Management of chronic non-healing wounds over the calcaneal tuberosity in a Sphinx cat

florin48260278_10156282671250432_7554491919091367936_nDiana Anghelescu DVM

Georgiana Ciochina DVM

Florin Cristian Delureanu DVM, MRCVS, OCQ(V)

February 2022

 

 

Abstract

 

 

Wounds that fail to heal through the normal healing phases in a routine timely manner are classed as chronic wounds. Factors like improper nutrition, hypovolemia, anemia, infection, excessive motion and endocrinopathies contribute to delay wound healing. The patient presented with chronic bilateral wounds over the calcaneal extremities without progression after approximately two months of conservative management consisting of local bandaging techniques. Therefore, a surgical approach was used to close both defects. In order to achieve closure of these particular lesions, a single releasing incision was utilized. After surgery the patient was hospitalized for 10 days and a “donut type” bandage was used to minimize the local trauma. The sutures were removed at 21 days after surgical intervention.

 

Key words: Chronic wound, “donut-type” bandage, calcaneal extremities.

 

Signalment and history

 

A six months old Sphinx cat weighing 2.1 kg was brought for a second opinion in december 2021 because of non-healing wounds at the calcaneal extremities. It was not clear the cause of these lesions but the owner noted a slowly progression of the wounds in approximately one month. At the initial veterinary practice the patient was locally treated with an antibacterial-steroid based ointment which was applied twice a day and a light bandage to cover the wounds. Afterwards, the owner was advised to improve the comfort of the home environment to prevent further trauma. There was no improvement noted after this treatment.

 

Clinical examination and findings

 

At the time of presentation, the wounds from both calcaneal extremities were quite similar in appearance. In terms of depth, a full thickness skin defect was present measuring approximately 1cm diameter. The wound from the left side presented mild moisture and small amount of slough was covering the surface while the wound from the right side was covered by a dry crust. There was no local pain and or purulent discharge and no bone exposure. A concurrent parasitic otitis was found during examination.

 

Treatment

 

Cytological examination of the lesions revealed a mild superficial bacterial infection along with an inflammatory response. The options of conservative and surgical management were discussed with the owner. Initially the owner opted for second intention healing. The bacterial infection was treated locally using chlorhexidine gluconate solution 0.02% daily for three days followed by application of medical grade Manuka gel covered by a light protective bandage. A recommendation of daily bandage changes was made for the first three days until the first recheck. An Elizabethan collar was recommended to prevent self-trauma but the owner declined. An otic swab confirmed the presence of Otodectes Cynotis and the patient received one dose of lotilaner for the parasitic infection and daily ear cleansing with clorhexidine with TRIS-EDTA for 2 weeks.

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Fig.1 Left (A) and right (B) calcaneal lesions. There is no marginal reepithelialisation and the wound margins are not inflamed. The left defect present a chronic pale granulation tissue and the right lesion is covered by a dry crust.

 

 

 

 

At the first check-up the lesions were considerably larger but also the owner reported that the patient managed to remove the bandages during the night. Moderate amount of slough was present on both defects and mild moisture was present (Figure 2).

Fig.2 Left (A) and right (B) calcaneal wounds. There is an increase in size of both wounds and the wound edges present mild inflammation.

Fig.2 Left (A) and right (B) calcaneal wounds. There is an increase in size of both wounds and the wound edges present mild inflammation.

At this moment a “dounut-type” bandage with hydrogel representing the contact layer for the next ten days was recommended (Figure 3). This type of bandage was ment to prevent against any further trauma and the hydrogel to help by wound debridement and keeping a moist environment. The the bandage was changed every three days.

 

 

 

 

 

Fig.3 Donut Type bandage. A “donut” pad was made by rolling long strip of cotton in a circular manner and was applied over the bony proeminence. The “donut” was fixed in place with padding gauze and tape.

Fig.3 Donut Type bandage. A “donut” pad was made by rolling long strip of cotton in a circular manner and was applied over the bony proeminence. The “donut” was fixed in place with padding gauze and tape.

At the ten days recheck there was no more slough or necrotic areas over the wounds but was no improvement in terms of size or granulation tissue quality. The surgical intervention was recommended at this state and the owner accepted.

