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.

Why won’t my wound heal?

Dealing with failed operations

Often patients ask me why their previous surgery won’t heal. Or, why it heals but then reopens.

Surgeons often blame this on:

  • the patient’s hygiene
  • quality of wound care
  • general health (“you just don’t heal well!”)
  • that they have mysteriously developed a new “cyst”
  • or “it was so extensive, we just couldn’t get all the cysts and tracts with the last operation”
  • there is too much hair, and hair removal needs to be more diligent
  • too much activity made the wound come apart

However, the actual reason for non-healing is usually the same in almost all cases:

  • the cleft was not completely flattened
  • the incision is in, or crosses, the midline

Of course, if a patient had a huge excision that was left open (or fell apart after closure) it will take a while to heal, and the size does matter. But, there should be good, steady progress. If it is taking many months, the wound actually gets larger, or the wound seems to heal – but then reopens, the cause has to do with the two reasons above.

When a patient gets to the point where it seems that it is just not healing, the original surgeon may suggest another excision! In general, this is the wrong approach, and just brings you back to square one. The best approach is one that will flatten the cleft and move the incision off the midline. My personal preference is the cleft-lift, which has been engineered to do exactly that. There are other flap procedures that may or may not work, depending on the expertise and experience of the surgeon performing the flap, but the cleft-lift is cosmetically the most appealing.

At our clinic we specialize in correcting the anatomy so that these wounds heal quickly. If you have been dealing with an open wound for more than two months without progress, contact us. We’re glad to help!

How to evaluate the quality of a cleft-lift

For a surgeon some operations are easier to learn than others. The cleft-lift procedure can be challenging to learn, and one of the problems for a surgeon trying to learn this without a mentor, is knowing when a cleft-lift looks good, as opposed to when it needs more tweaking. An operation like an appendectomy is easy for a surgeon to evaluate: if the appendix has been removed, he or she have achieved their goal! The goal of a cleft-lift is more subjective, and how it should look is not always intuitive to surgeons trying this for the first few times. Because of this, some surgeons are not convinced that the cleft-lift is a successful operation, because when they tried it, it failed.

I have created a web page that shows the differences between a successful and an unsuccessful cleft-lift. It shows an image of a successful cleft-lift, and is annotated as to why it succeeded, and another image of a failed cleft-lift, with the same annotations. This page may be more helpful to surgeons than patients – but even as a patient, it may help to know this information.

I did not include the photos in this post, because they are somewhat graphic, and you may not want to see them. But, if you are interested, this link will take you to the page.