As surgeons, when we do operations we have certain parameters that we look at to determine success of a procedure. But, patients can view things very differently, and what we consider a success, may not be what is working for our patients.
Here is an article I just published in a peer-reviewed, online, medical journal regarding the opinions of 500 patients regarding their cleft lift procedure.
Overall, 494 (98.8%) were “extremely satisfied” or “satisfied” with their procedure, and 496 (93.8%) feel that this is a reasonable first choice for a patient with pilonidal disease.
With permission, I thought I’d share a recent correspondence from a patient’s father, who is a physician who has retired from surgery and now works in a wound care clinic. He has been trying to get his daughter’s pilonidal wound to heal after three failed operations. He found that in spite of diligent wound care for over a year, that the wound kept partially healing, and then re-opening. Eventually, he brought her to see me for a cleft-lift. The communication below occurred four months after the cleft-lift procedure.
… Her surgical wound is completely healed and is beautiful. You did a masterful job of fitting those flaps together and the elevation of the edges near the anus healed and have flattened with anatomic contour. There have been none of the little pepper sized defects along the incision which for the last 2 years led to more openings, more disappointments and more misery.
She is reconnecting with activities she had been restricted from for 2 years. She is getting back many of the intangibles in her life which were taken from her by this unfortunate disease. She is losing weight and getting to be herself again and for that, I am eternally grateful to you. You did something for us that I nor the sum of my practice experience and contacts could have done. You educated me through your website about this affliction and gave us great hope. You were straightforward and encouraging in your contacts with us showing unsurpassed professionalism. I hope you and all of those important to you are doing well in these quite difficult times. Please accept our sincere gratitude, best regards and congratulations on such a fine outcome.
If I can in anyway help get the same educational message out about pilonidal disease, sign me up. What we never realized and I was never taught in Med school or in practice is that “pilonidal cyst” is a complete misnomer for this affliction. It really is a “disease” because it affects so much more than just that eccentric edge of the heightened gluteal cleft – especially when it just won’t go away!!! Please keep up your work. You have been blessed with a remarkable talent to really make a difference in patients and families lives particularly when most physicians don’t really understand pilonidal disease nor want to attend to those in need. I tell everyone who knows what we went through, the outcome we are now at, thanks to you!!
I read your paper with great interest and congratulate you on the content, presentation of honest data and the conclusions you draw. This is a paper that should be referenced in every general surgery text book because as you point out, the cleft lift procedure was not and is not taught in medical schools or in residencies – to include plastic surgery – as a more definitive solution to pilonidal disease based upon an anatomic etiology. Obviously, not every surgeon will have or develop the skills for this procedure that a master such as yourself has, but the anatomic knowledge of what causes the problem needs to be taught and the specialized, experienced approach that specialists such as you provide needs to be more widely recognized.
I think that this doctor is very articulate in expressing the relief that many patients and family feel after a cleft-lift successfully heals, often after many failed attempts with surgery and wound care. He is also pointing out the significant gaps in medical education about this difficult disease.
Even having your own surgeon and wound care expert in the house won’t make some wounds heal if the shape of the cleft is causing problems. Sometimes only a cleft-lift will help.
This is why I have limited my practice to pilonidal repair and cleft lift. It is results like these that make being a surgeon worthwhile.
Those of you old enough to have read Superman Comics may remember the Bizarro World where everything was the opposite of the real world. Sometimes our patients feel like they have entered Bizarro World when they come to our clinic because of the vast difference between the instructions and information I give my patients, as opposed to what they have been told in the past. The instructions I give are what I have found works for my patients with the operation I perform. So, I can’t say that the advice patients have received elsewhere by other surgeons is wrong, but I can say that they don’t apply to my cleft-lift patients.
Here are some examples:
We encourage sitting immediately after surgery! I believe that this is actually beneficial for the incision, since it opens up the bottom of the cleft and allows air circulation. I have never seen a situation in one of my post op patients where sitting has caused a problem.
We do not recommend any type of hair removal. Once the cleft is flattened, hairs should not be an issue anymore.
We close the wound. No open wounds, no packing, no complicated dressing changes.
We use dissolving sutures. The large, external, sutures that many surgeons use do not guarantee that the wound will stay together; they leave permanent, unsightly stitch marks; and can be very uncomfortable.
We allow showering the day after surgery. I would rather have the area around the incision clean. Letting the shower run on the incision and drain has not caused any problems in my patients.
We recommend patients go back to fairly normal activity, as long as it is gentle on the incision. We do not recommend any period of immobility.
We allow lying directly on the incision when sleeping. It is OK to sleep in any position that is comfortable.
We never use silver nitrate on wounds. It is a caustic chemical that does more damage than good.
These instructions are often met with incredulous expressions, since they contradict all previous instructions – but this protocol works very well. I am trying to make recovery from the cleft-lift as simple as possible, and get my patients back to normal activity as soon as possible. There are certain instructions I give that are very important to follow, and this is all complicated enough without adding restrictions that aren’t necessary.
The success rate in our clinic of ~98% primary healing speaks for itself as far as the wisdom of this protocol, and our patient’s responses to our post op instructions have been positive, as you can see from the answers to our survey below.