When I perform a cleft lift, the incision is not in the midline – so when you are sitting there is no force pulling the incision apart. In addition, the reasons patients can have non-healing or recurrence are not that the wound is pulled apart, but rather that it is folded over too much. By being folded and down in a cleft, it does not heal well, or sometimes at all. Then, when one does something seemingly trivial, that has a distracting force on the wound, it comes apart. It seems like the distracting force is what did the damage, but in reality it was the non- healing because of the fold.
When I do a cleft lift, I want air circulation to that area, and sitting opens it up and allows that air circulation. I encourage all my patients to sit immediately after surgery, and have a very high success rate, as evidence that the advice has some merit.
What about surgeons who tell patients not to sit for two weeks after surgery?
There is not much logic to telling a patient not to sit for only 2 weeks because the wound has very little strength at two weeks. If you look at the yellow dotted line on the graph below, a wound only has about 20% of its ultimate tensile strength at two weeks. In addition, at two weeks the dissolving sutures we use are already down to 50% tensile strength. So, two to three weeks after surgery is one of the most fragile times for the wound. If sitting is really detrimental to healing, the restrictions should be much longer.
At our clinic, we recommend that patients avoid contact sports, jogging and biking for six weeks from surgery, but we encourage sitting and other normal activities immediately.
Unfortunately, recurrence of pilonidal disease after surgery is a common problem. This article discusses the reasons why this happens, and presents a good solution.
In order to understand why pilonidal disease recurs, it helps to understand why it happens in the first place. Pilonidal disease is caused by the shape and depth of the gluteal fold. In some patients it is so deep and tight that during most of the day, it is tightly folded and no air can get in. Because of this pressure builds up in the cleft and anaerobic bacteria grow. The reaction of the skin to this situation is to create enlarged midline pores, which we call “pits”. Loose hairs that all off the body (mostly from the back of the head) get caught in these pores, work their way under the skin, and cause a “pilonidal cyst”.
Pilonidal disease manifests itself in several common ways:
a slightly painful lump that may get intermittently inflamed
a more severe infection, which we then call a pilonidal abscess
enlargement of the pits to the point that they cause open, draining and/or bleeding wounds
tunneling or sinus tract formation, where the midline pits connect to secondary openings off to the side of the crease
The best operations re-configure the gluteal crease so it is not so deep. The cleft-lift operation does this, and has a very low recurrence rate. However the operations that just remove the “cyst” do not flatten the crease, and have an extremely high failure rate.
So, why does pilonidal disease recur?
In almost all situations, when pilonidal disease recurs it is because the cleft was not flattened, and the incision for the surgery was placed in the midline of the cleft. It is NOT BECAUSE THE SURGEON DID AN INADEQUATE JOB OF REMOVING ALL THE CYSTS AND TRACTS! This is not “a cancer which has to be completely removed”; this is a benign disease caused by the shape of the cleft. Removal of the disease is of secondary importance to re-configuring the cleft. Radiologic studies such as ultrasound, MRI or CT scans do not give any useful information beyond what can be seen by a physical exam, and add no value.
So, how should recurrences NOT be treated?
More diligent personal hygiene will NOT solve the problem.
Greater efforts at hair removal is NOT the solution.
Another attempt at removal because “we didn’t get it all” or “you developed a new cyst” is NOT going to solve the problem
A MRI so we can find some elusive, missed tunnel or tract is NOT the answer
Re-operation with methylene blue dye injected to find elusive sinus tracts will NOT magically uncover the problem
The Cleft-Lift is the answer
The best solution is an operation which flattens the cleft, brings the incision off the midline, and removes whatever current wounds or tracts exist. The cleft-lift is the best operation to achieve this. The Karydakis Procedure is also a good option, if done properly.
After a cleft-lift procedure many surgeons place a drain. There are two different basic kinds in popular use.
One type is a “passive drain” and consists of a flat rubber strip that enters one area and exits another, and allows any fluid buildup to find a way out along the rubber drain and onto the dressing. It requires some occasional rolling pressure along the flap to push fluid out the drain site, and does not allow measurement of the output very precisely.
The other type is an “active drain”, which is referred to as a “closed suction drain”, or Blake Drain or JP (Jackson Pratt) Drain. It has a clear plastic tube that is placed under the flap, and connects to a clear plastic reservoir, which is emptied once or twice a day and the amount precisely recorded.
I prefer the Blake Drain type because it has been working well for me for many years, but either type is acceptable. However, the bigger questions are whether a drain is really needed at all? And, can failures be attributed to the lack of a drain in cases where one wasn’t used?
The logic of using a closed suction drain is that it:
prevents any fluid from accumulating under the flap, which could cause a chronic fluid collection (seroma) or infection
prevents fluid from leaking through the incision, which will weaken the incision and possibly sabotage the success of the operation
is an indicator of bleeding (the drainage will be red), or infection (the drainage will be creamy) and allows us to respond to the situation more quickly and appropriately.
pulls the tissues together with negative pressure so they will heal in the position the surgeon intended.
So, what happens if you don’t use a drain? There are no specific studies that compare patients with and without a drain after a cleft-lift, but there are studies that do this with the Karydakis procedure, which is very similar. One study, done in Turkey in 2005, showed that when a drain was not used, 32% of the patients had problems with fluid collections, as compared to 8% in the patients with drains. Another article, from Ireland in 2010 this time, compared using a drain with putting fibrin glue under the flap instead. In this series, there was a 24% complication rate when the drain was not used, vs 6% when it was used.
So, if one can extrapolate the Karydakis data to the cleft-lift, it seems that a drain is useful. But, can you get away without it? Sure: 70-80% of patients would probably do OK without it. The problem is knowing which patients are the ones who are going to have problems. At present, we have no way of prediction this. Afterwards, in patients with low drain output, we might be able to say they could have gotten away without a drain. In those with a large amount of output, that lasts over a week, we can certainly say they benefited from the drain. I use a drain in all patients, because I don’t think a 25-30% rate of problems from fluid is acceptable.
If someone’s cleft-lift failed, and they didn’t have a drain – can we blame it on that omission? It’s hard to say. Often, a poorly constructed cleft-lift goes hand in hand with the omission of a drain. But, without knowing all the details, it is hard to completely blame it on that one issue.
So, I wouldn’t choose your surgeon solely on whether they use a drain, or not. Instead, I would look at how much experience they have, what their interest level is with pilonidal disease, and what their success rates have been. BTW: if you’ve managed to read through this article, you now know more than most surgeons about this topic! Congratulations!