Excision Treatments

We here at the Pilonidal Support Alliance are believers in what is referred to as "off-midline" Pilonidal surgery. 
What off-midline means is to "stay out of the ditch" of the natal cleft.  Wounds directly in the midline of cleft are the hardest to heal and are under the greatest strain from body movement. Wounds heal better when out of the midline where the tension is less and they are more likely to be exposed to air.  The lower midline of the buttocks becomes an air seal that traps debris and bacteria in the area, leading to slower healing and greater incidence of wound breakdown. It is our opinion that any of 3 prime choices for surgical treatment will work effectively as long as the surgeon "stays out of the ditch."

1) Excision with Open Healing:
(aka - secondary healing, healing from the bottom up, healing from the inside out...)

What it is - In this procedure the abscess and sinuses are completely removed. The resulting wound is left open to heal. This is the slowest form of healing (8 weeks) but has a lower rate of infection and recurrence (5-15%) compared to traditional closed wound healing. During healing the wound is normally cleaned out and re-packed with gauze at least twice daily.  Some surgeons do not believe in packing - as long as the wound bed is flushed with water twice daily we support this technique as well.

Where it's done - Excision surgery for Pilonidals is usually done at an outpatient surgical center and takes an average of about 45 minutes; it is typically done under MAC Anesthesia, Spinal Block or General Anesthesia. You will spend 4 to 5 hours at the clinic and then go home afterwards.

Recovery time - Approx 8 weeks. The first week after the surgery will be the worst and you really will need to be home resting during this time. Most doctors will advise that you can return to work after the first week. You will be advised not to drive for the first few days after surgery (nor will you want to anyway.)  Some insurers will actually pay to have a home health nurse come and do your packing changes twice daily.  Otherwise, it is possible to do packing changes yourself (I did all my own), but easier if you have a spouse/family member/significant other to help.

What else you should know - An additional technique called "Marsupialization" is also sometimes used (the edges of the open wound are stitched all the way around like a button hole) to keep the wound from closing too quickly. This speeds up healing time by several weeks. 

For a detailed account of a surgery with open healing, see My Experience.
 

2) Excision with Primary Closure
(aka - healing by first intention, sutures, stitches)

What it is - In this procedure, the abscess and sinuses are removed and the wound is closed with sutures/stitches. Again, please note that we strongly suggest the surgeon stay out of the midline. Closed incisions that run into the lower midline are the hardest to heal and the most likely to fail.  

Where it's done - Excision surgery is usually done at an outpatient surgical center and takes an average of about 45 minutes; it is typically done under MAC Anesthesia, Spinal Block or General Anesthesia. You will spend 4 to 5 hours at the clinic and then go home afterwards.

Recovery time - Approx 4 weeks. The first week after the surgery will be the worst and you really will need to be home resting during this time. Most doctors will advise that you can return to work after the first week. You will be advised not to drive for the first few days after surgery.

What else you should know - Excision with primary closure is an option for people who cannot undergo an 8 week healing period. The drawback is that the infection rate is 20-25% for this procedure and if you do get an infection then you will have to go through open healing anyway.

• More recent medical techniques are now using Primary Closure with closed-suction drainage and antiseptic flushing of the wound --this seems to greatly reduce the infection rate, be sure to ask your surgeon about this if you are considering Primary Closure.

• It is very important for sutured incisions in this surgery to be off the midline.  Make sure you discuss this with your doctor!

• The danger with closed wound incisions (especially those close or on the midline) is that this area of the body moves in many directions during daily life and this movement places a great deal of strain on the sutures, especially those inside the wound.

• Also note, surgical wound infections can have very serious consequences (as in, fatal) so if you see drainage, redness, odor or swelling get to your doctor ASAP.

For a detailed account of a surgery done with closed healing, click here.

3) Cleft Lift / Modified Karydakis
(aka Cleft Closure)

What it is - These are both very similar procedures developed in-line with discoveries by Karydakis about the origins of pilonidal disease. In the Cleft Lift, the actual shape of the cleft is changed to be more shallow and allow for better healing. The surgery was originally developed to deal with surgeries that had failed to heal or continued to recur and is now being done more and more as a first surgery.

