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.
Unfortunately, recurrence of pilonidal disease after surgery is a common problem. This article discusses the reasons why this happens, and presents a good solution.
In order to understand why pilonidal disease recurs, it helps to understand why it happens in the first place. Pilonidal disease is caused by the shape and depth of the gluteal fold. In some patients it is so deep and tight that during most of the day, it is tightly folded and no air can get in. Because of this pressure builds up in the cleft and anaerobic bacteria grow. The reaction of the skin to this situation is to create enlarged midline pores, which we call “pits”. Loose hairs that all off the body (mostly from the back of the head) get caught in these pores, work their way under the skin, and cause a “pilonidal cyst”.
Pilonidal disease manifests itself in several common ways:
a slightly painful lump that may get intermittently inflamed
a more severe infection, which we then call a pilonidal abscess
enlargement of the pits to the point that they cause open, draining and/or bleeding wounds
tunneling or sinus tract formation, where the midline pits connect to secondary openings off to the side of the crease
The best operations re-configure the gluteal crease so it is not so deep. The cleft-lift operation does this, and has a very low recurrence rate. However the operations that just remove the “cyst” do not flatten the crease, and have an extremely high failure rate.
So, why does pilonidal disease recur?
In almost all situations, when pilonidal disease recurs it is because the cleft was not flattened, and the incision for the surgery was placed in the midline of the cleft. It is NOT BECAUSE THE SURGEON DID AN INADEQUATE JOB OF REMOVING ALL THE CYSTS AND TRACTS! This is not “a cancer which has to be completely removed”; this is a benign disease caused by the shape of the cleft. Removal of the disease is of secondary importance to re-configuring the cleft. Radiologic studies such as ultrasound, MRI or CT scans do not give any useful information beyond what can be seen by a physical exam, and add no value.
So, how should recurrences NOT be treated?
More diligent personal hygiene will NOT solve the problem.
Greater efforts at hair removal is NOT the solution.
Another attempt at removal because “we didn’t get it all” or “you developed a new cyst” is NOT going to solve the problem
A MRI so we can find some elusive, missed tunnel or tract is NOT the answer
Re-operation with methylene blue dye injected to find elusive sinus tracts will NOT magically uncover the problem
The Cleft-Lift is the answer
The best solution is an operation which flattens the cleft, brings the incision off the midline, and removes whatever current wounds or tracts exist. The cleft-lift is the best operation to achieve this. The Karydakis Procedure is also a good option, if done properly.