Learn why the Pilonidal RAF/Cleft Lift Procedure is the Most Effective Operation with the Lowest Recurrence Rate.

Pilonidal Disease is a chronic condition that affects many young adults. If you are looking for the best pilonidal “cyst” surgery procedure, the Sternberg Clinic has excellent treatment options.

The condition is often called a “Pilonidal Cyst,” resulting in overly aggressive surgery to remove the cyst with a normal tissue margin. Pilonidal disease, however, is just an infection and is not caused by a cyst. As a leading expert in the field, Dr. Sternberg specializes in a modern surgical procedure called The Cleft Lift Procedure, also termed the pilonidal RAF procedure, for the rotation of tissue around the anus and advancement of tissue across the midline of the natal cleft. It is the best pilonidal cyst surgery procedure for patients with Pilonidal Disease requiring surgery and has the highest success rate compared to conventional surgery.

Before and After The Pilonidal RAF /Cleft Lift Procedure

Photo Gallery

Cleft lift Procedure (Pilonidal RAF) Overview

Utilizing the solid concepts of Dr. Karydakis’ work from the 1970s to treat Pilonidal Disease with surgery, Dr. John Bascom in Eugene, Oregon, developed a variation of the operation called the “Cleft Lift.” Since that time, the operation has evolved and improved, and is now the best pilonidal cyst surgical procedure practiced by Dr. Jeffrey Sternberg, founder of The Sternberg Clinic for Pilonidal Surgery in San Francisco.

Patients with the following conditions are candidates for surgery:

• Primary disease with multiple pits or large divots
• Chronic disease with a draining sinus
• Open wounds resulting from surgical failure

The Cleft Lift procedure is the best pilonidal cyst surgery procedure for all forms of pilonidal disease requiring surgery and has a very low recurrence rate when performed by a surgeon experienced in the technique. Dr. Sternberg utilizes this technique as our primary operation for Pilonidal Disease. It should not be reserved as a fallback operation for failed conventional operations, and the later procedures should not be performed in the first place.

Symptoms and Causes

Patients who suffer from Pilonidal Disease typically have a deep buttock cleft. The deep natal cleft is the true cause of pilonidal disease. Patients acquire the disease after injury near the tailbone, usually from repetitive sitting or a fall (“Microtrauma Theory”). Because this deep cleft area of the buttocks remains deep, moist, and airless the injury is not able to heal. This is the perfect condition for the injury to become more infected, sending the patient toward Pilonidal Disease.

“Deep Valley vs. Rolling Hills”

This simple drawing illustrates how the Cleft Lift Procedure (Pilonidal RAF) not only cures a patient’s disease but also prevents it from reoccurring. The arrows in the top drawing demonstrate where a patient with a deep natal cleft buttock touches in the standing position. The surgeon reshapes a patient’s cleft from a “deep valley” to a much more shallow buttocks shape, or “rolling hills,” removing the area of the cleft where future infections might occur.

How the Cleft Lift procedure is performed

The Cleft Lift Procedure is an outpatient surgical procedure that is intended to cure Pilonidal Disease. Dr. Sternberg performs his surgeries in San Francisco.

The procedure takes about 1.5 – 2 hours. It is performed under spinal or general anesthesia. Patients experience minimal discomfort. The wound is completely closed, a drain is required, and no packing is required.

Most patients are allowed to return to daily activities, including athletics, after the drain is removed about 8 days later, and patients can return to full activity in about a month. After a Cleft Lift Procedure patients can sit without pain, wear bathing suits and walk in public locker rooms without embarrassment.

How does the Cleft Lift Procedure differ from other flap procedures?

The procedure involves the removal of scarred or pitted midline skin and skin from one side of the natal cleft. The abscess cavity is cleaned out, and the scarred cavity wall is released and rearranged to obliterate the cavity. The skin on the opposite side of the cleft is mobilized (freed from the underlying tissue) out past the edge of the natal cleft on the other side.

The deeper tissues of the now exposed buttocks cheeks are drawn and sewn together to ‘shallow the valley’ and to re-contour the cleft. The skin flap is then closed over the ‘shallowed’ valley and sutured to the side outside the cleft. The new natal cleft is less deep and smoothly transitions down toward the anus. Without the valley and divots, debris and hairs can’t collect. The resulting wound is off to the side of the midline so it is exposed to air and can heal well.

A temporary drain is placed under the flap of skin to prevent the accumulation of fluid and is generally removed in around one week. During this procedure, the only tissue that is removed is the skin. It’s important that no deep tissue is removed, as this can lead to the formation of “dead” or empty space that becomes filled with infected fluid and leads to an early recurrence.

The cleft lift is not like other flap procedures that either remove a lot of deep tissue resulting in disfiguring scars or that are so minimal that the cleft is not shallowed or re-contoured. Some surgeons make their incisions in the center of the deep, diseased area that makes the surgery hard to heal. Or, the flap incisions are often not moved enough to the side and get dragged back into the valley. If this happens, the valley is not reshaped and not shallowed. The persistent deep cleft again allows hair/debris to be trapped, leading to recurrent disease.

The cleft lift removes only the scarred skin, does not remove deep tissue, and puts the incision sufficiently to the side to heal well. Also, the cleft lift procedure is not disfiguring.  Most patients find the resulting scar cosmetically acceptable.  Data confirms that flap procedures, like cleft lift, resulting in a true lateralized closure are the ‘gold standard’ in the treatment of pilonidal disease. The Cochrane Collaboration review of the surgical treatment of pilonidal disease concluded, “off-midline closure should be the standard management when primary closure is the desired surgical option.