Complete blood work, including a CBC and a biochemistry panel, was done before surgery. The results were within reference levels. The patient underwent general anesthesia using dexmedetomidine (4.5mcg/kg IM) and methadone (0.18 mg/kg IM) as premedication followed by induction with propofol (6mg/kg IV) and maintenance with isoflurane and oxygen.

 

 

 

 

After wound bed preparation, the local skin assessment was performed aiming to obtain a robust and tension free closure. The assessment involved manipulation of the skin that surround the defects but also the skin from the nearby area (Figure 4). More skin was available proximal to the hock, medial and lateral compared with other areas. The options of surgical closure taken in consideration were: undermining, tension-relieving techniques in form of single releasing incision, Z-plasty, V-Y plasty and transposition flap from the lateral or medial aspect of the distal tibia. Initially undermining of the wound edges was performed and closure was attempted but there was too much tension. A single releasing incision was the option used to close these particular wounds.

Fig.4 Caudal view of the right hock. A manual manipulation of the skin that surround the wound is perform.

Fig.4 Caudal view of the right hock. A manual manipulation of the skin that surround the wound is perform.

The following steps were used for both wounds:

Initially the fibrotic thickened wound edge was removed and undermining was performed around in a circular manner (Figure 5). A 2cm parallel incision with the wound was made approximately 2cm dorsally and 1cm medial on the medial aspect of the distal tibia (Figure 6). Undermining was performed in a cranio-caudal direction connecting the incision with the wound bed. The skin was advanced into the defect and 3/0 monofilament in a simple interrupted suture pattern was used for closure (Figure 7).

Fig 5

Fig 5

Fig 6

Fig 6

 

 

 

 

 

The medial donor defect was left to heal by second intention. The surgical site was covered by a “donut-type” bandage placed over the hock and a nonadherent dressing over the new defect.

 

After surgery the patient was hospitalized in a padded room the same “donut” bandage but polyurethane foam was used as a contact layer over the new defects and the closed wound was not covered with any dressings. The bandage was changed every 3 days. The new defects ressolved within 8 days and no complications were noted at the surgical site.

Fig.7 Medio-caudal view of the right hock. The final appearance of the wound after closure.

Fig.7 Medio-caudal view of the right hock. The final appearance of the wound after closure.

 

The cat was discharged after 10 days and was sent home with the same bandage until the suture material was removed. In day 14 and 21 the sutures were removed an Elizabethan collar was appied to prevent self-trauma at home for the next 4 days. At the last recheck both hocks presented with normal scar tissue and no local discomfort. The owner reported that after the collar was removed the cat was not interested in her previously affected areas.

 

Discussion

The present case report describes the conservative and surgical approach of two symmetric chronic non-healing wounds associated with the calcaneal tuberosity together with the macroscopic description of the lesions.

Fig.8 Caudal view left (A) and right (B) calcaneal extremities four days after suture removal.

Fig.8 Caudal view left (A) and right (B) calcaneal extremities four days after suture removal.

 

The patient was presented with a history of more than four weeks of non-healing wounds at both calcaneal extremities. We treated conservatively with specific dressings and bandaging techniques for another two without improvement. Hence, a surgical intervention was recommended.

To achieve the maximum skin advancement the purposed skin incision was planned to be perpendicular to the wound. The reason why the releasing incision was performed slightly proximally to the defect and not perpendicular to it was to avoid exposure of the medial malleolus of the tibia which was sharp and was not covered by robust soft tissue. Therefore, this extremity could represent another pressure point exposed.

In order to minimise the chances of self-trauma, the patient was hospitalised in a soft padded room. The “donut” type bandage was still used for another 10 days. A follow up recheck four days post suture removal was made to make sure there are no post-operative complications. There was a normal scar tissue formed and no local discomfort present functional deficits (Figure 8).

