Monday, December 3, 2012

Cesarean Incisions in Women of Size: Supraumbilical?



We previously discussed cesarean incision choice in women of size ─ specifically, the choice of vertical (up-down) incisions vs. low transverse (side-to-side) incisions.

The gist of those posts is that for years many doctors were erroneously taught that a vertical (up-down) incision was best in very fat women.  They were taught that the area under a fat woman's belly (called an "apron", "pannus" or "panniculus") was far too prone to infection, so it was best not to do an incision there.  Instead, many were taught to do a vertical skin incision, which often turned into a vertical or "classical" incision on the uterus as well.

High-BMI women were told that this vertical incision would lessen their risk for complications like wound infection, wound separation, bleeding, etc., but when researchers finally got around to actually studying this, they found the opposite ─ that outcomes were not improved with vertical incisions, that vertical incisions actually worsen outcomes in many cases.  Furthermore, classical uterine incisions have poorer outcomes, both short-term and long-term, and therefore should not be undertaken lightly.

Despite the evidence that vertical incisions do not improve outcome and may worsen it, many doctors are still promoting the idea that an incision under the belly is far too prone to infection to use.  As recently as 2006, one OB-GYN wrote, "In general, there is a lot to be said for an incision not buried under the pannus of fat, so that fresh air can help keep the wound dry."  And the illustration above is from a 2009 article, which also highlights the supposed dangers of an incision under the belly.

Now some doctors are promoting another choice for cesarean incisions in very heavy women ─ one done above or near the belly button. This is called a "supraumbilical" (above the belly button) incision.  This incision is not new, but is gaining new traction among some OBs. While not extremely common, it is being promoted by some doctors as beneficial in supersized women.  But is it?

So today, let's talk about supraumbilical incisions and their pros and cons.
Trigger Alert - This post discusses the difficulties associated with surgery on the bellies of very fat women.  Some graphic details are included, and the tone of the research cited is often quite judgmental.  Therefore, readers who might find this triggering may wish to skip this post.
Supraumbilical vs. Low Transverse Incisions

The difficulty in doing abdominal surgery on very heavy women is the barrier that a large amount of belly fat presents.  If you cut through the middle of the belly, you are going through the thickest part of the belly, which takes longer, increases the risk for excessive bleeding, and inhibits healing because of decreased vascularization of adipose (fat) tissue.

Thus, surgeons have come up with 2 approaches to avoiding incisions in the fattest part of the belly. The first is a low transverse incision, under the belly, and the second is a supraumbilical incision, above or near the belly button (umbilicus).

The low transverse incision (usually Pfannenstiel or Joel-Cohen) has repeatedly been shown to have superior outcomes to other incisions, even in obese women.  However, doing it in women with very large bellies is not easy.

Low-transverse incision made under the belly
by pulling back the panniculus

In the picture just above, the woman's overhanging belly is pulled back via a strap or tape towards the mother's head.  This exposes the area under the panniculus (which tends to be thinner) and a low transverse (side-to-side) incision is made there.

Again, many doctors have erroneously been taught that this area is hot, moist, and "a veritable bacteriologic cesspool" (yes, actual quote from the medical literature) and thus highly prone to infection.  In addition, an assistant is sometimes required to hold back the belly during a cesarean, and this can be very physically tiring.  Therefore, some doctors have sought an alternative.

The supraumbilical incision has become popular in some obstetric circles as a possible alternative, especially for women with extremely large or "droopy" bellies.

The $64,000 question is whether this improves outcomes over low-transverse incisions.

Types of Supraumbilical Incisions

In most women, a supraumbilical skin incision translates to a vertical (up-and-down) incision in the skin above the belly button, as in the picture below (repeated from the top of the post). This then is usually accompanied by a vertical/classical incision in the uterus underneath.



This differs from the usual classical incision, which is a vertical (up-down) incision also , but done from the belly button down to the pubic bone.  This also involves a uterine incision in the upper segment of the uterus.



The main difference between a supraumbilical incision and the usual classical incision is that the supraumbilical is done above the belly button, not below it.

Sometimes a supraumbilical incision is done side-to-side (transverse above the belly button, on the upper uterine segment), a picture of which can be found here

However, in a few women with extremely voluminous and droopy bellies, a skin incision above the belly button translates into an incision into the lower segment of the uterus, as in the picture below.

