Summary
Once granulation tissue is elevated significantly above the skin level it is called "Proud Flesh". In most cases, it must be surgically removed. It is your vet's job to determine why it developed and what can be done to promote healthy wound healing going forward.
Surgical removal of proud flesh begins with wound cleaning. Vets usually wears latex exam gloves to perform this procedure. The wound is cleaned and hair clipped away so that the edges of the wound are visible. In some cases, sedation is used to help keep the horse still for the procedure.
In most cases, healthy young granulation tissue does not have much nerve supply, so proud flesh can be cut away with a scalpel blade without causing the horse much pain. In some cases, however, over time the granulation bed does develop a nerve supply. Due to this, I am always careful to test the tissue for sensation before cutting.
A scalpel blade is used to cut away the tissue. Granulation tissue is mostly made of blood vessels, so there usually is significant bleeding. How much bleeding depends on several factors.
The time that the procedure takes depends on the size and characteristics of the wound bed. Usually it just takes a few minutes. When the tissue is cut below skin level, vets often places a pressure bandage to stop bleeding.
Thereafter, your vet typically helps prevent recurrence of overgrowth of tissue through a variety of proud flesh inhibitors.
YOUR ROLE
As with any wound, it is critical that you perform the treatments and management of the equine as your vet instructs. If you are to perform bandage changes on a challenging wound, be sure to communicate with your vet using photos so your vet stays well informed of the wound's healing progress and can advise you on dressings and treatment.
Note: Some vets prefer to use caustic topical chemicals to "burn away" proud flesh. There are a variety of types of chemical types that destroy proud flesh.