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    • NOVEMBER 3, 2023
    • 0
    Is There Loss of Athletic Range of Motion After a Cleft Lift

    Is There Loss of Athletic Range of Motion After a Cleft Lift

    Do athletes have to worry that a cleft lift will restrict movement after the healing process?

    This is a common question that active patients have when contemplating proceeding with a cleft lift for pilonidal disease. Although it would logically seem that by flattening the gluteal cleft, that there would be some loss of flexibility in the gluteal area, this has not been the case in our clinic. When we perform a cleft lift, there is no change in the positions of the gluteal muscles or fascia – but rather only skin and underlying fat are adjusted. We are taking an area that actually has too much skin, and flattening it to a contour that is the natural shape for many individuals who do not have pilonidal disease.

    Keep in mind that the the relationship between the legs and the pelvis does not have a limitless ability to stretch. The distance between these structures is defined by the rigid pelvis and acetabulum (socket where the femur connects to the pelvis). The changes from a cleft lift are well within these limits.

    In our practice we have cared for patients who are football players, baseball players, basketball players, weight lifters, horse back riders, professional hockey players, professional golfers, Zumba fanatics, motorcycle riders, and even tightrope walkers and bull riders!

    So, could a patient perceive some tightness or have the perception that motion is limited? It is always possible, especially following other failed operations. But, it has not been a symptom that our patients have brought to our attention as a significant post-operative issue.

    Considering that the cleft lift has the highest success rate in treating pilonidal disease, it is a good choice for the active athlete who wants to resume full activity six-eight weeks after surgery.

     

     

     

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    • JULY 12, 2023
    • 0
    What is the Gips Procedure, and Does it Work?

    What is the Gips Procedure, and Does it Work?

    The Gips Procedure is one of the many pilonidal operations that fall into the “minimally invasive pilonidal surgery” category.

    This procedure is a modification of the Bascom pit picking procedure, and it was described by Dr. Moshe Gips, from Israel, in an excellent paper from 2008.

    He modifies the pit picking operation by using trephines (dermatome punches) to core out midline pits, follow their tracts, and remove all debris and cavity walls from cysts and sinuses. He leaves the openings created by these punches open to heal without suturing them closed.

    His reported series from 2008 included 1,358 patients. He found that 4.4% of patients did not heal from the surgery and required additional procedures.  Telephone interviews were performed in 85.8% of the remaining patients and they found a recurrence rate in these patients of 16.2%. Recurrences were noted between 1 month and 11 years post op, but 81% of the recurrences occurred within 5 years of the operation.

    It should be noted that Dr. Gips has a few postoperative routines that are part of his treatment protocol:

    • Patients are kept on their back for observation for one hour after the procedure.
    • Patients are instructed to shower several times daily starting the day after the operation.
    • A bulky dressing is placed between the gluteal cheeks, and securely taped in position for some time after the operation.
    • Patients returned to the clinic for follow-up every 1-2 weeks for wound debridment and shaving of the area.

    A recent meta-analysis of the Gips procedure has been published

    A meta-analysis is a statistical study combining the results of multiple studies in order to come up with conclusions that may be more significant than any of the individual studies alone. So, these studies include surgeons other than Dr. Gips, who are performing this operation.

    In this analysis thirteen observational studies with a total of 4,286 patients having a Gips procedure were studied. The basic statistical result was that the recurrence rate was 38.9% after more than 2 years of surgery. The conclusion of the study is that: “Despite apparent favorable outcomes of the Gips procedure, there is a high recurrence rate over time.”

    So, is the Gips procedure worth trying?

    That is a great question, and is something that an educated patient needs to  decide for themselves. A reasonable ballpark figure to use for any of the minimally invasive operations is that the failure rate is somewhere between 30-60%. This means that out of three patients, one or two will ultimately fail and require another procedure. Whether it is worth a try is a personal choice. (Also, keep in mind that not all presentations of pilonidal disease are appropriate for the minimally invasive operations.)

    A cleft lift done by an experienced pilonidal surgeon would be expected to have a failure rate around 2% in the kinds of patients who are candidates for a Gips procedure. Each patient has their own feeling about this difference in failure rate, and proceeding with either option is reasonable. Fortunately, having a failed Gips procedure does not usually make a subsequent cleft lift more difficult.

    Because of the high failure rate of the minimally invasive procedures, we do not perform them in our clinic anymore, but if you can find a surgeon skilled in any of the techniques, it is a reasonable option.

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    • JUNE 28, 2023
    • 0
    Smoking and Pilonidal Surgery

    Smoking and Pilonidal Surgery

    Is is absolutely necessary to stop smoking before a cleft lift operation?

    When surgeons perform flap procedures for various medical problems, it is a general rule that patients should stop smoking before and after the operation. This is because when a flap is created part of its blood supply is divided in the process of moving the tissue, and the surgeon is then relying on a small group of blood vessels to keep the tissue of the flap alive. Smoking causes blood vessel constriction (vasoconstriction) – in other words the blood vessels become smaller, and can carry less blood – and therefore carry less oxygen to the tissues.

