Managing wound separation after the cleft lift operation

Why might a wound separate?

Although my goal is to have all my cleft lift patients heal their incision quickly and uneventfully, sometimes there are problems. The most common problem is a slight separation of the lower portion of the incision, just as it curves inward toward the anus. This web page discusses this problem.

Who gets this problem?

It is not always predictable who will have some wound separation, but the things that seem to predispose to this are:

  1. previous pilonidal surgery
  2. pilonidal wounds near the anus
  3. being overweight
  4. Hidradenitis suppuritiva and other autoimmune diseases.

How frequent is this problem?

In my series of patients this occurs about 10% of the time. You can read my recent article which details my results in 700 patients over several decades of collecting data. Most surgeons do not have this kind of data, and really have no idea how often this happens in their own patients. You can not assume this number applies to other surgeon’s patients. Although I wish this number was lower, it turns out that this isn’t as big an issue as it seems (read more below)

With any operation, the cleft lift procedure included, healing of the incision has to occur. In general, this is a six week process after which wounds are at about 95% of their full strength. It gains that last 5% over the remainder of a year. However, the body is constantly strengthening and remodeling wounds for a lifetime. (This is evidenced by the fact that with severe vitamin C deficiency, called “scurvy”, old wounds will open up and start bleeding.)

There are things that can cause the incision after a cleft lift to separate:

  1. Wound infection
  2. Seroma formation (fluid build up under the flap).
  3. Hematoma formation (a collection of blood under the flap).
  4. Reactions to the suture material.
  5. Trauma to the the incision.
  6. The incision isn’t far enough off the midline, or a deep cleft remains.

What happens during the healing process?

The suture material provides strength for as long as 6 weeks, but it lingers in the tissues for up to six months. These sutures cause problems months later if patients have reactions to the residual suture. The suture that I use seems to be a good balance between strength and longevity.

What can I expect if the wound separates a bit?

This is where the construction of the cleft lift becomes very important. When I create a cleft lift two of my goals are to move the incision away from the midline and make sure the incision is not in a skin fold. If I can accomplish these things, any separation of the wound will usually heal.

This is what may differentiate this type of wound separation from any problems you may have had after other operations. In my experience if the wound is off the midline and outside of a skin fold it will always heal. So, the main thing is not to panic, and follow certain simple wound care instructions.

If a wound separates in the first month there is some sort of problem that has made the wound come apart. It may be fluid coming through that area, tension on the incision, infection, an autoimmune process, reaction to the sutures, etc. When this occurs it may continue to separate a bit more for a week or two, and then seem like not much is happening; the opening is not really getting bigger or smaller. But, if all goes well it will begin healing rapidly as it approaches six to eight weeks from the operation. Even fairly significant wound separations will be healed by week 12 if the wound is off the midline and outside the gluteal crease, as demonstrated in the image below.

There are times when the wound separation gets worse as weeks go by. When that happens, we begin to suspect that there is some other disease process causing this, and in our experience this is often the autoimmune skin process called HS (hidradenitis suppuritiva). If we suspect this, we may put you on specific antibiotics that show effectiveness with treating HS. If the process doesn’t seem to improve with these antibiotics, we will recommend a consultation with a dermatologist to determine the best therapy. It is not unusual that a patient has HS and pilonidal disease simultaneously, but is unaware of the HS component until other circumstances develop to point us to the diagnosis.

Wound separation that started around week 3, and well healed at week 12

Is there anything I can do to speed up healing?

The body’s healing process works on a six week time-line. So, no – you can not “speed up” healing, but you can make sure that you are optimizing the situation so as not to slow down healing. Those strategies are:

  1. Always keep a piece of woven gauze next to the open area to allow air circulation. Change as necessary so it stays dry.
  2. Keep the area clean with soap and water. It is OK to use antibacterial soap, but not imperative. This won’t make it heal faster.
  3. Be sure you are eating plenty of protein and you continue the recommended vitamins and supplements until this is completely healed. If you are deficient of any of the building blocks your body needs for healing, the process will not go according to the normal time-line.
  4. There are times when it will be helpful to use certain topical medications on the open area. (see below) We will let you know if we feel any of these would be helpful.
  5. Be as gentle with the incision as you can, especially in the first 4 weeks post-op.
  6. Wear loose clothing.
  7. Be patient and let me know how you are doing every couple of weeks, and always include photos.

Topical medications that may be helpful

  1. VITAMIN C SERUM: I probably recommend this the most for my patients with wound problems. You can read more about it by following this link: Vitamin C Serum.
  2. 10% METRONIDAZOLE OINTMENT: I only recommend this in situations where the wound is right next to the anus and I’m concerned that it is not getting enough air. You can read more about this by following this link: Metronidazole Ointment.
  3. SKINUVA SCAR CREAM: This is something that aids healing and improves scar appearance. Not everybody needs this, but there are times when it can be useful. I’m not aware of any downside to using this, but it is somewhat expensive.  This is available on Amazon, directly from Skinuva, or from other retailers.
  4. What about Manuka Honey? This is often used for open wounds, and I wouldn’t really consider a slight separation of the incision an “open wound”, but the terminology is subjective. You can read more about my thoughts on Manuka Honey in general in this blog post. I have not recommended it for these slight separations.

So, be sure to keep us notified of your situation

If you experience wound separation as described here, keep us notified of the situation, follow the instructions on this page, and realize that this usually will resolve with proper wound care. Of course, every patient is different, and no strategy works 100% of the time. If another operation is needed to change the shape of the cleft to get a wound to heal, we will discuss this around week 6-12 and make plans. But, understand that would be very unusual.