Category Archives: Scar reduction

Why are there so many kinds of scars from PS surgery?

As a boy growing up with a scar cluster front and centre on my belly, I found I had several fixations which have never really left me.

  1. I was desperate to know what caused this scar, left by pyloric stenosis (“PS”) surgery I had when just 10 days old.  Apart from my mother telling me several times that I had been “a little bit sick as a baby and a doctor had made me better” it wasn’t until much later in life that I pieced that puzzle together.
  2. I was also desperate to hide my belly from public view.  I shrank from people’s inquisitive stares and inevitable questions and felt deeply embarrassed because I couldn’t handle, let alone answer them.
  3. Whenever I saw people in beach or gym attire (and with a bare midriff) I was ravenous in my search for anyone with a scar similar to mine – but never found anybody like me in that way until in my adult life.

People02Only in recent years have I learnt that this somewhat bizarre cluster of phobias and fixations is by no means unusual for survivors of infant surgery.  As mentioned in a recent post, there are also many extroverts who totally escaped my problems – and often find them rather silly.

Obsession #3 has continued with me (and it seems with others in their more mature years).  In recent years I have seen quite a number of people with what look like being scars from PS operations, and this is largely because I have learnt that this “procedure” is done using a number of surgical techniques.  So my mind is now programmed to search for and recognize half a dozen scars!  Yes, weird and whacky!

The development of the internet has birthed several forum sites where people like me can network and break out of their feelings of isolation and self-flaggelation.  The web even allows us now to compare scars and to have many of our questions answered much more fully than my 1940s parents would ever have been able!

Recently Facebookers with an interest in their own or their child’s PS mentioned the sheer variety of scars from repairing PS, a fairly common condition remedied with a relatively simple technique.  My own research of this whole subject area enabled me to attempt an answer –

The pyloric ring muscle usually sits under and behind the right (and exit) end of the stomach, so below the right ribcage.  It can be fairly easily accessed from anywhere below the ribs and above the navel.

The navel (or umbilicus) itself is (or was once) often avoided as a point of access, especially if it hasn’t fully healed after the baby’s birth and as its folds are a haunt for germs.  The umbilical incision (“Tan Bianchi” after the surgeons who promoted it) is a semi-circle incision usually over the top of the navel, sometimes extended by one or both horizontals (making it an omega sign): through this the pylorus is worked on. The Tan Bianchi incision is now often used as it allows open access but (if done well) leaves a minimal scar.

The keyhole op (“minimal access surgery” or MAS) was introduced in the 1990s: a 5mm probe (tube or “port”) through or near the navel inflates the belly and adds light, and then two other probes (3mm) higher up allow instruments to enter and do the work on the pylorus. In recent years “single port MAS” has been introduced by which everything is done through the one port at the navel.  Special care with infection control is very important, and this technique comes with a higher number of infections, but it also leaves minimal scars and is therefore preferred by parents.  MAS requires a higher level of training and skill than open surgery, but experienced surgeons can use it with similar results and complication profiles.

The open incision was and is still the easy one for surgeons, but growing numbers of younger pediatric surgeons have now learnt the umbilical and/or MAS techniques.

Abdomen incisions1Open surgery involves cutting through layers of skin, fat, muscle, and the fine material that holds our abdominal bits and pieces in place, plus of course nerves and blood vessels.  There are several layers of muscle forming the wall of the abdomen, each running in different directions to enable them to do a variety of tasks and to add toughness.  Down the front and middle of the abdomen, running from the breastbone to the pubic region, is a strip of tough connective tissue called the “linea alba” or “white line”: it has less blood vessels and nerves and anchors the various muscle sheaths.

Conrad Ramstedt, who in 1912 pioneered and promoted the technique that is used to treat infant PS, used the median (or middle) incision down the linea alba that was and is still used for much (and especially major) abdominal surgery.  It gives good access, can be easily extended, and avoids the complex muscle layers on either side.

Other surgeons preferred to avoid this area for relatively short incisions, as the linea alba’s poor blood supply slowed healing and therefore increased the risk of wound rupture.  These doctors moved their vertical incision to the right, the “para-median” incision.

