Why does pilonidal surgery often fail?

For surgeons, defining and removing pilonidal disease during an operation is not a mysterious hunt, but rather a very straight-forward process.

Is is because all the pilonidal disease was not removed?

A very common question is why a pilonidal operation failed, and one of the answers often given is that some of the disease was not removed, and the failure is because of this residual disease. Although this seems like a simple explanation, it is usually false. Pilonidal disease is not cancer, and complete removal of every cell of disease is not linked with success or failure. This is a disease related to the shape and configuration of the gluteal cleft, and possibly to skin and hair type. In addition, when a surgeon operates, the cysts and sinuses are pretty easy to find, so this explanation really doesn’t make sense. You may hear about surgeons using special dyes (methylene blue) to help define sinus tracts. This is rarely, if ever, necessary – these things are pretty obvious to an experienced surgeon.

So, the adequacy of cyst and sinus removal is not the critical factor that determines success or failure, but what is important is changing the contour of the cleft (flattening it), and moving new, healthy skin to the midline. If we look at the various operations for pilonidal disease, the success rates seem to reflect how well this was accomplished.

Different Operations

The excisional operations are very “hit or miss” regarding their success. Large meta-analysis of these operations show success rates varying from 32-80% depending on the technique, but most surgeons when asked will tell you it is about 50/50.

The success rates of the minimally invasive procedures  also vary widely.  Ranges between 40-85% success are reported. Here is another discussion about minimally invasive techniques.

The success rates of the cleft lift and Karydakis procedures, which are very similar are very consistent. Many reported series show success rates around 97% even when patients are followed for 10 years or more.


So, if you’re being told that the failure is that sinuses or cysts were missed – I’d suggest seeking other opinions. If you are looking for the procedure with the best success rate, consider the cleft lift.

This is the only procedure we perform in our clinic because of its high success rate, rapid recovery, and superior cosmetic outcome.

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