Skittles is a 3-year-old, 10-pound miniature poodle. His appointment was innocuously labeled as a “Bandage Change," for a wound that was originally treated at our emergency clinic a couple of days earlier.
The surgeon on call had performed some initial wound care and established a treatment plan. As I hurriedly approached the treatment area, my assistant briefed me on the facts of the case. It was a busy day, and what was left of my mind was being pulled in many directions, so I was only half paying attention. After all, it’s just a bandage change, I thought.
I did hear that this was the result of what we call a “big dog, little dog” attack, from a few days earlier. But I was definitely not prepared for what I saw as I removed the bandage.
The wound was massive. Relative to Skittle’s body surface area, it was one of the two or three largest wounds I’d ever seen. The skin was completely ripped away, leaving only the underlying body wall of ribs, muscle and fat. From top to bottom, it spanned from just to the left of the spine, crossed over to the right side of the body, to the mid-abdomen. From front to back, it reached from the mid-thorax to the front of the thigh.
After assessing the wound, I met with the owners, who were understandably anxious about the plan and the prognosis. The surgeon who saw Skittles first had established a logical treatment course. The first thing would be to clean it up, meaning to remove any additional tissue that died, or "necrosed." They would then wait for the formation of granulation tissue. This is the bright red tissue that forms in a wound bed. It is a rich network of blood vessels, collagen and white blood cells that forms a protective barrier to infection, and a scaffold for healing.
It seemed impossible to close this massive wound in one go, so my colleague had planned a staged reconstruction, ultimately covering the wound with a skin graft. This would require waiting for an adequate bed of granulation tissue to form, which generally requires days to weeks to establish. This would require multiple wound treatments and bandage changes.
Skittles' wound included the area in front of the thigh, and the movement there would make grafting difficult. So I suggested that we try and close that area with remaining skin to reduce the size of the wound, and establish an environment more suited to grafting.
I told them I could try and close as much as possible, but we’d be lucky if we could reduce it by a fourth. They were unclear about what to expect, which made perfect sense, because I was too. In spite of that, they took a leap of faith and agreed to proceed.
When preparing to close a traumatic wound, one must remove all of the dead or dying tissue first. The skin edges are cut back to bleeding edges, and all of the crust and debris is cleared away. In our favor was the fact that Skittles is young with skin that can be more easily stretched.
The location presented an advantage, in that there was more area to draw from than, say, a large wound on a leg. First, I created a flap from the flank area, which was rotated up into the wound. Then a series of cuts were made in some of the tighter areas, which effectively made the skin like mesh. This technique maximized the distance the skin can be advanced over a wound. A little nip here and a tuck there, and it gradually became apparent that this massive wound was going to be completely closed, in that single procedure.
After surgery, I spoke with the family and happily explained that we had achieved far more than anticipated. It was then that they revealed to me what Skittles means to them. Besides the dad's description of him being “the best dog” he has ever had in more than 50 years, Skittles was far more than just a great dog.
This family was devastated by the loss of their son to a violent crime three years ago. It was then, as a beautiful little puppy, that Skittles entered their lives. They described him as their therapy dog who has helped them navigate their collective nightmare. I was glad I did not know this before the surgery began.
I have always claimed that the amazing capacity of dogs to heal makes surgeons look way better than they actually are. With a few touch-ups, the incisions held, and four weeks have now passed since Skittles' surgery.
I just received a text from his family with a picture of Skittles. A large white scar courses around her body from top to bottom. The hair is beginning to grow, and the mesh cuts are filling in leaving a slightly quilted appearance. Most people would notice the long scar first, but I see the beautifully healed, full-thickness skin where there had been an enormous void.
Skittles came to this family to help them heal. Healing does not mean that we are restored exactly as we were before the wound. There can be no healing without scars. Healing means becoming ready to resume our lives in spite of the scars. So, while Skittles is healing his literal wound, thankfully he can continue to help his family to cope with a very different kind of scar.