In the 1930s, two other incisions became popular for PS surgery.  Both avoided the vertical openings which it was claimed came with increased exposure of internal organs, and more wound complications.  By cutting through the several layers of muscle and repairing each separately, it was claimed that the wound was easier to control.  One of these incisions was angled just under the right ribcage, the Kocher or “gridiron” incision.  The other was transverse (“across”) and became the most popular one used for PS surgery to date.  Transverse incisions are placed wherever the surgeon likes or locates the pylorus: some are almost at navel level, other horizontal just under the ribcage, and most in between.

Reading the journal articles that advocate the writers’ incision preference has led me to conclude that a surgeon’s choice seems to depend more on their classroom or craft training than on truly decisive benefits or hazards.

The development of the umbilical and MAS techniques has occurred only since 1990, urged on by the cosmetic benefits which are usually and typically urged on conservative and technique-oriented doctors by the concerned parents of unknowing babies.

Postscript

Since writing this post I came across a website under the title of Common Abdominal Incisions.  It sets out in (what I find) fascinating detail and in generally understandable English the various considerations, benefits and hazards regarding the incisions used for many of the commonly used abdominal surgeries, and what each incision involves.  In the past I have sometimes found it necessary to “translate” the information given on a medical website, but in this case that seemed quite unnecessary.

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Pyloric stenosis: long-term complications

Parents with a pyloric stenosis (“PS”) baby are always reassured by their paediatrician and surgeon, as they should be.  Although PS is usually a fatal condition, it can be brought under control with a small surgical procedure that is very safe, and although this operation sometimes leaves the baby with one or two immediate but treatable problems like reflux, there are no long-term effects.

Reassurances like this are the norm – but are they telling enough of the story?

“If only we had known…”

In fact, the “silent majority” of those who have had surgery for PS seem to have no or only minor complaints (usually a sensitive tummy).  However, PS and its operation are relatively common, between 1 and 5 in every 1,000 infants in most of the countries where this blog is read.  And so online there are countless complaints about significant challenges for babies, children and adults after this operation.

The “Categories” search box to the right of this page gives access to some of the data and stories I have found.

Here are two personal stories about how PS affected adult survivors.

Both are from women who shared their experience in 2013 on Real Self, a U.S. website that promotes cosmetic or reconstructive surgery after weight loss, malformation, accident or surgery.

The first story is from a woman who writes about two things with which she struggled: deep loathing and self-consciousness  about her scar, a common issue especially for many who had PS surgery before minimal access techniques became available after about 1990.

Hernias  were this woman’s second nightmare, most likely caused by the violent vomiting of PS, the surgery, a constitutionally weak abdominal wall, or all of these.

The good news is that after 60 years and many surgical repairs she is now very happy.  She posted her story on 1 April 2013 under the nom-de-plume Adreamcometrue.

Surgical scar after herniation or rupture (but not the writer's)

Surgical scar after herniation or rupture (but not the writer’s)

My tummy problems began when I was 22 days old, in 1950.  No that is not a misprint.  I was born two months premature.  At 20 days I began projectile vomiting.  After a couple of days a diagnosis was made: pyloric stenosis.  Surgery was performed.  That surgery left my midsection a mess.  As a child and teen I was cursed with a huge vertical scar surrounded by bulging flesh.  Nothing like being a teen and wearing a long line bra.  Body issues were definitely present.

My first reconstructive surgery to repair multiple hernias was in 1970.  There were other hernia surgeries in 1982, 2000, 2005, and 2007.  After the surgery in 2007 I was left with a huge bulge on the upper left quadrant of my ab region.  Three different docs told me I did not have another hernia.  Finally, as I was shopping for a gown for my daughter’s up-coming wedding,  I was becoming more and more discouraged.  Dresses in my usual size were not fitting.

In frustration, I went to Dr. Barach (a plastic surgeon).  He made an appointment with a[nother] surgeon.  They both felt I had another hernia.  So on March 22 the surgeon took care of a hernia and a wall tear next to it and Dr. B took care of the tummy tuck.  I am so thrilled.  The first time I saw my middle, 5 days post op, I cried.  I never thought my middle could look this way… I look great with my drains and swelling.

