When is surgery an option?
Surgery is only appropriate for individuals who are persistently affected by pilonidal disease, and those who have had complications of procedures used to treat symptomatic disease. Irritation or pain by the tailbone, persistent drainage, and recurrent abscesses are all indications for an appropriate surgical procedure.
Why ‘conventional’ surgery for pilonidal disease is obsolete
Despite the apparent simplicity of the disease process, pilonidal disease often frustrates both patients and their surgeons because the disease often comes back after conventional surgical procedures. Most surgeons try and avoid operating on patients with pilonidal disease, as typical surgical outcomes are dismal and result in recurrent disease that is more complex than the original problem.
The most commonly performed procedures for pilonidal disease, which I will term conventional surgery, involve a wide excision of the affected area of skin and underlying fatty tissue, and:
- Re-closing the wound in the midline, or
- Suturing the edges of the wound open (marsupialization).
Pilonidal disease is poorly understood by many surgeons. They fail to appreciate that the deep cleft is the cause of the disease. These surgeons often remove too much skin and deep tissue and leave large defects that further deepen the cleft. Conventional operations can create large, disfiguring wounds that require labor-intensive postoperative care. Unfortunately, these sub-optimal operations have become the so-called ‘standard of care’’.
Above picture: This is an unhealed wound three years after a wide excisional procedure for pilonidal disease in a 19-year-old college student.
Removing large amounts of tissue is unnecessary since the cause of pilonidal disease is the deep valley of the natal cleft, so removing normal tissue is unnecessary and harmful. Because there is no ingrown hair/debris or cyst, a large excision is simply not needed. Furthermore, deep excision of the center of an airless, moist, diseased valley/cleft creates a wound that resists healing and increases the odds for recurrent disease.
What prevents healing with conventional surgery?
Pilonidal disease can respond to conventional surgery but often the remaining deep valley/cleft doesn’t allow enough air circulation for proper wound healing. The deep valley also stays moist, which encourages bacterial growth and additional skin damage. Because the cleft is still deep, the basic problem of trapping hair and debris in the pores of the cleft is still not corrected and pilonidal disease can happen again. Recurrent pilonidal disease requires a definitive surgical procedure to reduce the depth of the natal cleft valley so it remains well aerated, dry, and shallow so that hairs and debris can’t be trapped.
Curing pilonidal disease with better engineering
Now that we know that the deep valley is the cause of the disease, why not fix the valley? The goals of an ideal procedure to treat chronic pilonidal disease (or non-healing wounds that result from failed pilonidal procedures) include:
- Reduce the depth of the cleft to shallow the ‘airless’ valley
- Remove only diseased areas and leave deeper, healthy tissue intact
- Reshape the cleft to prevent ‘divots’
- Make the incision outside the valley (lateralization) to allow the incision to heal in the open air
- Leave a closed wound (no packing required)
- Perform the surgery on an outpatient basis
- Cause little discomfort
- Easy postoperative care
- Allow patients return to athletics within a few weeks
- Be cosmetically acceptable
The Cleft Lift Procedure is this ideal surgical procedure and is highly successful in curing pilonidal disease if it’s performed by a surgeon who is experienced in the technique.
Unfortunately, it’s very difficult for patients to find a surgeon with experience in the Cleft Lift Procedure. Patients often need to travel far to find such a surgeon. It’s worth it!