Why might a cleft lift need to be revised?

There are times when even a properly performed cleft lift will need another operation to adjust the shape of the cleft. The reasons for this fall into two categories:

  1. The original incision has failed to heal properly or has healed, but come apart later.
  2. A new fold has developed and now there is recurrent pilonidal disease in that fold.

Failure to heal properly

Although every attempt is made to reshape the gluteal cleft such that:

1. the incision is not in the midline

2. the cleft is flattened

3. the new configuration remains optimal in all positions (such as sitting, standing, lying down, etc)

This can be a difficult thing to accomplish. There are times when achieving this is a problem during the procedure itself because of previous surgery, intense scarring, or just the individual patient’s shape. Other times, the incision drifts toward the midline in the days or weeks after surgery. This is especially a problem if there is infection, wound separation, or severe reactions from autoimmune disease in the post-operative period; this can change the position of the scar and cause it to move toward the midline.

When this occurs, it is reasonable to try to reshape the bottom of the cleft again, which we call a “revision”. This is usually successful. This is a more likely reason to need a revision in patients who have had other previous operations and wounds very close to the anus at the start.

Recurrent pilonidal disease

In our clinic this is the most common reason for a cleft lift to need revision. This is not ever predictable. It is very difficult to flatten the cleft all the way to the anus in some patients just because of how their body is shaped. Most people do have some sort of midline fold above the anus in some positions, which flattens out in other positions. It is unclear why a fold that might not be a source for recurrent pilonidal disease might be a problem in one patient, and not another.

The only external factor that we have observed that might play a role in this is wearing clothing that is tight across the hips, that might be compressing the buttocks together.

Below is an example of a situation where a new fold developed and a new sinus developed.

pilonidal
This patient presented with a sinus. In the original operation the cleft was nicely flattened, and seemed to have an optimal configuration.
pilonidal
Nine months later, this pateint presented with a new sinus. As you can see, the small fold near the anus developed a primary sinus tract opening. This revision flattened the lower fold, and has solved the problem.

In the example above, the recurrent problem was not predictable, but was something that could be repaired by extending the cleft lift even farther down. As with most operation, sucess requires a delicate balance between too much and too little.

Conclusion

In general, there are no operations that are successful and complication free in 100% of patients. The cleft lift is the operation that has the highest success rate for treating pilonidal disease, but there are times when it fails and need revision. One of the aspects of the cleft lift that sets it apart from other flap procedures is that failures can be repaired by using the same principles as the first operation, but entending the procedure lower. These revisions, at least in our clinic, are almost always successful.

Letter from a grateful family

 

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.

Sitting after Cleft-Lift Surgery

We encourage sitting immediately after surgery.

When I perform a cleft lift, the incision is not in the midline – so when you are sitting there is no force pulling the incision apart. In addition, the reasons patients can have non-healing or recurrence are not that the wound is pulled apart, but rather that it is folded over too much. By being folded and down in a cleft, it does not heal well, or sometimes at all. Then, when one does something seemingly trivial, that has a distracting force on the wound, it comes apart. It seems like the distracting force is what did the damage, but in reality it was the non- healing because of the fold.

When I do a cleft lift, I want air circulation to that area, and sitting opens it up and allows that air circulation. I encourage all my patients to sit immediately after surgery, and have a very high success rate, as evidence that the advice has some merit.

What about surgeons who tell patients not to sit for two weeks after surgery?

There is not much logic to telling a patient not to sit for only 2 weeks because the wound has very little strength at two weeks. If you look at the yellow dotted line on the graph below, a wound only has about 20% of its ultimate tensile strength at two weeks. In addition, at two weeks the dissolving sutures we use are already down to 50% tensile strength. So, two to three weeks after surgery is one of the most fragile times for the wound. If sitting is really detrimental to healing, the restrictions should be much longer.

At our clinic, we recommend that patients avoid contact sports, jogging and biking for six weeks from surgery, but we encourage sitting and other normal activities immediately.