Experience with Rhomboid/Limberg Flap Healing - Concerned about granulation tissue

[It Hurts to Sit]

Hey everyone!

I'm new to posting on this site, but I've been reading threads for the last couple years (serial lurker...sorry).

I first became acquainted with the Pilonidal universe in 2013, when after months of discomfort, pain and itching, a doctor FINALLY figured out what was wrong with me. I had an open excision that healed well, and for 4 years I had no problems aside from some occasional scar tissue irritation.
Fast forward to Fall 2017. I thought I was having some scar tissue issues after I woke up the morning after a dance class with significant pain and drainage. Went to one surgeon, he "confirmed" it was my scar opening slightly, prescribed me antibiotics and sent me on my way.
He was wrong.
After the area didn't heal I went to a different surgeon who told me that while I didn't have a new cyst, I had an actively-draining sinus that I'd need to get taken care of. Yippee. He suggested the Rhomboid/Limberg flap in order to reduce the risk of recurrence because of the remaining sinus and pits I had.
He said I'd be out for a few days and would need to come in for two follow up visits to get the external stitches out (1/2 the first time, 1/2 the second).
I scheduled the surgery for a Monday, planning to take three full days off and work from home for the other two, then head back to work after my first follow up.
This was wishful thinking.
I had roughly 30 stitches (which I know seems small compared to some of you guys, but I'm a 5'1", 120 lb female, so that was a lot of surface area affected), and things healed well and I was released after my second follow up.
Two weeks later, I had a setback. I neglected to use my seat cushion at work (I am a writer and spend a lot of time on my behind at a computer), and when I woke up and went to the toilet, I had bright red blood trickling out of the wound.
Needless to say I panicked, called my mom who is a nurse, and immediately went back into wound protocol.
After speaking with the surgeon, he said it could be the incision pulling a little bit, OR it could be granulation tissue forming and causing issues/bleeding.
I also have some itching, but can't tell if it's the "good" itching of healing or something more sinister.

My question to my fellow sufferers/those who've had a Limberg procedure: Have you experienced this? Did it turn out to be granulation tissue or am I just going through the typical recovery and 6 weeks isn't long enough to be fully healed?

My surgeon seemed to think I'd be fine as I'm young and healthy, but I'm worried I'm having a setback and don't want to have to take more time off work.

Thoughts are appreciated!

 

[Hopeful88]

Hey everyone!

I'm new to posting on this site, but I've been reading threads for the last couple years (serial lurker...sorry).

I first became acquainted with the Pilonidal universe in 2013, when after months of discomfort, pain and itching, a doctor FINALLY figured out what was wrong with me. I had an open excision that healed well, and for 4 years I had no problems aside from some occasional scar tissue irritation.
Fast forward to Fall 2017. I thought I was having some scar tissue issues after I woke up the morning after a dance class with significant pain and drainage. Went to one surgeon, he "confirmed" it was my scar opening slightly, prescribed me antibiotics and sent me on my way.
He was wrong.
After the area didn't heal I went to a different surgeon who told me that while I didn't have a new cyst, I had an actively-draining sinus that I'd need to get taken care of. Yippee. He suggested the Rhomboid/Limberg flap in order to reduce the risk of recurrence because of the remaining sinus and pits I had.
He said I'd be out for a few days and would need to come in for two follow up visits to get the external stitches out (1/2 the first time, 1/2 the second).
I scheduled the surgery for a Monday, planning to take three full days off and work from home for the other two, then head back to work after my first follow up.
This was wishful thinking.
I had roughly 30 stitches (which I know seems small compared to some of you guys, but I'm a 5'1", 120 lb female, so that was a lot of surface area affected), and things healed well and I was released after my second follow up.
Two weeks later, I had a setback. I neglected to use my seat cushion at work (I am a writer and spend a lot of time on my behind at a computer), and when I woke up and went to the toilet, I had bright red blood trickling out of the wound.
Needless to say I panicked, called my mom who is a nurse, and immediately went back into wound protocol.
After speaking with the surgeon, he said it could be the incision pulling a little bit, OR it could be granulation tissue forming and causing issues/bleeding.
I also have some itching, but can't tell if it's the "good" itching of healing or something more sinister.

