Over 10,000 Article Views

The research is making a difference

Dr. Immerman published the article “The Bascom Cleft Lift for All Presentations of Pilonidal Disease” in February of 2021.

Since then, it has had over 10,000 views from 133 different countries. Clearly, this research is of interest to doctors and patients all over the world, and the concept of online publishing is an important way to spread information. Of the over 10,000 articles on the Cureus platform, this article is 217th in the number of reads.

Over 10,000 views from 133 different countries in one year. (PMC indicates views on PubMed.)

You can read the article yourself by following this link: “The Bascom Cleft Lift for All Presentations of Pilonidal Disease”

The article has been viewed by individuals in 133 different countries. Here are the top ones.

Although there are many published papers describing the benefits of the cleft lift operation, Dr. Immerman feels it is important that more papers are published to convince the surgeons of the world to learn this procedure.

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 patient 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.

Who is a “candidate” for a cleft lift?

When patients see a surgeon and ask about the cleft lift procedure this becomes an important question. We use the term “candidate”, but this is not an election! Often, surgeons will indicate to a patient that they are not “candidates” for the operation. The translation is that they do not think it is the best procedure for the patient, and don’t (or won’t) perform it.

Although when looking at the medical world from the outside, there often is the impression that medicine and surgery are completely scientific, and statements like this are absolute, sadly this is not the case. The appropriateness of the cleft lift procedure is very different from surgeon to surgeon, and they are giving you their opinion based on their particular research, training, and skills – as it applies to your situation. There are times when surgeons feel that a patient’s situation is not severe enough to warrant a cleft lift, or too severe to warrant a cleft lift. As a consumer of medical care, these recommendations need to be taken as opinions, not facts, and it is quite appropriate to seek alternative opinions.

At my pilonidal clinic, we perform the cleft lift on the entire spectrum of pilonidal disease, ranging from very minimal to the most difficult cases in the country. I understand that this is extremely controversial within the surgical world. There are many surgeons who feel that the cleft lift should be reserved for patients who have already failed other operations.

Here are a few facts about this:

  • Any operation involves time, cost, anxiety, and discomfort, even the ones called “minimally invasive“, and laser surgery for pilonidal disease. My feeling is that if you are going to have an operation, you should at least have the choice of the one with the highest success rate.
  • A recent meta-analysis of ~90,000 patients reported in the surgical literature came up with data on various operations (keeping in mind that in general, surgeons only report their data if they think that they are doing a very good job.) The failure/recurrence rates at 120 months in this study are:
    • Open excision: 19.9% failure
    • Closed excision: 32% failure
    • Limberg flap: 11.4% failure
    • Pit Picking: 15.6% failure (at 60 months)
    • Cleft lift or Karydakis flaps: 2.7% failure
  • Not every surgeon knows how to perform the cleft lift procedure, or does it so rarely that they are uncomfortable recommending it to any category of patients, and are reluctant to refer patients to the regional experts.
  • In our clinic I am so concerned with the actual success of the procedure, I have kept data on every cleft lift I’ve performed since 1993, and have published that data.
  • Some surgeons say that the infection rate with the cleft lift is very high. That is not true, and in my paper I demonstrate an overall infection rate of 2.6%.

The take-away from this discussion is that if you are looking for the highest chance of a “one and done” type of procedure, seek out the experts in this field and ask THEM if you are a “candidate”!