Stephen J. Birchard DVM, MS, Diplomate ACVS

Tuesday, June 28, 2022

Medical and Surgical Treatment of Severe Thermal Burns in a Cat

Signalment and Presentation

Maximus, a healthy 6-month-old mixed breed neutered male cat, was presented for severe thermal burns over large areas of his body after jumping into a bathtub filled with scalding hot water.  The injury occurred just a few hours before presentation.


On admission, Maximus was tachycardic and severely painful. All four paws were red, swollen, and bleeding. The skin on his ventral abdomen and thorax was bright red and bruised. It appeared that the injury affected about 50% of his body. There was no other previous history of medical problems.


Initial Treatment

Maximus was initially administered intravenous fluids, antibiotics, and buprenorphine for pain. Continuous intravenous infusion of fentanyl was added to the treatment regimen soon after admission. Blood tests showed evidence of dehydration and elevated serum potassium. Silver sulfadiazine was used as the topical cream medication on the burned areas.


Maximus was non-ambulatory because the skin of his footpads was peeling off, leaving subcutaneous tissue exposed. Over the next several hours, the burned areas on his legs, chest, and belly gradually became purple in color. Some of the burned skin on his chest was becoming hard and leathery. (Fig. 1a,b) On a pain scale from 1-24 (1 being little or no pain, 24 being the worst pain possible), the attending clinician listed Maximus as 24. Intravenous lidocaine and ketamine were added to the fentanyl infusion to provide more analgesia. The dosage of fentanyl was also increased.

Fig. 1a: Maximus several hours after admission to the hospital

Fig. 1b

After sedating him with intravenous propofol, all of Maximus’ burned areas were carefully clipped and cleaned. With the hair removed, the burned regions were more clearly visible; the total surface area of his burned body appeared to be closer to 60%. 


More blood tests showed that Maximus’ albumin was already below normal. Albumin was being depleted because of the severe inflammation of the damaged skin and loss of albumin-rich fluid that oozed from his wounds. A nasogastric tube was placed to augment his dietary intake. 


Wound Management

On day two after admission, Manuka honey (Medihoney) was begun as the topical medication on the wounds, and standard bandaging was continued. The burned areas were gradually declaring themselves, and on day 4, some were starting to turn yellowish-brown and becoming hard and crusty. Escars were developing, indicating full-thickness skin injury. (Fig. 2)

Fig. 2: Escar development over mid abdomen and rear legs

To simplify the bandage changes that were time-consuming and painful, the attending clinician Dr. Becky Ball began covering Maximus with infant onesies, little pajama outfits that completely covered the entire body, legs, and feet. (Fig. 3) Each day the onesie was removed, the wounds gently cleaned, Medihoney ointment applied, and a clean onesie replaced. 

Fig. 3: Onesie pajama bandage applied.

Maximus was discharged 12 days after admission. The owner, a physician, assumed the nursing care at home. Rechecks with Dr. Ball were scheduled every 4-5 days for wound assessment. The escars gradually peeled away from the healthy skin, exposing new granulation tissue underneath. No evidence of infection was seen, and Maximus' appetite was good. 


Maximus continued to be re-examined about every two weeks. The eschars completely sloughed off, and the skin defects were contracting and closing well. But, as the skin tightened in his inguinal region, scar tissue pulled his rear legs medially, severely restricting his mobility. (Fig. 4) Surgery would be necessary to alleviate the contracture and allow Maximus to use the hind legs better. 

Fig. 4: Wound contraction of inguinal skin.

Skin Reconstruction


Seven months after Maximus’ injury, a caudal superficial epigastric axial pattern skin flap was performed to alleviate the inguinal wound contracture. (Fig. 5a-b) Click here for a detailed description of the skin flap procedure. The surgery went well, and he was discharged from the hospital the following day.

Fig. 5a: Axial pattern skin flap design. Arrow indicates the direction of rotation of the flap after it is dissected out.

Fig. 5b: Completed skin flap procedure.

Seven days postoperatively, suture removal was performed. The skin flap was viable and had healed well to adjacent skin. Maximus was much more mobile and less painful. Seven months postoperatively, he was examined again and was doing well with all wounds healed and his function back to normal. (Fig. 6, 7)

Fig. 6: Appearance of inguinal area seven months after skin flap reconstruction.

Fig. 7: Maximus and his owner 15 months after his injury.



Maximus overcame a severe injury with burns over a large portion of his body. He exemplifies the remarkable wound healing process, particularly when supported with good nursing care. Manuka honey was effective in preventing infection and encouraging wound healing. Dietary support was instrumental in avoiding hypoproteinemia and malnutrition. Excessive wound contracture necessitated skin flap reconstruction, improving mobility and relieving chronic pain. 

