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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”!

The Latest Clinical Research

Dr. Immerman’s results on 700 cleft lift patients

Dr. Immerman has been keeping track of his cleft lift patients since 1993, and has just published his results in a peer reviewed scientific article. Although this was meant to be viewed by the surgical community, patients are certainly welcome to take a look at it.

The major findings described in the paper are:

  • Patients who had a cleft lift, but did not have any previous surgery and did not have wounds near the anus, had a 98.7% success rate with a single procedure.
  • Patients who had previous failed pilonidal surgery had a success rate of 94.7%.
  • Patients who had wounds actually on the edge of the anus were the most difficult group to treat and had a success rate of 84.4%, but a second revisional operation almost always solved the problem.
  • No patients in this series had a recurrence occur after 24 months from the cleft lift surgery.
  • There was no category of patient in whom this was not a highly successful approach.

If you would like to view the article, you may view and/or download it from THIS LINK.

It is important, when choosing a surgeon, to know their actual experience and results with this procedure, and Dr. Immerman is proud of his results, and is glad to share them. Taking care of pilonidal disease can be very humbling, and a 100% success rate is very elusive, but these results are coming close and have defined certain groups of patients who are at higher risk of recurrent problems or failures. Currently, there is not another operation that has a better success rate, and the cleft lift is indeed a good solution in all situations.

Flap Terminology Confusion

The difference between Bascom’s Operation and The Bascom Cleft-Lift

There are many different operations for pilonidal disease and the terminology can be confusing. At our clinic we perform the Bascom Cleft-Lift. However, there are other operations that are often confused with this. This post will, hopefully, end that confusion.

Bascom’s Operation (aka “Pit Picking)

This operation removes the midline pores with small incisions and makes an incision off to the side which is used to clean out the cyst. It is also called pit picking, or “Bascom’s Simple Surgery “, or the “Bascom I Procedure”, and is in the category of “minimally invasive” pilonidal operations.

The Bascom Cleft-Lift (aka “Cleft-Lift” or “Cleft Closure”)

Dr Bascom coined the term “cleft-lift” for his rotation flap operation. Originally, Dr Bascom called it a “cleft closure”, but he changed the name because he felt the “cleft-lift” terminology was better accepted by patients. Dr Bascom described this procedure in 1987. It has also been referred to ast the “Bascom II Procedure”, to differentiate it from the one described above.

The Karydakis Procedure

This was the early iteration of the cleft-lift as described by George Karydakis in 1973. This is similar to the cleft-lift in that it is an off-midline closure flap, but has some differences in how the subcutaneous tissue is handled. It is still considered a good procedure.

Other flaps

There are several other operations called flap procedures, such as the Limberg Flap, Rhomboid Flap, Z-Plasty, V-Y Plasty, and Dufourmentel Flap which are quite different from either the cleft-lift or Karydakis procedures. These flaps bring tissue into the midline to fill a defect. The cleft-lift and Karydakis Flaps remove tissue from the midline to flatten the cleft. These are not “Bascom” procedures and have no relationship to the cleft-lift.

Modified Cleft-Lift

A surgeon often might use this term if he or she feels that they are doing an off-midline closure flap operation, but not exactly like Dr. Bascom described. Overall, the differences may be unimportant within the grand scheme of things, because every patient presents a different challenge either by their body habitus, location of disease, or procedures that they have already been through. The main thing is that it bring the incision off the midline and flatten the cleft.