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    • MAY 17, 2024
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    Pilonidal Specialists?

    Pilonidal Specialists?

    Is there really such a thing as a “pilonidal specialist”?

    In many conversations on social media the term “pilonidal specialist” is used to describe a certain category of surgeon. The American College of Surgeons does not recognize this as a “specialty”, yet there are surgeons who take this disease process very seriously, and devote a significant part of their practice to dealing with this difficult problem.

    Is it really better to see one of these “specialists”?

    The answer is “probably”. These surgeons understand that pilonidal disease is not a trivial problem with minimal consequence to patients, but a disease that is painful and disruptive, and requires expertise to manage.

    These surgeons might be general surgeons, colorectal surgeons, or plastic surgeons. The specific type of residency or fellowship training is not the issue, but rather the mastery of the surgical techniques involved.

    I say “probably” because it may be difficult to see these surgeons because they live far away, or are not covered by your current insurance. If those things are not obstacles, then I would say “absolutely yes!”.

    Which specialist should I see?

    If you are willing to travel, and insurance is not an issue, my recommendation is to find a surgeon with expertise in the cleft lift operation. Multiple studies have shown it to have the highest success rate and the easiest recovery. It is a procedure that does require specific training and experience, and this is why you may get a better result from one of the clinics that specialize in this, as opposed to a surgeon who only does a few of these a year. It is also why there might not be one near you. Using one of these specialists is especially important if you have had previous, failed surgery, or have wounds or sinus tract openings near the anus.We are not the only clinic in the United States that specializes in pilonidal disease with the cleft lift operation, but we feel that we are one of the best. Feel free to contact us for a virtual consultation.

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    • MAY 15, 2024
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    Why does pilonidal surgery often fail?

    Why does pilonidal surgery often fail?

    For surgeons, defining and removing pilonidal disease during an operation is not a mysterious hunt, but rather a very straight-forward process.

    Is is because all the pilonidal disease was not removed?

    A very common question is why a pilonidal operation failed, and one of the answers often given is that some of the disease was not removed, and the failure is because of this residual disease. Although this seems like a simple explanation, it is usually false. Pilonidal disease is not cancer, and complete removal of every cell of disease is not linked with success or failure. This is a disease related to the shape and configuration of the gluteal cleft, and possibly to skin and hair type. In addition, when a surgeon operates, the cysts and sinuses are pretty easy to find, so this explanation really doesn’t make sense. You may hear about surgeons using special dyes (methylene blue) to help define sinus tracts. This is rarely, if ever, necessary – these things are pretty obvious to an experienced surgeon.So, the adequacy of cyst and sinus removal is not the critical factor that determines success or failure, but what is important is changing the contour of the cleft (flattening it), and moving new, healthy skin to the midline. If we look at the various operations for pilonidal disease, the success rates seem to reflect how well this was accomplished.

    Different Operations

    The excisional operations are very “hit or miss” regarding their success. Large meta-analysis of these operations show success rates varying from 32-80% depending on the technique, but most surgeons when asked will tell you it is about 50/50.

    The success rates of the minimally invasive procedures  also vary widely.  Ranges between 40-85% success are reported. Here is another discussion about minimally invasive techniques.

    The success rates of the cleft lift and Karydakis procedures, which are very similar are very consistent. Many reported series show success rates around 97% even when patients are followed for 10 years or more.

    Conclusion

    So, if you’re being told that the failure is that sinuses or cysts were missed – I’d suggest seeking other opinions. If you are looking for the procedure with the best success rate, consider the cleft lift.

    This is the only procedure we perform in our clinic because of its high success rate, rapid recovery, and superior cosmetic outcome.

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    • DECEMBER 31, 2023
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    Dealing with Pilonidal Wounds that Open and Close

    Dealing with Pilonidal Wounds that Open and Close

    Sometimes wound from pilonidal surgery seem to heal, but then open up again, and this happens multiple times.

    This is a common problem, and usually means that there is still a residual cleft, that the scar from previous surgery is in the cleft, and the skin is fragile and intermittently breaks down, and then seems to heal. Sometimes these small wounds can be the starting point of a new pilonidal sinus, but other times, the wounds remain superficial and do not tunnel anywhere.

    During one of the phases when the wound seems healed, it is impossible to say if it is going to stay that way, but most patients eventually get a sense of the transient nature of the healing, and come to the conclusion that any healing is temporary.

     

    What should be done in this situation?

    The first part of the answer to this question is another question: What kinds of treatment are commonly tried, but rarely successful?

     

    So, what is successful?
    • Re-shaping the gluteal cleft so there isn’t a remaining fold, and moving the scar away from the midline. In other words, a cleft lift.

    Why is a cleft lift the answer?

    The reason that this wound keeps falling apart is not because of infection, a generalized failure of wound healing, lack of oxygen, or not enough time. It is because of the configuration of the cleft that has remained after the previous operation. This problematic shape can develop after cyst removal, cyst drainage, minimally invasive procedures, flap procedures, and even a cleft lift. In any of those situations a cleft lift, or cleft lift revision can be the solution.

    Although having another operation can seem like a lot to go through, especially if you have had a previous procedure, but overall it may actually be easier, less time consuming, less painful, and less expensive than another 30 wound clinic visits.

    If this is happening to you, feel free to reach out to us. We can help.

     

      

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    • NOVEMBER 9, 2023
    • 0
    I Had a Cleft Lift and it Failed

    I Had a Cleft Lift and it Failed

    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, a new fold developed since the operation, 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 it is reasonable to be evaluated for 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 3% of our patients, but many 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.

    Dr. Immerman has published an article describing the technique of repairing a failed cleft lift, and shown the results in 76 patients over a 10 year period. The article is available online, and can be viewed by following this link.

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

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