Maximus' owner, a neonatologist, was instrumental in his recovery. She assumed the challenging nursing care at home and was diligent in the tedious work of medicating, bandaging, and maintaining good hygiene.


Maximus’ complete story is told in Dr. Birchard’s book: Their Tails Kept Wagging: Pets Show Us How Hope, Forgiveness, and Love Prevail, a collection of inspirational stories of severely ill pets who survived due to modern medicine and compassionate caregivers. For more information, click here.




Thursday, March 31, 2022

How Pets Can Help Heal the Trauma of Parental Estrangement

Their Tails Kept Wagging: Pets Show How Hope, Forgiveness, and Love Prevail
by Stephen J. Birchard
and Fe Anam Avis

Available on and other major booksellers' websites.

Tuesday, March 8, 2022

Their Tails Kept Wagging: Pets Show Us How Hope, Forgiveness, and Love Prevail (by Dr. Stephen Birchard)


The Veterinary Key Points blog frequently uses the medical stories of dogs and cats to help illustrate the surgical illness or injury being discussed. Hershey had infected wounds on her back and rear legs that required skin reconstruction, Josie was shot with an arrow through her heart, car trauma ruptured the trachea in Tigger, and Jack developed a large hard palate tumor that we repaired with cartilage from his ear. 


These stories and others like them are the focus of a book I’ve written entitled: Their Tails Kept Wagging: Pets Show Us How Hope, Forgiveness, and Love Prevail. In it, we go beyond the pet’s medical ordeal and recognize their courage and incredible will to live. Despite poor odds of survival, their “tails kept wagging,” telling us that they refused to give up. I openly discuss the emotional ups and downs that my staff and I experienced as the animals fought their way through critical illness. The veterinarian/patient bond, a rarely discussed aspect of clinical practice, is a genuine part of daily life as a vet and affects us in profound ways. I try to bring that aspect of veterinary practice to the surface in the book. 


The book is written for the general public, but I invite you to read it because I believe the stories will also resonate with vets and their staff. For more information about the book, go to:

Their Tails Kept Wagging


I would love to hear your thoughts about the animals in this book and their tales of survival. What patient stories can you share, and how did their fight for life transform you as a doctor and person?

Stephen’s quotes

"For life is a seamless web. It connects us not merely with one another, but with all that is sentient; with all that shares its miracle of birth and feeling and death."— Abe Fortas

Tuesday, March 1, 2022

Reconstruction of Bilateral Caudal Maxillectomy Using an Autogenous Auricular Cartilage Graft

Stephen J. Birchard

Rebecca L. Ball

History and Physical Examination

Jack was a 4-year-old neutered male golden retriever that presented for inspiratory stertor for several weeks. (Fig. 1)

Fig. 1: Jack

There was no other history of illness. On routine physical examination, no abnormalities were identified, but oral examination under sedation revealed a 4cm diameter firm circular mass in the caudal hard palate. (Fig. 2) The mass was not movable and extended the entire width of the hard palate between the molar teeth. 

Fig. 2: Caudal hard palate mass

Diagnostic Tests

Plain film radiographs of the thorax revealed no evidence of metastasis. CT imaging of the oral cavity showed invasion of the bone of the hard palate and extension of the mass into the nasal cavity. A punch biopsy of the mass was obtained, and histopathology revealed multilobular osteochondrosarcoma.


Surgical Treatment

Under general anesthesia, the mass was excised by bilateral caudal segmental maxillectomy, including excision of the molar teeth on each side. After incising the mucosa around the mass and dorsal to the teeth, the maxillary bones and hard palate were incised with a bone burr and osteotome. The mass penetrated the hard palate but was not invasive into the nasal turbinates. The mass was excised, and bleeding was controlled with electrocautery and Vetspon in the nasal cavity. (Fig. 3)

Fig. 3: Appearance of surgical site after resection of the mass.

The large oronasal defect was closed by constructing bilateral mucosal flaps using buccal mucosa on each side of the defect and then sliding them to the midline. The flaps were closed on the midline in 2 layers: 4-0 PDS simple interrupted in the submucosa, and 4-0 PDS simple interrupted in the mucosa and sutured to the mucosa of the hard palate and soft palate in a similar manner. (Fig. 4)


Fig. 4: Oronasal defect closed by bilateral buccal mucosal flaps.

The mass was submitted for histopathology. (Fig. 5) Multilobular osteosarcoma (MLO) was confirmed, and complete resection with clean margins was reported.


Fig. 5: Tissue specimen submitted for histopathology.

Postoperative Care and Complications

Five days postoperatively, Jack presented for anorexia and a foul odor from the mouth. Oral examination revealed partial dehiscence of the rostral and caudal aspects of the buccal mucosal flaps, creating oronasal fistulae at both sites. Conservative management was initially recommended to feed soft food meatballs followed by mouth flushing with clean water. 


