About the Surgery
What Else Should I Know?
Some patients with pilonidal disease are told that they have a condition called Coccydyia. Coccydynia, or tail bone pain, is caused by trauma to the tail bone. The injury can be acute, from a fall, or chronic, from repeatedly sitting on hard surfaces or riding a horse, for instance.
Pilonidal disease also, can arise after trauma, such a fall. Distinguishing between pilonidal disease and coccydynia can be difficult. The key to determining which condition is causing discomfort is to identify the midline pits or pores that are seen in pilonidal disease. Most of the time, swelling (from an abscess under the skin) is also present in pilonidal disease. Swelling is rare in coccydynia.
The cleft-lift procedure is generally performed under spinal or general anesthesia. With either form of anesthesia, you will be kept sedated so that you sleep throughout the procedure and won’t remember it.
How long is the operation?
The operation typically takes around one hour. There is an additional half hour of set-up after you are in the operating room and sedated. During this time, the operative site is shaved with special surgical clippers, and the skin coverage flap is measured and drawn. Please do not shave your natal cleft before surgery as you may create small cuts that increase your chance of infection.
Most patients experience very little discomfort from the operation. Most individuals experience some numbness on the side of the flap that can take around 6-8 weeks to completely go away. The numbness always goes away.
The discomfort is usually well controlled with the two prescribed pain medications: Motrin/Ibuprofen and a narcotic. The Motrin/Ibuprofen should be taken regularly, three times a day with meals, and the narcotic pain reliever should be taken only as needed for additional discomfort. Please take all pain medications with food or they may cause nausea.
Additionally, you will be prescribed an antibiotic for two weeks after the procedure to decrease your chance of developing a postoperative infection.
A drain will be placed at the time of surgery. The drain looks like a thin rubber band. The purpose of the drain is to keep the 2 skin openings (one at the top of the flap and the other in the lower portion of the incision) from closing early after the procedure and to aide in wicking fluid from under the skin flap. You will receive instructions on how to take care of the drain at the surgery center or hospital. Also, please view the drain care video (link).
It’s important to have another person help with the drain care, as it’s difficult for you to see the area well. To start, place a piece or two of gauze just above the upper drain hole to soak up the expressed fluid. Then roll a piece of tightly wound gauze (like a small rolling pin) up the skin flap towards the upper hole to force fluid out of the hole. This should be done three times a day for the 9 days that the drain stays in. Roll during each session until little fluid comes out of the upper hole (typically 8-10 times/session). Don’t worry if fluid comes out of the upper portion of the incision. That’s okay.
If there seems to be fluid trapped under the flap and little to no fluid is coming out of the upper hole during the rolling process, please dilate the upper hole with a Q Tip.
For the first several days after surgery, there may be a fair amount of drainage (typically pinkish or reddish fluid). In between the rolling procedure, place a thick layer of gauze over the drain sites and hold in place with the supplied mesh pants or tight-fitting underwear (boxer shorts won’t work, get black briefs). Please don’t use tape as it may damage your skin. The purpose of the gauze is to protect your clothing and furniture – so be careful to cover the area well for several days to avoid staining your furniture. Change the gauze when it becomes moist so your skin stays dry and protected.
After several days the amount of drainage will decrease and you will feel more secure leaving the house and possibly going to work or school.
Please make an appointment to see Dr. Sternberg 1-2 days after surgery and bring your drain helper. I will want to go over the rolling procedure with both of you in the office, as it is critical for a good outcome. Also make an appointment for 9 days after surgery (the Friday following surgery if it performed on a Wednesday) to have the drain removed. Don’t worry &emdash; removing the drain doesn’t hurt at all! If you travelled a great distance for surgery, I will give you clear instructions so that you can safely remove the drain yourself at home.
Please don’t exercise while the drain is in place. Walking is okay. You are allowed to sit on the operative site immediately after surgery (it actually helps push fluid from under the flap). Once the drain is removed, you may begin to exercise.
Yes. You can shower in the evening, the day of surgery. Make certain to remove all of the gauze first. It’s important to keep the wound dry after showering. Soaking in a bathtub, however, is not permitted for 4 weeks or until the wound is fully healed.
