More About “Minimally Invasive” Pilonidal Surgery

Fibrin Glue. Kshar Sutra, Phenol, RFA, and Seton Treatment of Pilonidal Disease

In a previous post I discussed several “minimally invasive” pilonidal treatments, and you can read about them here. However, there are a few other kinds of minimally invasive therapies that are worth discussion. They are:

  • Fibrin Glue
  • Kshar Sutra
  • Phenol Injection
  • RFA (Radio Frequency Ablation)
  • Seton treatment
  • Cryosurgery

These are all addressing the pilonidal sinus tract, which is one of the more common presentations of pilonidal disease. These treatments would have no place in the treatment of a large, non-healing wound. I’ll describe each of these separately:

Fibrin Glue Treatment of Pilonidal Sinus

The sinus tract is cleaned out of hair and debris. Fibrin glue is then injected into the sinus tract to obliterate any space in the sinus tract. (Fibrin glue is a biological adhesive which consists of concentrated human fibrinogen which is activated by the addition of bovine thrombin and calcium chloride.)


Kshar Sutra Treatment of Pilonidal Sinus

The sinus tract is cleaned out, the midline pits are removed, and a medicated thread is put in the sinus tract origin, and out the sinus tract exit, and tied in a circle. It is left in place until it causes the tract to scar down and heal.


Phenol Injection for Pilonidal Sinus

This is a technique that is more popular in Europe than the United States. The sinus tract is cleaned out and some form of phenol is instilled into the tract. There are several forms of phenol such as cream-gel, liquid and crystals. Phenol is a caustic, antiseptic, germicide, and has a local anesthetic effect. (It has been used as an embalming fluid!)


RFA (Radio Frequency Ablation) of Pilonidal Sinus

In this technique the sinus is surgically removed, and an electrocautery unit is used to destroy the residual sinus tissue. As surgeons, we use electrocautery in almost every operation. It is a machine that turns electrical energy into heat energy. (often termed a “Bovie” after the inventor). In this instance, certain kinds of tips are used on the machine to facilitate the procedure.


Seton Treatment of Pilonidal Sinus

This is similar to kshar sutra, in that a thread is placed through the two ends of the sinus and tied. Patients come in weekly for the thread to be tightened, until it cuts through the tissues. The inflammation from the thread obliterates the sinus.


Cryosurgery for Pilonidal Sinus

This is very similar to using RFA or Laser – where energy is used to destroy the sinus, but in this case liquid nitrogen is used to destroy the tissues by freezing.


You may be noticing a theme here:

  • They all of these put something in the sinus tract to obliterate it (chemicals, heat energy, freezing, foreign body, glue).
  • They are not very different than EPSiT, SiLaC (laser surgery), pit picking, or Gips Procedure.
  • They may or may not be able to be done in an office setting.
  • They all require multiple post op visits.
  • They do not re-shape the gluteal crease.

The literature regarding the success rates of these procedures is not the most robust. However, when the literature is evaluated the recurrence rate is reported as 15% – 40%. Many studies contain small numbers of patients and short follow up times. Of course, only surgeons with good results report their outcomes, and many surgeons don’t write papers about this at all!

My take on all of these minimally invasive procedures is:

  • They are are a reasonable first step in a specific group of patients with a SHALLOW CLEFT who present with ONLY a sinus or two.
  • They are NOT an option when dealing with open wounds and non-healing surgery.
  • The patient has to accept that there is a significant failure rate. At best one out of five patients will fail, and more likely one out of three.
  • None of these procedures has been shown to be significantly better than the others.
  • Although they may cause some minor scarring and distortion, they do maintain the original shape of the gluteal cleft, if that is of cosmetic importance to the patient.
  • They are not widely accepted by surgeons, and it may be difficult to find one to perform the procedure.
  • In almost all situations, if they fail, a cleft-lift is still a future option.

I do not perform any of these operations, because I do not feel that the success rate is worth the time, expense and discomfort for a procedure with a low success rate. Especially, if it requires travel across the country to see me. If you are interested in these minimally invasive procedure, I suggest you try to find someone local to evaluate and treat you. If the minimally invasive therapy fails, then come see me for a cleft-lift.

