Should I have a wide excision for my pilonidal cyst?

A very common question

Here is the scenario: a patient has a pilonidal cyst and sees a board certified general surgeon in whom the patient has faith in their skills. The surgeon recommends a wide excision, with or without primary closure (sewing it back together) and possibly with a post op wound VAC (wound vacuum device). They are told that it will take a few weeks to heal and has the highest success rate of the various pilonidal operations.  If the patient asks about a cleft lift the surgeon says:

  • The cleft lift is only for “severe cases”.
  • The cleft lift has a high failure rate.
  • The cleft lift has a high infection rate.
  • The procedure I do “is sort of like a cleft lift”.

So – what should the patient do?

The most important thing is that the patient be educated in the facts regarding the treatment of pilonidal disease, and is able to make an intelligent decision. So, let’s look at the accuracy of what this patient is being told.

A wide excision will only take a few weeks to heal.

This is extremely variable, and depends on the size of the excision and the depth of the cleft. The typical healing time in a good situation is about 3 months. But, there are numerous times when it is still not healed at one year. The reason for this is that wounds do not heal well buried in a cleft, and often will develop into new pilonidal disease, rather than healing.

A wound VAC is a good way to get things to heal quickly.

In general, wound VAC devices work very well to get wounds elsewhere on the body to heal faster. However, in the gluteal crease they are hard to get in position, awkward to have in place, and it is not unusual to have the VAC device get the wound almost healed, but never fully healed; or the wound heals but opens up once the VAC is removed.

Open excision has the highest success rate.

This is definitely incorrect. This may have been true long ago, but the newer advancements in treatment of pilonidal disease, especially with the cleft lift have changed this. In general, a reasonable success rate to ascribe to open excision is 50-70%. The success rate of a properly performed cleft lift is in the 95-99% range. This is a huge difference: at best one out of three open excisions fail.

The cleft lift is only for severe cases.

This is not true in our clinic, nor in the clinics of the other cleft lift specialists. Every patient has a different idea regarding how aggressive they want to be with their first operation. Some patients want to start out with a “minimally invasive” operation, and others take a “one and done” approach. The high success rate with the cleft lift makes it the only procedure needed in over 95% of the situations.

The cleft lift has a high failure rate.

The cleft lift has a high infection rate.

This is not true either. In our clinic the infection rate is around 3%.

The procedure I do is sort of like a cleft lift.

If your surgeon says this, I’d investigate his or her experience with the procedure a bit more thoroughly. Some surgeons feel that an excision with primary closure, where they try to get the closure a bit off the midline is the same as a cleft lift; but it is not. The cleft lift is a very specific procedure with many technical aspects that must be done correctly.

In Conclusion

How you should proceed depends upon how you put all this information together with your own personal situation, and you need to consider geography, finances, and personal needs. But, excision has a high failure rate, and another operation might be needed if it fails. A cleft lift can be done after multiple failed excisions – but it makes the situation more difficult.

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