Yes, you should be performing the cleft-lift procedure for pilonidal disease.
I am a general surgeon in Eau Claire, Wisconsin, and I began performing the cleft-lift operation in 1993 because I found that the results with wide excision were unacceptable. Patients were unhappy and I was unhappy. I dreaded having pilonidal patients appear at my clinic, and I wanted to avoid operating on them.
The cleft-lift has changed all that. Now, I welcome pilonidal patients with enthusiasm because I know I can solve their problem with minimal complications and a very high degree of success.
I did not invent this operation, nor am I the only surgeon performing this and performing it almost daily. Here are some details about the timeline of the development of this operation, which is a modification of the Karydakis procedure. These are both considered “flaps with off midline closures” and have been part of the surgical armamentarium since 1973. However, it is disturbing to hear from patients, that my colleagues are unaware of it, believe it has a high complication rate, or that it should only be reserved for hopeless cases. None of these statements are true. I wrote a paper in 2013 with a series of 86 patients, and you can read that here. In 2021 I published a second paper with a series of 700 patients, and you can read that here. At present, after completing over 1000 cleft lift operations, my success rate in patients who have not had previous surgery, nor have perianal wounds is 98.9%.
The one thing that I personally may have added to the clinical knowledge base is how to deal with patients who present with wounds near or directly on the anus from pilonidal disease – a scenario not well covered in the original description of the Bascom Cleft-Lift. These technical modifications are a logical extension of the cleft-lift procedure, and are described in my 2021 paper.
Exactly what operation to perform on a patient who prevents with a history of abscesses or simple sinus tract is controversial. There are several “minimally invasive” pilonidal procedures that are applicable in these situations and work in some patients, although the percent success rates are not well documented. Examples of these procedures are pit picking (i.e. Bascom’s Simple Operation), Gips Procedure, SiLaC, EPSiT, Fibrin Glue, Kshar Sutra, Phenol Injection, RFA (Radio Frequency Ablation), and Cryosurgery. It is quite appropriate to develop expertise with one of these and use it in simple situations. However, keep in mind that long term studies of their effectiveness are few and far between. A recent paper comparing the Limberg Flap to Pit Picking demonstrated a 62% five year failure rate with Pit Picking. It is hard to reconcile that with the 1.1% failure rate with a properly performed cleft lift.
For more complex situations, the cleft-lift is the ideal procedure; and I believe it is an excellent option in simple situations as well because of it’s >98% success rate. In my opinion, there is no longer an indication for wide excision with midline closure, wide excision with secondary healing, or marsupilization. Although some will disagree, I believe that these are archaic and outdated procedures that should be relegated to history. A recent meta-analysis of multiple types of pilonidal operations has demonstrated the superiority of the off-midline closure procedures, and the inferiority of the excisional operations.
There are other flap procedures that are popular, such as VY Plasty, Bilateral VY Plasty, Z-Plasty, Limberg Flap (rhomboid flap, Dufourmentel Flap). These use a different paradigm than the cleft-lift or Karydakis flaps, in that they bring tissue into the midline to fill a defect, as opposed to removing skin to flatten the cleft. The main problems with these flaps is that they are cosmetically unacceptable, and when they fail, there isn’t an easy solution (although in our clinic we have repaired many of these with a cleft-lift).
I have helped other surgeons develop skill with this procedure, and continue to offer my experience and time to those interested both in the U.S. and internationally. If there is some way I can help you develop the skills and knowledge you need, feel free to fill out the Contact form on this website and we can have a conversation. These forms come directly to me, and I will respond.
Thanks for your interest, and feel free to let me know your thoughts.