 

 

References:

 

  1. Michael M. Pavletic– Atlas of Small Animal Wound Management and Reconstructive Surgery, Fourth edition, 2018 John Wiley & Sons, Inc;
  2. Nicole J. Buote, DVM, DACVS-SA- Updates in Wound Management and Dressings, Veterinary Clinics of North America: Small Animal Practice 2021 Elsevier Inc;
  3. Theresa Fossum- Small Aminal Surgery 5th Edition, April 2018, Elsevier Inc;
  4. Steven F. Swaim, Walter C. Renberg, Kathy M. Shike- Small Animal Bandaging, Casting, and Splinting Techniques, Iowa State University Press, United States 2011;
  5. Baranoski, S, Ayello, EA. 2016. Wound Care Essentials: Practice Principles, 4th ed. New York: Wolters Kluwer;
  6. Hunt TK, Williams H. 1997. Wound healing and wound infection. Surg Clin N Am 77:587–606.
  7. Bryant RA, Nix DP. 2016. Acute and Chronic Wounds: Current Management Concepts, 5th ed. St. Louis: Elsevier Inc.

BSAVA Congress 2022 is going hybrid!

C22-Tickets-On-Sale-1200x630-FB-Tw20 January – Registration for Europe’s largest small animal veterinary event is now open! The British Small Animal Veterinary Association (BSAVA) Congress will be held from 24-26 March in Manchester for an exciting programme packed with 100+ hours of world-class CPD delivered by over 50 world-class speakers from around the globe.

 

Hybrid and virtual possibilities

The live event is due to be held in Manchester, with the opportunity for delegates to attend online through an interactive virtual platform which will run alongside the live event (‘hybrid’ format). This means you can get the chance to catch up with your peers and experience a live event while not missing out on sessions with the option to catch up on demand.

And of course, if you can’t travel to Manchester, you’ll still be able to attend the event, as the congress can also be followed at a distance (‘virtual format’).

 

Long-form lectures are out, immersive experience is in

Last year’s online event proved top CPD can be delivered remotely in a highly interactive and engaging way. Returning to a face-to-face format enables us to take that even further and provide delegates with a truly immersive experience,” says Sarah Fitzpatrick, BSAVA Head of Partnerships and Events.

Many sessions at this year’s event feature two speakers delivering different perspectives on a topic, followed by a Q&A. With just 15-20 minutes to get into the detail, lectures will get straight to the point, be fast-paced and rich in content. “A day in the life of….”, a new feature for the 2022 event, will see actors play out scenarios, with experts and the audience invited to discuss the options before returning to the actors to play out the scene.

 

Meet-the-speakers and free drop-in practicals

Manchester has a proud history in science, as well as politics, music, arts and sports. The Manchester Central convention centre is an award-winning venue in the heart of the city. The size of the iconic building has enabled the organisers to bring the whole of Congress under one roof.

Alongside industry partner stands’, delegates will be able to drop-in to practical sessions and perfect a technique such as undertaking cytological examination, reading radiographs and even performing endoscopy in as little as 15 minutes. For the first time, the practical sessions will be included within the ticket price. There’s also the opportunity to meet the speakers in a dedicated space in the exhibition during lecture breaks.

 

Early bird discounts apply until 17 February

To register, simply go online on www.bsavaevents.com! Early bird rates apply until 17 February. Virtual-only rates are £203 + VAT and Hybrid (in-person & virtual) rates are £405 + VAT for BSAVA* and FECAVA**-members. Reduced rates also apply for WSAVA*** members, veterinary nurses and students.

Accreditations from RACE, the New Zealand Veterinary Association and the Swiss Veterinary Association (GST/SVS) are pending. All participants will have 60 days access to all virtual and on-demand content after the event.

 

* For information on how to become a BSAVA member please visit: www.bsava.com/Membership

** As FECAVA member, proof of membership of one of FECAVA’s member associations may be required. To check, please visit www.fecava.org/associations.

*** Veterinarians who are members of WSAVA through their national organisation can claim a 10% discount on the BSAVA non-member rate.

 

Learn ans Travel-Iva Novak, final year veterinary student from the University of Zagreb, Croatia

Iva Novak, a final year veterinary student from the University of Zagreb, Croatia share with us her amazing experience:

iva novak 6After living one year in a pandemic, I decided to take one last chance at an Erasmus adventure before graduating this summer. When I came to Padova, I first took a couple of days to explore the beautiful Prato della Valle, Palazzo Bo and the historic center; and also find my way to the clinic. The San Marco veterinary clinic and laboratory is located outside of the city itself, halfway from Padova to Vincenza, another beautiful Italian city. The location makes it available to clients and owners from all over Italy, but also Spain, France, Switzerland and the Balkans. It stretches over 50,000 square meters and 2 floors, with a terrace that gives a wonderful view of the nearby fields.

