For most patients, we recommend the cleft-lift procedure for the best results.
Although Dr Immerman prefers the cleft-lift procedure, there are several other operations described to combat this problem. This page discusses some of the most commonly performed operations. The cleft-lift is described at the bottom of this page.
Drainage of Abscess
Often this is the first procedure needed, since an abscess is often the first sign of the disease. The purpose of this is to relieve the infection that has become trapped under the skin. It is also called “lancing” or “incision and drainage”. You can read more about this here.
Excision and Primary Closure
This means to excise (remove) the diseased tissue and sew it together with hopes that it will heal. This is a fairly simple operation, but can be disappointing. It may look like it is going to heal nicely for about a week or so, and then separate. Often this separation is blamed on an infection, but that is not usually the case. It comes apart because it is down in the cleft. At that point, prolonged wound care may be needed to get it to heal.
This means that the diseased area is removed, but there is no attempt to close the wound. The wound is left to heal in by itself, which usually takes a few months . This is called “secondary healing” or “healing by secondary intention”. It will require frequent dressing changes, packing, or even a Wound-Vac to help it close. The reason this is a popular operation among surgeons, as compared with the one above, is that patients and surgeons don’t suffer the disappointment when a closed wound separates a week or two after surgery. In this situation, the surgeon resigns themselves to the fact that wounds down in the gluteal cleft rarely heal easily, and by leaving it open they are admitting defeat.
This operation represents an even greater admission of defeat. The disease tissue is excised and the edges of the wound are sutured down to the base of the wound (sacrum) and left to heal. The concept is that by creating a permanent cavity, the disease will not recur. This does have a chance of eventually healing – but it will leave a permanent, deep, dent in the sacral area – which patients find unsightly and uncomfortable – since there is essentially no fat layer to pad this area when sitting.
The three surgical options below are in the category called “minimally invasive pilonidal surgery”.
Pit Picking (sometimes called “Bascom’s Operation”)
This operation consists of making tiny incisions around the midline pores, and removing the little sinus tracts that are burrowing their way under the skin. A second incision is made off to the side, and through this any hair or debris is swept out. Dr Bascom recommends it for minimal disease. I did this as my primary approach for several years – but I did not found it 100% effective. I don’t feel that the success rate is high enough to be my recommendation to a patient who wants their problem solved with one procedure. The reason for failure is that the deep gluteal cleft remains, and new pilonidal disease will often develop.
There are several newer procedures that may or may not prove to be successful for the treatment of pilonidal disease. EPSIT is a procedure where a small endoscope is placed into the sinus tract opening and the hairs and inflammatory tissue is removed. This is basically a variation of pit picking, and has its indications, but also has its limitations. It does not flatten the cleft, so does not address the primary problem.
The method of curetting (scraping) out the sinus tracts and cavities and filling them with fibrin glue is a newer technique that has been described in the surgical literature. The data supporting the success of this procedure is not robust. In theory it is something that may work in some situations, but does not flatten the cleft, so does not address the primary problem. Over the years fibrin glue has been tried on many different disease entities, often with disappointing results. I suspect that this will have its place in some situations, but will have a disappointing recurrence rate.
Excision and Skin Grafting
This is rarely done, but is an option. The area of disease is removed, and skin is taken from elsewhere on the body and grafted over the wound. While most operations for pilonidal disease are done as an outpatient, this may require inpatient hospitalization for immobilization and wound care while the graft “takes”.
This is a “flap procedure” where a skin flap is moved from one area to another. It is called a Z plasty because the final scar has three limbs in the shape of a “Z”. The pilonidal disease is removed, and the Z-Plasty is an attempt to cover the defect. This is not a bad idea, but has to be done very aggressively in order to flatten the gluteal cleft. The cosmetic result is not appealing, and if it fails, it is hard to correct secondarily.
V-Y Advancement Flap
This is another “flap procedure”. In this procedure the diseased tissue is removed, and a flap off to one side is moved to cover the defect in the midline. It is called a V-Y Flap because the incision that the surgeon makes is in the shape of a “V”, but it is closed so the scar looks like a “Y”. Just as with the Z-Plasty, it has to be done by an experienced pilonidal surgeon so that in addition to covering the defect the cleft is flattened. The cosmetic result is not appealing either.
Limberg Flap (rhomboid flap)
This is another flap procedure. In this case the area removed is a crooked square, and is reconstructed with another square of tissue. As with the other flap procedures, it is a good idea – but has to be done by an expert. The appearance after a Limberg Flap is not particularly natural appearing either, and because of its cosmetic inferiority, I do not recommend it.
Colostomy to help heal difficult pilonidal wounds
I only mention this in order to suggest that it is NOT a viable solution for any situation involving pilonidal disease. There are times when surgeons are frustrated by the lack of healing, and suggest that diverting any stool from the anal area will promote healing. This is a very drastic, dangerous, and demoralizing procedure that rarely, if ever, has a place in the treatment of pilonidal disease. The healing problems are not the presence of stool or absence of personal hygiene – but rather the shape of the cleft.
There are several operations that fall into the category of “off midline closures” including the Cleft-Lift Procedure, Cleft-Closure, Kaydakis Operation, Modified Karydakis Operation, etc. The basic concept with these procedures is that the pilonidal disease is removed along with the skin on one side of the cleft, and the skin from the other side is raised up and brought across the midline. The goals are to (1) remove the active disease; (2) flatten the cleft; (3) bring the incision away from the center line; (4) obtain primary healing; (5) prevent recurrent disease; (6) achieve an acceptable cosmetic appearance. Of all the procedures listed on this page, this accomplishes all these goals the most effectively. Dr Immerman performs a procedure that is very similar to the cleft-lift that Dr Bascom describes, with a few technical advancements that he has found successful (particularly when dealing with perianal disease). Any of these “off midline closure” procedures require a surgeon experienced and interested in treating pilonidal disease.
Click here to see an Image Gallery of Post-Op Cleft-Lift Procedures. (Note: this gallery contains images of buttocks with surgical scars.) Not all patients look quite this good after surgery – but many do. If you perform an internet image search for the various other procedures listed on this page, you will get an idea of the appearance the other flaps will create.