4 things you should never say or hear about lumps

Removing skin masses is one of my most common surgeries.

Some skin masses are small. Some are in difficult locations, making the surgery tricky. Some are gigantic. Many were claimed to be “impossible to remove” – yet we still removed them. Some were supposed to be cancerous – and were benign. Some were supposed to be benign – and were cancerous. Yet others were indeed impossible to remove and required leg amputation.

What’s a pet lover to do? What is the right thing to do?

The problem with small skin masses is that they can be very misleading. I have come across multiple tiny masses, sometimes the size of a grain of rice, that were aggressive cancers.

Here is an example of a 1/3 inch mass, barely visible, hard to feel, under a cat’s fur. By some miracle, his owner found the mass and wisely decided to have it removed.

The biopsy revealed a fibrosarcoma, which is a notoriously aggressive cancer in cats.

Here are the 4 things you should never say or hear about lumps:

. “Just watch it.”

. “Keep an eye on it.”

. “It’s just a cyst.”

. “It’s just a fatty tumor.”

“Just watching” a mass grow bigger and bigger, or “keeping an eye” on a mass that keeps getting larger and larger, is exactly how we end up with masses the size of pumpkins.

By then, surgery is much more invasive, anesthesia is much longer, and the fees are much higher.

The “cyst” myth is just as unfortunate. A cyst is an actual diagnosis. It’s typically a benign mass that is usually filled with fluid. There are different types of cysts: follicular or epidermoid cysts, sebaceous cysts, dermoid cysts etc.

But the vast majority of so-called “cysts” I remove are not cysts. It was an assumption by the pet owner. “Cyst” is often used instead of “mass” or “tumor,” and it’s misleading at best.

“It’s just a fatty tumor” is something else I hear all the time. If someone tells you that, you should have a reasonable degree of doubt. NOBODY can assure you with 100% certainty that they know the diagnosis of a mass with further testing.

Why? Because I have never met anybody with microscopic vision.

You can only say what a mass is after testing it.

Case in point: a mast cell tumor is a very common skin tumor. It is nicknamed “the great imitator” because it can feel like anything – including a benign fatty tumor. As you can imagine, mistaking a benign tumor for a cancerous one can lead to really frustrating situations.

2 tests for skin masses:
There are 2 ways to test a mass.

1. A needle test:
During a needle test or Fine Needle Aspirate (or FNA), a needle is placed in the mass. Some cells are taken out and placed on a glass slide. It is then read under the microscope.
It can either be read “in house,” meaning by your vet, or ideally it is sent out to a pathologist, who reads the cytology (ie the study of cells).
My personal impression is that although cytology is cheaper and faster (a few days), it can provide misleading results.

2. A biopsy:
A biopsy is a way to take a sample of the mass, ie some actual tissue, and not just cells. Being able to study the cells’ architecture, organization and relationship provides completely different information and a much safer diagnosis.
The biopsy is always sent to a pathologist, who reads the histo-pathology (ie the study of abnormal tissue).
My personal impression is that although a biopsy cytology is more expensive and take longer to read (7-10 days), it provides the most reliable results.

So what’s a loving pet owner to do?

At a minimum, skin masses should get tested via a needle test. Occasionally, they should be biopsied before surgery. Ideally, they should be removed and biopsied. Admittedly, it can get expensive since some dogs seem to be covered in masses, sometimes benign fatty masses. That’s where pet insurance is so helpful.

Here is an example of a giant mass in a Lab, whose owner was told to “just watch it” because it was tested as a benign fatty tumor.

So why bother if a mass is benign?

Benign doesn’t mean you should ignore it.

I have removed benign masses that were the size of a tennis ball, or a grapefruit, that prevented the patient from walking normally. I have removed benign masses that required leg amputation. And I have removed benign masses that were the size of a pumpkin that caused pain (by stretching the skin) and made the patients lose their balance.

If you find yourself in a situation where your vet seems to be brushing something off that genuinely concerns you, you have the right to seek a second opinion and I would encourage you to do so.

Bottom line: waiting is rarely a wise option.

