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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!