Based on the stories shared by others here, I can only imagine what I will look like 6 months from now.  I have been seen by my plastic surgeon two times since returning home and have another appointment this afternoon.  Keeping my fingers crossed that the drains will be removed.  Thank you to everyone who reports here.

This website has been very useful and comforting.  I am looking forward to returning to the gym and am continuing to eat healthy…. well… Easter doesn’t count… Does it?  Have a great day!

P.S… Insurance covered the hernia portion of surgery but not the plastic surgeon’s bill.  The use of the Operating Room was also pro-rated, and we had to pay $875 for that.

Some days later she continued –

I am now 13 days post-op.  On day 10 my drains were removed…

I hadn’t taken my own “before” pics.  I asked for a set, which they gave me.  Now I have to figure out how to scan them onto my computer so I can post them.  What a difference!  My pre-op size 6 jeans fit with no muffin top.  Yay!..

The plastic surgeon reminded me that my walking should not resemble exercise, when I complained that it took 15 minutes to walk about ¼ mile.  The plastic surgeon said I shouldn’t even consider using a treadmill for a 6 weeks.  I was in the gym 5 days a week prior to surgery.  Due to issues that make me easily develop hernias and tears, I can’t do CORE exercises.

 *          *          *

The second story is a powerful reminder of the real risk of complications long after PS surgery and also during and after any subsequent surgery.  These problems are often unexpected and possibly disastrous.  This woman prepared for cosmetic surgery full of both anticipation and fear.  She first posted on 1 Jan 2013 as “1hotway” and I have felt it helpful to add some comments.

First of all, I just want to thank all of you beautiful ladies for sharing your amazing stories.  This site has been a true godsend to me.  I am 38 years old with 3 beautiful boys … All of the damage to my tummy was done with my first born.  I was 20, so I never really got to enjoy my body.  I got terrible stretch marks, and needless to say a two piece was never worn again.  I have been at a pretty average weight my whole life. …

The writer's damage after carrying children and two surgeries

The writer’s damage after carrying children and two surgeries

When I was a baby I had a little stomach issue called Pyloric Stenosis.  It left about a 3″ scar on the upper right side of my abdomen.  I also had my gallbladder removed at the age of 21. [This quite often happens after the PS operation but the risk is it seems never mentioned. Ed.]  They unfortunately had to do the open surgery that left about a 7″ scar on my upper right abdomen.  Ugh!  Right?  I look like a road map!

I am sooooo ready for this. Thank goodness I have a wonderful hubby who loves me just the way I am.  One of the four plastic surgeons I saw for a consult said he didn’t think I was a good candidate for the TT [tummy tuck].  The other three said it would be fine.  Of course this makes me very nervous.  I don’t want to settle or compromise for my results.  It’s all or nothing…

A few days later she wrote –

I love looking at all of these amazing stories, but some of them aren’t so wonderful.  I guess it is good to read the good and the bad, but frankly it scares the heck out of me.  Necrosis???  [The death of tissue cut off from the blood supply by the old scar(s) and then plastic surgery. Ed.]  That is really scary stuff.  I have just read some terrifying reviews on that.  I can only PRAY that doesn’t happen to me.  One of the plastic surgeons I saw said that I am at a higher risk for this because of myprevious abdominal surgeries.  My plastic surgeon that is doing my TT isn’t concerned at all.  He is confident there shouldn’t be a problem since my surgeries were so long ago.  I am getting really nervous and excited.

2 February 2013

Paid in full. Got recliner. Pre-Op in a week. This girl is ready and nervous.

11 February 2013

Had my pre-op today.  BP was a little high.  Probably from reading & signing all of the consent forms.  Not exactly thrilled about reading all of the worst case scenarios.  Trying not to think about all the bad stuff that could happen is easier said than done right?  Any ways, got my prescriptions and doctor took my before pics.  I’m all set now.  Just have to wait for the big day…

18 Feb 2013

Well, I can’t believe it’s finally almost my turn.  I think I have everything all dialed in.  My husband is amazing.  He keeps telling me to just relax and breathe, he will take good care of me…  I wish I could just do that…