Phil Zeltzman, DVM, DACVS, CVJ, Fear Free Certified

Dr. Phil Zeltzman

Dr. Phil Zeltzman is a traveling veterinary surgeon in Pennsylvania & New Jersey. An award-winning author, he loves to share his adventures in practice along with information about vet medicine and surgery that can really help your pets. Dr. Zeltzman specializes in orthopedic, neurologic, cancer, and soft tissue surgeries for dogs, cats, and small exotics. By working with local family vets, he offers the best surgical care, safest anesthesia, and utmost pain management to all his patients. Sign up to get an email when he updates his blog, and follow him on Facebook, too!

Your last surgery of 2020 was what???

I am perfectly aware that this is going to sound very weird to some pet owners.

I (still) wanted to share this because this surgery – the very last one I performed in 2020 – easily solves an annoying, itchy, ongoing “back end” problem…

Rigby, a super sweet 7 year old Pitbull, has had repeated urinary tract infections (UTIs).

The cause was an extra skin fold that covered her vulva.

The end result is a dark, moist, warm environment where bacteria thrive… then go up into the bladder, causing repeated infections.

This common (and under-diagnosed) condition is called a redundant vulvar fold, aka hooded vulva, vulvar fold dermatitis or recessed vulva.

The solution is a reconstructive surgery to remove the extra skin (vulvoplasty or episioplasty).

The main challenge in surgery is to remove just the right amount of skin. Not too little, and not too much.

Rather than a long story, here are before and after pictures.

On the left, you cannot see a vulva at all. It’s covered by the skin fold.

On the right, immediately after surgery, you can see the vulva.

Please be aware, this picture can seem graphic to some readers!

After 3 weeks, Rigby’s back end looks much better. Her vulva is visible, with no skin fold, and therefore no hidden place for bacteria to hide.

Her owner writes: “Her surgical wound is healed and the sutures are almost absorbed. She’s completely stopped licking and all of the inflammation/ irritation from the post op pictures is healed. The anatomy really looks perfect.”

Phil Zeltzman, DVM, DACVS, CVJ, Fear Free Certified

www.DrPhilZeltzman.com

Dr. Phil Zeltzman

Dr. Phil Zeltzman is a traveling veterinary surgeon in Pennsylvania & New Jersey. An award-winning author, he loves to share his adventures in practice along with information about vet medicine and surgery that can really help your pets. Dr. Zeltzman specializes in orthopedic, neurologic, cancer, and soft tissue surgeries for dogs, cats, and small exotics. By working with local family vets, he offers the best surgical care, safest anesthesia, and utmost pain management to all his patients. Sign up to get an email when he updates his blog, and follow him on Facebook, too!

A (double) Christmas miracle…

Once upon a time, there was a dog named Madeline.

The 7-year-old shepherd mix had had trouble urinating for about 2 months. She strained to urinate, with frequent attempts, and accidents in the house.

Long story short (you can read the entire story here: https://www.drphilzeltzman.com/blog/tag/leiomyosarcoma/), she eventually got an ultrasound which showed a mass at the junction of the bladder and the urethra (the tube between the bladder and the outside world).

Depending on its position, the mass would randomly block the urethra, making it physically impossible for Madeline to urinate. Not only is this incredibly uncomfortable, it can lead to various complications, including severe kidney damage.

Madeline’s owners went to several family vets and specialists to find a solution. They were told that the mass could not be removed or it would cause urinary incontinence.

The only treatment suggested was radiation therapy – for a mere $11,000 – and which might also lead to incontinence.

Madeline’s owners “felt hopeless. We couldn’t focus at work. Every day, we would wake up not knowing if this was the day that our dog would not be able to urinate and we would have to put her down. I felt like the vets gave our dog a death sentence with no answers and no option for her to have any help whatsoever. This did not seem right to us. It did not seem ethical. We asked them desperately what they recommended and they told us if there is one thing that they could recommend, “it is not to get surgery.” (…) She has no more than two weeks to live. We needed to monitor her closely to see when things got worse because then we would know when to put her down.”

Madeline’s owners found me through my website, and they reached out for help.

After reviewing her medical record and ultrasound report, I suggested a 2-step surgery:

Part 1. Remove as much of the tumor as possible.

Part 2. Place a “cystostomy” tube to drain the bladder through an opening in the skin.

About 1 week after surgery, the biopsy report came back. The mass was a rare cancerous tumor of the muscle of the bladder called leio-myo-sarcoma.