A supraumbilical skin incision,
but with a low uterine incision

[Sorry for the blurry image above; it is from a medical study and is very small. When enlarged, the text becomes blurry.  The words from L to R are "panniculus", "umbilicus", "projection of the pubic symphysis", "abdominal and low uterine segment incisions".]

In other words, in a few women the belly droops down low enough that it pulls down the alignment of the skin over the uterus, so that the skin area above the belly button sits near the the pubic bone (pubic symphysis), over the lower uterine segment instead.  In such a case, a supraumbilical skin incision can translate into a low transverse uterine incision. Since lower-uterine segment (LUS) incisions have fewer complications, this combines the advantages of easier surgical access with a supraumbilical skin incision and the better long-term prognosis of a LUS uterine incision.

However, most of the time, a supraumbilical skin incision means a uterine incision in the upper uterus, which carries more risks, both short-term and long-term.  

Patterson (2002) and Bakhshi (2010) compared outcomes in women who had classical incisions vs. low transverse incisions.  They found that women with classical incisions had more infections, more hysterectomies, more blood transfusions, longer operating time, and more intensive care admissions.  They also had far more uterine scar separations in future pregnancies.  Therefore the decision to do a supraumbilical incision potentially has far-reaching implications.

Some doctors are far too quick to resort to supraumbilical incisions on "morbidly obese" women, and at BMIs that don't truly require it. Since most supraumbilical incisions result in classical uterine incisions, doctors are putting these women at considerable risk, whether it's because they don't want to deal with the mechanical challenges of a low transverse incision, or because they have erroneously been taught that the risk of infection is higher in an under-the-belly incision.

Cosmetic Considerations

Another problem with supraumbilical incision that scarring that accompanies it.

The negative cosmetic and psychological impact of a giant scar above the belly button in women of size must not be underestimated.

Research on supraumbilical incisions never considers this, as if the surgeons believe that the bellies of women of size are already so repugnant that a giant scar in the middle of the belly is of no consequence.  Yet, as with midline vertical incisions, the potential psychological impact of such a disfiguring scar is tremendous.

I have a friend who had multiple cesareans ─ not because she wanted them but because of the fat-phobic ignorance of her first OB.  That OB had been taught that a low transverse incision was too prone to infection in obese women, so her first cesarean was supraumbilical, with a classical vertical incision on the uterus. Her next two cesareans were low-transverse repeat cesareans with a different OB, since she could not find anyone who would  let her try a VBAC with a prior classical incision. Her subsequent OB was very frank that the decision to do a supraumbilical incision was totally unnecessary in her first cesarean, and very sympathetic to her frustration that this arbitrary decision by the first OB had totally taken away all her options in subsequent pregnancies.

Even as time lessened the scarring, she found the supraumbilical scar far more disfiguring than her low transverse scars.  She wrote:
I had a supraumbilical incision, so I have this huge scar about 1 inch wide in the middle of my abdomen.  Not very pretty.... 
As far as cosmetics go, my LT [low transverse] incision is so far down it starts right above my pubic hairline...so it's barely noticeable, and in an area no one else but [my husband] would see.
The scarring from a supraumbilical incision is noticeable, and it does matter to women of size.  Just because their bellies are large doesn't mean that cosmetic considerations are irrelevant.

Oh, and those subsequent low-transverse incisions my friend had?  No infection issues at all, despite what her first OB was taught.  But the psychological impact of that first, supraumbilical scar has stayed with her for years. And the doctor's choice for a supraumbilical incision denied her any choices in her future births, any chance at a VBAC, and exposed her to the risks of classical cesareans, not to mention the risks of the subsequent repeat cesareans that were mandatory with the doctors in her area.

The cosmetic considerations of such a disfiguring scar in such an easily-seen place should not be underestimated when making the decision about incisions in women of size.  Just because a woman is obese doesn't mean these cosmetic considerations are moot.  Nor should the limitations supraumbilical incisions place on future pregnancies be shrugged off lightly.

Supraumbilical Incisions: A Summary

To be fair, supraumbilical incisions have certain advantages from the surgeon's point of view. They offer easier accessibility to the uterus in women with very large amounts of belly fat.  They are also less demanding on the O.R. staff, who often have to "pull back" and hold the pannus away from the lower uterine segment, which can be difficult and tiring. One can appreciate and sympathize with the technical demands of doing abdominal surgery in heavy women.

