ABSTRACT: This is the second in a series of articles on advanced wound management focusing on difficult wound locations and the importance of continuity of nursing care This case deals with an eight-year-old Labrador retriever which, after removal of a mast cell tumour from the cranial right shoulder, experienced postoperative wound breakdown. One of the contributing factors was the wound location which was in an area of movement. It was difficult to maintain an appropriate dressing and this article charts the progress of how a successful outcome was achieved.

Winston, an eight-year-old Labrador retriever, had previously been seen for a one centimetre raised skin lump on the right cranial shoulder. The lump had increased in size to two centimetres in diameter and fine-needle aspirate biopsy confirmed it to be a mast cell tumour.

Surgery was performed to remove the tumour with three centimetre margins and subsequent histopathology reported that the tumour was completely excised. There was an increased risk of delayed healing owing to the ‘release of proteolytic enzymes at the time of surgery’ – this includes histamine which ‘may result in acute inflammation, erthyema, oedema, ulceration and irritation’.1

The patient was on restricted exercise because the wound was in a highly mobile area and was under mild tension. Five days postoperatively, the wound began to break down. Although the author did not see the patient in the initial stages, the patient was presented to her at day 10 postoperatively and was managed by her thereafter, to ensure continuity of care.

This article charts the progress of wound healing using advanced wound management and the complications of maintaining a suitable dressing owing to the wound location and to demonstrate how a combination of factors can contribute to wound breakdown.

Case diary 

Day 1

Surgery was performed to remove the lump. An absorbable monofilament suture was used subcutaneously – polydioxane (PDS II, Ethicon, Johnson and Johnson) – and interrupted cross mattress sutures were put in the skin (to try and relieve the tension on the wound) using a non-absorbable braided nylon (Nylomide AK, Animus Surgical).

An injection of long-acting amoxicillin (Duphamox, Pfizer) was given, along with an injection of meloxicam (Metacam, Boehringer). A five-day course of carprofen (Rimadyl, Pfizer) was dispensed to start the following day.

Day 3

The owner reported that the wound was bleeding and was instructed to bathe the wound with saline, three times daily. The wound was checked, all the sutures were in place and there was no evidence of breakdown.

Day 6

The wound had begun to break down in the centre. The sutures still remained in place. A 4.2cm x 2.2cm deficit was present. The wound was cleaned with a 0.05 per cent solution of the antiseptic chlorhexidine gluconate (Hibitane). A hydrogel (Vetalintex, Robinsons Animal Health Care) was applied. Both were dispensed for the owner to continue to use at home, five times daily.

It was suggested that further surgery might be required.

Day 7

The wound had broken down further.

It was cleaned with a sterile saline spray (Aquaspray, Animalcare) and the central sutures were removed as they were no longer supporting the wound. Healthy granulation tissue was present. It was decided that the wound was to be left to heal by secondary intention rather than surgical repair.

Manuka medical honey (Activon, Advancis Medical) was used, with a secondary hydrophilic foam dressing (Allevyn, Smith & Nephew) held in place with nine skin staples. A chest bandage was used to assist in holding the dressing in place.

A seven-day course of antibiotic, amoxicillin/clavulanic acid (Clavaseptin, Vetoquinol) was dispensed.

Day 10

The case was referred to the author. A 3.7cm x 3.7cm full skin thickness wound was present (Figure 1). The Allevyn was over-saturated with the volume of wound exudate that had been produced. Only one staple remained in place and the Allevyn had slipped out of position.

 Figure 1: Day 10,3.7cm x 3.7cm

The wound was cleaned and assessed (Table 1). Granulation tissue was present. 

The wound edges were thickened and inflamed. The wound was dressed with honey and an alternative secondary hydrophilic foam dressing was used (Cutimed Siltec, BSN Medical). This has a perforated silicone contact layer which gently adheres to wounds, but is atraumatic on removal. It is also ‘super¬absorbent’ to cope with the high level of wound exudate.

A full chest bandage was used, extending it partially down the right foreleg to try and hold it in place, and to prevent slipping of the foam dressing ventrally. An elastic adhesive bandage (Tensoplast, BSN Medical) was applied over the edges of the dressing to support it further.

Day 15

The owner reported that the leg/foot had swollen. The foam dressing was a little worn owing to friction on movement of the leg – but had remained in place. The absorptive properties of the Cutimed Siltec were more suited to the wound exudate volume. Huge improvement was seen (Figure 2).

Figure 2: Day 15. 2.5cm x 2.2cm

The wound had reduced in size to 2.5cm x 2.2cm. The granulation tissue had almost filled the deficit. The remaining sutures were removed and the wound dressed with a 50:50 honey and hydrogel mix used with the Cutimed Siltec. A further five-day course of antibiotic, Clavaseptin, was prescribed.

Day 17

The wound was redressed as the dressing had slipped – movement of the shoulder and the position of the wound made it difficult to get the dressing to stay in place.

Day 21

The wound was much improved and had reduced in size to 1.4cm x 1.4cm (Figure 3). There was no skin deficit as the wound was now superficial. Healthy granulation tissue was present. The wound was redressed with hydrogel and Cutimed Siltec and held in place using an Hlastoplast layer only around the chest and shoulder. This was chosen as an alternative to full dressing layers, to try and hold the Cutimed Siltec in place more effectively. It was also a lighter dressing for the patient to tolerate.

Figure 3: Day 21.1 4cm x 1,4cm

Day 27

The wound was continuing to improve and reduce in size (Figure 4). A very superficial 1cm x 1cm wound area was present; but because of the difficulties in getting a dressing to remain in place, it was decided to leave it open at this point. The owner was instructed to clean the wound with saline twice daily and to use a hydrogel three times daily, and was asked to return when the wound was fully healed.

Figure 4: Day 27,1 cm x 1 cm superficial wound present

Day 93

The owner returned to the surgery two months later to show the author the wound in a fully healed state (Figure 5). The skin was slightly pink, and scar tissue could be felt on palpation. There was full hair re-growth.

Figure 5: Day 93, fully healed

The owner reported that the patient occasionally licked at the area but was otherwise unaffected.


As in the case history in the first article in this series (vnj August 2012, 27: 303-306), owner compliance was very good. The wound progressed very well and began to heal much faster than the author had anticipated, as the wound had been quite deep. This reinforces the authors belief in adopting an advanced, moist wound management approach when presented with wounds.

Although it was a difficult area to dress and required large dressings to begin with, the author feels it worthwhile to attempt dressings in these situations and modify them to suit. If an open wound can be provided with the optimal healing environment, then results will be obtained more quickly and will reinforce owner confidence in your care and judgement.

After dealing with other cases involving wound breakdown following mast cell tumour removal – especially in areas of tension – the author feels there may be an indication for providing a prophylactic moist wound dressing with honey immediately after surgery in order to forestall wound breakdown.


Caroline Calder RVN MBVNA

Caroline qualified in 2001 after attending Myerscough College, whilst working in Carlisle. For the last six years she has worked at a small animal practice in Durham. Since attending a CPD course in 2010, she has developed a keen interest in wound management.

To cite this article use either

DOI: 10.1111/j.2045-0648.2012.00210.x or Veterinary Nursing Journal Vol 27 pp 336-339

• VOL 27 • September 2012 • Veterinary Nursing Journal