My question to my fellow sufferers/those who've had a Limberg procedure: Have you experienced this? Did it turn out to be granulation tissue or am I just going through the typical recovery and 6 weeks isn't long enough to be fully healed?

My surgeon seemed to think I'd be fine as I'm young and healthy, but I'm worried I'm having a setback and don't want to have to take more time off work.

Thoughts are appreciated!

Hey! I think we’ve all been serial lurkers on the site for awhile LOL

I think 30 stitches is a lot! But I had the cleft lift, so it’s a little different. But I did have a similar set back (and am almost fully closed and healed, so there’s hope). About 2 weeks after my surgery and the removal of all external stitches, the bottom of my incision opened due to fluid build up. My surgeon did not place a drain, which I think was the issue. My only complaint so far, as it extended my healing- but I’ll take it.

In regards to your surgeon’s thoughts- I really do think it was from tension on your incision etc. I also don’t think 6 weeks is enough time! It was a serious surgery, I’d give yourself some more time!!

Granulation tissue is a normal stage of wound healing, you’d see it more in “open healing” as I do since the bottom of mine is now technically healing from the “bottom up”. What you’d be worried about is hyper-granulation tissue. But that can be managed with Silver Nitrate, if needed.

Has your mom taken a look and made sure nothing is open, etc? If so and it’s not, I’d just watch it closely and give it some extra TLC for a few weeks. Use your cushion, avoid sitting for prolonged time. I use a sit to stand desk that has been a savior and a cushion for all required sitting. Increase your protein and take vitamins A,C, and E which all promote healing. I think you’ll be okay

 

[It Hurts to Sit]

Hey! I think we’ve all been serial lurkers on the site for awhile LOL

I think 30 stitches is a lot! But I had the cleft lift, so it’s a little different. But I did have a similar set back (and am almost fully closed and healed, so there’s hope). About 2 weeks after my surgery and the removal of all external stitches, the bottom of my incision opened due to fluid build up. My surgeon did not place a drain, which I think was the issue. My only complaint so far, as it extended my healing- but I’ll take it.

In regards to your surgeon’s thoughts- I really do think it was from tension on your incision etc. I also don’t think 6 weeks is enough time! It was a serious surgery, I’d give yourself some more time!!

Granulation tissue is a normal stage of wound healing, you’d see it more in “open healing” as I do since the bottom of mine is now technically healing from the “bottom up”. What you’d be worried about is hyper-granulation tissue. But that can be managed with Silver Nitrate, if needed.

Has your mom taken a look and made sure nothing is open, etc? If so and it’s not, I’d just watch it closely and give it some extra TLC for a few weeks. Use your cushion, avoid sitting for prolonged time. I use a sit to stand desk that has been a savior and a cushion for all required sitting. Increase your protein and take vitamins A,C, and E which all promote healing. I think you’ll be okay

Ha, I'm just glad there is a community for this nonsense/nightmare.

Yeah, it was a lot of stitches. I asked about cleft lift, but with the amount of tissue he wanted to remove, he thought Limberg was the better option.

It's possible mine was a fluid-build-up situation that resulted in some incision opening and the oozing/drainage. When I contort myself with a mirror to look at it, there was a small (think size of a pen tip) opening at the top apex of the scar, and then some redness on the more inside corner further down.

I haven't been able to see my mom since this started (she lives 2 hours away, where I had my surgery, as I'm just out of grad school and not quite settled), but I've sent her photos and she is the nurse for the surgeon actually so he was able to look at it.

I think I'm going to just continue the TLC like you said. I shower and wash with Hibiclense (all hail the savior it is), and then keeping it as dry as possible. I've gotten over using the cushion at work, and I try to lay/sit on my side as much as I can when I do have to not stand.

Thanks for the vitamin/protein suggestion. I take a multi, but I may try to up those through some additional juices or something.

Good to know there is hope!

 

[Hopeful88]

Ha, I'm just glad there is a community for this nonsense/nightmare.

Yeah, it was a lot of stitches. I asked about cleft lift, but with the amount of tissue he wanted to remove, he thought Limberg was the better option.