However, given the downsides of supraumbilical scars, this is not enough.  Supraumbilical incisions need to be shown to result in clinically superior outcomes, and they have not been.  Although researchers expected that supraumbilical incisions would improve outcome in very fat women, the data showed that they did NOT actually improve outcome.  Outcomes were actually similar among women with low transverse incisions and supraumbilical incisions.

Again, most of these supraumbilical incisions result in uterine incisions in the upper uterine segment, which is MUCH more risky, much  harder to recover from, and which has profound implications for any future pregnancies.  It also essentially ensures the woman must always have repeat cesareans in the future. Furthermore, they leave a large, very disfiguring scar on the upper abdomen of women after the surgery is over.  A low transverse skin incision is also scarring, but is far less obvious and far less disfiguring in most cases.

The whole premise of doing supraumbilical incisions was to improve outcome for obese women. If they do not improve outcome while simultaneously placing the woman at extra risk and being quite disfiguring, there is no good reason for doing supraumbilical incisions in most cases.

Yes, supraumbilical incisions are easier to perform and are easier on the operating room staff.  Yes, low transverse incisions are harder in supersized women and can present many technical and physical challenges.  However, the bottom line is that the surgeon's convenience should take a back seat to the best interests of the mother and baby (and future babies).

Of course, there may occasionally be situations where such an incision might be useful, such as in a woman with extreme obesity, a woman with an extremely large and droopy belly, or a woman with a complicated placenta previa (low-lying placenta).  No one is saying that supraumbilical incisions should be absolutely banned, only that they should be kept for very rare cases where they are truly needed.  They should not be done routinely, even in high-BMI women.

Fortunately, most cesareans being done today are low-transverse incisions, even in women of size.  However, there are some doctors who use classical or supraumbilical incisions as a routine alternative to low transverse incisions in "morbidly obese" women, and their threshold for using it is far too low in some cases.  The mean BMI for a supraumbilical incision in the Tixier study below was 47, which is near my own BMI.  Many women of this BMI (including me) and a lot larger have had low transverse incisions with no problems, so any routine use of supraumbilical incisions in this size is highly questionable.

A supraumbilical incision can be a useful tool under certain extreme circumstances.  It's worth documenting the technique for that reason. Even so, it must be pointed out that supraumbilical incisions do not improve outcome over low transverse incisions, and they should never be used routinely or because they are easier for the O.R. staff.

An incision like this has far too many implications for maternal health and future pregnancies. Only under special, extreme circumstances should a supraumbilical incision be utilized.


*Images from "Delivery and postpartum concerns in the obese gravida" (Phillips, Obmanagement, Feb 2009), Gunatiake and Perlow 2011, and the Tixier 2009 study below.

