While I see around 5 or more new patients with pilonidal issues a week, and around 40% of those patients travel from outside of the Bay Area to meet with me because they have complex pilonidal issues, a young patient who I evaluated this week stands out.  He’s a high school student and has suffered from pilonidal disease/pilonidal cyst disease for a year or two.  Let’s call him Larry (not his real name).  Last year he underwent a major excisional procedure by his local surgeon.  The wound was initially closed but opened up in several places in the weeks following surgery.  His surgeon re-operated on him to “clean up” the wound and remove more “diseased tissue” and matters became even worse.  Larry has been receiving care at a wound clinic for the last 6 months, going several times a week with his parents, who have been instructed to perform daily cleaning and packing.  Larry’s wounds have become larger and more painful, and the drainage has increased, irritating his skin and making it impossible for him to exercise and challenging for him to sit in class or study.

Larry and his parents travelled the several hours to San Francisco to meet with me.  Larry, had a draining pilonidal sinus with a long sinus track from just above his anus to the top of his buttock cleft.  The sinus track was full of purulent material (pus).  I was concerned that this wound harbored antibiotic-resistant bacteria as Larry had been prescribed multiple rounds of different antibiotics for the last 6 months.  So, I cultured his wound and sure enough it grew a multi-drug resistant bacterium that is only treatable with intravenous antibiotics.

Larry is certainly going to need surgery as this wound/sinus will not heal without it.  The Cleft Lift Procedure is the proper operation for him.

Several important tenants that I have learned in my 17 years of performing Cleft Lift surgery:

1. Pilonidal problems rarely require antibiotics.
   1. Acute abscesses require surgical drainage
   2. Sinuses and open wounds will not heal with antibiotics
2. When operating on a grossly infected complex pilonidal issue such as Larry’s
   1. I try to obtain preoperative deep wound cultures as I have been amazed by the unusual and difficult to treat organisms that have grown.
   2. Pre-operative antibiotics are often important for good outcomes and help prevent postoperative infections (since his wound will be closed during a cleft lift procedure).
   3. When operating on a patient with an antibiotic-resistant bacterial wound infection, pre and post-operative culture-directed antibiotics are a good idea.

Larry will be having a PICC line inserted and will require daily intravenous antibiotics administered by a nurse.  I have utilized this protocol many times before with excellent outcomes.  I anticipate that Larry will do well with Cleft Lift surgery and will have a smooth recovery.