You would think that surgeons would be more willing to refer when they’re out of their comfort zone

Andrew is a college student who aspires to be a doctor.  Hours of study made the pilonidal abscess that he had since his mid-teens pretty unbearable.  He met with a local surgeon who seemed fairly confident that she could cure his pilonidal disease.  But, after two operations and a persistently draining wound, Andrew was worse-off than he had been before surgery.  The COVID pandemic hit and now Andrew was relegated to sitting in front of a computer for hours on end in order to participate in classes.  The wound from his failed pilonidal surgery seemed to get worse rather than better and he had to endure twice a day wound care from his parents that was painful, embarrassing, and demoralizing.  He also had to travel to a wound clinic with his parents twice a week for additional treatments which didn’t seem to help.  He missed school and his parents missed work.  This was disrupting and emotionally draining for the entire family.

Andrew’s surgeon wanted an out as she was becoming disheartened over the non-healing wound.  She referred Andrew to a plastic surgeon at the local major academic center.  That plastic surgeon told Andrew and his family that he had a great deal of experience in treating pilonidal disease.  He offered to perform a Cleft Lift procedure and cure Andrew of his pilonidal disease.  The operation apparently went smoothly but within a week the wound had reopened.  Andrew was taken back to the operating room to have the wound washed out and reclosed.  Nonetheless, it reopened and remained open.  

Now, the academic plastic surgeon wanted an out too.  He referred Andrew to The Sternberg Clinic, admitting that I had the most experience with pilonidal disease on the West Coast.  Andrew’s parents asked why he hadn’t sent them to my office in the first place.  The plastic surgeon didn’t have a good answer for them.  So they traveled to San Francisco for a consultation with me and I evaluated Andrew’s open wounds (now two).  One wound was 6 cm in length and abutted the anus making repair very challenging.  The wounds were deep and hidden in a deep cleft (valley between the buttock cheeks).  There was no chance that these wounds would heal in this deep airless cleft and because they connected to a large cavity under the surgical wound above them.  It didn’t appear that the previous surgeon had performed a cleft lift procedure as the cleft was still deep.  After the cleft lift procedure, the cleft is shallow.

I advised a repeat Cleft Lift procedure.  The operation was challenging but went well and Andrew had an excellent outcome.

It is such a shame that surgeons don’t refer patients with complex pilonidal disease more freely and frequently.  In this case as in most it would prevent much suffering for patients, parents, and surgeons alike.  Luckily, Andrew is fine.  He is back to his usual self: sitting for school, participating in sports, traveling without worries, and applying to medical school.  I’m certain that his own challenging medical experience will influence his career.

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