It's possible mine was a fluid-build-up situation that resulted in some incision opening and the oozing/drainage. When I contort myself with a mirror to look at it, there was a small (think size of a pen tip) opening at the top apex of the scar, and then some redness on the more inside corner further down.

I haven't been able to see my mom since this started (she lives 2 hours away, where I had my surgery, as I'm just out of grad school and not quite settled), but I've sent her photos and she is the nurse for the surgeon actually so he was able to look at it.

I think I'm going to just continue the TLC like you said. I shower and wash with Hibiclense (all hail the savior it is), and then keeping it as dry as possible. I've gotten over using the cushion at work, and I try to lay/sit on my side as much as I can when I do have to not stand.

Thanks for the vitamin/protein suggestion. I take a multi, but I may try to up those through some additional juices or something.

Good to know there is hope!

Haha I hear you on the mirror thing, I’ve gotten veryyy up close and personal with a mirror myself

 

[siouxatc]

So I will just give you a little bit of detail about my experience with the Modified Limberg Flap in December at Emory. This was my fourth surgery after two failed closed operations and a failed wide excision. Everything went well immediately after surgery was in the hospital for one night and was discharged in the morning. I had about 40 or somewhat stitches. Everything was going fine for the first two weeks. After week one I got the Jackson Pratt drain out and then the stitches came out the following week. Two weeks later which was about a month after the surgery I had some drainage coming from the lower area of the scar closer to the rectum. I returned to the reconstructive surgeon and he said that there was some sort of fluid build up and all the tissue underneath hadn't adhered yet at the time it didn't look infected. I was advised that could take up to six months to completely scar down underneath. He was able to stick an entire cotton tip applicator underneath the flap. I went back to packing with a half inch iodoform packing strip twice a day. Fast forward to the end of January I had an abscess form on the upper left portion of the scar and I ended up in the hospital for four days since my wbc was high and they had to i and d it. I was advised I had a some sort of bacterial infection underneath the scar was placed on Vancomycin while I was in the hospital and Clindamycin with Cipro when I was discharged.. After that happened I healed up fairly well and everything has been all closed up now for week. I would advise you to keep hair out of the area that you're having the issue with. Wounds can open up down there due to the warm moist anerobic environment so I don't think it would hurt to possibly get an antibiotic that is effective against mrsa staph etc since I was told this can cause wound break down issues. Also i found that vitamin c zinc and a good multivitamin with increased protein intake helped me with the healing process. If you have any questions feel free to pm me.

 

[It Hurts to Sit]

Just posting a final update here: Everything turned out to be OK. Surgeon thinks it was likely a little fluid build up, and that the itching was just the healing/scar tissue/general moistness of the area (ew gross sorry).

I'm now 3.5 months post-op, and while the scar is GNARLY and will twinge every now and then, I'm doing a lot better. Every so often I'll wash with the Hibeclense when I've been exercising or outside all day (sweating....). Anyway. Hopefully I'm not one of the 5% that has issues after this *knocks on all the wood*

 

[Krissy]

Just posting a final update here: Everything turned out to be OK. Surgeon thinks it was likely a little fluid build up, and that the itching was just the healing/scar tissue/general moistness of the area (ew gross sorry).

I'm now 3.5 months post-op, and while the scar is GNARLY and will twinge every now and then, I'm doing a lot better. Every so often I'll wash with the Hibeclense when I've been exercising or outside all day (sweating....). Anyway. Hopefully I'm not one of the 5% that has issues after this *knocks on all the wood*

Hi, just wanted to check in and see how you are doing after all this time? I’ve been recommended to get this same procedure but this will be my 3rd operation.
I’m also female with a similar build to you! Curious to see if you have had any reoccurances as mine seemed to happen 2-3 years after my procedures.
Thanks!

 

[Nana Tadros]

If it is not closed yet, I would highly recommend the cleft lift surgery by an experienced surgeon. I have seen lots of failures after a Limberg flap. Do not be discouraged, their is hope but you need to see someone experienced enough who does a lot of cleft lifts. There are surgeons out there who claim they do it but they do not have the experience. My favorite surgeon is Dr Wadie in Raleigh. He did my 2 sons surgeries and gave them their lives back after so many failed surgeries. If you can go to Raleigh, please do. He is in anew practice now called Carolina Pilonidal Center