Welcome to “Bizarro World”

Posted on by Steve Immerman

Getting the right advice at the right time

Those of you old enough to have read Superman Comics may remember the Bizarro World where everything was the opposite of the real world. Sometimes our patients feel like they have entered Bizarro World when they come to our clinic because of the vast difference between the instructions and information I give my patients, as opposed to what they have been told in the past. The instructions I give are what I have found works for my patients with the operation I perform. So, I can’t say that the advice patients have received elsewhere by other surgeons is wrong, but I can say that they don’t apply to my cleft-lift patients.

Here are some examples:

  • We encourage sitting immediately after surgery! I believe that this is actually beneficial for the incision, since it opens up the bottom of the cleft and allows air circulation. I have never seen a situation in one of my post op patients where sitting has caused a problem.
  • We do not recommend any type of hair removal. Once the cleft is flattened, hairs should not be an issue anymore.
  • We close the wound. No open wounds, no packing, no complicated dressing changes.
  • We use dissolving sutures. The large, external, sutures that many surgeons use do not guarantee that the wound will stay together; they leave permanent, unsightly stitch marks; and can be very uncomfortable.
  • We allow showering the day after surgery. I would rather have the area around the incision clean. Letting the shower run on the incision and drain has not caused any problems in my patients.
  • We recommend patients go back to fairly normal activity, as long as it is gentle on the incision. We do not recommend any period of immobility.
  • We allow lying directly on the incision when sleeping. It is OK to sleep in any position that is comfortable.
  • We never use silver nitrate on wounds. It is a caustic chemical that does more damage than good.

These instructions are often met with incredulous expressions, since they contradict all previous instructions – but this protocol works very well. I am trying to make recovery from the cleft-lift as simple as possible, and get my patients back to normal activity as soon as possible. There are certain instructions I give that are very important to follow, and this is all complicated enough without adding restrictions that aren’t necessary.

The success rate in our clinic of ~98% primary healing speaks for itself as far as the wisdom of this protocol, and our patient’s responses to our post op instructions have been positive, as you can see from the answers to our survey below.

This is what our patients feel about the activity restrictions after cleft-lift surgery.

Facts about hair and pilonidal disease

Posted on by Steve Immerman

Some of the first research on the subject

The term “pilonidal” means “nest of hair”. We know that pilonidal cysts contain loose hairs. These hairs are not “ingrown”, but instead they are hairs that fell into the gluteal crease and found their way under the skin, either by entering a midline pore or directly piercing the skin itself. 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.