Surgical Revision

The rostral oronasal fistula was repaired two weeks postoperatively using an autogenous auricular cartilage graft. Under general anesthesia, a 2 cm by 3 cm rectangular section of auricular cartilage was harvested from the inner leaf of the base of the left pinna. (Fig. 6) 

Fig. 6: Red rectangle indicates the approximate size and location of the harvested auricular cartilage graft. (This is not Jack but is a dog with similar size and anatomy of the ear pinna.)

After lightly debriding and undermining the mucosa along the perimeter of the oronasal defect, the cartilage was placed in the defect with the edges inserted underneath the mucosa. The cartilage was sutured to the mucosa with 4-0 PDS simple interrupted pattern. (Fig. 7) 

Fig. 7: Closure of mucosa over cartilage graft (yellow arrow) and remaining oronasal defect (green arrow) to be repaired later.

An esophagostomy tube was placed in Jack to allow feeding while bypassing the oral cavity.


Three weeks postoperatively, Jack presented to repair the remaining defect in his palate. The cranial defect had healed well over the cartilage graft. He was doing well with only occasional difficulty drinking water. Under general anesthesia, a hinged buccal mucosal flap was performed to close the caudal oronasal fistula. (Figs. 8)


Fig. 8: Closure of hinged buccal/pharyngeal mucosal flap over remaining defect. (Arrow indicates the direction of the inverted flap.)


Two weeks after this final reconstruction, Jack returned for a recheck examination. On oral exam, the flap was intact and healing well. (Fig. 9)

Fig. 9: Healed defect after flap revision. 

Three months later, another recheck examination showed complete healing of all flaps and no persistent oronasal fistulae. Jack was doing well clinically with normal eating, drinking, and activity levels. 


Jack lived 6 more years after his surgery to remove the MLO. He did well during that time with no issues related to his surgery and no tumor regrowth. He eventually died of causes unrelated to the MLO. Even with a prolonged recovery and multiple revision surgeries, the owners were pleased that they had pursued the treatment of Jack’s oral tumor. 


Bilateral segmental maxillectomy is a surgical option for oral neoplasia of the hard palate, mainly when the tumor is on the midline. Reconstruction is by creating bilateral sliding buccal mucosal flaps that are sutured to each other on the midline over the hard palate defect.

Dehiscence is common due to the tension across the incisions and the lack of underlying bone. Reconstruction of the resultant defect is challenging due to the scarcity of available local tissue. Autogenous auricular cartilage grafts have been reported to augment the closure of oronasal defects in dogs and cats. (1,2). This technique was effective in Jack repairing one of the defects in his mucosal closure. It provided a surface for the oral mucosa to proliferate and fill the oronasal defect. The remaining defect was judged to be too large to do an additional cartilage graft but healed with a hinged buccal/pharyngeal mucosal flap. The long-term results of the reconstruction surgeries were excellent. Further clinical studies are warrented to evaluate the auricular cartilage graft technique for other oral cavity disorders such as cleft palate.  


Dr. Becky Ball was the primary surgeon in all procedures performed on Jack and directed his postoperative care. 


1. Soukup JW, Snyder Cj, Gengler WR. Free Auricular Autograft for Repair of an Oronasal Fistula in a Dog. J Vet Dent, Summer; 26(2): 86-95, 2009

2. Cox CL, Hunt GB, Cadier MM. Repair of Oronasal Fistulae Using Auricular Cartilage Grafts in Five Cats. Vet Surg 36:164-169, 2007.


Friday, January 21, 2022

Traumatic Tracheal Avulsion in Cats: Diagnosis and Surgical Repair

Fig. 1: 6 mo. old DSH named Tigger

 Signalment and History

Tigger is a 6-month-old male neutered Domestic Short Hair cat who was presented for repair of a fractured left femur. (Fig. 1) Tigger had been hit by a car a few days before presentation. 


Physical Examination


On physical examination, the left rear leg was moderately swollen and crepitus was evident at the midshaft femur. The cat was also mildly dyspneic with tachypnea and mildly labored breathing. Thoracic auscultation was within normal limits. 


Diagnostic Evaluation


Thoracic radiographs showed pneumomediastinum and avulsion of the thoracic trachea with air-filled mediastinum seen bridging the gap. (Fig. 2) A mid-shaft oblique femoral fracture was also found. Tigger was transferred to the ICU for continuous monitoring and oxygen therapy if necessary. 

Fig. 2a: Lateral thoracic radiograph of Tigger showing the ruptured trachea 
and mediastinal "pseudo-airway." (white arrows)

                Fig. 2b: Ventro-dorsal thoracic radiograph of Tigger.

