Common Misconceptions about the Cleft-Lift Procedure

The recovery from cleft-lift is prolonged and painful.

The recovery from cleft-lift is an easier recoveries when compared to the other procedures for pilonidal disease. Most patients say that the pain is minimal, and they only take analgesic pain medications for a few days. There are no open wounds, packing, or shaving. There is a small drain that is left in place for a few days, and removed in the office. Most patients are back to full activity, except contact sports, within a week. Here is a link to an article which shows data regarding what 500 of our patients feel about the ease of their recovery.

Cleft-Lift is a “new” procedure.

It depends on your definition of “new”. Dr Bascom began writing about this in 1987, and his operation is a modification of one by Dr Karydakis which had been already described at that point. Dr Immerman has been performing this since 1993, and now has an approximate overall 98% success rate with a single procedure.

Most surgeons don’t perform the cleft-lift because it doesn’t work.

The cleft-lift, as with every difficult surgical procedure, has a learning curve. If it is not done properly, it will not work, so it is important to see a surgeon who has experience and success with the procedure. Most surgeons are not taught this procedure during their residency training, and those who do perform it had to learn it afterwards. At our clinic the success rate is 98% – which compares very favorably to any other procedure.

Not all patients with pilonidal disease are “candidates” for a cleft-lift.

In medicine, anything is possible, but in the last twenty years we have never seen a patient in whom a cleft-lift was not an option. Certainly, in some patients it is more difficult than others, and the success rate is different in varying situations. (There are also situations where it may not be appropriate such as in patients taking blood thinners, patients colonized with MRSA, patients with mobility issues, patients unable to tolerate anesthesia, or patients with extreme obesity.)  If a patient finds that their surgeon does not feel that they are a candidate for a cleft-lift, they should investigate whether they can find a surgeon who is more comfortable with difficult cases. We have been successfully operating on patients who have failed other operations for many years, including failed cleft-lifts. A recent publication by Dr Immerman has demonstrated that the cleft-lift works well in all situations.

I’m seeing a board certified surgeon, and he/she is recommending wide excision – so I should follow his/her advice.

In general, the advice given by a board certified general surgeon or colo-rectal surgeon is good and should be followed. But, in this specific situation there seem to be many surgeons who are not familiar with the cleft-lift procedure, and therefore do not address it. If it is not discussed by your surgeon – you should find a surgeon who is familiar with the procedure.

The cleft-lift is best done by a colo-rectal surgeon.

It is strange that pilonidal disease is categorized as a colo-rectal problem, since it has no relationship to the colon or rectum. Many colo-rectal surgeons are not interested or experienced in the treatment of this disease – but others are. General surgeons and plastic surgeons may or may not have an interest in this. Dermatologists, to my knowledge, are not skilled in the cleft-lift procedure. The best guideline for finding a surgeon is to specifically look for one who is experienced and interested in treating pilonidal disease. Our bias is that he, or she, should be experienced with cleft-lift also.

The cleft-lift procedure should be reserved for difficult, severe, or recurrent disease.

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.

If I have wide excision and it fails, I can always have a cleft-lift later.

This is usually true, but the scarring and distortion from the excision will usually make the cleft-lift more difficult. In addition, the recurrent disease often appears very close to the anus, which also makes the cleft-lift harder, and may effect the success rate. Additionally, the prolonged wound care and high failure rate are disruptive, expensive, and depressing.

I’ll save time and money by seeing a local surgeon who does not perform cleft-lift. If my disease comes back, I’ll travel to see someone who does.

This may or may not be wise. There are times when open excision results in prolonged healing, time off of work and school, expensive dressing changes, wound-vac application, multiple office visits, and significant discomfort. If you find a surgeon who is skilled in pit picking, Gips Procedure or EPSIT, that is a better first choice than wide excision. In general, the most successful procedure is also the most cost effective. In our opinion, a successful cleft-lift will be the most cost effective in the long run, even if you factor in out-of-pocket travel expenses, but if you want to try pit picking, Gips or EPSIT – go for it!

I’ve heard that if I wait until after age 40 my pilonidal disease will go away.

Although it is unusual to start getting pilonidal disease after age 40, preexisting problems often will not go away if they have been untreated.  The reason it is rare for this to start at that age is that the gluteal cleft naturally opens up and widens as we age, and the cleft is less of a problem. However, lingering sinus tracts and cysts may still be present and cause problems.