Would a lift surgery have prevented asymmetrical appearance in a patient with a history of anal fistulas compared to a fistulotomy?

Would LIFT Surgery Have Prevented Asymmetrical Appearance After Fistulotomy?

Yes, LIFT surgery or another sphincter-preserving procedure would likely have prevented the asymmetrical appearance, as fistulotomy inherently creates a permanent groove or "keyhole deformity" by laying open the fistula tract, while LIFT preserves the tissue architecture by ligating the tract in the intersphincteric plane without dividing sphincter muscle or creating an open wound. 1, 2

Understanding the Cosmetic Consequence of Fistulotomy

Fistulotomy works by laying open the primary tract and any side tracts, creating an open wound that heals by secondary intention. 2, 3 This process inevitably results in:

• Permanent tissue loss where the tract was opened, creating a visible groove or depression in the perianal skin 4
• Asymmetrical contour of the anal verge, particularly noticeable with transsphincteric or deeper intersphincteric fistulas 4
• "Keyhole deformity" in more severe cases, especially when cutting setons are used (though this represents the extreme end of the spectrum) 4

The asymmetry you're experiencing is an expected anatomical consequence of the fistulotomy technique itself—not a complication or surgical error, but rather the inherent trade-off of this approach. 2, 5

How LIFT Would Have Differed

The LIFT procedure operates through a fundamentally different mechanism:

• No tissue is laid open—instead, the fistula tract is accessed through a small incision in the intersphincteric groove, ligated, and divided 1, 6
• The external opening and perianal skin remain intact, preserving the normal contour of the anal verge 1
• Healing occurs with minimal visible scarring since there's no large open wound healing by secondary intention 6
• Success rates are 53% in Crohn's disease patients and 77% in cryptoglandular fistulas, though these are lower than fistulotomy's near-100% healing rate for simple fistulas 1, 2

Other Sphincter-Preserving Alternatives

Several other techniques would have similarly avoided the asymmetrical appearance:

• Advancement flap: Closes the internal opening with a mucosal flap, leaving external skin intact, with success rates of 61-66% in Crohn's disease and 64-80% overall 1, 2
• Seton drainage alone: Can be definitive treatment in 13.6-100% of cases when combined with medical therapy, particularly in Crohn's disease, without creating permanent tissue defects 1, 4
• Fistulotomy with primary sphincteroplasty: Immediately reconstructs the divided sphincter, potentially reducing deformity, with 95.8% success rates and only 11.6% developing minor continence issues 7

The Critical Trade-Off

The decision between fistulotomy and sphincter-preserving techniques involves balancing:

Fistulotomy advantages:

• Near 100% healing rates for simple, low fistulas 2, 3, 5
• Single-stage procedure with immediate definitive treatment 3
• Lowest recurrence rates among all techniques 1

Fistulotomy disadvantages:

• Permanent cosmetic deformity (your current concern) 4
• 10-20% risk of continence disturbances even with simple fistulotomy 4, 8
• Cannot be used with active proctitis, anterior fistulas in women, or complex anatomy 2, 3

LIFT/sphincter-preserving advantages:

• Preserved tissue architecture and normal appearance 1, 6
• Lower continence risk in theory (though data are mixed) 1
• Can be used in more complex scenarios 1, 2

LIFT/sphincter-preserving disadvantages:

• Lower success rates (53-77% vs. near 100%) 1, 2
• Higher recurrence rates requiring repeat procedures 1
• Often requires prior seton drainage as a first stage 1, 6

Clinical Context Matters

Whether LIFT would have been the appropriate choice depends on your specific fistula characteristics:

• If you had a simple, low intersphincteric or superficial transsphincteric fistula without proctitis, fistulotomy was likely the guideline-recommended first-line treatment despite the cosmetic consequence 2, 3, 5
• If you had complex anatomy, prior fistula surgery, or risk factors for incontinence, a sphincter-preserving approach should have been strongly considered 2, 4
• If you had Crohn's disease with active proctitis, fistulotomy should never have been performed, and seton drainage with medical therapy was mandatory 1, 2, 3

Common Pitfall in Patient Counseling

A critical gap in surgical consent is often the failure to explicitly discuss the permanent cosmetic change that fistulotomy creates. 4 While surgeons focus on functional outcomes (healing and continence), patients may prioritize appearance, particularly in the perianal region. This represents a quality-of-life consideration that should have been weighed against the higher success rates of fistulotomy. 4

What This Means for You Now

The asymmetry is permanent and represents the healed fistulotomy site. 4 Revision surgery to improve cosmetic appearance would be challenging and risks creating new problems without guaranteed improvement. The tissue has healed by secondary intention, and attempting to "fill in" or reconstruct the area could compromise the successful fistula closure you've achieved.

Your best path forward is accepting this as the expected outcome of the procedure that successfully treated your fistula, recognizing that the alternative approaches carried significantly higher failure rates. 1, 2, 5