iva novak 3

My first day I was greeted by Dr. Busato who gave me a tour of the clinic, which seemed like a spaceship to me, as I was impressed with magnetic name cards that opened the clinic’s doors! It was nice to put a face to the name of the person I had been messaging with to plan this whole visit, and as expected Dr. Busato was as nice and welcoming in person as she was over email. I am not the best Italian speaker but it turned out that there was no language barrier as everyone at the clinic spoke English and I had no trouble following cases.

iva novak 1 iva novak 4

To get me started, my first week I was put in the hospitalization ward; where each day one doctor is in charge, but the nurses are the true heart and engine, with over 100 cages, often full, and the nurses still know every patient’s quirks and details. The patients are divided into 6 rooms: for cats, dogs, dogs’ oncology, cats’ oncology, dogs’ infectious and cats’ infectious ward. The intensive care unit is separate and equipped with special beds for patients that can be moved to different areas of the clinic, specialized monitoring devices to provide optimal patient care and diagnostics, CPAP, continuous electrocardiographs, fresh gas and oxygen flow for each patient and round the clock care given by the amazing team lead by Dr. Rocchi. We gave hope and a fighting chance to every animal that walked through the clinic’s door and thanks to doctors Pelizzola, Grossi, Botto and Pallares I practiced my E-FAST skills, ultrasound volemic status assessment, wound management; and there was always good food at morning rounds.

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The scale of the clinic is so that if I were to write about each department, this article would turn into a book! San Marco is a tertiary clinic so it provides patients with general medicine and specialist care in neurology, cardiology, nephrology, dermatology, oncology, ophthalmology, orthopaedics, nutrition, and behavior science but one of the most important departments there is radiology. I learned just how big of a part echography can play in disease diagnostics and control check-ups and I also spent one week studying CT diagnostics, which was a whole new world for me. I was lent literature to prepare since CT diagnostics weren’t a part of my studies at the University of Zagreb, and with the help of Dr Negro I was quickly able to follow and recognize pathologies in multiplanar reformatted reconstruction and three-dimensional volume renderings.

 

As a referral clinic they take in over 6000 patients a year, so cases were abundant but I learned even more during the weekly evening lectures and clinical cases presented almost daily by the clinic’s rotating and specialist interns. The clinic is research oriented, they publish around 30  peer reviewed papers every year and they also provide professional training, traineeships, specialised and rotating internships and residency with evening lectures, seminars and congresses that I have all been attending.

 

My morning would start in the staff kitchen, where I got to master my coffee-making skills with the instructions given to me by the clinic’s interns, and during lunch, we would exchange pasta recipes. In cardiology, Dr Ledda taught me how to use spectral, flow, and tissue doppler and being one of the doctors that can perform interventional radiology he taught me the theoretical part of it as well. Out of internal medicine, I had the honour of working with Dr Furlanello, Dr Zoia, and Dr Pantaleo. We would receive their own patients, as well as consultations and referrals from other clinics all over Italy.

Since my time there was short compared to the number of procedures they perform at the clinic, out of ophthalmology I was able to only attend one electroretinography on a Tibetan mastiff with SARD syndrome. During surgery week, I observed a TTT with trochleoplasty, nodulectomy with a flap, extrahepatic portocaval shunt closing with fluoroscopic portography and a correction of tibial varus among other procedures. I also helped perform bronchoscopy, rhinoscopy, colonoscopy, gastroscopy with duodenoscopy, and uretroscopy. The endoscopy equipment was also used for intracervical artificial insemination, which was performed by a doctor Ferré.

 

In the end, one of the things you can’t miss when you first walk into the San Marco clinic is the big swimming pool that can be seen from the waiting room. It is used for physical therapy but I can’t say I didn’t see any of the staff jumps in just before it is supposed to be emptied. At physical therapy, they explained to me the history and progress of every patient and taught me how to use laser therapy in theory and practice along with applied hydrotherapy in the pool or the underwater treadmill.

 

Now, after 3 months, my adventure is coming to an end, I plan on visiting all the beautiful places in Veneto and surrounding regions I still haven’t seen, like Bologna, Verona and Milano.

