

After trimming antisepsis field operator and 10% betadine solution, and took the subconjunctival tissue and skin incision, incision between the vertebrae C1-C4 (fig. 3)

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fig 5

fig 7 new

fig 6

After removing sternocephalic muscle, inferior thyroid artery is highlighted, (Fig 4/5) muscle sternohyoid that close side of trachea, esophagus, carotid, highlighting recurrent laryngeal nerve and muscle along the neck (Fig. 6)

The latter is detached the ventral tubercle of the affected disc space, resulting in highlighting the ventral face of the ring disk.

Discuss ring incision rise to the spinal canal, then extract the affected disc (Fig.7)

fig 7

fig 7

fig 8

fig 8

Hemostasis was secured with ultra incision Harmonic Scalpel(Fig.8)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

  • After surgery

 

Postoperative treatment containing corticotherapy 5 days, antibiotherapy 5 days and a bladder catheter the first 24 hours.

Surgery is commonly recommended on dogs that do not respond to medical treatment, have progressive clinical signs, or have more severe neurological deficits.

The efficacy of medical therapy may only be seen in patients that have minimal neurological deficits.

 

 

 

 

 

Discussion:

 

  • After surgery evolution of the clinical case has been very good.
  • 72 hours postoperative, the patient is able to move without any help. (Video)
  • After two months postoperative the animal is completely healed, and does not manifest any neurological symptoms.
  • The success rate with surgery is generally high provided that the spinal cord hasn’t been compressed for a long time (chronic spinal cord injury). Chronic cord injuries can be treated successfully with surgery, but the outlook is less favorable than it is for short-term (acute) injuries.

Who is Dr Andrei Timen?

  1. Who is Andrei Timen?

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Dr Andrei Timen

I graduated Faculty of Veterinary Medicine Cluj-Napoca , Romania in 1993. After six months work in large animals I joined Surgery Department In Faculty of Veterinary Medicine Cluj  from 1994 till 2006.

With two colleagues we started also private practice Trivet in 1996 in Cluj-Napoca. In 2002 I graduated the PhD program in orthopaedic surgery. In 2006 I started a new project , Trivet Clinic  with 5 vets  full time employed  where I am practicing now. Cluj-Napoca is the second city in Romania , having more than 500000 habitants and about 60 cabinets and clinics offer veterinary services for pets.15439979_1293073300765382_1452308516314094008_n

  1. Is it hard to be president of Small Animal Association on The Balkans?

I was AMVAC president for 4 years . Now I am Past president since November 2017. AMVAC means more than vets association. It is an honour to be president of Romanian Small Animal Vets Association. The team work is the most important thing and I was lucky to have dedicated colleagues. Every year we try to improve the level of education in our meetings.  In our first conference 12 years ago we had 60 vets and now more than 1100 join every year the congress. During this time we had great support from the veterinary companies and from Romanian Veterinary Chamber. Everybody understood that continuous education will improve the quality of medical acts in all practices.12800187_1033673523372029_6432084009150298114_n

3.How you combine  your professional life and your family life?

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Dr Anderi Timen and his wife

We are a vet family , my wife is also veterinarian so it is very easy to combine those aspects of life. Most of our holidays are linked to veterinary conferences, so the combination is a success one.

4.What do you think about professional level of veterinary medicine on the Balkans?

I am happy to see that the level of veterinary medicine in Balkans is improving day by day. More and more facilities are offered for the pets and the number of vet clinics is bigger every year. It means that we are on a right way and a great benefit will be the insurance program for small animals. I hope that in a few years pet  insurance companies will understand the opportunities to be present in Balkans also.

  1. What are you doing outside of professional life?

I like to practice winter sports, skiing and ice skating. Free time is dedicated to our family members 2 dogs and a cat. Also volunteer projects are taking part of my life.1468572_541932935880810_88657000_n

  1. Your opinion about Vets on The Balkans?

Sharing information between colleagues from this region is very important for the profession.Cooperation between vets from different countries were started and will continue on the benefits of our clients.

 

Do you have the Right Mindset to Success?

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Dr Elli Kalemtzaki

Do you have the Right Mindset to Success?

 

Helen is an exceptional veterinary professional. She’s been running her own veterinary practice for several years now. Her clients love her and have great trust in her.

However, she feels that she has hit a plateau because her business is not growing at the rate she would like. Finding ways to attract new clients is challenging, frustrating and intimidating for her.

