Different surgeons will have different criteria for deciding when a cleft-lift is appropriate. Some will reserve it for recurrent disease, but others view it as the first line procedure for anyone with symptoms and a deep gluteal cleft. Dr. Immerman’s personal observation is that patients don’t want the most minimal treatment, they want the most effective. Recurrences are demoralizing, disruptive, expensive, and painful. Over the last 28 years we have gone from recommending it only for the most severe cases, to recommending it to any patient with symptomatic pilonidal disease and a deep cleft. This is based on our observations, high success rate, and our attempt to get patients through this problem as quickly and pain free as possible. But, it is certainly up to the individual patient to decide how aggressive they want to be from the start. If pit picking, Laser ablation, Gips Procedure or EPSIT seem more appealing, they will not create a problem with performing a cleft-lift as a second or third procedure. Wide excisions, Z-Plasty, VY-Plasty, Limberg Flap, and Rhomboid Flaps are other solutions – but if they fail, a subsequent cleft-lift is possible, but more difficult.