I embarked on an Erasmus in the middle of the pandemic but I was lucky to be welcomed into an amazingly organized clinic, following the rules and measurements put in place, my Erasmus experience was barely affected by the pandemic. I am thrilled to have had this opportunity to meet amazing people who work in the same field as me. I can recommend San Marco Vet Clinic to colleagues that want either basic training or to further their skills with specialist grade education. Thank You to everyone who shared their knowledge with me. I will treasure it for a lifetime.

Achieving primary closure on the proximal third of the tail after 4 cm mass removal in a dog

51559132_952390804967417_8511078558653743104_nFlorin Cristian Delureanu    

DVM, MRCVS

December 2019

Abstract

Defects located on the tail are challenging due to lack of skin. Second intention healing, skin grafts or random local flaps can be used as a treatment in this particular area. Primary closure can be used when small defects are present but risk of dehiscence and vascular compromise is very increased due to tension and tourniquet effect. In cats was described a perineal axial pattern flap used for covering a defect located on the proximal third of the tail. Also a “spiral closure technique” can be used to close small to medium size defects on the tail. The use of the advancement flap is usually the first choice in approaching the closure of defects if they can not be closed by undermining and suturing. This article illustrates the usage of advancement flap from the base of the tail for closing the surgical defect left after excision of a tumor located on the dorsal proximal third of the tail in a dog. No complications were noted after surgery and the tail maintained the normal function.

 

Case report

 

A 5 years old female neutered cross breed dog was admitted for assessment of a lump located on the tail. The owner was not sure for how long time the lump was in that place and how fast developed, was just recently observed on the tail.

On general examination no abnormalities were detected. A 4 cm mass was identified on the dorsal aspect of the mid proximal third of the tail. The mass had round shape, located under the skin and well attached to the coccygeus muscle. On palpation, local temperature was normal, elastic-firm consistency, without local pain. No other abnormalities were detected. Fine needle aspirate was recommended and performed before surgery.

Cytologic interpretation: marked pyogranulomatous inflammation, epithelial proliferation, neoplasia probable and evidence of mineralization.

 

 

 

Surgical approach and suture technique

 

Surgical site was aseptically prepared and the patient was placed on the table in ventral recumbency. Before starting the procedure, another evaluation of the mass in relation to the skin located on sacro-coccygeal area but also with the skin which surrounds the mass was done. Before incision, the skin mobility was checked. In physiological position a small skin fold was observed cranially to the lump (Fig.1).

78346759_2393783297549969_4542870446093107200_n

Figure 1. Preoperative appearance of the sacrococcygeal area after surgical site preparation. The tumor have a spheric shape, is located in the proximal third area of the tail-dorsal aspect and have a wide base of implantation. At the base of the tail a small fold can be observed

A circular incision was performed 3mm distance from the mass. No.10 scalpel blade was used to create the skin incision and the dissection until the muscle was done with Metzenbaum scissors.

 

A thin capsule that surrounds the mass was discovered at the junction between it and the coccygeal muscle. At that point the dissection was performed with the scalpel blade until the end. Care was taken to avoid the major vassels of the tail( Fig 2, Aand B)

Figure 2. Intraoperative view of the tail. (A) Right lateral side before tumor excision and (B) left lateral side after full excision hightlights the intact lateral coccygeal veins (yellow and black arrows).

 

 

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Fig 2

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Fig 2

 

 

 

78752190_487893868488710_7100718041469550592_n

Figure 3. Transverse section at the level of caudal vertebrae illustrates distribution of the muscles

The tail movements are coordinated by 6 pairs of muscles (12 muscles in total) that are distributed concentrically over the coccygeal vertebrae (Fig.3).

 

 

 

The vascular supply of the tail is composed by 2 lateral caudal veins and arteries located

on lateral sides and the median caudal artery and vein. In this case both caudal lateral veins were preserved. Minimal bleeding was present and the small blood vassels were ligated with 3/0 PGA. Two parallel lines extended from the proximal border of

the defect to the base of the tail were  made in the skin deep to the muscle. Meticulous dissection of the skin was performed with Metzenbaum scissors until the fold located at the base of the tail. The flap was elevated and advanced distally to cover the defect

(Fig.4 A). The flap managed to cover ¾ of the defect without tension. Undermining of the skin  located on the distal border was attempted to obtain the mobility that can help to cover the ¼ of the defect but faild. To obtain the maximum coverage, walking sutures were used to further advance the flap. The first bite went deep into the dermis and the second bite in the tendinous portion of the m.  sacrocaudalis dorsalis  lateralis (sacrococcygeus dorsalis lateralis).Few walking sutures were placed so that the tension is equally distributed (Fig. 4B).

