Who is a “candidate” for a cleft lift?

When patients see a surgeon and ask about the cleft lift procedure this becomes an important question. We use the term “candidate”, but this is not an election! Often, surgeons will indicate to a patient that they are not “candidates” for the operation. The translation is that they do not think it is the best procedure for the patient, and don’t (or won’t) perform it.

Although when looking at the medical world from the outside, there often is the impression that medicine and surgery are completely scientific, and statements like this are absolute, sadly this is not the case. The appropriateness of the cleft lift procedure is very different from surgeon to surgeon, and they are giving you their opinion based on their particular research, training, and skills – as it applies to your situation. There are times when surgeons feel that a patient’s situation is not severe enough to warrant a cleft lift, or too severe to warrant a cleft lift. As a consumer of medical care, these recommendations need to be taken as opinions, not facts, and it is quite appropriate to seek alternative opinions.

At my pilonidal clinic, we perform the cleft lift on the entire spectrum of pilonidal disease, ranging from very minimal to the most difficult cases in the country. I understand that this is extremely controversial within the surgical world. There are many surgeons who feel that the cleft lift should be reserved for patients who have already failed other operations.

Here are a few facts about this:

  • Any operation involves time, cost, anxiety, and discomfort, even the ones called “minimally invasive“, and laser surgery for pilonidal disease. My feeling is that if you are going to have an operation, you should at least have the choice of the one with the highest success rate.
  • A recent meta-analysis of ~90,000 patients reported in the surgical literature came up with data on various operations (keeping in mind that in general, surgeons only report their data if they think that they are doing a very good job.) The failure/recurrence rates at 120 months in this study are:
    • Open excision: 19.9% failure
    • Closed excision: 32% failure
    • Limberg flap: 11.4% failure
    • Pit Picking: 15.6% failure (at 60 months)
    • Cleft lift or Karydakis flaps: 2.7% failure
  • Not every surgeon knows how to perform the cleft lift procedure, or does it so rarely that they are uncomfortable recommending it to any category of patients, and are reluctant to refer patients to the regional experts.
  • In our clinic I am so concerned with the actual success of the procedure, I have kept data on every cleft lift I’ve performed since 1993, and have published that data.
  • Some surgeons say that the infection rate with the cleft lift is very high. That is not true, and in my paper I demonstrate an overall infection rate of 2.6%.

The take-away from this discussion is that if you are looking for the highest chance of a “one and done” type of procedure, seek out the experts in this field and ask THEM if you are a “candidate”!

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.

Are Wound VAC’s Really That Great?

The pros and cons of wound V.A.C.’s

A suction device used to help heal a wound has several names: Wound V.A.C, VAC, “vacuum assisted wound closure” or “negative pressure wound therapy (NPWT)”. Sometimes they are referred to based on the specific brand of the machine, like a “Pico” or “VERAFLO”. VAC stands for” Vacuum Assisted Closure”. It consists of foam placed over an open wound, that is sealed with adhesive plastic, and connected to a machine that applies suction and removes fluid.

Note: this is not the same as a “closed suction drain”, also called a JP Drain, Jackson Pratt Drain, or Blake Drain. These are tubes that go INSIDE closed wounds to remove fluid.

Negative Pressure Wound Therapy is very helpful in getting wounds to heal faster and minimize daily dressing changes. The VAC has to be changed periodically, but less frequently than usual open wound care.

But, is it a good solution for pilonidal wounds?

I suppose it depends on how you look at the situation. There are quite a few negatives (no pun intended) attributed to the use of the wound VAC for pilonidal wounds:

  • It is an extremely awkward location to have a wound VAC, and it is hard to keep it well secured in place, especially with wounds next to the anus.
  • It has to be changed frequently, the materials are expensive, and it has to be changed by a wound care professional, either in their clinic, or by a home-care visit.
  • It is noisy, smelly, and embarrassing; and the VAC changes can be painful.
  • It may have to be in place for months at at time.
  • Even if it helps a wound to heal, it provided no guarantee that it will stay healed once the VAC is removed. The placement of a VAC is an extremely abnormal situation which does not replicate the environment and anatomy that will exist when it is removed. Frequently, when it is removed, the wounds open up again. Note: This is true for gluteal crease wounds, not wounds elsewhere on the body.

Although philosophically one could look at the use of a VAC in this situation as a difficult therapy that is trying to make the best of a bad situation, I don’t agree with that analysis. I think the smarter choice is to see a pilonidal expert and have surgery to close the wound. This short-cuts the whole situation, and usually turns this into a full recovery in about six weeks with a very low chance of recurrence. (I have not used a VAC on any of my patients in 27 years of pilonidal surgery.)

FURTHER SURGERY may seem like an illogical way of dealing with an open wound, that occurred BECAUSE of surgery, but if done properly it works. It is also appropriate with failed flap procedures, including previous failed cleft-lifts. If your current surgeon says that the wound can’t be closed – get another opinion. It may just mean that he or she does not know how to close it. There is almost always a faster and easier solution.

Contact us if you need help!