References

Supraumbilical Incisions

Houston MC and Raynor BD. Postoperative morbidity in the morbidly obese parturient woman: supraumbilical and low transverse abdominal approaches. American Journal of Obstetrics and Gynecology 2000 May;182(5):1033-35. PMID: 10819819
OBJECTIVE: Our purpose was to determine the differences in postoperative morbidity in obese women who had a supraumbilical or a Pfannenstiel incision at cesarean delivery. STUDY DESIGN: A case-control retrospective review was conducted of all patients who were at greater than 150% ideal body weight when undergoing cesarean delivery between 1989 and 1995 by means of either a supraumbilical or a Pfannenstiel incision. Patients were excluded if medical records were unavailable. A total of 15 women who had a supraumbilical incision and 54 who had a low transverse incision were included in the analysis. Antenatal complications were examined, as were age, weight, and training level of the surgeon. Postoperative complications were then compared. RESULTS: The groups were similar in age and antepartum complications. However, mean weight and percentage of ideal body weight in the supraumbilical group were both higher (P less than .00001 and P less than .0001, respectively), with the supraumbilical group 83 lb heavier on average. No significant differences were seen in any postoperative complication. CONCLUSION: Postoperative morbidity in morbidly obese women undergoing cesarean delivery does not differ between a supraumbilical approach and the low transverse abdominal incision.
Tixier H et al. Cesarean section in morbidly obese women: supra or subumbilical transverse incision? Acta Obstetrecia et Gynecologica Scandanavica 2009;88(9):1049-52. PMID: 19639463
The obstetrician is more and more frequently faced with the decision to perform a cesarean section in obese women. We describe a technique of supra or subumbilical transverse cesarean section (depending on the height of the projection of the upper edge of the pubic symphysis) specifically designed for morbidly obese women with a voluminous panniculus. We evaluated feasibility and associated morbidity in a retrospective descriptive series of 18 patients operated between 2003 and 2008. We assessed the quality of access to the lower uterine segment and facility to extract the fetus. The mean body mass index was 47.7 kg/m(2) (range 40.1-60.8). The incision was subumbilical in 13 women (72.2%) and supraumbilical in 27.7%. With this technique, the exposition, the section of the lower uterine segment, and extraction of the baby are simple. It can be easily generalized and quickly learnt.
J Reprod Med. 2007 Mar;52(3):231-4. Cesarean birth in the morbidly obese woman: a report of 3 cases. Porreco RP, et al.  PMID: 17465294
BACKGROUND: Primary and repeat cesarean births are a frequent occurrence among morbidly obese women. Technical difficulties encountered in caring for these patients, coupled with physiologic differences, affect their operative management. CASES: Three morbidly obese women (190-296 kg, body mass index 56.7-93.6) had cesarean births utilizing a supraumbilical incision and internal retention abdominal wall closures. Alternative anesthetic management was required in 2 patients. Bariatric operative and postoperative equipment was required in each case, and varying thromboprophylaxis strategies were employed. CONCLUSION: Careful planning along with appropriate specialty consultation is required for a safe and successful cesarean birth in the morbidly obese woman.
J Obstet Gynaecol. 2002 Nov;22(6):691. 'Classical' caesarean section at or near term in the morbidly obese obstetric patient.  Nicholson SC, Brown AD, MacPherson HM, Liston WA.   PMID: 12554273  [no abstract available]
"Morbidly obese obstetric patients undergoing caesarean section with a large, protruding panniculus present major technical problems to the obstetrician and anaesthetist and significant operative risk to themselves...It is our practice to perform a high transverse abdominal incision, avoiding the subpannicular fold, thereby reducing the risks of wound infection, necrosis, and dehiscence."   
Kmom summary: Case report of 2 cesareans in morbidly obese women (BMI 58 and 70) with a large panniculus.  Surgeons used a high transverse abdominal incision just below the umbilicus.  The lower uterine segment could not be accessed, so they did a classical fundal uterine incision.  They briefly discussed alternatives to this subumbilical transverse incision, including supraumbilical midline incisions and a panniculectomy (surgical removal of the pannus, which can be associated with many complications) before the cesarean.  They completely dismissed the fact that low transverse incisions have been used successfully on women of this size in the past.
Successful Low Transverse Incisions Used on Supersized Women

Obstet Gynecol. 1978 Apr;51(4):509-10. Cesarean section in the massively obese. Ahern JK, Goodlin RC.   PMID: 662236
"The case histories of 4 massively obese patients who underwent cesarean section are summarized. In all, a Pfannenstiel incision was made beneath the patient's huge panniculus, and a lower segment cesarean section was easily accomplished. There were no postoperative wound infections and all of the women had an essentially benign postoperative course." 
Kmom Summary: Case report of 4 women who each weighed more than 400 lbs. and were delivered via a Pfannenstiel cesarean incision underneath the panniculus.  The surgeons were surprised by the ease of delivery ("no more difficult than in women of only half their weight") and felt that the Pfannenstiel/low transverse incision was the reason for their good outcomes. They disagreed with earlier statements by other authors that "only a novice" makes a transverse incision under the panniculus.
Anaesth Intensive Care. 1999 Apr;27(2):216-9. Anaesthesia for LSCS in a morbidly obese patient. Patel J. PMID: 10212725
Kmom SummaryThe management of a morbidly obese parturient with a body mass index of 88 is reported. She developed asthma during the pregnancy. Lumbar epidural anaesthesia was successfully used for an elective caesarean section and tubal ligation.  Special note: A lower-uterine segment Pfannestiel incision was used with NO problems or infection in this woman who was nearly 500 lbs. at the time of her cesarean.
N Am J Med Sci. 2012 Jan;4(1):13-8. Cesarean section in morbidly obese parturients: practical implications and complications. Machado LS. PMID: 22393542
...A Medline search was conducted to review the recent relevant articles in english literature on cesarean section in morbidly obese women. The types of incisions and techniques used during cesarean delivery, intra-operative and postpartum complications, anesthetic and logistical issues, maternal morbidity and mortality were reviewed. Morbidly obese women with a body mass index (BMI >40 kg/m(2) are at increased risk of pregnancy complications and a significantly increased rate of cesarean delivery. Low transverse skin incisions and transverse uterine incisions are definitely superior and must be the first option. Closure of the subcutaneous layer is recommended, but the placement of subcutaneous drains remains controversial. Thromboprophylaxis adjusted to body weight and prophylactic antibiotics help in reducing postpartum morbidity....
Retracting the Panniculus for a Low Transverse Incision

