With permission, I thought I’d share a recent correspondence from a patient’s father, who is a physician who has retired from surgery and now works in a wound care clinic. He has been trying to get his daughter’s pilonidal wound to heal after three failed operations. He found that in spite of diligent wound care for over a year, that the wound kept partially healing, and then re-opening. Eventually, he brought her to see me for a cleft-lift. The communication below occurred four months after the cleft-lift procedure.
… Her surgical wound is completely healed and is beautiful. You did a masterful job of fitting those flaps together and the elevation of the edges near the anus healed and have flattened with anatomic contour. There have been none of the little pepper sized defects along the incision which for the last 2 years led to more openings, more disappointments and more misery.
She is reconnecting with activities she had been restricted from for 2 years. She is getting back many of the intangibles in her life which were taken from her by this unfortunate disease. She is losing weight and getting to be herself again and for that, I am eternally grateful to you. You did something for us that I nor the sum of my practice experience and contacts could have done. You educated me through your website about this affliction and gave us great hope. You were straightforward and encouraging in your contacts with us showing unsurpassed professionalism. I hope you and all of those important to you are doing well in these quite difficult times. Please accept our sincere gratitude, best regards and congratulations on such a fine outcome.
If I can in anyway help get the same educational message out about pilonidal disease, sign me up. What we never realized and I was never taught in Med school or in practice is that “pilonidal cyst” is a complete misnomer for this affliction. It really is a “disease” because it affects so much more than just that eccentric edge of the heightened gluteal cleft – especially when it just won’t go away!!! Please keep up your work. You have been blessed with a remarkable talent to really make a difference in patients and families lives particularly when most physicians don’t really understand pilonidal disease nor want to attend to those in need. I tell everyone who knows what we went through, the outcome we are now at, thanks to you!!
I read your paper with great interest and congratulate you on the content, presentation of honest data and the conclusions you draw. This is a paper that should be referenced in every general surgery text book because as you point out, the cleft lift procedure was not and is not taught in medical schools or in residencies – to include plastic surgery – as a more definitive solution to pilonidal disease based upon an anatomic etiology. Obviously, not every surgeon will have or develop the skills for this procedure that a master such as yourself has, but the anatomic knowledge of what causes the problem needs to be taught and the specialized, experienced approach that specialists such as you provide needs to be more widely recognized.
I think that this doctor is very articulate in expressing the relief that many patients and family feel after a cleft-lift successfully heals, often after many failed attempts with surgery and wound care. He is also pointing out the significant gaps in medical education about this difficult disease.
Even having your own surgeon and wound care expert in the house won’t make some wounds heal if the shape of the cleft is causing problems. Sometimes only a cleft-lift will help.
This is why I have limited my practice to pilonidal repair and cleft lift. It is results like these that make being a surgeon worthwhile.
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.