Post-operative Wound Healing Concerns Following Pilonidal Cyst Excision

Case at a Glance

A 26-year-old male presents with concerns about wound healing 9 days following pilonidal cyst excision surgery, noting a possible break in the scab formation at the surgical site with associated mild discomfort and drainage.

Patient's Story

The patient underwent pilonidal cyst excision surgery 9 days prior to presentation. He reports noticing what appears to be a break in the scab formation at the surgical site, located near the gluteal cleft opening. The patient describes seeing underlying tissue that resembles what would be expected beneath a healing wound. He experiences mild stinging sensation typical of superficial skin wounds but denies deeper pain. The patient has limited experience with wound healing, making him uncertain about the severity of his observations. He notes that this concern was not addressed in his post-operative instruction sheet.

Initial Assessment

Post-operative day 9 following pilonidal cyst excision. Patient reports break in scab formation with visible underlying tissue and mild superficial discomfort. No signs of deep tissue involvement or severe pain reported. Patient scheduled for routine post-operative follow-up in 2 days.

The Diagnostic Journey

Clinical examination revealed a surgical wound extending from the coccyx toward the anal verge, consistent with pilonidal cyst excision. At the superior aspect of the gluteal cleft, there was evidence of scab disruption with exposure of underlying granulation tissue. The patient later reported onset of mild serous drainage from the affected area. He appropriately cleaned the site with antiseptic and applied topical antibiotic ointment with sterile dressing.

Final Diagnosis

Normal post-operative wound healing with minor scab disruption - no evidence of wound dehiscence or infection

Treatment Plan

Current pain management regimen maintained with gabapentin and celecoxib, with tramadol available for breakthrough pain. Patient advised to continue wound care with antiseptic cleansing and topical antibiotic application. Scheduled post-operative follow-up appointment to be kept as planned for comprehensive wound assessment.

Outcome and Follow-up

Patient advised that findings were consistent with normal healing process and scab disruption commonly occurs during post-operative recovery. No immediate intervention required. Routine post-operative appointment scheduled for continued monitoring and wound care guidance. Patient educated on normal versus concerning wound healing signs for future reference.