Is a Cleft Lift Appropriate for “Mild” Pilonidal Disease?

Is a cleft lift for mild pilonidal disease like “going after a fly with an elephant gun”?

Many surgeons feel that for very severe pilonidal disease the cleft lift is the best option when performed by an experienced pilonidal surgeon. But, what is the best approach for patients with mild disease? This is a very commonly asked question, and if you ask ten surgeons, you will get ten different answers which range from:

• “it’s not so bad, just live with it”.
• “just keep it clean, and perform hair removal and it may be fine”.
• “just wait until you are 40 years old, and it will all go away”.
• “you are a candidate for pit picking (or some other “minimally invasive” pilonidal operation)”.
• all the way to a recommendation for some sort of flap procedure, including the cleft lift.

So, what is the answer?

Unfortunately, there is no absolute answer that fits with every patients needs, and every surgeon’s skill-set. But, as the patient your best approach is to try to understand all the options available to you, and attempt to choose the one that meets your philosophy of how you would like to be treated. Fortunately, pilonidal disease is not a life-threatening condition, and the goal is to take care if it in a way that meets your needs.

Here are some facts:

• If you have been diagnosed with pilonidal disease the idea that it will go away with no treatment is wishful thinking.
• Pilonidal disease is not caused by obesity, poor hygiene, sitting, or excessive hair, and addressing these issues will not make the disease disappear.
• Although it is unusual for new pilonidal disease to appear after age 40, previous untreated disease will not magically disappear once that age is attained.
• There are many “minimally invasive” pilonidal operations that all are very similar in their concept, which is to remove the sinus and hope things heal and don’t recur. These include pit picking (Bascom1), Gips Procedure, EPSiT (Endoscopic Pilonidal Sinus Treatment), SiLac (laser surgery), Fibrin Glue, Kshar Sutra, Phenol, RFA, and Seton Treatment. It is my estimation that these all have a long term success rate that, at best, is 70% (in other words, about 1 in 3 will ultimately fail). Many of these require more than one treatment in order to obtain the 70% success rate.
• There is no harm in trying the minimally invasive treatments as it pertains to future more aggressive surgery, but there is time, expense, discomfort, and the disruption involved with having medical procedures.
• Excisional procedures such as “open excision” or “closed excision” are antiquated procedures and should not be performed at the current time. They have success rates in the 30-50% range, and have a long, painful and difficult recovery.
• In experienced hands, the cleft lift procedure has a long term success rate over 95%.

How we handle pilonidal disease in our clinic

We only perform the cleft lift procedure because of our excellent results and the ease of recovery when compared to the other procedures. We have no quarrel with the idea of performing a minimally invasive procedure first and hoping it works, but we will not perform these procedures because of the high failure rate, which is an especially significant issue when patients are traveling across the country to see us.

Dr. Immerman published a paper approaching this form the point of view that the cleft lift is reasonable for all presentations of pilonidal disease, and it is an open-source article and can be read by following this link. In patients who present with minimal pilonidal disease the success rate is 99%. This paper followed 700 patients, and at this time we have continued to track our experience with 1400 patients, and the data has not changed.

Dr. Immerman also published a paper on patient satisfaction after the cleft lift procedure, and that can be viewed here. In this study, of the 500 respondents, 494 (98.8%) were “extremely satisfied” or “satisfied” with their procedure. There is more detail in the article.

So, as you can see there is no “absolute answer”, but hopefully this web page has answered some questions, and will help you organize your research so you can come up with the treatment plan that works best for you.