Once an anal fissure has become chronic, conservative treatments can at best bring temporary alleviation. For it to heal permanently, a surgical intervention is inevitable. The little „ulcer“ is being cut out together with the skin proliferation and the wound is left to heal, for which the above mentioned conservative treatments are helpful. If, in spite of anesthesia, the inner sphincter is still very tight, especially the lower margin, it can make sense to notch the lower part (shown in the image) to ensure complete healing of the fissure, usually a moderate elongation is sufficient.