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.

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”!

Pilonidal Disease: Can I Avoid Surgery?

Will this go away by itself? Is it manageable with non-surgical care?

This is a commonly asked question. Although I am a surgeon, I realize that surgery is not for everyone, and nobody is really excited about having an operation if there is another option. Drainage of a painful, infected, abscess (lancing, I&D) is often an emergency and is very obviously necessary, other operations are elective – meaning that a patient has a chance to think about it, weigh the pros and cons, and decide if that is the route they want to proceed.

The decision is easy if the pilonidal disease is painful, embarrassing, disruptive and depressing, and it’s clearly time to do something about it. On the other hand, for other patients surgery is not really the route they want to go. There can be various reasons for this:

  • The symptoms aren’t that bad.
  • Their philosophy that surgery is only a last resort.
  • Financial considerations.
  • Concern regarding the cosmetic change.
  • General fear of surgery and hospitals.
  • Lack of a qualified specialist nearby.

These are all reasons to step back and see if there is a non-surgical approach that will work. It is a rare situation in which pilonidal disease becomes life-threatening. For various reasons, there isn’t very robust data regarding the recurrence rate of pilonidal problems. So, I can’t really tell you that if you had one abscess, what the chances are that you will have another. In a specific situation, if I can evaluate the anatomy, I may be able to predict whether future problems are expected or not. But, if you are not seeing a pilonidal specialist, it will be hard for you to come to any conclusion on your own.

These are situations where future problems are very likely:

  • Multiple, enlarged midline pores or actual open wounds.
  • A very deep gluteal cleft. Sometimes this is apparent, because it takes some strength to spread the buttocks apart to see the base. Or, in other situations, the crease seems to open up easily when prone, but folds when standing. Brownish discoloration (hyperpigmentation) of the skin on either side of the cleft is a clue that this is a problem.
  • Multiple abscesses.
  • The presence of a sinus.

Sometimes after an abscess has been drained, there are no visible abnormalities. This is the kind of situation where it is not clear how much a problem it will be in the future. This web page discusses that situation.

But, if you are dealing with any of the situations described above, it is possible to get along without surgery, but the pilonidal disease is going to be an intermittent long term problem and, contrary to some rumors, will not just disappear after age 40.

Diligent attempts at hygiene, antiseptics, dressings and at times antibiotics may help minimize symptoms, but most likely won’t completely eradicate the problem. A discussion of home remedies can be found here. However, if a patient’s issue is that surgery is not feasible now because of finances or other obligations, some of these home remedies may make delay less painful.

In general my recommendation is that the best approach is to proceed with surgery at some point, and the sooner this is treated, the sooner patients can get on with their lives. I believe the cleft-lift operation by an experienced pilonidal surgeon is the best combination of high success rate coupled with ease of recovery. Contact us if this is something you would like to explore.