The pros and cons of wound V.A.C.’s
A suction device used to help heal a wound has several names: Wound V.A.C, VAC, “vacuum assisted wound closure” or “negative pressure wound therapy (NPWT)”. Sometimes they are referred to based on the specific brand of the machine, like a “Pico” or “VERAFLO”. VAC stands for” Vacuum Assisted Closure”. It consists of foam placed over an open wound, that is sealed with adhesive plastic, and connected to a machine that applies suction and removes fluid.
Note: this is not the same as a “closed suction drain”, also called a JP Drain, Jackson Pratt Drain, or Blake Drain. These are tubes that go INSIDE closed wounds to remove fluid.
Negative Pressure Wound Therapy is very helpful in getting wounds to heal faster and minimize daily dressing changes. The VAC has to be changed periodically, but less frequently than usual open wound care.
But, is it a good solution for pilonidal wounds?
I suppose it depends on how you look at the situation. There are quite a few negatives (no pun intended) attributed to the use of the wound VAC for pilonidal wounds:
- It is an extremely awkward location to have a wound VAC, and it is hard to keep it well secured in place, especially with wounds next to the anus.
- It has to be changed frequently, the materials are expensive, and it has to be changed by a wound care professional, either in their clinic, or by a home-care visit.
- It is noisy, smelly, and embarrassing; and the VAC changes can be painful.
- It may have to be in place for months at at time.
- Even if it helps a wound to heal, it provided no guarantee that it will stay healed once the VAC is removed. The placement of a VAC is an extremely abnormal situation which does not replicate the environment and anatomy that will exist when it is removed. Frequently, when it is removed, the wounds open up again. Note: This is true for gluteal crease wounds, not wounds elsewhere on the body.
Although philosophically one could look at the use of a VAC in this situation as a difficult therapy that is trying to make the best of a bad situation, I don’t agree with that analysis. I think the smarter choice is to see a pilonidal expert and have surgery to close the wound. This short-cuts the whole situation, and usually turns this into a full recovery in about six weeks with a very low chance of recurrence. (I have not used a VAC on any of my patients in 27 years of pilonidal surgery.)
FURTHER SURGERY may seem like an illogical way of dealing with an open wound, that occurred BECAUSE of surgery, but if done properly it works. It is also appropriate with failed flap procedures, including previous failed cleft-lifts. If your current surgeon says that the wound can’t be closed – get another opinion. It may just mean that he or she does not know how to close it. There is almost always a faster and easier solution.
Contact us if you need help!
Dealing with failed operations
Often patients ask me why their previous surgery won’t heal. Or, why it heals but then reopens.
Surgeons often blame this on:
- the patient’s hygiene
- quality of wound care
- general health (“you just don’t heal well!”)
- that they have mysteriously developed a new “cyst”
- or “it was so extensive, we just couldn’t get all the cysts and tracts with the last operation”
- there is too much hair, and hair removal needs to be more diligent
- too much activity made the wound come apart
However, the actual reason for non-healing is usually the same in almost all cases:
- the cleft was not completely flattened
- the incision is in, or crosses, the midline
Of course, if a patient had a huge excision that was left open (or fell apart after closure) it will take a while to heal, and the size does matter. But, there should be good, steady progress. If it is taking many months, the wound actually gets larger, or the wound seems to heal – but then reopens, the cause has to do with the two reasons above.
When a patient gets to the point where it seems that it is just not healing, the original surgeon may suggest another excision! In general, this is the wrong approach, and just brings you back to square one. The best approach is one that will flatten the cleft and move the incision off the midline. My personal preference is the cleft-lift, which has been engineered to do exactly that. There are other flap procedures that may or may not work, depending on the expertise and experience of the surgeon performing the flap, but the cleft-lift is cosmetically the most appealing.
At our clinic we specialize in correcting the anatomy so that these wounds heal quickly. If you have been dealing with an open wound for more than two months without progress, contact us. We’re glad to help!
Some of the first research on the subject
The term “pilonidal” means “nest of hair”. We know that pilonidal cysts contain loose hairs, but until recently there has not been much research done on what kind of hairs are in the cysts, and why one patient develops pilonidal disease and another does not. Here are some of the more recent facts found by researchers in Germany:
- Stiffer hairs have more of a tendency to get in these cysts than softer hair.
- Most of the hairs in a pilonidal cyst come from the back of the head.
- Hair on the back of the head is stiffer than the hair in the gluteal crease, possibly explaining why hair from the head is more common in cysts.
- Patients who sweat more have LESS incidence of pilonidal disease than the opposite counterparts. Wet hairs are less stiff, and this may explain why.
- Most of the hairs in a cyst are found to be short and have sharp ends and no roots.
- In spite of the usual precautions a barber takes to keep hair from from falling down a customer’s back, cut hairs are immediately found at the level of the low back after a haircut.
- I have not seen any evidence that showering is a critical time, and that it matters if you rinse your hair forward or back.
This information is all very new, and it’s significance remains to be seen. But, it does suggest that the time after a haircut may be critical in the penetration of pilonidal pits by sharp, stiff hairs, and an immediate shower is a good idea. Although we do not generally recommend hair removal as a solution to pilonidal disease, nor a necessity after cleft lift surgery, if you feel that you do want to do this, we don’t recommend shaving – but rather recommend using a clipper to keep the hairs short.