Cleft-lift vs. Pit Picking

What are the pros and cons?

Cleft-lift and pit picking are two very different operations. Although both are for pilonidal disease, they each have their pluses and minuses. Here, I’m going to discuss them both. But as background, there are four basic categories of operations for pilonidal disease:

  • Off midline closures. This includes Cleft-lift and Karydakis flaps.
  • Minimally invasive procedures: These include pit picking, laser ablation (SiLaC), EPSIT, phenol injection, kshar sutra, Gips, and Lord-Miller procedures.
  • Excisional procedures: Excision with or without primary closure, and marsupialization.
  • Other flap procedures: Such as V-Y Plasty, Z-Plasty, Limberg Flap, Rhomboid Flap, Dufourmental Flap.

I’m not going to discuss the last two categories, other than to say that excisional procedures are outmoded methods of treatment and should not, in my opinion, be performed; and that the other flap procedures can be effective if done by an expert, but have an unsatisfactory cosmetic appearance.

When comparing “minimally invasive procedures” to “off midline closures”, there are dramatic differences. But, keep in mind that although almost every patient is a candidate for a cleft-lift or Karydakis procedure, patients with large open wounds are not good candidates for the minimally invasive procedures. In general, if a patient is a candidate for any one of the minimally invasive procedures, they are candidates for any of the others, so for the purposes of this discussion, I’m going to refer to Pit Picking, but these comments can apply to the other minimally invasive procedures as well.

Pros of Pit Picking

  • the incisions are small
  • there is no change to the overall appearance/shape of the gluteal cleft
  • there are minimal activity restrictions after the operation
  • it might end up being less painful than the other operations

Cons to Pit Picking

  • because the cleft is not flattened, pilonidal disease can recur
  • because the incisions are down in the cleft, there are times when they won’t heal
  • it is not always as pain-free as we would like
  • in order to be successful, it may require a burdensome dressing regime and multiple office visits
  • there is a significant overall failure and recurrence rate, and recurrences seem to occur at the worst possible times.

Pros to Cleft-Lift

  • If done properly it has the lowest failure and recurrence rate
  • it is an option for almost every pilonidal situation
  • hair removal is not necessary after the procedure

Cons to Cleft-Lift

  • it changes the shape of the gluteal cleft (although, it should change it to a configuration that is normal for someone without pilonidal disease)
  • there is a incision which is ~4-9” long, depending on the situation
  • most surgeons place a drain for a few days

Conclusions

There is certainly no problem with starting out with pit picking, and progressing to a cleft-lift if necessary. But, this requires the understanding by the patient that pit picking may fail. Having a previous failed pit picking procedure will not make a cleft-lift impossible, or even more difficult.

Some patients feel that pit picking is worth a try, in spite of the fact that it is an operation that has expense, discomfort, and down-time associated with it. Others prefer to start right off with the most successful operation, even if it is a “bigger” procedure. Either philosophy makes sense. At our clinic we do not perform pit picking anymore because of the high failure rate, but other clinics do, and if a minimally invasive procedure is what you want, we encourage you to seek out someone qualified. If it is a cleft-lift that you want or need, our clinic has one of the highest success rates in the world. Contact us, and we will be glad to help!

Honey for Pilonidal Wounds

One of the interesting ways of dressing open wounds is with honey. It is available in “medical grade” form, and often Manuka honey is specifically used. (This is honey from the manuka tree which has a antibacterial compound not present in other types of honey.)

The characteristics of honey that make it something that can be used on open wounds are:

  • It has some antibacterial properties
  • Because it is such a concentrated substance it pulls water out of tissues, which may decrease swelling
  • It has a slightly acidic ph, which may help wound healing

But, the real question is whether or not the physical characteristics of honey promote better or faster wound healing than other topical wound treatments. One important concept in treating patients is that:

Just because something logically sounds like it would be beneficial, doesn’t mean it actually will be.

This is why clinical trials, research studies, and literature searches are so important in determining what we should actually do to solve clinical problems. A simple example of this is that Betadine, is a great antiseptic that we use all the time to sterilize skin. But, we’ve found that when used for any length of time on open, infected, wounds it not only impairs healing, but is toxic to the patient!

As far as honey goes, it doesn’t seem to be much better or worse than other topical treatments when used on open wounds. It may be beneficial for some types of burns.

As far as pilonidal wounds goes, there are studies that show that pilonidal wounds can heal when honey is used. But, when compared to other topical treatments, such as silver, zinc, hydrogel, foam, wound VAC, etc., there does not seem to be a particular advantage to any of them. The benefit of using something that has antibacterial properties at all is open to debate.

My analysis of all this is:

  • It is reasonable to use honey on an open wound, but it is not preferred over other modalities for any specific reason.
  • Honey is not an appropriate treatment for an acute abscess or for application on closed incisions.
  • The most important maneuvers to get pilonidal wounds to heal are to keep things clean and dry and get air circulation to the wound. Unfortunately, this may not be possible without further surgery.
  • If sinus tracts have formed, even the smallest wound will never stay healed with honey or any kind of wound care.
  • Proper nutrition, including high protein and vitamin intake is probably more important than the specific local wound care.

If pilonidal surgery is done properly, such that the cleft is flattened and the incision is off the midline, complex and prolonged wound care will not be needed. In our clinic we do not have to deal these issues, except in complicated situations where we are trying to fix poorly done surgery elsewhere.

What is the place of silver nitrate for pilonidal wounds?

The “art” of surgery.

As surgeons, we each have have years of training and experience plus an enormous body of scientific and clinical information at our fingertips. There is so much information, that the correct way to apply it is open to interpretation. This is where the “art” comes in. Here, I would like to discuss my opinion regarding the use of silver nitrate, as applied to pilonidal wounds after surgery, or in place of surgery to get pits and openings to close.

Silver nitrate is a chemical that chemically burns tissues. It usually comes on a wooden applicator stick, and when applied to exposed tissues, causes a chemical cauterization (burning) of the wound.

Surgeons do this when they have no idea why something is not healing. This is the surgical equivalent of “turning-it -off and back-on-again”. (We do this with our electronics when we don’t know how to fix something, but hope that a reboot will do the trick.)

In this instance, surgeons are blaming the lack of wound closure on “hyper-granulation tissue”. This occurs when there is visible, good, healing tissue inside the wound, but the skin isn’t closing over it. There are times in surgery when this makes sense and is a reasonable strategy – but NEVER with pilonidal wounds. The hope is that burning away the tissue, will give the wound a fresh start at healing – but without understanding why it wasn’t healing in the first place!

The reasons that this is not a good strategy are:

  • It is painful.
  • It takes time away from doing the correct thing to fix the problem (surgeons can keep applying silver nitrate for MONTHS before they give up on it as a therapy).
  • The reason for lack of healing of pilonidal wounds is NEVER because of hyper-granulation tissue. (More here on the reasons why pilonidal wounds won’t heal.)

The correct solution is to:

  • Perform corrective surgery to adjust the location of the incision, (which in my preference is a cleft-lift).
  • Make sure the area is being kept clean and dry.
  • Keep gauze tucked in any folds with open wounds, to allow air circulation.
  • Consider GENTLE, topical medications that promote healing and/or control specific bacteria.
  • Maximize protein intake, and consider the vitamins and supplements I’ve recommended.

I believe that many patients have proper care delayed, are traumatized, and may even have small wounds enlarged buy the use of silver nitrate.