How do we determine which patients to accept for a cleft lift operation?

At the Evergreen Surgical Pilonidal Clinic we feel that the cleft lift operation is an excellent option to treat pilonidal disease in almost all patients. However, there are many parameters that we evaluate in order to determine if an individual patient is best served by a cleft lift at our clinic. This is why we ask for detailed information about you, about your medical history, and for specific photos of your pilonidal disease before we schedule any surgery. It is our goal to provide high quality, personalized care by performing an operation that is the right operation for you, highly successful, has very few potential complications, and has minimal requirements for post-operative care. If there is a high chance that a patient will require more intensive post-operative care than usual, is at high risk for complications, or if it is not the best operation for the patient’s disease – we suggest that the patient find more appropriate care close to their home.

What we are trying to avoid is performing an operation that is unnecessary, or to have surgical complications that actually make the situation worse then when we started! This is especially important if Dr. Immerman is not going to physically be there to help take care of any post-operative problems.

Severe, off-midline pilonidal disease

In over 99% of situations the patients who approach us for a cleft lift have disease localized to the midline of the gluteal cleft, or just slightly off the midline. If the disease has been neglected for a long period of time, and has progressed far from the midline, it may require weekly clinic visits for many months after the surgery. For patients who live far away, this is clearly not feasible and requires a local surgeon.

Lack of evidence of pilonidal disease

This is the opposite of the paragraph above. That there are times when patients are diagnosed with pilonidal disease by a medical practitioner (or self diagnose) yet with the history, medical records, and photographs we cannot confirm that this is actually the correct diagnosis. Sometimes, it is necessary to allow some time to elapse to observe how the situation progresses before considering surgery. We don’t want to perform an operation that a patient doesn’t need.

Hidradenitis Suppuritiva and other Autoimmune Skin Diseases

Hidradenitis (HS) is a skin condition that occurs in the armpits, groins, and gluteal area and causes repeated infections in the skin of those areas. We have found that it causes significant problems with the healing and response to cleft lift surgery, including repeated infections, wound separation, and suture reactions. It is our conclusion that it is best that the HS is treated by a dermatologist and under control before a cleft lift procedure. If the HS is mild, and does not seem to involve the gluteal area, we have found it safe to perform the surgery, but institute some of the treatments for HS to prevent problems. There are also other autoimmune skin diseases that would have to be well treated before it was safe to proceed with a cleft lift.

Steroids

There are many medical conditions that require treatment with systemic steroids, such as prednisone. Orally taken steroids significantly slow down the healing process, which can be a major problem for all surgical patients (topical steroids like cortisone cream or Flonase spray are not a problem). Some operations have incisions in locations where this is not a big issue. But because of its location on the body, the cleft lift procedure is very sensitive to slow healing, and if a major wound separation occurs it can cause significant problems. We require that patients have not taken steroids for at least a month before the cleft lift operation, nor during the six week healing/recovery period.

Obesity

There is concern that individuals who are very heavy may have healing issues because of the forces placed on the incision with sitting and lying down, and because of the extreme mobility of the tissues which make construction of the optimal contour challenging. At our clinic we do not offer this to patients over 350 lbs.

Mobility Issues

If patients are unable to move around independently and spend most of their time sitting, and have impaired sensation of the gluteal area, we are reluctant to perform this operation because of concerns regarding wound separation which could turn a small wound into a large, chronic wound.

Blood Thinners

In our experience patients on blood thinners (anticoagulants) for various medical reasons very frequently have bleeding problems after the cleft lift operation. The issue is not life-threatening hemorrhage, but bleeding into the wound which adversely affects healing of this operation. Even when we have tried to bridge patients with short-acting Lovenox  we have seen problems. For this reason, we require patients to discontinue any type of anticoagulation, including platelet inhibitors like Plavix and Brillanta (and even aspirin) before we perform a cleft lift. The amount of time before surgery that they need to be stopped depends on the specific medication, but it should be held for six weeks after surgery. Since these medications are not prescribed without firm indications, this can create a problem. Sometimes, anticoagulants are prescribed for a specific period of time, after which they can be stopped. Other times they are required permanently, which makes it difficult to find a safe time to perform a cleft lift.

Behavioral Issues

It is important that patients follow our instructions regarding limiting activity and avoiding trauma to the incision for six weeks. Usually, someone else can help with dressings and the drain, but if because of psychological issues or behavioral problems the activity instructions can not be followed, a cleft lift is not the best option.

High risk of infection

If a patient has had MRSA (methicillin resistant staph aureus) infection or infection with some other type of antibiotic resistant bacteria, and is found to still be colonized with that bacteria, we will require antibiotic treatment and evidence that they are no longer colonized. This is usually overseen by an infectious disease specialist. A post-operative infection with antibiotic resistant bacteria can be very dangerous, and sabotage the success of the operation. In addition, patients on chronic immuno-suppressants may not be candidates for a cleft lift depending on the situation.

Chronic Malnutrition

If patients are not well nourished, we would want to reverse that situation before performing a cleft lift. Here is more on nutrition.

Inability to tolerate anesthesia

We perform the cleft lift under general anesthesia. There other ways to do this, but if we can not come up with an acceptable and safe way to perform the operation comfortably, than some other option should be explored.

Conclusion

As a patient, it may be disappointing to hear that our clinic does not feel that coming to Wisconsin for a cleft lift is a good idea in your situation, but these decisions are made based on the treatment and recovery of many hundreds of our previous patients, and with an attempt to provide the best and safest care possible with the information that you have provided to us.

Although by reading this page it may seem that there are quite a few reasons why we don’t feel it safe to operate on patients, the reality is that these reasons are rarely an issue. It also may seem that Dr. Immerman is being overly conservative regarding patient selection, but keep in mind that our clinic accepts the worst cases of pilonidal disease in the country, and we often gladly attempt to repair patients who have been deemed irreparable by their previous surgeons. As opposed to some other pilonidal clinics, we do not demand that patients stop smoking, we accept pediatric age patients, and we allow sitting and showering right away. These differences between practices are what makes surgery an “art” rather than a “science”, yet we have based our recommendations on 40 years of surgical practice, and 30 years of performing the cleft lift – so there is a lot of science involved.

Although we are very aggressive in attempting to repair pilonidal disease, we are uncompromising in our desire to do this as safely as possible, and to make sure that the patients we do treat recover well and are satisfied with our care.