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.

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.

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.