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.

What is the place of silver nitrate for pilonidal wounds?

Posted on by Steve Immerman

The “art” of surgery.

As surgeons, we each have have years of training and experience plus an enormous body of scientific and clinical information at our fingertips. There is so much information, that the correct way to apply it is open to interpretation. This is where the “art” comes in. Here, I would like to discuss my opinion regarding the use of silver nitrate, as applied to pilonidal wounds after surgery, or in place of surgery to get pits and openings to close.

Silver nitrate is a chemical that chemically burns tissues. It usually comes on a wooden applicator stick, and when applied to exposed tissues, causes a chemical cauterization (burning) of the wound.

Surgeons do this when they have no idea why something is not healing. This is the surgical equivalent of “turning-it -off and back-on-again”. (We do this with our electronics when we don’t know how to fix something, but hope that a reboot will do the trick.)

In this instance, surgeons are blaming the lack of wound closure on “hyper-granulation tissue”. This occurs when there is visible, good, healing tissue inside the wound, but the skin isn’t closing over it. There are times in surgery when this makes sense and is a reasonable strategy – but NEVER with pilonidal wounds. The hope is that burning away the tissue, will give the wound a fresh start at healing – but without understanding why it wasn’t healing in the first place!

The reasons that this is not a good strategy are:

  • It is painful.
  • It takes time away from doing the correct thing to fix the problem (surgeons can keep applying silver nitrate for MONTHS before they give up on it as a therapy).
  • The reason for lack of healing of pilonidal wounds is NEVER because of hyper-granulation tissue. (More here on the reasons why pilonidal wounds won’t heal.)

The correct solution is to:

  • Perform corrective surgery to adjust the location of the incision, (which in my preference is a cleft-lift).
  • Make sure the area is being kept clean and dry.
  • Keep gauze tucked in any folds with open wounds, to allow air circulation.
  • Consider GENTLE, topical medications that promote healing and/or control specific bacteria.
  • Maximize protein intake, and consider the vitamins and supplements I’ve recommended.

I believe that many patients have proper care delayed, are traumatized, and may even have small wounds enlarged buy the use of silver nitrate.