2 March 2013 – 6 days post-op

Started getting a strange pain in my right shoulder blade.  By day 7 it was traveling down the right side of my back.  It hurt to take a deep breath in.  I saw my plastic surgeon.  Had a drain removed and told him about the pain I was experiencing.  He assured me it was nothing.  4 hours later I drove myself to the ER because the pain was getting worse.  They ran labs, X-ray, and CT scan.  They confirmed Ihad a pulmonary embolism and admitted me to the hospital right away.  I now have been getting shots in my tummy to break up the clot.  I also have to be put on Coumadin for six months.  This has been the scariest thing in the world to me.  I should have never put myself at this kind of risk with 3 kids and a husband who need me.  I’m very lucky it was caught so early.  Many others aren’t so fortunate…

I’ve noticed that the risk is much greater than I thought.  This has been my biggest fear in getting this surgery.  I felt confident with all of the precautions that were taken during and after the surgery but clearly it wasn’t enough.  I tried to be mobile, I had a shot of heparin right before the surgery, they used the leg squeezers on me too.  Obviously it was just out of my control.  I will never have an elective surgery again.  The risk is just way to great…

4 April 2013

…I still won’t ever say it was worth it, considering all I have been through.  Just so happy to be alive and here with my amazing husband and beautiful boys.

12 Feb 2014

Hello, it has been almost a year since my TT.  I’m going to be honest. I probably wouldn’t go with Dr. H… if I could do it over again.  I think he is a little arrogant and I would definitely go with a doctor who takes every precaution they can.  I know that Pulmonary Embolisms are rare, but most people don’t live through them, so I would go with the safest route.  There really is no way of knowing if the clot came from my pelvis or one of my legs.  I tried to be mobile as often as I could, so just not sure.  I also have to say that I wasn’t impressed with how long it would take for the staff to respond to my messages…

*          *          *

Ugly scarring, herniation, adhesions blocking the gall-bladder, necrosis and other problems related to the scar, fear of the list of hazards we have to acknowledge before submitting to surgery, complications from the surgery…

The stories of just these two women (and the previous posts in this series) make me think I’ll keep encouraging those who can to try, even press for the medical treatment option for their PS baby before they sign a consent to surgery.

2013’s most visited infant surgery (SIS) posts

This last post for 2013 on the “Surviving Infant Surgery” (SIS) site was written away from home and after a very busy but delightful, Christian, and family Christmas.  I thought if might be of interest to list the most visited posts of this blogsite during the past year.

It is with continual surprise and gratitude that after three years I continue to see the interest in the SIS blog rise each year, so that the total “hits” now number almost 50,000.  Even more gratifying is the feedback from many readers, online and by email.  The message of your comments is, “Thank you, you’re helping people like me (or us) so much with your honesty, careful writing, shared experiences, and by helping me / us to realize that my / our experience is far from a lone or odd one.  Do keep up the good work.”

The post that drew the most interest by quite a margin was about the possible long-term effects of infant pyloric stenosis (“PS”) and the surgery that often follows it, Ramstedt’s pyloromyotomy.

ponderAdhesions after a pyloromyotomy were a frequent and often troublesome concern among those who used this blog during 2013.  Two of the top 10 discussed this, the posts # 2 and # 6.  The 2nd most visited post dealt with the effect of the surgical scar and internal adhesions on a pregnancy, and the subject of #6 was the adhesions that can be expected after any abdominal surgery – with special reference to the trouble adhesions have been found to cause to people after an infant pyloromyotomy.  Sadly, this is one of the subjects raised by PS and its surgical “remedy” that most doctors brush off with a vengeance: there is no prescription, no surgery, and no other easy way of dealing with abdominal adhesions.

The subject that had the next (3rd) most readers’ interest was related to this also: Does an abdominal scar cause trouble during pregnancy?  The short answer is that it can – but usually if any, it is a relatively minor discomfort.

The post with the 4th highest number of “hits” discussed a deep fear and occasional reality: Can PS raise its horrible head again after a pyloromyotomy?   Continued vomiting, although of a less violent form, is quite common, even to be expected, after a pyloromyotomy, although usually only for a short time.  It is very understandable that parents who have just been through the harrowing experience (indeed, traumatic for many) of infant PS will be more than anxious about this possibility.  While most doctors and hospital staff are reported to be very supportive in this situation, many parents are unsettled (to say the least) by the earlier bland and simplistic assurances that “surgery fixes PS immediately, permanently, and without any after-effects”.