    Is this an issue for cleft lift patients?

    Fortunately, the skin flap created for a cleft lift has a very, very good blood supply, and vasoconstriction has not been an issue in our patients. If the flaps are created correctly, lack of blood supply is not a problem. So, in our clinic we do not consider smoking a “contraindication” (reason not to proceed) to the surgery.

    However…

    You should not be smoking. Ever. It is an extremely unhealthy behavior, and this post should absolutely not be viewed as condoning smoking.

    However, we also understand that smoking is addictive, and that if a person smokes and has pilonidal disease, they need the same quality treatment that a non-smoker requires, so these are pertinent questions.

    But, if you do smoke, maybe this should be a time to look into strategies to quit smoking.

    Also, always wear your seatbelt.

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    • JUNE 25, 2023
    • 0
    Functional Medicine and Pilonidal Surgery

    Functional Medicine and Pilonidal Surgery

    How do we use Functional Medicine in pilonidal patients?

    Treating pilonidal disease has many challenges. Of course, it is necessary to choose the right operation, perform it correctly, and care for it properly after surgery. However, there are times when all those things are done correctly, yet wounds fall apart or do not heal. As surgeons, we look for consistency regarding how our patients recover, and are often mystified when things don’t go as expected.

    If a surgeon performs a cleft lift every month or two, it is hard to get a good handle on the differences between patients regarding their types of pilonidal disease, locations of wounds and sinuses, and body shapes. However in a clinic like ours, where we are dealing with pilonidal patients and cleft lift procedures on a daily basis, it becomes dramatically more clear when a patient is not healing as expected.When we are approached by patients who have had failed operations elsewhere, it is very helpful if we can recognize the reasons for their previous failures. If it is because they have had an operation with a high failure rate, and the pattern of the failure is as expected, it is reasonable for us to proceed with revisional surgery in order to try to salvage the situation.

    However, if the previous failures seem to be more dramatic and unexpected than usual – we have to investigate why that happened so it doesn’t happen again. One of our strategies is to maximize our patient’s nutritional status, and the details of that is on this web page.

    However, there are other times when we perceive that there may be other metabolic factors involved and feel that they need further investigation. This is where Functional Medicine plays a role.

    What is Functional Medicine?

    In the words of Dr. Mark Hyman:

    FUNCTIONAL MEDICINE … seeks to identify and address the root causes of disease, and views the body as one integrated system, not a collection of independent organs divided up by medical specialties. It treats the whole system, not just the symptoms.

    Another way to look at this, as it applies to treating failed pilonidal surgery, is that we are searching for the root cause of the surgical failures to prevent them from continuing to be a problem with the next operation. We do this by looking at the whole patient, not just the surgical site. The kinds of problems that we are looking for are nutritional deficiencies, uncontrolled inflammation, auto-immune diseases, intestinal problems, and environmental toxicities. We want to define and control these issues to help insure that future surgery has the highest chance of being successful.

    Who benefits from a Functional Medicine evaluation?

    If in assessing the medical and surgical history that you have sent us, plus our evaluation of the photos of the operative site, Dr. Immerman feels that there are factors beyond the basic pilonidal issues involved, we may recommend a battery of tests looking at nutritional parameters, toxicity, inflammation, and autoimmune diseases. If these point to metabolic issues, we will recommend a Functional Medicine evaluation, and possibly a period of treatment, before considering additional surgery.

    We can help you find a Functional Medicine practitioner for this. You can continue to have your regular family physician in addition to a Functional Medicine physician – often the testing and treatment recommendations are so different between these two medical disciplines that they don’t overlap at all.

    If you want to search for a practitioner yourself, the Institute for Functional Medicine (IFM) website has a great search engine to help with that.

    A few things to know about Functional Medicine clinics:

    • They usually do not accept insurance as payment, and visits will have to be paid out-of-pocket.
    • Some of the testing may be covered by insurance, but much of it is not.
    • Most visits can be performed virtually.
    • These practitioners are often booked months in advance, so do not be surprised if there is a significant wait for your first appointment.
    • You may find that the practitioners listed on the IFM website are of various qualifications: MD (medical doctor), DO (osteopathic physician), RN (nurse), NP (nurse practitioner), Dietitian, or DC (doctor of chiropractic). We’re happy to help you figure out who is best for your situation.
    • After performing a number of tests, you may be prescribed specific diet recommendations.
    • You may be prescribed various vitamins and supplements, that are usually not covered by insurance.
    • There may be follow-up testing after a period of time to see what kind of progress you have made.

    This sounds like a big deal! Is it really worth it?

    Yes! This may be the most important action you take for your general health, not just your pilonidal problem. This may prevent future diseases, and help turn around current issues.

    If we recommend that you see a Functional Medicine practitioner, it is in your best interest to do so.

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