There is much conversation between patients and surgeons, and among patients themselves, regarding the appearance of their post-operative incisions, wounds, and drainage after pilonidal surgery of all kinds. I am going to attempt to discuss some of the things that patients observe, and what they actually represent; and try to debunk and demystify some of the erroneous information patients are hearing. This discussion applies to previous cyst removal, pit picking and laser surgery, and previous flap procedures of any kind.
If after an open excision there is one spot that won’t heal after 6-12 weeks, I would consider the operation a failure. The way to really evaluate the situation is to look at the location of the open spot while standing. If the spot is directly in the midline, and is hard to see when standing because it is down in the gluteal fold, it is most likely going to be a chronic or recurrent problem. At this point you could embark on months of wound care, possibly at a wound clinic, and it may heal – but probably will not. The better solution is additional surgery, and the sooner you come to that conclusion, the sooner you can move forward with a solution. Another excision is not the best approach: a cleft-lift will flatten the cleft and set the stage for healing.
One has to understand the difference between “infection” and “contamination”. An infection is defined as bacteria trapped under the skin and invading surrounding tissues. If a wound is completely open, or mostly closed but draining through an opening, then the bacteria are not trapped – so what is occurring is contamination. The kind of bacteria and the amount of bacteria will be variable. The best thing to do is keep the area clean, change dressings daily, and wait for it to heal. Antibiotics will most likely not speed up the healing process.
If a wound opens up and starts draining or bleeding, that is not a good thing; but whether it will heal or not depends on the shape of the cleft and the position of the opening. It is not unusual after any surgery, including a cleft-lift, for there to be some separation, particularly in the lower part of the incision. However, if the incision (and therefore the opening) is not in the midline, but off to the side, it will always heal. Whether the drainage is watery, purulent, or bloody is not really the important characteristic.
The reason that the skin over some of these wounds is fragile, is because it is down in a cleft or skin fold. Wounds don’t heal well down in a cleft, and may partially heal, and then tear open. Paradoxically, it isn’t spreading of the cheeks and the wound being pulled apart that is the problem – it is the fact that the wound is buried in the cleft, is not open to the air, and has anaerobic bacteria surrounding it that causes the fragility. The solution is to change the shape of the cleft, and get the incision up out of the cleft.
If you are concerned about your general ability to heal, then please read my page on Nutrition for Healing, and increase your protein intake and take the vitamins and supplements I recommend.
As with most things, it depends on the exact situation. If the part of the incision that has separated is off the center line, and the cleft has been nicely flattened, it may be just an area that has weakened, but will heal in over the next few weeks. If the area of separation is deep in the center fold – then this may represent a problem that won’t heal, and might need further surgery. Incisions that come close to the anus are notorious for separating a bit – but then healing in slowly over the upcoming weeks.
This highlights the significant difference between surgeons and how they perform the cleft-lift procedure. I am particularly diligent in doing my best to get the incision away from the midline, flattening the cleft, not creating a new cleft, and avoiding too much tension on the incision. It is not possible to always get it perfect, but when there is a problem, it usually is from not being aggressive enough in moving the incision over. If you are a patient of mine, and are having some separation of the wound, please read this page: “Understanding Wound Separation”.
I always place a suction drain under the flap after surgery. This stays in place about 4-7 days, and removes any fluid that might accumulate under the flap. Studies have shown that without a drain, about 20% of patients can have fluid accumulate, and this can cause serious problems with the success of the operation. So, if a surgeon wants to do a cleft-lift without a drain – it is not totally unreasonable. But, at our clinic (with 75% of our patients living a long distance from our office) we don’t feel that the omission of a drain is worth the risk. Trying to take care of a patient with wound problems who can’t come into the office is difficult and complex. If your surgeon is close by, and easy to see if needed, it is more reasonable to try this operation without a drain.
When patients have a closed excision, these wounds frequently do not heal, and surgeons say it is because they became infected. Actually, that is not the case. These wounds come apart because they are down in the gluteal cleft, and because of the location, they do not heal. As they fall apart, bacteria begin growing in the wound, and it appears as if infection caused the incision to separate – but actually it is the opposite. The separation allowed bacterial contamination.
When I perform a cleft-lift, the incision is placed out of the cleft, and off the midline. This prevents the situation described above from happening, and is the reason why the infection rate in our clinic is about 3 percent.
If you had a closed excision, and begin having bleeding, drainage, or wound separation from a part of the incision that is down in the gluteal cleft – you may have trouble getting this to heal. If that is the case, you should look at my page Help! I Just Had a Wide Excision!, to see what your options are.