Anesthesia and Surgery


Tigger was sedated and an intravenous catheter was placed. The right side of his thorax was clipped and an initial cleansing of the surgical site was performed. Anesthesia was induced with propofol and an endotracheal carefully placed. The size of the endotracheal tube was smaller than indicated to avoid further injury to the trachea. Intermittent positive pressure ventilation (IPPV) was avoided to prevent disruption of the tenuous mediastinal connection between the ends of the ruptured trachea.


The right lateral thorax was prepared for aseptic surgery. A right lateral thoracotomy was performed at the 4thintercostal space. A Buford rib retractor was placed and the cranial thorax was explored. Dissection of the trachea confirmed a complete avulsion of the trachea midway between the thoracic inlet and the carina. The mediastinum was serving as the only connection between the 2 ends of the ruptured trachea. 


The mediastinum was carefully dissected and the proximal trachea exposed. The endotracheal tube was found within the tracheal lumen, grabbed with thumb forceps, and pulled farther out. The tube was then inserted into the distal tracheal segment. IPPV was then begun and maintained for the duration of the anesthetic episode. The ends of the ruptured trachea were healthy; no debridement was necessary. The tracheal anastomosis was performed with 4-0 PDS in a simple interrupted pattern. The sutures were placed by grabbing 1-2 tracheal rings on each side of the anastomosis and were full-thickness bites from outside to inside, exiting the tracheal lumen. (Fig. 3) All sutures were pre-placed to allow accurate placement and then tied. (Fig. 4)

Fig. 3a: Surgical exposure of the trachea in Tigger after preplacing sutures across the gap. Note endotracheal tube (ET) within the tracheal lumen. 

Fig. 3b: Appearance of the trachea after completing the tracheal anastomosis.

Before closing the thorax, the endotracheal tube was gently pulled back and forth within the trachea to confirm that no sutures had penetrated the tube. A thoracic drain tube was placed and the thoracotomy closed routinely. The fractured femur was then repaired. Tigger recovered uneventfully from anesthesia. 


Postoperative Care


Tigger was returned to the ICU and given intravenous fluids and analgesics for pain. He did well overnight with stable vital signs and eupneic breathing. One day postoperatively Tigger was doing well with no dyspnea, normal vital signs, and a good appetite. Minimal amounts of air or fluid had been recovered through the thoracic drain tube so it was removed. Tigger continued to do well and was discharged from the hospital on the 2nd day postoperatively with continued analgesic therapy and instructions to keep him indoors and restrict activity. 


Tigger returned for a recheck examination 1 month postoperatively. The referring veterinarian had removed skin sutures 2 weeks after surgery and the thoracic and leg incisions were well healed. On physical examination, Tigger was bright and alert with pink mucous membranes and normal auscultation of the heart and lungs. He was weight bearing on the left rear leg. Repeat thoracic radiographs were normal with only a slight indentation of the tracheal lumen at the site of repair. (Fig. 5) Radiographs of the left femur showed normal progression of healing at the fracture site. Tigger was discharged with instructions to continue rest and return in 4 weeks for repeat radiographs of the left femur to assess continued healing.




Tracheal avulsion in cats is rare but has been reported. (1). It is likely the result of blunt trauma that causes the head and neck to be hyperextended which stretches the trachea leads to rupture. The site of rupture is usually the thoracic trachea midway between the thoracic inlet and the carina. The airway lumen is maintained by the mediastinum resulting in a so-called “pseudo airway”, allowing the cats to continue ventilating. In one study some cats presented up to 3 weeks after the traumatic episode. (1)


Cats with tracheal avulsion present for variable signs of dyspnea. Cats with delayed diagnosis may have trachea stenosis as fibrosis occurs at each end of the ruptured segments. Removal of the stenotic tracheal rings may be necessary to facilitate an adequate lumen at the anastomosis. (2)


The anesthetic protocol for these cats is designed around providing adequate oxygen flow and ventilation without causing iatrogenic disruption of the pseudo trachea. After induction, endotracheal intubation on Tigger was performed carefully without attempting to bridge the gap with the tube which could cause more injury. IPPV was avoided until the endotracheal tube was manipulated by the surgeon to provide a secure pathway for the delivery of oxygen. Immediately after thoracotomy, the first objective was to quickly pull the endotracheal tube from the proximal tracheal segment and place it in the distal segment to allow ventilation with oxygen and anesthetic gas. The trachea could then be carefully repaired. 


Based upon our experience with Tigger and a review of the reported cases, the prognosis for cats with tracheal avulsion is good after a successful repair. Most cats show adequate healing of the airway and can go on to live a normal life. 




1.     R N White, C A Burton. Surgical management of intrathoracic tracheal avulsion in cats: long-term results in 9 consecutive cases. Vet Surg, Sep-Oct 2000;29(5):430-5


2.     Fingland RB. Obstructive upper airway disorders. In: Saunders Manual of Small Animal Practice, 3d edition, Birchard SJ, Sherding RG, eds., Elsevier, 2006, pg. 1663-1664.