She doesn’t really enjoy marketing, and her efforts have been ineffective because she’s uncomfortable promoting herself. She believes that being a good veterinarian should be more than enough to attract new clients to her practice. She relies on word of mouth to attract clients, but with growing competition in the veterinary profession this is no longer enough.

Does Helen’s situation sound familiar? Maybe you are facing similar challenges in attracting more clients and generating the full earnings potential of your business. Vet school did not prepare you for the business world. You had to go through long years of study to obtain the knowledge and skills required to be a good veterinary practitioner. And then you decided to start your own private practice. And this was an entirely new experience. An experience that requires a totally different skill set.

 

You want to make a difference! You are talented at what you are doing and you love helping your patients. But maybe you’re not attracting as many clients as you would like. You assume it will just happen naturally since you are good at what you do. But this is not always the case and this is why you need a marketing strategy in order to make more people aware of what you are offering, to show how you are better than competition and attract more of the clients that you prefer to work with.

 

Helen is in exactly this same place! And she too has been wondering what she could do differently with her business.

 

Marketing can be particularly challenging. Why? Because there’s always the possibility of rejection. When we put out our message and present our services there’s always a possibility that people might not be interested. This is why Helen, like many other veterinary practice owners, tends to avoid or resist marketing activities.

The first thing Helen needs to realize is that her own mindset is the major obstacle to the growth of her business. Like everything else in life, our attitude and mindset determine how we approach something and whether or not we succeed.

Tony Robbins says that 20% of the obstacles are around the mechanics of running a business and 80% have to do with your psychology – that is, your own fears, limits and stories about why your practice isn’t where you want it to be.

Most people think that they need to change their strategy to make real change. Whilst strategy is absolutely important, it’s not the first element to start with. Take a moment and think about your perceived limitations. They may be the “reasons” why you’ve convinced yourself you can’t achieve something.

Here are some of Helen’s limiting beliefs:

  • Marketing is bragging about what I am doing, it feels unnatural. It’s simply not me!
  • If I write this article on pet care nobody will like it and I will make a fool of myself
  • Clients get so frustrated from prices. They constantly blame me for charging them a fortune.

What does it cost Helen to think in this way? The cost is never moving an inch in her marketing, not attracting clients, and staying indefinitely stuck.

Helen has to realize that these thoughts are blocking her success and are probably not true; she needs to start exploring alternative and more realistic beliefs: “Marketing is about helping my clients learn what I am doing and to make informed decisions” or:  “Some people will like my article and might even think I’m smart for writing it.”

This shift of mindset through working with her marketing coach can have a more profound impact on Helen’s marketing effectiveness than anything else.

Marketing is a game of communication. Learning how to communicate in the most appropriate ways will get the attention and interest of your potential clients. The more you communicate, the more the relationship and trust builds.

Do You Want More Practice-Building Support?

 

e.kalemtzaki@gmail.com

 

Ask questions, get engaged, and let me know how I can help you!

Full thickness mesh graft in a cat with degloving wound – case presentation

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Delureanu FlorinCristian

Dr Delureanu FlorinCristian

Veterinary Center Otopeni

Bucharest, Romania

 

 

Introduction

An ample loss of skin with underlying tissue and exposure of deep components (eg. tendons, ligaments, bones) define a degloving injury. This kind of wounds are most frequent seen on the distal limbs, medial tarsus/ metatarsus. The main cause of deglowing wounds is car accident, special when the animal is dragged or pushed by a moving car. In all of the cases bacteria and debris are present in the wound.

Free grafts are described as a piece of skin detached from an area of the body and placed over the wound. There are two tipes of free grafts when we talk about graft thickness: full thickness (epidermis and entire dermis); partial/split thickness (epidermis and a variable portion of dermis). Skin grafts are using when exist a defect that cannot be closed by skin flaps or direct apposition. Two factors influence skin graft survival: revascularization and absorbtion of the tissue fluid.

Case report

A 4 years old female shorthair cat, weighting 3,25kg was presented to our clinic. Before that, the owner was at another clinic for consult and he was disappointed because they recommended euthanasia or amputation of the limb. Besides, the first vet treated the cat with Amoxi+Clavulanic Acid and Nekro Veyxym. The owner said that she went missing for about 10 days.

Clinical examination

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Picture 1. Dorsal aspect of the metatarsal wound Deep tissue is affected; low to moderate discharge is present.