Self-exam1The post that came 5th in popularity in 2013 reflects another area of anxiety and emotional pain that has come with the surgery for PS: while some care nothing about their scar, others can tell tall stories about it, and some hardly think about it, there are many “py babies” who grow up to hate their scar with deeply felt hatred and embarrassment and would dearly love to be rid of it.  So one of my posts on scar reduction plastic surgery rated #5 in interest.

Symptoms of post-traumatic stress sometimes result from the anxiety, surgery, and maternal separation that PS can bring, especially from the way the condition and its surgery were handled up to the late 20th century.  This subject was also discussed in many posts, but the one that rated # 8 in 2013 made the top 10.

By using the “Categories” search box (top right of the page) or searching for keywords or “tags”, readers will usually be able to find a number of posts on each of these and other subjects.

The “My Story” page (with its tab at the head of every page) has also rated very well.  Thank you for your interest, encouragement and support!

At the end of another productive year of SIS, I want to thank all my readers and especially those who have given feedback online or by email.

Improvements in infant surgery (2) – Tidy scars

Those of us who have had abdominal surgery realise sooner or later that scars take on a look of their own.  Our bodies are each unique, as are the skills of a surgeon, the standard of their work, the course of healing and the interaction of all these factors over what is typically a 2 year healing period.

Adults usually choose when to have surgery and sometimes their surgeon, and as a result they have some sense of involvement and perhaps sometimes even some control as to the outcome of their surgery and the appearance of their scar.  In the course of my lifetime of work with people, I have been amazed how many adult people regard their new scar as an interesting showpiece, even a badge of their fortitude or survival skills!

P1060101aThis is not always so after infant surgery.  I had pyloric stenosis (“PS”) surgery at the tender age of 10 days, and cannot remember being greatly aware of my scar until almost 6 years later.  It was then that I remember feeling traumatized by continual embarrassment and humiliation as my parents stonewalled my questions about the weird and alien “thing” on my belly, and by feeling lost both for words and emotionally in dealing with the curiosity of classmates and grown-ups.

Now I realize that my PS scar is above average for 1940 surgical work: not unnecessarily large but a bit untidy (off center) and surrounded by a galaxy of sizeable pockmarks from the kind of needlework which of course grows with the baby and is now used very much less routinely.  I am especially struck by the number of people who having had infant surgery and have considered or acted to have their scar modified and reduced.  Only the most extroverted and confident of us whose lives were saved by early surgery seem to find it easy to talk about or flaunt our scar.

Now at last, after almost a lifetime, I have come to terms with my stomach scar, and have learnt that this is what most of us find as we age.  I also realize it’s not bad compared with some others of the time, and don’t think it can be much improved now.  But knowing my own and others’ struggles with this bit of self-acceptance, I am rather too often angered by the haughty, patronizing, dismissive or flippant way some surgeons go into print about their attitude to their work of cutting into and repairing their clients’ bodies and to their patients’ feelings and deeper needs.  Here is an example –

In the vain world in which we live, patients often consider the quality of the skin closure as a benchmark of our technical skills. Although it is of minimal overall importance, clean, neat and well approximated skin edges without evidence of suture material often impress and please patients.
(Reference available on request.)

If this petty peeve were an isolated example, I would not be writing about this subject.

Surgeon01Almost all of us whose lives have been saved by infant surgery are I am sure thankful for this gift, but it is very difficult for any patient to be grateful for the insensitivity of this and similar surgeons.  They should find other work, perhaps in a butcher’s business, an abattoir, or a veterinary clinic.  Not strutting their stuff on my and other people’s bodies, especially when their little patients aren’t near old enough to challenge them about their work or attitude… something that’s also too often impossible among adults.

Most medical workers have very clear ideas about which doctor they would consult and which surgeon they would allow to work on their body.  I wonder why?  The medical world may take many of each year’s smartest and most promising students – but it still has a lot to learn.