Madeline recovered well and immediately started urinating on her own.

Eight months after surgery, the tube became clogged and we collectively decided to remove it, rather than to replace it. It was a bit of a gamble, but Madeline was doing so well that we decided that the cons outweighed the pros. It was a judgement call, but so far it paid off: 4 months later, she continues to urinate on her own and is full of energy.

Madeline’s owner writes: “It’s truly a miraculous story and we still can’t get over it. We were so lucky to find you! Madeline is doing amazing! She has so much energy and acts like a puppy again. It was one of the best decisions of my life to get that surgery for Madeline.”

But wait! There’s more!

A few days ago, a desperate pet owner read Madeline’s story in my blog, and reached out to me. The subject line of the email was “I beg you for help.”

She wrote: “My dog Ninja, a 6 year old Siberian Husky, just had a ultrasound, and a CAT scan, then surgery to drain a cyst in his enlarged prostate (17 cm long – about 7 inches).”

“Because of the volume, it was pressing on the colon and the bladder. Ninja couldn’t defecate or urinate!”

“It was then discovered that the bladder has been so overstretched, that it couldn’t contract and enable Ninja to urinate. A urinary catheter was placed temporarily… and euthanasia was recommended!”

“I don’t want to put him down. He is eating, drinking and (now) pooping. He acting normal but can’t pee. Please help me, I am very desperate.”

We quickly scheduled surgery. Ninja had the same procedure as Madeline: a “cystostomy” tube to drain the bladder through an opening in the skin.

Of course, it’s a bit early to tell how Ninja will do long-term. So far, he is recovering well from surgery and is able to void through the tube. His loving owners are taking excellent care of him and got an unexpected, early Christmas present.

But wait! There’s more!

When I told Madeline’s owner that her blog may have saved another dog’s life, she shared:

“We are getting married on the date Madeline was saved a year ago: January 15!

And wait for it…

“Madeline will be the ring bearer in our wedding.”

So what’s the moral of the story?

You are your pet’s best advocate. If something makes no sense to you, don’t give up. Clearly, there isn’t a solution or a cure for every condition. But at least, explore your options.

This is exactly what Madeline’s and Ninja’s owners did. They didn’t take no for an answer, and saved their dogs’ lives.

Happy Holidays…

Phil Zeltzman, DVM, DACVS, CVJ, Fear Free Certified

Dr. Phil Zeltzman

Dr. Phil Zeltzman is a traveling veterinary surgeon in Pennsylvania & New Jersey. An award-winning author, he loves to share his adventures in practice along with information about vet medicine and surgery that can really help your pets. Dr. Zeltzman specializes in orthopedic, neurologic, cancer, and soft tissue surgeries for dogs, cats, and small exotics. By working with local family vets, he offers the best surgical care, safest anesthesia, and utmost pain management to all his patients. Sign up to get an email when he updates his blog, and follow him on Facebook, too!

Does the length of my pet’s incision matter?

Clients often ask me how long their pet’s incision will be after surgery.

Does the length of a pet’s incision matter?

The short answer is no. When it comes to incisions, it’s not the length that matters, but the care taken to keep it clean and protected.

Incisions heal side to side, not end to end, meaning that a 1 inch incision and a 10 inch incision heal at the same pace – most often 2 weeks.

It’s very predictable.

It pretty much would be that simple, if it weren’t for pet’s obsession with licking their “wound.”

Why do they do it? It’s an instinct. They can’t help it. They don’t know better.

But people should…

In addition, the incision area may become itchy as fur grows back. A pet’s natural response to itchiness or anything unusual is to lick or chew.

A few simple recommendations need to be followed to ensure that the incision heals without complications.

. Activity should be kept to a minimum. The skin and underlying tissues need time to heal. During healing, they cannot be stretched or moving constantly because motion slows healing down.

This is the reason why strict rest is critical for proper healing. Stairs, furniture, running, jumping and playing must be prevented during healing. Walks should be minimized to no more than 5 minutes, on a short leash, and for bathroom duties only.

. You should inspect the incision once or twice daily to make sure it looks good. If you see drainage, you can clean it with a soft cloth and tap water. Avoid using antiseptics of any type (peroxide, alcohol, cleaning solutions etc.) or triple antibiotic ointment. Only tap water. Then gently blot it dry.