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Picture 2. Ventral aspect of the wound; Note the big swelling and the holes at the base of the fingers (red arrows)

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Picture 3. Deep wound with circular aspect, approximate 1,5cm diameter located near saphenous vein

After a thorough clinical exam we found that all was normal excepting the degloving injury. The back right leg was affected. There was a massive inflammation with infection and a lot of debris on the dorsal surface of metatarsal area and ventral, above metatarsal pad. On the dorsal surface of metatarsal area (Picture 1). Besides, also in the ventral area, another wond proximal to the metatarsal pad and 3 deep holes was identified at the base of second, third and fourth finger (Picture 2). It could be distinguished the chronic aspect. A third lesion was registrated on the same leg, in the medial aspect of the thigh. This wound was deep with a circular shape (Picture 3). We estimated that the lesion occurred about two weeks ago. We register pain and high local temperature after palpation. The cat was stable, normothermic, with normal color on mucous membrane, CRT 3seconds and normal superficial lymph nodes.

 

 

 

 

 

 

 

Radiograph of the affected back limb

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Picture 4a

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Picture 4b

Two x-ray views was made to eliminate bone changes or foreign bodies (Picture 4a, Picture 4b).

Picture 4a, 4b- Specialist describe: Suspected slight thickening of phalanges cortical 1 fingers 3-4 and gently bending them. Soft tissue swelling of the tibio-tarso-metatarsian region.

 

 

 

 

 

 

 

Approach 

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Picture 5a

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Picture 5b

After evaluation, the initial recommendation include a good wound management under anesthesia. Before surgical debridment (Picture 5a, 5b), culture was done.

Picture 5a and Picture 5b – Dorsal and ventral aspect of the lesions after surgical debridment

 

Next, wound lavage was initiated with one bag of 500 ml of worm saline (the most easy way to deliver fluids on the wound is to connect the saline bag with a administration set to the syringe and needle with a 3-way stop cock a large amount of liquid is needed to be effective).

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Picture 6. Wound closure by simple interrupted suture.

Finally, this first stage ends with a wet to dry bandage. A primary wound closure was performed for the lesion placed on the medial aspect of the thigh (Picture 6), after intensive cleaning, removal of foreign bodies and dead skin .

Empirically the cat receive Cefquinome until the result arrive and for pain management we administered Tramadol 3mg/kg and Meloxicam 0,1-0,2mg/kg. The cat recover well after anesthesia.

 

 

 

Culture result

One day before performing surgery, we recived the culture result. Streptococcus canis (++++) was identified and was sensible to many antibiotics. Amoxicilin+Clavulanic Acid (Synulox) was initiate for general therapy and chloramphenicol ointment (Opticlor-Pasteur) for local therapy.

Next, a full thickness mesh graft was used on the dorsal aspect of the limb due to the length and depth of the wound and the other wound was left for healing by second intention, both being protected by bandages. In the next 10 day the limb wounds was treated in the same manner. Removal of bacteria, granulation tissue formation and the beginning of epithelization were supported by next bandages as follows: ·

Day 1 – wet-to-dry bandage was used after surgical debridment. (this kind of bandages adhere to the wound and remove the little layer of dead tissue when we take off). Soaked in warm saline 1-2 minutes before removing, they were changed after 24hours one to the other. Cotton gauze was the primary contact-layer of the bandage.

  • Day 2 and day 3
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    Picture 7a Fresh Sorbalgon is applied on both wounds. This dressing can absorb 20-30 times its weight in fluid, stimulate fibroblast and macrophage activity.

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    Picture 7b Calcium alginate dressing must be changed when the fibres transforms in gel.

– moisture retentive dressing (MDR) – calcium alginate (Sorbalgon-Hartmann) was the primary contact-layer. It is good to use when it exist high exudate like in our patient (Picture 7a, 7b).

 

 

 

  • Day 4,6 and day 9
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Picture 8. Hydrocolloid is indicated because he stimulate granulation and epitelisation and have a good autolytic debridment

– moisture retentive dressing (MDR) – hydrocolloid (Hydrocoll-Hartmann) was the primary contact-layer because the discharge decreased (Picture 8).

