I Had a Cleft-Lift and It Failed!

Am I doomed?

The short answer is, “no”. But, what should you do now?

When a cleft lift fails – meaning that either the incision came apart and isn’t healing, or a new cyst, sinus, or wound has developed – it is usually because the cleft-lift failed to flatten the ENTIRE cleft, or that the incision from the cleft-lift ended up in the midline.

Fortunately, this can be repaired by revising the cleft-lift. The revision will flatten the lower portion of the cleft and bring the incision away from the midline. This is usually successful in salvaging the situation. Of course, nobody wants another operation – but it is better to just get this taken care of, then letting it linger. If six weeks or more has elapsed since your cleft lift, and you are still dealing with problems, then you should consider a re-operation.

Who should do this re-operation? You should make sure that it is a surgeon with a broad experience in re-operating on failed pilonidal surgery and failed flaps, since there is a unique skill-set needed for this. At the Evergreen Surgical Pilonidal Clinic, we have had extensive experience with this kind of re-operative surgery and are happy to see patients who have had failed surgery elsewhere. In our clinic we have had to re-operate on about 2% of our patients, but all of these had already had previous failed operations and/or wounds next to the anus, and were in the most difficult categories of pilonidal disease to treat.

THIS WEB PAGE will show you the difference between a successful and an unsuccessful cleft-lift. The takeaway being that although many surgeons call their procedure a “cleft-lift”, there are various degrees of quality and success based on the surgeons experience and expertise.

If you’ve had a cleft-lift and it has failed, don’t give up. Contact us for help!

Honey for Pilonidal Wounds

One of the interesting ways of dressing open wounds is with honey. It is available in “medical grade” form, and often Manuka honey is specifically used. (This is honey from the manuka tree which has a antibacterial compound not present in other types of honey.)

The characteristics of honey that make it something that can be used on open wounds are:

  • It has some antibacterial properties
  • Because it is such a concentrated substance it pulls water out of tissues, which may decrease swelling
  • It has a slightly acidic ph, which may help wound healing

But, the real question is whether or not the physical characteristics of honey promote better or faster wound healing than other topical wound treatments. One important concept in treating patients is that:

Just because something logically sounds like it would be beneficial, doesn’t mean it actually will be.

This is why clinical trials, research studies, and literature searches are so important in determining what we should actually do to solve clinical problems. A simple example of this is that Betadine, is a great antiseptic that we use all the time to sterilize skin. But, we’ve found that when used for any length of time on open, infected, wounds it not only impairs healing, but is toxic to the patient!

As far as honey goes, it doesn’t seem to be much better or worse than other topical treatments when used on open wounds. It may be beneficial for some types of burns.

As far as pilonidal wounds goes, there are studies that show that pilonidal wounds can heal when honey is used. But, when compared to other topical treatments, such as silver, zinc, hydrogel, foam, wound VAC, etc., there does not seem to be a particular advantage to any of them. The benefit of using something that has antibacterial properties at all is open to debate.

My analysis of all this is:

  • It is reasonable to use honey on an open wound, but it is not preferred over other modalities for any specific reason.
  • Honey is not an appropriate treatment for an acute abscess or for application on closed incisions.
  • The most important maneuvers to get pilonidal wounds to heal are to keep things clean and dry and get air circulation to the wound. Unfortunately, this may not be possible without further surgery.
  • If sinus tracts have formed, even the smallest wound will never stay healed with honey or any kind of wound care.
  • Proper nutrition, including high protein and vitamin intake is probably more important than the specific local wound care.

If pilonidal surgery is done properly, such that the cleft is flattened and the incision is off the midline, complex and prolonged wound care will not be needed. In our clinic we do not have to deal these issues, except in complicated situations where we are trying to fix poorly done surgery elsewhere.

What is the place of silver nitrate for pilonidal wounds?

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.