Figure 4. Undermining and elevation of the skin flap. (A) Stay sutured were placed on the flap corners (yellow arrows) to manipulate the skin; (B) Closer wiev of the first walking suture. First bite (blue arrow) is inserted deep in the dermis and the second bite is inserted in the tendons of m. sacrocaudalis dorsalis lateralis (black arrow).

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Fig 4

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Fig 4

 

 

 

 

 

 

 

 

 

 

 

 

Nor following this procedure the primary defect has not been fully covered. In the end, horizontal mattres pattern (“U” shape) was used on the edge of the flap and full coverage was achieved under moderate tension (Fig.5).

 

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Figure 5. Dorsal aspect of the tail after final closure

 

Usually after advancing a flap “dog      ears” will result at the base. In this particular    case minimal “dog ears” were present. For a    cosmetic appearance and to preserve the soft     tissue, central suture technique was performed     on the lateral sides of the skin flap due to crescent    shaped defect. There are many ways to close up a crescent shaped defect but in this particular case central suture technique was chosen to avoid “dog    ears” removal. First simple interrupted suture was placed     in the middle of the defect and after, another  sutures in the middle of the two defects obtained   and so on until complete closure.

 

The central closure technique distributes the “dog ears” all along the sutures line in small increments (Fig.6a, 6b). In the end, the final aspect of the tail in relaxing position was changed due to advancement flap. The tail gain a curved up position (Fig.6).

Figure 6. Central suture technique. (a) Left lateral view of the tail illustrates no “dog ear” present at the base of the flap due to suture technique. The black line show the curved shape of the tail after the final closure. (b) Illustration of closure of crescent shape defect1.

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Fig 6

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Fig 6

 

 

 

 

 

 

 

 

 

 

 

Postoperative care 

 

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Figure 7. Postoperative view after bandage application

For protection, a soft padded bandage was      used to cover the surgical site, this being made up of  square gauze applied on top, fixed in place with an elastic band; Stirrups were applied over the gauze and  extended proximally to the base of the tail and Vetrap  was used as a last layer (Fig.7).

 

The patient was sent home with booster collar to prevent self trauma and 3 days of robenacoxib, also in the surgery day a NSAID injection was administered with the same nonsteroidal anti-inflammatory drug. Until the first recheck (3 days post surgery) the bandage has fallen due to excessive tail movement in 24 hours but the owner apply another one at home; Four days after surgery the patient present for the first recheck, on inspection the tail was less curved in compare with the day the surgery was performed and no complications were present. The owner reports the patient was comfortable at home after surgery, and did not show any changes in behavior. The same bandage was applied in the same manner and this time did not slip until the second visit.                 The patient has presented for sutures removal in day 10 aftert surgery . No postoperative complications were present and the tail was less curved upwords. One last visit was 34 days after surgery. Due to the weight of the tail, continous tension was applied on the skin over time and the natural position was regain (the processes of mechanical creep and stress relaxation) (Fig.8). The owner reptorts the patient was comfortable in all this period and does not seem to be disturbed by surgery.

Figure 8. Ventral (A) and right lateral (B) aspect of the tail after sutures removal – 10 days post surgery; (C) Dorsal view of the tail 34 days after surgery.

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Fig 8

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Fig 8

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Fig 8

 

 

Histopthologic result and prognosis

 

The mass (Fig. 9) was put into a containter with formol and sent to the lab for histopathologic examination. Pilomatricoma partially ruptured and mineralized, associated with moderate granulomatous inflammation. This is a benign tumour of the hair follicle, slow growing, non-invasive, and generally rarely metastasizes (malignant variant exists but is rare). was the diagnosis and clear margins were achieved and the prognosis is was good. Poodles, Schnauzers and Kerry Blue and Bedlington terriers may be predisposed.

 

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