 

 

 

 

 

Describing surgical procedure:

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Picture 9. The wound is refreshed by removing the new epithelium formed around the whole wound

Preoperative surgical site preparation: The cat was placed in left lateral recumbency, with the wound exposed. The limb was clipped entirely and povidone iodine and alcohol was used for aseptic surgery. Sterile warm saline 0.9% was use for wound lavage. Meanwhile a colleague prepare the donor site in the same manner- lower cranio-lateral thorax (right side). Almost 1mm of epithelium that has started to grow from the wound edges over the granulation tissue was removed using a thumb forceps and a no. 10 scalpel blade (Picture 9). A perpendicular incision was made right at the edge of haired skin with epithelium. The wound was incised all around and after that the epithelium was removed by advancing the scalpel blade under the epithelium around

the wound. Then, undermining was performed around the wound edges. A fragment of sterile surgical drape was used over the wound to get the exact shape. The drape “pattern” was placed to the donor area.

 

 

To maintain the wound moist, i placed over it a cotton gauze moistened in warm sterile saline 0.9% while the graft is transferred.

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Picture 10. The donor site-removing the skin; black arrow show the direction of the hair groth.

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Picture 11a. Skin from dorsal thorax is advanced

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Picture 11b. Simple interrupted suture is used for skin closure.

The direction of hair groth was marked with a black arrow above the donor site so that the direction of the hair groth on the graft will be the same as the hair groth direction on the skin surrounding the wound. After that, the margins of the drape “pattern” was traced on the skin. The skin of the donor bed was incised with No.10 scalpel balde and removed using thumb forceps and Metzenbaum scissors (Picture 10). The defect left after removing the graft was primary closed by undermining and advancing the skin edges with walking sutures using 3-0 monofilament absorbable suture material and finally the skin was sutured in a simple interrupted suture manner using 2-0 monofilament absorbable suture (Picture 11a, 11b).

 

 

 

 

 

 

 

 

 

 

Preparing the graft

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Picture 12. Final aspect of the skin graft after removal

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Picture 13. The skin is stretched on the receiving bed so the incisions made in it expand.

The dermal side of the graft was placed on a polystyrene board with a thickness of 10cm covered with a sterile drape and after that we fixed and stretched with 21G needles. The subcutaneous tissue was removed from the graft. Next, made parallel incisions was made in the graft, 0.5-0.7cm long and apart (Picture 12). At the end, the graft was placed on the granulation bed and sutured with 4-0 monofilament nonabsorbable suture in a simple interrupted suture manner. Additional tacking suture was placed to ensure the expansion of the mesh incision and allow the fluid drainage (Picture 13).

 

 

Choosing the right bandage after grafting and aftercare

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Picture 14. Grassolind is ointment free of medication, broad mesh, air permeable and exudate; impregnated with neutral ointment. Ointment contain petroleum jelly, fatty acid esters, carbonate and bicarbonate diglycerol, synthetic wax.

It is important to use a nonadherent primary dressing. My initial choise was Grassolind (Hartmann), is sufficiently porous to allow easy passage of exudate from the wound surface, preventing maceration of surrounding tissue (Picture 14). The ventral metatarsal wound maintain hydrocolloid dressing (Hydrocoll-Hartmann) as primary layer. After that, a thin layer of chloramphenicol oinment (Opticlor-Pasteur) was used all around both wounds and over the graft.

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Picture 15. Note that the “half clamshell” is extended with approximately 1cm toward fingers (red arrow) so the leg does not touch the ground

Over the first dressings was applied 5cmx5cm compress (Medicomp-Hartmann) and a roll gauze was the second layer. After a few laps of gauze stirrups was placed to secure the bandage in place. Extemporaneous half “clamshell” splint (Picture 15) was made from plastic material wich was curved in such a way that the limb was fixed in semi flexion. The splint is a little bit longer than the extremity of the pelvic limb (“toe-dancing” position), thus provide a maximum relief pressure. In the proximal area, under the splint, I put cotton to prevent pressure injuries on the caudal aspect of the thigh. Applied from proximal to distal and with moderate tension, elastic warp was the final protective layer of the bandage and it was secured at the proximal end with tape.

 

 

 

 

Changing bandages

The bandage was changed in day 1, 3, 5, 7 and 10 post op. In day 10 the suture material was removed from the graft and from the donor site. From day 17 to day 29 hydrogel (Hydrosorb-Hartmann) was used as primary bandage layer and the bandage was changed from 4 to 4 days. In day 29 no discharge was present in the bandage; the wound was completely healed and 0,2-0,4 mm of hair was present in the center of the graft.

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Picture 16. Delayed healing on day 45 – epitelization stopped at this level.