Pilonidal Disease: Can I Avoid Surgery?

Will this go away by itself? Is it manageable with non-surgical care?

This is a commonly asked question. Although I am a surgeon, I realize that surgery is not for everyone, and nobody is really excited about having an operation if there is another option. Drainage of a painful, infected, abscess (lancing, I&D) is often an emergency and is very obviously necessary, other operations are elective – meaning that a patient has a chance to think about it, weigh the pros and cons, and decide if that is the route they want to proceed.

The decision is easy if the pilonidal disease is painful, embarrassing, disruptive and depressing, and it’s clearly time to do something about it. On the other hand, for other patients surgery is not really the route they want to go. There can be various reasons for this:

  • The symptoms aren’t that bad.
  • Their philosophy that surgery is only a last resort.
  • Financial considerations.
  • Concern regarding the cosmetic change.
  • General fear of surgery and hospitals.
  • Lack of a qualified specialist nearby.

These are all reasons to step back and see if there is a non-surgical approach that will work. It is a rare situation in which pilonidal disease becomes life-threatening. For various reasons, there isn’t very robust data regarding the recurrence rate of pilonidal problems. So, I can’t really tell you that if you had one abscess, what the chances are that you will have another. In a specific situation, if I can evaluate the anatomy, I may be able to predict whether future problems are expected or not. But, if you are not seeing a pilonidal specialist, it will be hard for you to come to any conclusion on your own.

These are situations where future problems are very likely:

  • Multiple, enlarged midline pores or actual open wounds.
  • A very deep gluteal cleft. Sometimes this is apparent, because it takes some strength to spread the buttocks apart to see the base. Or, in other situations, the crease seems to open up easily when prone, but folds when standing. Brownish discoloration (hyperpigmentation) of the skin on either side of the cleft is a clue that this is a problem.
  • Multiple abscesses.
  • The presence of a sinus.

Sometimes after an abscess has been drained, there are no visible abnormalities. This is the kind of situation where it is not clear how much a problem it will be in the future. This web page discusses that situation.

But, if you are dealing with any of the situations described above, it is possible to get along without surgery, but the pilonidal disease is going to be an intermittent long term problem and, contrary to some rumors, will not just disappear after age 40.

Diligent attempts at hygiene, antiseptics, dressings and at times antibiotics may help minimize symptoms, but most likely won’t completely eradicate the problem. A discussion of home remedies can be found here. However, if a patient’s issue is that surgery is not feasible now because of finances or other obligations, some of these home remedies may make delay less painful.

In general my recommendation is that the best approach is to proceed with surgery at some point, and the sooner this is treated, the sooner patients can get on with their lives. I believe the cleft-lift operation by an experienced pilonidal surgeon is the best combination of high success rate coupled with ease of recovery. Contact us if this is something you would like to explore.

Facts about hair and pilonidal disease

Some of the first research on the subject

The term “pilonidal” means “nest of hair”. We know that pilonidal cysts contain loose hairs, but until recently there has not been much research done on what kind of hairs are in the cysts, and why one patient develops pilonidal disease and another does not. Here are some of the more recent facts found by researchers in Germany:

  • Stiffer hairs have more of a tendency to get in these cysts than softer hair.
  • Most of the hairs in a pilonidal cyst come from the back of the head.
  • Hair on the back of the head is stiffer than the hair in the gluteal crease, possibly explaining why hair from the head is more common in cysts.
  • Patients who sweat more have LESS incidence of pilonidal disease than the opposite counterparts. Wet hairs are less stiff, and this may explain why.
  • Most of the hairs in a cyst are found to be short and have sharp ends and no roots.
  • In spite of the usual precautions a barber takes to keep hair from from falling down a customer’s back, cut hairs are immediately found at the level of the low back after a haircut.
  • I have not seen any evidence that showering is a critical time, and that it matters if you rinse your hair forward or back.

This information is all very new, and it’s significance remains to be seen. But, it does suggest that the time after a haircut may be critical in the penetration of pilonidal pits by sharp, stiff hairs, and an immediate shower is a good idea.