. Speaking of drainage, what should you expect? Initially, some bleeding is possible. But then the red should turn to pink, and the pink should turn to clear (or light yellow). Then it should stop. Many times, you will not see any drainage.

If you see anything different, including a whitish, yellowish or greenish discharge, please get in touch with your vet or surgeon ASAP.

. You may also see bruising and swelling, both of which are common after surgery, just like in humans. It should decrease over time, then disappear.

. Whether stitches, skin glue or staples were used, the end result is the same: the edges of the skin should touch each other, and progressively fuse.

. The incision and surgery area should not smell much. If you notice a strong or foul smell, please get in touch with your vet or surgeon ASAP.

The next picture is a bit graphic, so please skip it if you have a sensitive stomach. It is not for the faint of heart.

. Most pet go home with a plastic cone (aka E-collar or Elizabethan collar) around their neck. It should be kept on at all times (24/7), even to eat, to prevent your pet from licking or chewing at the incision, which could cause it to open up and possibly get infected. We don’t use a cone when the incision is in the mouth or in a location where the edge of the cone might cause harm by rubbing on it. Throat and neck incisions come to mind.

REMINDER: THE NEXT PICTURE IS A BIT GRAPHIC. YOU HAVE BEEN WARNED.

(caption: this dog was allowed to lick the incision, which didn’t open up but looks rough 2 weeks after surgery)

. Since your pet shouldn’t be able to lick the incision, you also need to prevent other pets from licking. We don’t know why they have this bizarre habit… we just know they do. So pets recovering from surgery should be separated from other pets so they can heal peacefully.

. You may have heard an urban legend that claims that pet saliva helps with healing. It’s a myth!

Is it important to remember that your pet’s tongue has been in all kinds of weird places. Yes, including that place!

Therefore, their tongue is covered in bacteria, some of which are very aggressive. When you smear a surgical incision with fecal bacteria… guess what can happen!

The next picture is very graphic, so please skip it if you have a sensitive stomach. It is not for the faint of heart.

. Of course, the other risk of licking or chewing is opening up the incision, partially or entirely. Sadly, that may require another surgery to stitch it closed. Ironically, it will require another anesthesia, more money… and another plastic cone!

REMINDER: THE NEXT PICTURE IS VERY GRAPHIC. YOU HAVE BEEN WARNED.

(caption: This dog was allowed to lick the incision, which opened up partially. A second surgery is needed to clean it up and close it. In the end, it’s always the pet who pays the price…)

. We cover some incisions with a Band-Aid, not to replace the plastic cone, not to protect them from the tongue, but to protect them from the environment. This may reduce the risk of infection.

So the rules as simple: prevent licking of the incision, keep your pet strictly rested, and you will give your pet the best chance at healing completely and uneventfully, the first time around, no matter the type of surgery.

Phil Zeltzman, DVM, DACVS, CVJ, Fear Free Certified

Dr. Phil Zeltzman

Dr. Phil Zeltzman is a traveling veterinary surgeon in Pennsylvania & New Jersey. An award-winning author, he loves to share his adventures in practice along with information about vet medicine and surgery that can really help your pets. Dr. Zeltzman specializes in orthopedic, neurologic, cancer, and soft tissue surgeries for dogs, cats, and small exotics. By working with local family vets, he offers the best surgical care, safest anesthesia, and utmost pain management to all his patients. Sign up to get an email when he updates his blog, and follow him on Facebook, too!

How do I know if my pet is in pain?

This is a very common question… and it does not have an easy answer.

An entire book could be written about pain!

Instead of a book, here are some general, practical guidelines.

1. Limping

This is one of the most difficult message to convey. Yet it’s simple.

LIMPING = PAIN – 99% of the time.

2. Decreased activity

If your pet suddenly or progressively doesn’t play as much or as long as usual, it’s important to find out why.

3. Difficulty in stairs

To simplify, going downstairs puts more pressure on the front legs, so they may be the issue.

And going upstairs puts more pressure on the back legs, so they may be the source of the problem.

4. Changing habits

If your dog runs like a maniac to greet you when you come back from work every single time, and progressively or suddenly doesn’t, why is that?

If your cat loves napping on a window sill to enjoy the sun, every single day after breakfast, and doesn’t anymore, why is that?