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Picture 17b. Honey improve wound nutrition, promotes the granulation tissue and epithelization, reduce inflammation and edema. Also it has a wide antibacterial effect.

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Picture 17a. DTL laser type is alaser light emitting diode in the red field (wavelength 650 nm) and infrared (wavelength 808 nm) of the light spectrum with next clinical effect: anesthetic effect; decreases edema and inflammation; activates microcirculation; stimulates wound healing; improves tissue trophicity; reflexogenic effect.

A delayed healing occurred at the wound in the ventral region (Picture 16). From day 29 to day 59 epithelization has advanced very hard and granulation tissue has captured an appearance of ulcer (in this time the wound was asepseptic prepared and hydrocolloid and hydrogel was used as primary layer bandage and without the splint). In day 59 the wound was refreshed on the surface with a scalpel blade and laser therapy (Picture 17a) and medical Manuka honey (Picture 17b) was used daily for 14 days. After that, a complete healing was reached.

 

 

 

 

 

 

 

Illustrating wounds evolution after surgery

 

Day 1

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Day 11

 

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Day 28

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Day 35

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Day 49

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Day 11 after honey and laser therapy

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 Day 16 after honey and laser therapy

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Comparing day 1 and after 3 Months

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Erythema multiforme or TEN (toxic epidermal necrolysis – toxic shock syndrome)

stef art

Marina-Ştefania Stroe, DVM

Marina-Ştefania Stroe, DVM

Romania

History

Dog, half breed, M, intact, 4 years old, unvaccinated and without treatment for intestinal parasites, fleas and ticks, 10.2 kg.

The main concern was the ophthalmologic problem.

Three weeks ago he had problems with the hind limbs and he had difficulty in moving. Previous treatments: meloxicam, gentamicin, steroidal anti-inflammatory.

The possibility of ingestion of a toxic (plant / substance) is not excluded.

Clinical exam

-white mucous membranes, no lesions in the oral cavity;

-necroses in the auricular pavilions with a visible marginal line, foreskin necrosis, yellow crusts and areas of necrosis predominantly on the posterior limbs, tail, dry-looking fur, which is easily detached;

-after detachment, the skin is denuded, ulcerated, very painful on palpation;

-cutaneous hyperesthesia;

-minimal normal auricular secretion;

-corneal erosions, dry eyes, agglutinated secretions at this level;

-faded cardiac noise; imperceptible pulse;

-rectal examination: doughy feces consistency, normal color;

-abdomen in tension;

-blood pressure (indirect oscilometric metod): 138/102 (112 mmHg).

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TESTS

-Chest and abdomen rx and ultrasonography: free fluid; enlarged spleen.

-Ultrasound guided abdominal puncture: yellowish ascitic fluid, orange tint, after spinning small, white deposit. Protein: 1 g / 100 ml.

-Blood tests: low red blood cell counts, thrombocytopenia, leukocytosis, granulocytosis; elevated liver transaminases, bilirubin and amylase normal values, normal kidney parameters.

-Bleeding time: normal.

-Negative tests for infectious diseases.

-Abdomenocentesis: 335 ml of ascitic fluid and cytological exam: MODIFIED TRANSSUDAT WITH ERYTHROCYTE POLLUTION

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Fig 10

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Fig 9

Fig. 9: Cutaneous cytology, direct impression smear from necroses of the pinnae (Fig.10): nonsegmentated immature young neutrophils, lymphocytes, few macrophages in whose cytoplasm are found bacilli, bacterial population predominantly represented by bacilli, but also cocci, oxyphilic cell matrix

Fig. 11: Cutaneous cytology, direct impression smear from yellow scale, tail (Fig. 12): neutrophils in all stages: mature segmented, degenerative stage, but also young with eukromatic nucleus and evident nucleoli, macrophages with basophilic cytoplasm, slightly vacuolized, eucromatic nucleus, nucleic streamming, erythrocyte infiltrate.

Fig. 14: Tape prep from yellow scale, hind limb

keratinocytes on the surface of which are attached cocci, degenerate inflammatory cells

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Fig 11

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Fig. 13: Trichogram – hair with normal structure, some hair with degraded cuticle, rap A / T: 4/6, follicular cast, negative for demodex and dermatophytes.

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Fig 14

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Fig 13

Superficial and deep skin scrapes: negative.