Can I sit down immediately after the procedure?
I recommend that you try and keep the wound clean and dry. Remove the gauze bandages when having a bowel movement or showering. Please clean the wound carefully after a bowel movement. Wet wipes or Balneol lotion on toilet paper works best. After cleaning or showering, blot the wound and your perianal area carefully with a towel, and then dry completely with a hairdryer on the ‘low’ setting.
Tight-fitting underwear is best to wear while recovering from the cleft lift as it helps hold dressings over the wound and compresses the operative site (discouraging fluid accumulation). The dressing applied after surgery is there to protect your clothing. Don’t use tape to hold gauze in place as it can injure your incision – instead use tight-fitting underwear to hold dressings in place.
Steri-strips (thin paper-like tapes with parallel fibers in them) will be placed on the skin across your incision. Don’t remove them. They are intended to support the wound and should be left in place until they fall off.
Will I have a scar?
Once your drain is removed (7-10 days after surgery), you will be encouraged to return to most activities. Bike, motorcycle, or horseback riding must be avoided for one month. Swimming or soaking in a tub should be avoided until the drain holes and incision have fully healed (generally a week or 2 after the drain has been removed).
The majority of patients will be prescribed the following medications:
- Ibuprofen, a NSAID that relieves pain and decreases inflammation
- A narcotic pain reliever
- Docusate Sodium, a stool softener
All medications should be taken with food or they may induce nausea. The Ibuprofen is the more important of the pain relievers as it decreases inflammation. Ibuprofen should be taken 3 times a day for 10 days, while the narcotic should only be taken every 4-6 hours if needed (and discontinued once your pain is adequately relieved by the Ibuprofen). Also, narcotics may cause constipation, so you should only take narcotics if you need to.
Most insurance companies won’t pay for the stool softener prescription. If your pharmacy doesn’t fill that prescription, please purchase over the counter Docusate Sodium. This is a lower strength than I recommend. Please take 2 tablets of the over the counter variety twice a day for the period time you are taking the narcotic pain reliever.
Should you feel constipated (miss having a bowel movement for a day or two), please take 2 tablespoons of Milk of Magnesia (an over the counter laxative readily available at all pharmacies) 3 times a day until you have a bowel movement.
Please let Dr. Sternberg, or his office staff, know if you have any allergies or prior reactions to the medications listed above, well in advance of surgery.
- Around 20% of patients may have some minor incisional separation near the anal end of the wound. This is generally not a problem and should not delay recovery.
- An infected fluid collection can occur under the flap but is rare. It may delay your recovery; however, you should still end up with an excellent result. Since changing the type of drain placed at the time of surgery to one termed a ‘passive’ drain, no such complications have occurred.
Shaving before or after a cleft lift operation is not advised and it may cause problems for the following reasons:
- The disease is not caused by ingrown hairs
- Hairs that deposit in pilonidal wounds are shed hairs that may come from areas other than the buttocks and natal cleft
- The skin of the natal cleft is sensitive, and small nicks and cuts from shaving can contribute to infections. Chemical hair removers are very irritating.
- Once you have undergone a successful cleft lift procedure, you are no longer at significant risk of developing a recurrent pilonidal abscess
- Laser hair removal is expensive, time consuming, and unnecessary for the above reasons
In patients with long clefts and in those patients with pits or unhealed wounds approaching the anus, the surgical incision needs to end close to the anus. Nonetheless, having a bowel movement shouldn’t be much of a problem. Several pointers:
- Don’t get constipated! Take the stool softener and Milk of Magnesia if needed (see the next FAQ section)
- Use wet wipes or Balneol (better) to clean after a bowel movement for several weeks after surgery.
Not as a result of the procedure. But – taking a narcotic can definitely lead to constipation and the prescribed stool softener should be taken also. If you go for a day without a bowel movement please buy Milk of Magnesia. It is available over the counter. Take 2 tablespoons every 8 hours until you have a BM.
Will I be cured?
Most likely! The intent of the cleft-lift procedure is to prevent recurrent pilonidal disease.