If your dog loves going on a walk, or a run, or a bike ride, and doesn’t anymore, why is that?

5. Difficulty jumping

If your pet routinely jumps on the couch, or your bed, on in your car, or on a chair, and suddenly or progressively doesn’t as easily, it may be because of pain.

6. Difficulty getting up

Struggling to get up after a nap or in the morning, or stiffness in the legs, can also be a sign of pain or arthritis.

7. Change in appetite

Painful pets often lose their appetite, even for a favorite treat. It could be sign of pain in a leg (difficulty walking to you or to the bowl), or neck pain (reaching the bowl, which may need to be elevated), or pain in the mouth or in the teeth.

8. Not wanting to be touched

Pain can lead to “guarding” a leg or the belly, or becoming “head shy”. A classic example is a pet with ear pain or an ear infection (e.g. Cockers). Similarly, no longer wanting to be petted or picked up is a sign to take seriously.

9. Hunched position

A hunched position can be a sign of belly pain or back pain. Either way it can be very serious.

10. Reluctance to move a body part

This can apply to legs, and also to the neck. If your dog doesn’t like moving the neck up, down or to the side, and tend to look at you without moving the head, it can be a sign of neck pain.

11. Hiding

Cats are notorious for this. Either they hide, or they sleep in unusual places.

12. Grooming changes

Not grooming as much, or over-grooming or licking a particular body part can also be a sign of pain or arthritis.

13. Vocalizing

Crying or vocalizing may be a sign of pain, but PLEASE do not count on that to decide your pet is in pain. Many pets, if not most, will not cry when in pain.

14. Aging

Just kidding!

As I always say, “age is not a disease.” While slowing down can be normal, just like in people, limping or being in pain is not.

We can successfully treat countless conditions we were unable to help with before. You no longer have to accept your pet no longer playing or not wanting to go on walks because he or she is “just getting old.” It’s probably because they are painful or have arthritis. Both can and should be treated!

15. Off

Nobody knows your pet as well as you do! Sometimes, a subtle change, a gut feeling, a new routine, can give you an indication that something’s off.

Trust your instinct. Don’t brush it off. Ask yourself – or you vet – what this is happening. Everything happens for a reason in the pet world!

Here are a few more important points to keep in mind:

1. Hiding

Animals are very good at hiding when something is wrong. Remember, in the Wild, if an animal acts sick, they get eaten. Sadly, our pets have kept this ability. Cats are notorious for that.

2. Expression

Pain and its expression can vary dramatically from breed to breed, and from pet to pet. We know for a fact that some pets are more stoic, and others are more… “sensitive”.

3. Surgery

In my world as a surgeon, surgery is a classic way to help painful patients. Fixing a broken leg, repairing a torn ACL or removing a cancerous mass are just a few examples.

4. No surgery

But keep in mind that there are many ways to decrease or stop the pain without surgery including: weight loss, cold therapy, heat therapy, joint supplements, environmental changes, improving traction, acupuncture, harnesses, physical therapy, massage etc.

5. Warning

Please do NOT give any medication over the counter, or any human medication, or leftover medication from this or another pet, unless directed by your veterinarian.

Many human drugs are toxic to our pets, even deadly.

Something as “simple” as aspirin is a huge problem in a pet because:

1. We cannot give a better, safer, stronger anti-inflammatory drug for 7 days after stopping the aspirin and

2. If surgery is necessary, we cannot perform it safely for 7 days because aspirin thins the blood and increases the risk of bleeding!

ANY source of pain should be a reason to see your family vet or a board-certified surgeon.

As I always say, “pain is not acceptable.”

Pain should be taken very seriously – and vets are here to help you, help your pet.

Phil Zeltzman, DVM, DACVS, CVJ, Fear Free Certified

Dr. Phil Zeltzman

Dr. Phil Zeltzman is a traveling veterinary surgeon in Pennsylvania & New Jersey. An award-winning author, he loves to share his adventures in practice along with information about vet medicine and surgery that can really help your pets. Dr. Zeltzman specializes in orthopedic, neurologic, cancer, and soft tissue surgeries for dogs, cats, and small exotics. By working with local family vets, he offers the best surgical care, safest anesthesia, and utmost pain management to all his patients. Sign up to get an email when he updates his blog, and follow him on Facebook, too!