By Christopher Winkler, DVM, For The Education Center
Originally Published In Veterinary Practice News, June 2018 –Download as a PDF
A CO2 laser cauterizes blood vessels up to 0.5 mm in diameter as it cuts, allowing excellent visualization of the tissues as the surgery proceeds. The precise incision and hemostasis control that the laser provides are especially valuable when operating near delicate structures such as the eyes, nose, and face. Decreased direct tissue contact and the ability to destroy pathogens (which often can frequent areas such as facial folds) decrease infectious contamination during and following surgery on the face. Nerves and lymphatics also are sealed, decreasing postoperative pain, swelling, and discomfort, and allowing the pet a faster recovery time with less tendency to self-mutilate.[1]
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- Figure 1: Stenotic nares.
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- Figure 2: Right entropion.
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- Figure 3: Left entropion.
Case
Gracie is a 4-year-old spayed female Chinese shar pei suffering from stenotic nares (Figure 1) as well as a severe bilateral entropion of both upper and lower eyelids (Figures 2, 3) and from the very heavy and excessive facial folds on her scalp. On presentation, Gracie was unable to open her eyes without outside assistance and was suffering minor bilateral corneal lesions. It was immediately observed that resection of part of the scalp would be an essential part of her surgical treatment to reduce pressure on the upper eyelids.
Anesthesia
The patient was premedicated with dexmedetomidine 125 mcg/m2 IM, cefovecin 3.6 mg/lb SQ, and carprofen 4.4 mg/kg SQ. The patient was induced with Propofol 3 mg/kg IV, and general anesthesia was maintained with isoflurane via endotracheal tube.
Laser equipment
A 20 W Aesculight surgical CO2 laser with a flexible hollow waveguide and adjustable hand-piece.
Laser settings
- Focal spot size: 0.25 mm
- Marking: 4 W repeat pulse, 20 Hz, 20 msec, 40 percent duty cycle
- Scalp incisions: 15 W continuous wave
- Entropion/Stenotic nares: 6 W continuous wave
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- Figure 4: The procedure began by marking the incisions with the laser on a spot size of 0.25 mm, and 4 W repeat pulse (20 Hz, 20 msec, 40 percent duty cycle). First on the nares.
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- Figure 5: And then the excess skin of the scalp, in two diamond-shaped sections over each eye. First on the right side and then on the left.
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- Figure 6: The marking is completed on the scalp and on the nares.
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- Figure 7: Full-thickness skin incisions then commenced, first on the scalp with the laser set for 15 W continuous wave. The focal spot size is still 0.25 mm. Note lack of hemorrhaging.
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- Figure 8: Following resection of each area on the scalp, the edges were sutured first with 2-0 PDS horizontal mattress sutures, and then closed by skin sutures using 2-0 monofil in a simple interrupted or cruciate pattern.
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- Figure 9: The left facial fold resection alone has improved the contour of the left upper eyelid. The author did not see the need to continue with an entropion resection of the left upper eyelid after observing this.
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- Figure 10: The eyes are protected with moistened gauze. The eyelids are marked for entropion resection with the laser set for 4 W Repeat Pulse (20 Hz, 20 msec, 40 percent duty cycle). The spot size remains 0.25 mm. First the upper right lid was marked.
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- Figure 11: The laser was then set for 6 W continuous wave at 0.25 mm spot size to begin the entropion correction. A thin piece of tissue is removed from the upper and lower lids on the right side.
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- Figure 12: Removal is carefully done in stages to assess how much the eyelid will be everted on suturing.
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- Figure 13: The eyelids were sutured with 2-0 monofil in a simple interrupted or cruciate pattern.
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- Figure 14: Correction of the lower left eyelid in progress. The CO2 laser provides excellent hemostasis for increased visualization and speed in this procedure.
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- Figure 15: Completing the procedure by widening the stenotic nares. The laser was left at 6 W continuous wave with a focal spot size of 0.25 mm.
Postoperative care
A therapy laser was applied to both scalp incisions (297 J each, 40 cm2 x 2) and the nares (157 J, 5 cm2). The patient was administered atipamezole 250 mcg/kg and butorphanol 0.2 mg/kg at surgical recovery. An Elizabethan collar was applied. The patient was discharged later the same day with carprofen 50 mg PO BID for seven days. Postoperative discussion with Gracie’s owners included close observation for any sutures contacting the eyes, observing for drainage or dehiscence of the incisions, and the possibility of removing more skin in the future as required.
Follow-up occurred at eight days and suture removal at 16 days. Gracie healed quite well with no complications and very satisfactory results (Photos 19 and 20).
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- Figure 16: Pet’s right side on completion of the procedure.
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- Figure 17: Pet’s left side on completion of the procedure, eyelid margins now clearly visible.
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- Figure 18: Frontal view of the pet immediately on completion of the procedure. Note the widened nares.
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- Figure 19: Eight days postop.
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- Figure 20: Sixteen days postop, sutures removed; Gracie appears quite pleased with herself.
Dr. Christopher Winkler graduated from Ross University School of Veterinary Medicine in 2001 and is the owner of Suffolk Veterinary Group Animal Wellness and Laser Surgery Center in Selden, Long Island, N.Y. He uses both CO2 and diode laser wavelengths in his practice, often combining them when possible. He is a diplomate of the American Board of Laser Surgery, a veterinary medical laser safety officer, and a Fellow of the American Society for Laser Medicine and Surgery. Dr. Winkler is keen to advance laser education in veterinary medicine and surgery and is available for consultation and training in small animal laser surgery and laser therapy.
References
- Berger N, Eeg PH. Veterinary Laser Surgery: A Practical Guide. Iowa: Blackwell Publishing, 2006.
This Education Center article was underwritten by Aesculight of Bothell, Wash., the manufacturer of the only American-made CO2 laser.
