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”!

More About “Minimally Invasive” Pilonidal Surgery

Fibrin Glue. Kshar Sutra, Phenol, RFA, and Seton Treatment of Pilonidal Disease

In a previous post I discussed several “minimally invasive” pilonidal treatments, and you can read about them here. However, there are a few other kinds of minimally invasive therapies that are worth discussion. They are:

  • Fibrin Glue
  • Kshar Sutra
  • Phenol Injection
  • RFA (Radio Frequency Ablation)
  • Seton treatment
  • Cryosurgery

These are all addressing the pilonidal sinus tract, which is one of the more common presentations of pilonidal disease. These treatments would have no place in the treatment of a large, non-healing wound. I’ll describe each of these separately:

Fibrin Glue Treatment of Pilonidal Sinus

The sinus tract is cleaned out of hair and debris. Fibrin glue is then injected into the sinus tract to obliterate any space in the sinus tract. (Fibrin glue is a biological adhesive which consists of concentrated human fibrinogen which is activated by the addition of bovine thrombin and calcium chloride.)


Kshar Sutra Treatment of Pilonidal Sinus

The sinus tract is cleaned out, the midline pits are removed, and a medicated thread is put in the sinus tract origin, and out the sinus tract exit, and tied in a circle. It is left in place until it causes the tract to scar down and heal.


Phenol Injection for Pilonidal Sinus

This is a technique that is more popular in Europe than the United States. The sinus tract is cleaned out and some form of phenol is instilled into the tract. There are several forms of phenol such as cream-gel, liquid and crystals. Phenol is a caustic, antiseptic, germicide, and has a local anesthetic effect. (It has been used as an embalming fluid!)


RFA (Radio Frequency Ablation) of Pilonidal Sinus

In this technique the sinus is surgically removed, and an electrocautery unit is used to destroy the residual sinus tissue. As surgeons, we use electrocautery in almost every operation. It is a machine that turns electrical energy into heat energy. (often termed a “Bovie” after the inventor). In this instance, certain kinds of tips are used on the machine to facilitate the procedure.


Seton Treatment of Pilonidal Sinus

This is similar to kshar sutra, in that a thread is placed through the two ends of the sinus and tied. Patients come in weekly for the thread to be tightened, until it cuts through the tissues. The inflammation from the thread obliterates the sinus.


Cryosurgery for Pilonidal Sinus

This is very similar to using RFA or Laser – where energy is used to destroy the sinus, but in this case liquid nitrogen is used to destroy the tissues by freezing.


You may be noticing a theme here:

  • They all of these put something in the sinus tract to obliterate it (chemicals, heat energy, freezing, foreign body, glue).
  • They are not very different than EPSiT, SiLaC (laser surgery), pit picking, or Gips Procedure.
  • They may or may not be able to be done in an office setting.
  • They all require multiple post op visits.
  • They do not re-shape the gluteal crease.

The literature regarding the success rates of these procedures is not the most robust. However, when the literature is evaluated the recurrence rate is reported as 15% – 40%. Many studies contain small numbers of patients and short follow up times. Of course, only surgeons with good results report their outcomes, and many surgeons don’t write papers about this at all!

My take on all of these minimally invasive procedures is:

  • They are are a reasonable first step in a specific group of patients with a SHALLOW CLEFT who present with ONLY a sinus or two.
  • They are NOT an option when dealing with open wounds and non-healing surgery.
  • The patient has to accept that there is a significant failure rate. At best one out of five patients will fail, and more likely one out of three.
  • None of these procedures has been shown to be significantly better than the others.
  • Although they may cause some minor scarring and distortion, they do maintain the original shape of the gluteal cleft, if that is of cosmetic importance to the patient.
  • They are not widely accepted by surgeons, and it may be difficult to find one to perform the procedure.
  • In almost all situations, if they fail, a cleft-lift is still a future option.

I do not perform any of these operations, because I do not feel that the success rate is worth the time, expense and discomfort for a procedure with a low success rate. Especially, if it requires travel across the country to see me. If you are interested in these minimally invasive procedure, I suggest you try to find someone local to evaluate and treat you. If the minimally invasive therapy fails, then come see me for a cleft-lift.

What’s the deal with LASER surgery for pilonidal sinus (SiLaC)?

It sounds so simple!

Lasers are used for many things in the medical profession, and especially in surgery. Lasers are currently being used to eradicate pilonidal sinuses, and a beam of light sounds like such a simple and pain free solution to a difficult problem. I think when patients envision a laser being used for surgery, they think of a beam of light shining on the tissues and magically curing problems!

In some situations that is exactly what happens, but in others, the laser is used very differently. In the case of eradicating a pilonidal sinus, the laser is attached to a fiber-optic conduit, which brings the light energy to a specialized tip, that turns the light into heat. So, no part of a light beam is in contact with the tissues, but a red-hot fiber-optic tip is used to burn tissues.

There is a category of “minimally invasive” treatments for pilonidal disease that remove the pits and sinus tracts, but do not address the shape or depth of the gluteal cleft. These rely on some method to remove the sinus “tunnel” and hope it will heal. The tunnel can be eradicated with chemicals, surgery, or heat. In the case of laser surgery, heat is used to burn the tissues in hopes that they will subsequently heal and that the sinus will not recur.

So, this is a destructive process, involves burning tissue, may not be pain free, and may or may not be a permanent solution to a patient’s pilonidal disease. In general, it is no more effective than Epsit, pit picking or Gips procedures, which accomplish the same thing without the expensive laser equipment.

Also, it should be noted that this is very different from using a laser to permanently destroy hair follicles, in order to prevent hair regrowth. In that case, a light beam is indeed used. But, it is not a treatment modality that we feel is necessary in taking care of pilonidal disease.

So, although this sounds very “space age” and pain free, it is just a variation of already described procedures to treat pilonidal disease. In our clinic, we do not perform the “minimally invasive” procedures, but rather prefer the cleft-lift because of its superior success rate.

Addendum: There has been a discussion of this on Reddit, and this link will take you to one patient’s experience with laser surgery. This poster’s experience may, or may not, be typical, but it is one possible outcome: Link

And, here is and update on that post two years later: Link