I am glad that one of the most-read posts on this blogsite is devoted to a better understanding between doctors and patients.  Here’s hoping.

Scar revision by tattoo

There are times when a picture is worth a thousand words – or more!  And this subject surely asks for pictures even more strongly than my previous post on scar reduction surgery.

In a Comment on this previous post, Wendy stated (in my words) that she would not want any more tampering with her pyloric stenosis scar because of the complex feelings she has had about it all her life.  From my own journey after the same surgery I’m pretty sure I know just what she feels.  I want to explore this after time for more reflection.

And like Wendy I belong to today’s older generation, many of whom regard body art including tattooing in a very different way from much of our younger set.

However, I have been blown away by the creative and effective way in which some people have combined their surgical body scar with art, some to hide their scar and some to embellish it, even with humour, but always with the clear aim of reclaiming their abdomen as their own.  Why should the scar on my abdomen represent for the rest of my years the workplace (and all-too-often a rather unsightly one) of perhaps a long-ago surgeon who had little care for how I their patient would think and feel one day, or of my own body after it has gone somewhat berserk in dealing with the damage from a surgical assault, resulting in a collection of hideous keloid scars, troughs and pits?

For what it’s worth (and we are all so different), I have found that my own very limited efforts to modify my scar would be regarded by many as self-injuring, but they were also my attempt to claim some authority and ownership over what had happened to my body very early and without any of my involvement.  This may seem weird to some, perhaps – but it’s true.

As with scar-revision and reduction or “plastic” surgery, it is not hard to find websites advertising “scar tattoos” or “tattooing over scars”.  Here are five of the best results I found from a limited search; click on the image to enlarge it.

Cobertura cicatriz Elaine - Flickr EspScar w tattoo covering01

Scar w tattoo surround01Soobie - midliner w cherry-tattooScar revision tattoo01

Scar reduction surgery

Almost a year ago I posted about scar reduction after infant surgery.  I won’t repeat what I wrote then, so if you are really interested in this subject, please click on the link and read that introductory material first: this post adds to it.

Many young and middle aged people are considering having their less-than-attractive scar from infant surgery revised.  Many others who have had infant surgery don’t care about their scar and know little about what caused it, they may even flaunt it with smart humour and even cleverer legends, or they just want to “move on”.  Somebody whose first pyloric stenosis (PS) surgery failed to relieve the obstruction and thus lives with two scars (considerately placed at 90° from each other) wrote recently:

i never had a problem, in fact the reverse.  my scars have always been there so nothing to be ashamed about. some people have glasses, some are bald, that’s me as well, lots of people have far more difficult socially handicapping problems.  accept your scar as a badge of survival and move on. 

Blessed are the extroverts and those whose infant illness is past and forgotten and whose surgical scars are overlooked – neither of them affecting them in any way.

However, not everybody is in that blissful condition!  And these folk are simply too numerous, their emotions too complex and deep-seated, and their well-being is too compromised for them to be brushed off.

This blogsite and that of a fellow blogger are dedicated to giving information, advice, resources, and encouragement to these people, with the message:  “we are not freaks, we are not alone, and healing is quite possible”.

Many may not be able to afford the cost of scar revision, but it seems that in many countries with health insurance this kind of surgery can be covered.  It’s certainly worth asking around and trying.

Even then, scar revision is not for everybody.

  • Some, having experienced past surgery’s effects on them, will not want it again for a non-life-threatening matter.
  • Others have to be told that scar revision surgery would be inadvisable, for any of several technical / anatomical reasons.
  • For others again, there is little or nothing to be gained in cosmetic terms: a surgical scar can only be removed or improved by creating another scar.

Abdominal scars that have become sunken, indented or that sprawl over a large area can often be revised with the most benefit, and when this surgery is done on someone with loose or excess skin (after several pregnancies or weight reduction like gastric banding surgery), there is much skin and tissue that can be removed with great cosmetic benefits: many scars can be cut out, greatly reduced in size, and often even moved far enough downward to be hidden from public view.  Sunken scars can often be separated from underlying tissue and smoothed, and the abdomen can be made taut and more even.