The history of cleft reshaping procedures and the cleft lift

Dr. George Karydakis first developed the concept of asymmetric excision for pilonidal disease and published his experience in 1973. His operation demonstrated some important concepts: wounds off of the midline (where they are exposed to air) will heal, and a shallower cleft (because of his operation) helps prevent recurrent disease (shallow clefts don’t collect debris). The original Karydakis operation required hospitalization and caused a moderate degree of discomfort.

Utilizing the solid concepts of Dr. Karydakis, Dr. John Bascom in Eugene, OR, developed a variation of the operation called the Cleft Lift Procedure. In the almost 40 years since its origination, the operation has evolved and improved to its current form. I had the privilege to meet and operate with Dr. Bascom in 2000 and learned the basic concept of the Cleft Lift Procedure.

A few years later, I had the opportunity to visit with Dr. John Bascom and his son, Dr. Tom Bascom, and observe them performing the Cleft Lift Procedure. I was pleased to learn that we have each developed similar, more contemporary versions of the original operation. I continue to refer to the procedure as the ‘Cleft Lift Procedure’ as a tribute to Dr. John Bascom, who has devoted much of his professional life to this underappreciated disease. His hard work, insight, and excellent judgment led to a well-tolerated and reproducible procedure that can be performed in an outpatient setting.

Podcast

Pilonidal Podcast: Dr. Sternberg explores the disease in 3 min. or less.
Ep. 1: What is Pilonidal Disease?

Hosted by Dr. Jeffrey Sternberg, MD, FACS, FASCRS

Founder of The Sternberg Clinic for Pilonidal Surgery in San Francisco, California

Listen to the full audio series

About early disease and acute abscesses

Acute pilonidal abscesses should be treated with prompt surgical drainage. This is an office-based procedure and will yield prompt relief of pain. Don’t worry! The drainage procedure rarely causes significant discomfort, and you should feel much better within hours. Antibiotics may be prescribed after a drainage procedure but rarely should be prescribed without draining the acute abscess.

Pit excision procedures

After healing from an acute abscess drainage, pits may become visible in the natal cleft midline. What to do at this point is controversial. Some surgeons recommend pit excision. While this may help prevent future acute abscesses or the progression of pilonidal disease to a chronic abscess, this strategy has not been well-researched. Sometimes, pit excision can lead to worse disease. Pit excision or “picking” is only appropriate for patients with one or few pits and no sinus.

Each case should be treated individually. Often, conservative and non-excisional care is the best approach.

A Cleft Lift can be performed with excellent outcomes if recurrent or persistent disease occurs after pit excision.

Pilonidal disease sometimes skips a early stage and presents for the first time as advanced disease that affects a significant portion of the cleft. Cleft lift surgery is necessary and the only appropriate option in this situation.

Description of the Cleft Lift Procedure

The following diagrams demonstrate the principles of the cleft lift procedure. The portion of the body pictured here is the buttock area viewed while a person is lying on his/her stomach with the buttocks up facing the viewer and pulled apart to show the valley of the natal cleft.

In the diagram below, the outline represents the contours of the buttocks and anal area. The dashed line is the rim of the natal cleft and is marked while a patient stands in a relaxed position. When standing, these lines meet. With the patient lying flat on his/her stomach and the buttock cheeks taped apart (as in these diagrams), the valley of the natal cleft is revealed. The red dots within the natal cleft represent dilated pores or ‘pits.’ The red dot in the upper left corner is the sinus (tunnel) opening often associated with a chronic pilonidal abscess.

In the diagram below, an island of skin is marked to the left of the midline. This purple area is excised, and the flap is elevated off the right side of the cleft. The underlying abscessed tissue is unroofed and cleaned. The abscess cavity wall is preserved, as it will heal if in folded on itself. Next, the deep tissues of the ‘valley/cleft’ are sewn together (not shown) to accomplish three goals: 1) to make the cleft less shallow, 2) to re-contour the cleft to remove divots, and 3) to minimize tension on the flap. Minimizing tension on the flap is vital to preventing the incision from being dragged back into the cleft. The arrows show the direction of flap advancement (across at the top and middle of the cleft, and rotated around the anus). Hence, the name I prefer for the procedure is the Pilonidal RAF (rotational and advancement flap), as this better describes what the procedure is and is less confusing.

A closed suction drain is inserted during surgery through a small hole at the upper portion of the flap and is placed under the flap. It drains fluid from under the skin flap so that the flap will stick to the underlying tissue. You or your helper will need to drain the fluid from a collection bulb twice a day while the drain is in place and you will need to keep track of how much fluid is being drained each day. The drain is usually removed 8 – 10 after surgery after 2 consecutive days with less than 15 CCs/mls of fluid drainage. If you travel a significant distance to have surgery, your helper will be shown how to easily remove the drain.

How do I take care of the drain?

You will receive instructions on how to take care of the drain at the surgery center or hospital.

Please view the drain care video before your surgery, and ensure that you have a caretaker who can assist you with the drain procedure for around 8 days. Watch the drain video for instructions.

Pilonidal Surgery Patient FAQ

The Sternberg Clinic shares its instructions for preparing and recovering from the Cleft Lift surgery, including tips for patients and caregivers.

Meet Your Surgeon, Dr. Jeffrey Sternberg

After many years performing major abdominal operations including open and laparoscopic resections for colon cancer, rectal cancer, Crohn’s disease, and Ulcerative colitis, I have chosen to concentrate my efforts in a few highly specialized areas of surgery where I feel I can make the greatest positive impact on patients.

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