J Am Coll Surg. 2001 Oct;193(4):458-61. Caesarean delivery and celiotomy using panniculus retraction in the morbidly obese patient. Thornton YS.   PMID: 11584977   [no abstract available]
Kmom SummaryCase series of successful low transverse incisions in 47 morbidly obese pregnant women and 9 obese gynecologic patients, all of whom weighed between 208 to 500 lbs, with BMIs between 33.8 to 76.4.  Shows in pictures their technique of using cloth tape across the abdomen and from both sides of the lower abdomen to the upper body (described as the "suspender" method) to pull the panniculus towards the head and expose the lower uterine segment so that a classical vertical or supraumbilical approach was not needed.  They noted that this technique used materials on hand at most hospitals (instead of specialized bariatric instruments), gave "excellent exposure of the operative field without piercing the skin," and took away the need for a surgical assistant to constantly hold back the panniculus during the operation. Despite the incision being in the "moist subpannicular fold" so vilified in the literature, there were NO wound infections or dehiscences, even in the most obese patients.
MedGenMed. 2006 Feb 21;8(1):52. Preventing a surgical complication during cesarean delivery in a morbidly obese patient: a simple apparatus to retract the abdominal panniculus. Viegas CM, Viegas OA.   PMID: 16915182   Free full text here (includes illustrations not for the faint of heart).
"This case report highlights an unusual intraoperative complication that has medical and medico-legal implications. A simple apparatus designed to retract the panniculus of an obese patient might reduce complications when performing abdominal surgery in such cases." 
Kmom Summary: Case report of a cesarean performed on a morbidly obese mother (BMI 54) who was also a very heavy smoker (which impedes healing).  They induced labor by breaking her waters, but as a result, the baby presented in a brow position and developed fetal distress during the prolonged induced labor.  An urgent cesarean was performed under general anesthesia.  A medical student was drafted to manually hold back the large panniculus during the cesarean.  Her incision healed up well afterwards, but the patient developed severe ulcers at the pressure points where the medical student held back her belly (picture available at the full text site; it's very graphic, be warned).  In response to this case, the authors invented a special apparatus to hold back the panniculus in heavy women during cesareans, using a bar over the surgical bed, chains hooked to the bar and then connected to a Doyen's Retractor, which is used to hold back the panniculus. A picture of this device is available in the article.  The authors state they've used it successfully with no problems since, but do not present any data on this claim.  
Risks of Classical Cesareans 

