Why might a cleft lift need to be revised?

Posted on by Steve Immerman

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 patient 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.

I Had a Cleft-Lift and It Failed!

Posted on by Steve Immerman

Am I doomed?

The short answer is, “no”. But, what should you do now?

When a cleft lift fails – meaning that either the incision came apart and isn’t healing, or a new cyst, sinus, or wound has developed – it is usually because the cleft-lift failed to flatten the ENTIRE cleft, or that the incision from the cleft-lift ended up in the midline.

Fortunately, this can be repaired by revising the cleft-lift. The revision will flatten the lower portion of the cleft and bring the incision away from the midline. This is usually successful in salvaging the situation. Of course, nobody wants another operation – but it is better to just get this taken care of, then letting it linger. If six weeks or more has elapsed since your cleft lift, and you are still dealing with problems, then you should consider a re-operation.

Who should do this re-operation? You should make sure that it is a surgeon with a broad experience in re-operating on failed pilonidal surgery and failed flaps, since there is a unique skill-set needed for this. At the Evergreen Surgical Pilonidal Clinic, we have had extensive experience with this kind of re-operative surgery and are happy to see patients who have had failed surgery elsewhere. In our clinic we have had to re-operate on about 2% of our patients, but all of these had already had previous failed operations and/or wounds next to the anus, and were in the most difficult categories of pilonidal disease to treat.

THIS WEB PAGE will show you the difference between a successful and an unsuccessful cleft-lift. The takeaway being that although many surgeons call their procedure a “cleft-lift”, there are various degrees of quality and success based on the surgeons experience and expertise.

If you’ve had a cleft-lift and it has failed, don’t give up. Contact us for help!

Honey for Pilonidal Wounds

Posted on by Steve Immerman

One of the interesting ways of dressing open wounds is with honey. It is available in “medical grade” form, and often Manuka honey is specifically used. (This is honey from the manuka tree which has a antibacterial compound not present in other types of honey.)

The characteristics of honey that make it something that can be used on open wounds are:

  • It has some antibacterial properties
  • Because it is such a concentrated substance it pulls water out of tissues, which may decrease swelling
  • It has a slightly acidic ph, which may help wound healing

But, the real question is whether or not the physical characteristics of honey promote better or faster wound healing than other topical wound treatments. One important concept in treating patients is that:

Just because something logically sounds like it would be beneficial, doesn’t mean it actually will be.

This is why clinical trials, research studies, and literature searches are so important in determining what we should actually do to solve clinical problems. A simple example of this is that Betadine, is a great antiseptic that we use all the time to sterilize skin. But, we’ve found that when used for any length of time on open, infected, wounds it not only impairs healing, but is toxic to the patient!

As far as honey goes, it doesn’t seem to be much better or worse than other topical treatments when used on open wounds. It may be beneficial for some types of burns.

As far as pilonidal wounds goes, there are studies that show that pilonidal wounds can heal when honey is used. But, when compared to other topical treatments, such as silver, zinc, hydrogel, foam, wound VAC, etc., there does not seem to be a particular advantage to any of them. The benefit of using something that has antibacterial properties at all is open to debate.

My analysis of all this is:

  • It is reasonable to use honey on an open wound, but it is not preferred over other modalities for any specific reason.
  • Honey is not an appropriate treatment for an acute abscess or for application on closed incisions.
  • The most important maneuvers to get pilonidal wounds to heal are to keep things clean and dry and get air circulation to the wound. Unfortunately, this may not be possible without further surgery.
  • If sinus tracts have formed, even the smallest wound will never stay healed with honey or any kind of wound care.
  • Proper nutrition, including high protein and vitamin intake is probably more important than the specific local wound care.

If pilonidal surgery is done properly, such that the cleft is flattened and the incision is off the midline, complex and prolonged wound care will not be needed. In our clinic we do not have to deal these issues, except in complicated situations where we are trying to fix poorly done surgery elsewhere.