 

 

 

 

 

 

 

 

 

 

 

 

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Fig 15

Fig. 15:

-Direct and consensual pupil reflex present;

-Reduced visual acuity;

– Schirmmer test 0 mm / min;

-Florescein test: Positive

Diagnosis: OU Corneal melting ulcer F +

Diagnosis and other differentials

Blood smear, cell morphology: moderate, hypochromic, regenerative anemia,; leukocytosis, neutrophilia, moderate non-specific cellular toxic status, eosinopenia, lymphopenia. In this case, the leukogram (neutrophilia, eosinopenia and lymphopenia) may suggest treatment with corticosteroids, stress, hyperadrenocorticism, severe inflammation (chronic) with various etiologies (viral, bacterial, fungal).

Skin biopsy: histopathological aspects advocate for hyperkeratosis with paracheratosis and chronic inflammatory response involving the epidermis, jonctional area and superficial epidermis.

Final diagnosis

Histopathological aspects may show Erythema multiforme or TEN (toxic epidermal necrolysis – toxic shock syndrome), which is a late reaction, surprised in a chronic, secondary phase due to fibroblast proliferation.

 

The toxic shock syndrome may be a reaction to drugs, chemicals or food

 

Treatment

Enrofloxacin (dose: 5 mg / kg) at 12h po;

Amoxicillin and clavulanic acid (dose: 20 mg / kg) at 12h po;

Furosemide (dose: 5 mg / kg) at 12h iv;

Tramadol (dose: 2mg / kg) at 12h iv;

Parenteral nutrition;

Bathing (chlorhexidine);

Acetylcysteine, Tobrex, Corneregel 6-7 times / day (lack of tears).

 

What are WSAVA and FECAVA? Who are these people? World Award for the Balkans veterinarians or something much more?

22045765_10214950207297979_2320859194427414874_nWhat are WSAVA (World Small Animal Association) and FECAVA (Federation of European Companion Animal Veterinary Associations)? Me, as a local veterinarian from the Balkans (East Europe) these two names were something far away from my daily job and my daily professional work. I am sure many veterinarians from my region are the same.

 

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FECAVA Board

 

 

 

 

When you have the possibility to be part of their event, in fact, it is the product of their job, you are able to realize what really means WSAVA and FECAVA. To be able to create that kind of event you need to have a lot of people who really love their job and who strongly believe in their idea.WSAVA Board

 

 

 

 

 

 

Yes, it is a huge veterinary congress, very well organized, with thousand of possibilities , subjects and full of knowledge, but this is not the point. They create a meeting, a space, where you are able to speak with veterinarians all over the world, to understand where you are in that world.  You get new ideas, how to make your job better, how to make your daily work easier and to have more time to be happy, which is the most important in life. For me, this means “global vet”.

 

They have teams for every subject and field of veterinary medicine, all these people try to learn you something that will help you to refresh your daily work and to have better results for every single case in your practice. So, are they huge associations, far way from our job? You do not know these people, but they are the people who give their time and their life to help you every day. You do not see their help, you think , they are some people who have totally different job from your, but it is exactly the opposite.

 

And I am so proud to say that between this group of people, there are some veterinarians from the Balkans. Dr Denis Novak, Dr Lea Kreszinger , Dr Gizem Taktak and Dr Robert Popa are part of that important group who really care about us.

 

 

 

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Dr Lea Kreszinger, Croatia

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Dr Denis Novak, Serbia

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Dr Robert Popa, Romania

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Dr Gizem Taktak, Turkey

 

 

 

 

 

 

 

 

 

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Dr Ann Criel

 

 

 

 

 

 

 

 

 

I wish all the veterinarians from the Balkans to have the chance to meet the board of WSAVA and FECAVA, to feel the pleasure to speak with them and to realize how close they are to all of us. The pleasure to hug Dr Katharina Brunner from Switzerland, to enjoy funny and deep friendly chats with Dr Ann Criel from Belgium is priceless experience in life.

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Dr Katharina Brunner

 

 

 

 

 

 

 

 

 

 

I would like to express my gratitude to WSAVA Board and Hills Pet Nutrition ( and personality  to Dr Jolle Kirpensteinjn and Dr Iveta Becvarova)  for the possibility to realize these things that I have shared with you. Thank you, FECAVA for such a kindly attitude to me. It was more than award and honour, it is something for a life time. THANK YOU!

With Love

Dr Luba Gancheva

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Dr Jolle Kirpensteinjn and Dr Iveta Becvarova