Obstet Gynecol. 2002 Oct;100(4):633-7. Maternal and perinatal morbidity associated with classic and inverted T cesarean incisions. Patterson LS, O'Connell CM, Baskett TF.  PMID: 12383525
OBJECTIVE: To estimate the maternal and perinatal morbidity associated with cesarean delivery involving the upper uterine segment compared with that of low transverse cesarean delivery. METHODS: A 19-year review of a perinatal database and the relevant charts was used to determine the maternal and perinatal morbidity associated with low transverse cesarean, classic cesarean, and inverted "T" cesarean deliveries. RESULTS:Over the 19 years, 1980-1998, there were 19,726 cesarean deliveries: low transverse cesarean, 19,422 (98.5%); classic cesarean, 221 (1.1%); and inverted T cesarean, 83 (0.4%). As a proportion of all cesarean deliveries, the rates of low transverse cesarean and classic cesarean have remained stable, whereas the rate of inverted T cesarean has risen from 0.2% to 0.9%. Maternal morbidity (puerperal infection, blood transfusion, hysterectomy, intensive care unit admission, death) and perinatal morbidity (stillborn fetus, neonatal death, 5 minute Apgar less than 7, intensive care) were significantly higher in classic cesarean compared to low transverse cesarean. Some maternal morbidity (puerperal infection, blood transfusion) and perinatal morbidity (5 minute Apgar less than 7, intensive care) were also significantly higher for inverted T cesarean compared to low transverse cesarean. CONCLUSION: Classic cesarean section has a higher maternal and perinatal morbidity than inverted T cesarean and much higher than low transverse cesarean. There is no increased maternal or perinatal morbidity if an attempted low transverse incision has to be converted to an inverted "T" incision compared to performing a classic cesarean section.
Am J Perinatol. 2010 Nov;27(10):791-6. Epub 2010 May 10. Maternal and neonatal outcomes of repeat cesarean delivery in women with a prior classical versus low transverse uterine incision. Bakhshi T, et al.  PMID: 20458666
We compared maternal and neonatal outcomes following repeat cesarean delivery (CD) of women with a prior classical CD with those with a prior low transverse CD. The Maternal Fetal Medicine Units Network Cesarean Delivery Registry was used to identify women with one previous CD who underwent an elective repeat CD prior to the onset of labor at ≥36 weeks. Outcomes were compared between women with a previous classical CD and those with a prior low transverse CD. Of the 7936 women who met study criteria, 122 had a prior classical CD. Women with a prior classical CD had a higher rate of classical uterine incision at repeat CD (12.73% versus 0.59%; P < 0.001), had longer total operative time and hospital stay, and had higher intensive care unit admission. Uterine dehiscence was more frequent in women with a prior classical CD (2.46% versus 0.27%, odds ratio 9.35, 95% confidence interval 1.76 to 31.93). After adjusting for confounding factors, there were no statistical differences in major maternal or neonatal morbidities between groups. Uterine dehiscence was present at repeat CD in 2.46% of women with a prior classical CD. However, major maternal morbidities were similar to those with a prior low transverse CD.

6 comments:

The Happy, Homeschooling, Hoosier Housewife said...

I am not reading the entire article based on trigger factors. I can tell you that as a women of size I had two successful low transverse incisions. No infection either time AND very quick healing time.

I was told by my awesome hospital staff to keep the area very dry. For a couple of weeks I kept a clean white paper towel tucked up around the incision. It kept the area dry and would also alert me if there was any drainage from the incision.

Paige Janzen said...

I had a c-section earlier this year, and on the operating table I remember the surgeon (and other staff assisting) contemplating the best placement for incision. I ended up having a transverse one just underneath my belly button (so not under the "apron" as it could be coined). I did end up having cellulitis, and was on antibiotics for two weeks. I also had the staples in for 10 days (the local health nurse came to my house for removal after being discharged), and it took about two months to heal completely.

That being said, I am very appreciative that they did the surgery that way. The OB surgeon jokingly told me that I wouldn't be on the cover of the swimsuit edition of Sports Illustrated with this incision, and we all had a good chuckle about it. Had they decided to go with the transverse under the apron (as some other friends of size of mine) I worry that the cellulitis may have gotten worse, or if other infections had developed.

Well-Rounded Mama said...

Actually, research shows BETTER outcomes with the under-the-apron incision, and that includes wound complications.

Perhaps you developed this infection *because* you had this higher incision. An incision in the area with more belly fat means less vascularization to help heal the wound. OTOH, perhaps not; perhaps you would have gotten the infection regardless. No way to know for sure.

But the research is clear that a low transverse incision actually has the best outcomes, even in high -BMI women.

Well-Rounded Mama said...

Another factor is what dosage of antibiotics they used. Emerging research suggests that docs don't use a high-enough or long-enough antibiotic dose in "obese" women having cesareans. This can predispose to infections, especially long-lasting, resistant ones.

loudy227 said...

I'm 300+ lbs. and I had a low transverse incision this year. Had no problems. My doc was being cautious and had me keep my staples in 5 days longer than usual. I kept a sanitary pad tucked under there to keep it dry. Worked great! I always remember my mom had a huge scar from when I was born. I can't even see mine! There are lifestyle effects, even if you aren't a bikini model :)

Anonymous said...

I had twins almost 3 years ago and my incision was under the "apron". They used all internal stitches, no staples. My scar is very minimal and I healed great.