It has been found that whilst most upper and lower midline scars often respond well to revision surgery, but those under the ribcage (from a sub-costal or Kocher’s incision which was often used in the past for PS and gallbladder surgery) can be difficult to work on, as they have often developed adhesions binding them to underlying muscle and abdominal structures.

Those very interested in this surgery should visit several scar revision websites, of which RealSelf seems to be the largest, and there are many more.  Use the Search box for the kind of surgery and scar you’d like to know more about.  You can learn much from these sites’ questions and specialists’ answers, and from the “before and after” photo albums.

With this post I include several “before and after” photos of scar revisions shown in web advertising.  I am grateful to the people and websites who make this material freely available.  They illustrate something of what can and cannot be expected of scar revision surgery.  I have posted the photos in a small format – click on them for more detail, and feel free to ask for links to the related websites.

If you are interested in this kind of surgery, be reminded that –

  • it may not result in a major improvement of your scarring;
  • not all scars can be much improved and none can be totally erased;
  • how a scar heals is critical: good care can result in better healing, but this can never be totally controlled;
  • surgeons differ greatly on what is advisable and possible – so don’t let one closed door deter you, weigh up what you are told, and if necessary shop around;
  • the finest scar revision is usually done by plastic surgeons, so ask about your surgeon’s background and check out a good range of photos of his or her work.

Appendectomy02c b4 & after RealSelfDoctor’s Note: The left image is of a 26 year old female with an ugly indented appendectomy scar from her childhood.  The second photo was taken 2 months after scar revision surgery and this scar should continue to improve with time and scar management.

Belly13c-after PSBelly13c-before PSThese images show a woman’s gall bladder removal scar before and after revision surgery after weight reduction.  In removing tissue the scar is lowered and smoothed but not reduced, and her navel has been reconstructed.

Transverse01-frontA transverse scar that has become sunken can be much improved but without a tummy tuck it’s not out of sight.  A tummy tuck requires excess skin and underlying fat that can be removed, drawing this scar closer to the pubic region.

MidlineUpper02 after

MidlineUpper02 beforeThis vertical midline scar had spread and become sunken and it is marked for removal.  The plastic surgeon has taken great care to replace it with a much tidier and thinner scar-line and will be please it has healed well.

Check01 beforeCheck01 afterThe scars left by the repair of some of the major congenital abdominal conditions of infancy can often be significantly improved in later life. Here the scars from drainage tubes have been removed as well as the old-style “railway line” scar. Again, there was no tummy tuck.

PoustiPS01b afterPoustiPS01a beforeThis 33 year old mother of 4 has a history of bowel problems and surgery which left her with a large scar, ruptured (herniated) abdominal muscles and no umbilicus. Her repairs are detailed here. She had scar revision, abdominal wall repairs, abdominoplasty (a tummy tuck)… and is understandably enthusiastic about the result.

Past Pylorix Pages – Pyloric Stenosis treatment since 2000

What a difference a century makes!  100 years ago most babies with a medical problem such as pyloric stenosis died, as did many other little ones.  Infections, disease, illnesses, poverty, accidents and tragedies claimed huge numbers of lives.  Lack of effective birth control is not the only reason why so many people had (and in some countries still have) lots of babies.

Prof Dr Conrad Ramstedt operating - so different from 100 years later!

A century ago this year a German Doctor, Conrad Ramstedt, published a report on his accidental discovery of what has been labelled since “the Ramstedt pyloromyotomy”, which revolutionised the treatment of infant pyloric stenosis (PS).  Before 1912, medical treatment (with a drug) was the preferred treatment for PS, even though more or less than half the babies so treated died of starvation or dehydration anyway.  The several surgical remedies then available were so severe and crude that they were regarded as a last resort.  Read: “accompanied by an even higher risk of death – but you just might be lucky”.

In the previous post I included one of several photos published by a German university, showing the huge cosmetic improvement of PS surgery.  In the two previous posts I mentioned and illustrated the two surgical techniques which were introduced some 20 years ago to give PS babies a future with minimal scarring from their life-saving operation: peri-umbilical and laparoscopic surgery.

Many of the medical journal articles of the past 10-20 years that deal with PS have dealt with one of two subjects: the pros and cons of umbilical and laparoscopic pyloromyotomy, and the advances of anesthetic drugs and technique.

