The Latest Clinical Research

Dr. Immerman’s results on 700 cleft lift patients

Dr. Immerman has been keeping track of his cleft lift patients since 1993, and has just published his results in a peer reviewed scientific article. Although this was meant to be viewed by the surgical community, patients are certainly welcome to take a look at it.

The major findings described in the paper are:

  • Patients who had a cleft lift, but did not have any previous surgery and did not have wounds near the anus, had a 98.7% success rate with a single procedure.
  • Patients who had previous failed pilonidal surgery had a success rate of 94.7%.
  • Patients who had wounds actually on the edge of the anus were the most difficult group to treat and had a success rate of 84.4%, but a second revisional operation almost always solved the problem.
  • No patients in this series had a recurrence occur after 24 months from the cleft lift surgery.
  • There was no category of patient in whom this was not a highly successful approach.

If you would like to view the article, you may view and/or download it from THIS LINK.

It is important, when choosing a surgeon, to know their actual experience and results with this procedure, and Dr. Immerman is proud of his results, and is glad to share them. Taking care of pilonidal disease can be very humbling, and a 100% success rate is very elusive, but these results are coming close and have defined certain groups of patients who are at higher risk of recurrent problems or failures. Currently, there is not another operation that has a better success rate, and the cleft lift is indeed a good solution in all situations.

Suction Drains after a Cleft-Lift

Are they really that important?

After a cleft-lift procedure many surgeons place a drain. There are two different basic kinds in popular use.

  • One type is a “passive drain” and consists of a flat rubber strip that enters one area and exits another, and allows any fluid buildup to find a way out along the rubber drain and onto the dressing. It requires some occasional rolling pressure along the flap to push fluid out the drain site, and does not allow measurement of the output very precisely.
  • The other type is an “active drain”, which is referred to as a “closed suction drain”, or Blake Drain or JP (Jackson Pratt) Drain. It has a clear plastic tube that is placed under the flap, and connects to a clear plastic reservoir, which is emptied once or twice a day and the amount precisely recorded.

I prefer the Blake Drain type because it has been working well for me for many years, but either type is acceptable. However, the bigger questions are whether a drain is really needed at all? And, can failures be attributed to the lack of a drain in cases where one wasn’t used?

The logic of using a closed suction drain is that it:

  • prevents any fluid from accumulating under the flap, which could cause a chronic fluid collection (seroma) or infection
  • prevents fluid from leaking through the incision, which will weaken the incision and possibly sabotage the success of the operation
  • is an indicator of bleeding (the drainage will be red), or infection (the drainage will be creamy) and allows us to respond to the situation more quickly and appropriately.
  • pulls the tissues together with negative pressure so they will heal in the position the surgeon intended.

So, what happens if you don’t use a drain? There are no specific studies that compare patients with and without a drain after a cleft-lift, but there are studies that do this with the Karydakis procedure, which is very similar. One study, done in Turkey in 2005, showed that when a drain was not used, 32% of the patients had problems with fluid collections, as compared to 8% in the patients with drains. Another article, from Ireland in 2010 this time, compared using a drain with putting fibrin glue under the flap instead. In this series, there was a 24% complication rate when the drain was not used, vs 6% when it was used.

So, if one can extrapolate the Karydakis data to the cleft-lift, it seems that a drain is useful. But, can you get away without it? Sure: 70-80% of patients would probably do OK without it. The problem is knowing which patients are the ones who are going to have problems. At present, we have no way of prediction this. Afterwards, in patients with low drain output, we might be able to say they could have gotten away without a drain. In those with a large amount of output, that lasts over a week, we can certainly say they benefited from the drain. I use a drain in all patients, because I don’t think a 25-30% rate of problems from fluid is acceptable.

If someone’s cleft-lift failed, and they didn’t have a drain – can we blame it on that omission? It’s hard to say. Often, a poorly constructed cleft-lift goes hand in hand with the omission of a drain. But, without knowing all the details, it is hard to completely blame it on that one issue.

So, I wouldn’t choose your surgeon solely on whether they use a drain, or not. Instead, I would look at how much experience they have, what their interest level is with pilonidal disease, and what their success rates have been. BTW: if you’ve managed to read through this article, you now know more than most surgeons about this topic! Congratulations!

Is the Cleft-Lift a New Procedure?

My surgeon said he never heard of it because it was a new, specialized procedure.

It depends on your definition of “new”. The cleft-lift is a procedure that has had several modifications, within the category of operations for pilonidal disease collectively called “off midline closures”:

  • In 1973 Dr. George Karydakis, a Greek surgeon, published his experience with a successful operation to treat pilonidal disease with an off midline closure. We call his procedure the Karydakis Procedure, and it is very similar to the cleft-lift.
  • Dr. John Bascom began writing about this in 1987 and has published numerous articles on the subject. He modified the Karydakis Procedure, and called his modification a “cleft-closure”, and later changed the name to “cleft-lift”. It is often referred to as the Bascom Cleft-Lift.
  • Dr Immerman has been performing the Bascom Cleft-Lift since 1993, and now has an approximate overall 98% success rate with a single procedure. He has some slight modifications as well.
  • This operation is not a “secret” and there are many, many scientific papers on the subject.
  • A retrospective meta-analysis of 89,000 worldwide patients, followed for up to 20 years, was published in February 2018 which showed that the Bascom Cleft-Lift and Karydakis Procedures had the lowest recurrence rate. You can download and read that article here.

So these procedures have been in the surgical literature for well over 40 years, and are widely known by pilonidal surgeons throughout the world. When studying a board certification study course ten years ago (created by the American College of Surgeons) I came across a question on pilonidal disease where the correct answer to “which procedure has the lowest recurrence rate” : is the cleft-lift. (Indicating that it is the accepted answer to the question as recognized by the ACS.)

So, this is not a new procedure. It is not fringe science. It is not a gimmick. It is not “fake news”. This is one of the best ways to treat pilonidal disease in 2020. (Minimally invasive surgery is also an option, and I discuss that here.) Of course, it is “specialized” – as is every other operation we surgeons perform. If your surgeon has not heard of the cleft-lift procedure, I cannot explain why. You will have to draw your own conclusions.

So, this is not a new operation, but if you are struggling with pilonidal disease, it may give you a new life.