With the both techniques, the surgeon removes an ellipse as he/she excises the pilonidal. The resulting defect, a football shaped ellipse or "cavity", lies parallel to the midline but to one side. The surgeon removes the medial edge of the buttock. To cover the "cavity" the surgeon undercuts the other side and pulls across the midline a flap of skin and thick fat. The cleft becomes shallow and the single suture line lies in open air to the left of the midline. By almost flattening the cleft, the gathering of loose hairs is less likely, and the there is no portal of entry left for hair entry (they always enter a midline hole, not one on the side), thus greatly reducing the risk of recurrence.

One of the key elements to both the Cleft Lift and the Modified Karydakis are that all incisions are made to the side of the midline, never right down the middle. 

Where it's done - Hospital or Outpatient Surgical Center.  Usually scheduled as a day surgery with the patient going home that evening. In some cases and overnight stay may be suggested.

Recovery time - Patients usually return to work after 2 weeks. Healing is usually complete within 4 weeks.

What else you should know - Finding a surgeon doing this technique is challenging, you may need to travel to a major city.  Also, your insurer may not cover the surgery, be prepared to fight for it.  Your surgeon may be willing to learn the surgery - there is a DVD available and Dr. Bascom is happy to consult on cases and provide support.

USA Surgeon List:
http://www.pilonidal.org/pdfs/PiloMDs_USA_11_2008.pdf

Non-USA Surgeon List:
http://www.pilonidal.org/pdfs/PiloMDs_NON_USA_11_2008.pdf

Surgeon Hall of Fame Forum: http://www.pilonidal.org/forums/forumdisplay.php?f=25

For a detailed patient account of the Cleft Lift procedure, see Kyle's Page.
For a medical description of the Cleft Lift by Dr. Bascom, see this PDF.
For a medical description of the Karydakis Flap by Dr. Kitchen, see this PDF.
For a YouTube video of the surgery, see this video *WARNING* this is an actual surgery and is very graphic.  http://www.youtube.com/watch?v=XucofeyyGb8

Other Flap Surgeries
(Limberg Flap, Z-Plasty, Rotational Flap)

**Note** is our general opinion that these surgeries are less effective choices and anyone considering them should first search for a surgeon doing either Modified Karydakis or Cleft Lift. 

What it is - To treat pilonidals with a Limberg flap, the surgeon removes an oblong-shaped plug containing pilonidal abscess, skin and fat, thus creating a "cavity." To fill the "cavity" the surgeon extends the cut laterally then downwards and mobilizes a block or flap of skin and thick fat, from the buttock beside and below the cavity. The surgeon swings the flap into the center and pulls together the edges with sutures. The re-positioned plug makes the cleft become shallow but leaves a more complex suture line than after the Karydakis. The Limberg flap works well if sutures are positioned out of the cleft. Rotation flaps loosen the entire buttock and rotate it to move tissue into the midline cavity. Z-plasty loosens triangular flaps on each side of the midline to fill the cavity, with points of the flaps toward the head and foot. The surgeon crosses the pointed flaps to cross the midline in a horizontal direction, thus converts an N shaped incision to a Z shaped closure.

Textbooks suggest the source of pilonidal failure-to-heal is a "cavity" unfilled. Bascom reviewed failed operations and found otherwise. Instead, pilonidal operations fail when a surgeon leaves a suture line or an overhang within a cleft, especially a deep and tight one. Operations succeed when a surgeon reshapes the cleft, changes deep to shallow, and when he/she moves the cleaned-out chronic abscess walls in place. Cleft lift thus creates no cavity. The cleft lift operation, like a face lift operation, moves flaps, but of skin only, not fat or muscle. Cleft lift excises excess tissue, but skin only, and covers the walls of the cleaned-out abscess with a thin flap; leaving the abscess wall in place where it will heal. The resulting wound, like the Karydakis operation, ends up with a vertical scar to one side of a shallower midline. Because of its similarity in appearance it is sometimes called a modified Karydakis operation.

Where it's done - Hospital, average stay of 3 to 5 days.  This is a major surgery that requires an overnight stay.

Recovery time - Patients usually return to work after 2 weeks. Healing is usually complete within 4 weeks.


For a detailed account of a flap surgery, see Cathy's Page.
 

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