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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.

Letter from a grateful family

 

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.

Sitting after Cleft-Lift Surgery

We encourage sitting immediately after surgery.

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.