Both peri-umbilical (“through the umbilicus”) and laparoscopic surgery are skills that require patient learning, special equipment and extra careful use.  It is clear from the literature that whilst many small town general surgeons would perform the occasional PS operation on a baby (though all-too-often rather crudely), the new techniques required a specialist team and a well-equipped and funded hospital.  No wonder so many pyloromyotomies today continue to be done “the old way”: the material on the web indicates that all the old incision favourites may still be found today, together with surgeons who still sew through a baby’s skin rather than burying their craft inside the wound or using adhesive glue or tape.  Some of these little ones will grow up with a more disfiguring scar than mine from long-ago 1945!

However, in many countries the great majority of infant surgery is competently done from a technical point of view, and more often than not uses one of the two new and preferable techniques.

Laparoscopic surgery uses several instruments inserted through 2-5mm stab wounds

One 2004 article reported on a review of 8 medical articles comparing a total of 355 open (long incision) and 240 laparoscopic pyloromyotomies.  It concluded that open surgery, apart from being more available results in slightly fewer complications from collateral damage, and thus had a greater immediate success rate – although the report remarked that this difference might only be due to a learning curve.  Where available, the laparoscopic technique is comparable in terms of operating time, and better in terms of post-operative recovery time and hospital stay whilst giving a clear cosmetic benefit to the patient (and parents).

Another study comparing open and laparoscopic pyloromyotomy generally supported the previous report, and also found that the minimal access (laparoscopic) method results in the less pain and post-operative vomiting.  Articles on the umbilical route reported that while potentially being the least scarring and having fairly similar benefits to the laparoscopic technique, it does run a higher risk of infection unless the site is very thoroughly cleansed and antibiotic treatment is given before the surgery.

Pediatric anesthesia is another subject that has attracted considerable attention during the past decade, and understandably for me, I was particularly interested in what I learnt about anesthetic technique for pyloromyotomy.  Reading several of these articles has made me aware of the enormous complexity of this field: I am grateful that I could understand more than enough to benefit greatly from what I read, but I must also say that the material is too extensive and technically challenging for me to be able to pass much of it on.  However, some general observations will be valuable.

  • The effects of PS on a tiny baby affect many parts of its fragile little body, and anesthetic drugs have their own powerful effects: these two must be very well understood and then carefully matched and monitored during surgery.
  • When I was operated on in 1945, some surgeons used ether, others local anesthetic around the incision, and some (from what I have been able to find, a fairly substantial minority) used alcohol and/or sugar to pacify the baby, or nothing at all, perhaps or of necessity together with a paralysing drug.  As ether has so many side effects, I can understand why so many of the contemporary report writers (and I suspect my surgeon) used local anesthetic – and probably paralysed and sedated their little patient.  (With what effects we have found out since.)
  • Ether, so common, useful (and feared) in almost all surgery since the mid-1800s, was phased out in most “developed” countries in the 1980s.
  • Today, local anesthesia is still used occasionally, for minor surgery, when other medical conditions make unconsciousness too hazardous, or when the parents refuse general anesthetic use.
  • Despite critical information and policies laid down in the 1980s, there still seem to be surgeons today who don’t use pain relief for infant surgery.  However, it is being increasingly recognised that pain does affect even newborn infants, and pediatric anesthesia is now an established field in medical knowledge and practice.
  • There is an ongoing debate about the preferred way to intubate a baby (inserting a tube into a baby’s throat to deliver gases and prevent the breathing in of vomit and mucous).  There seem to be arguments for doing this before general anesthesia is induced (with inevitable trauma to the baby) rather than after.  It seems that most anesthetists today will intubate a baby after it has first been put to sleep with an intravenous sedative and its throat has been relaxed.
  • A long inventory of anesthetic drugs is available today; each has its uses, benefits and drawbacks, and a PS surgery will normally involve the use and/or mixtures of several of these, as well as pain relieving drugs for the post-operative hours and days.
  • Pediatric anesthesia only started to become a recognised specialty about 1940, just a few years before my surgery.  Today the pediatric anesthetist is certainly a vital and skilled member of the PS surgery team.  We have come a long way.