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.
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.
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:
The original incision has failed to heal properly or has healed, but come apart later.
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.
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.
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.
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:
RFA (Radio Frequency Ablation)
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 two out of three (Update: an article from June 2022 has demonstrated a 62% failure rate of pit picking at five years. You can download and read the article by following this link).
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.