Who is a “candidate” for a cleft lift?

Posted on by Steve Immerman

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”!

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

Posted on by Steve Immerman

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. The five year results of  “pit picking” or the “Bascom 1” procedure has recently been published, and this series demonstrated a 62% failure rate.

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 laser pilonidal cystectomy sounds very “space age” and pain free, it is just a minor 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.