Pilonidal Disease is a chronic condition that affects many young adults. Many doctors misdiagnose it as a “Pilonidal Cyst” and don’t treat patients properly as a result since pilonidal disease is really just an infection and is not caused by a cyst. As leading experts in the field, The Sternberg Clinic for Pilonidal Surgery specializes in a modern surgical procedure called The Cleft Lift. It is the best choice of treatment for patients with Pilonidal Disease requiring surgery, and has the highest success rate compared to conventional surgery.
Cleft lift procedure overview
Utilizing the solid concepts of Dr. Karydakis’ work from the 1970s to treat Pilonidal Disease with surgery, Dr. John Bascom in Eugene, Oregon, developed a variation of the operation called the “Cleft Lift.” Since that time, the operation has evolved and improved to the procedure practiced by The Sternberg Clinic for Pilonidal Surgery in San Francisco.
Patients with the following conditions are candidates for surgery:
- Primary disease with multiple pits or large divots
- Chronic disease with a draining sinus
- Open wounds resulting from surgical failure
The Cleft Lift procedure is the proper procedure for all forms of pilonidal disease requiring surgery and has a very low complication rate when performed by a surgeon experienced in the technique. The Sternberg Clinic utilizes this technique as our primary operation for Pilonidal Disease. It should not be reserved as a fallback operation for failed conventional operations, and the later procedures should not be performed in the first place.
Watch the Video
Learn about Pilonidal Disease and how to treat it with the Cleft Lift procedure in this illustrated video by Dr. Jeffrey Sternberg, MD, FACS, FASCRS of The Sternberg Clinic for Pilonidal Disease in San Francisco, California.
Symptoms and causes
Patients who suffer from Pilonidal Disease often have a body shape that includes a deep cleft in the buttocks. Patients acquire the disease after incurring an injury near the tailbone, usually from repetitive sitting or a fall. Because this deep cleft area of the buttocks remains dark and moist, the injury is not able to heal. This is the perfect condition for the injury to become more infected, sending the patient down a path toward Pilonidal Disease.
“Deep Valley vs. Rolling Hills”
This simple drawing below illustrates how the Cleft Lift procedure not only cures a patient’s disease, but also prevents it from reoccurring. The surgeon reshapes a patients cleft from a “deep valley” to a much more shallow buttocks shape, or “rolling hills,” removing the area of the cleft where future infections might occur.
How the Cleft Lift procedure is performed
The Cleft Lift procedure is an outpatient surgical procedure that is intended to cure Pilonidal Disease. Dr. Sternberg performs his surgeries in San Francisco.
The procedure takes about an hour. It is performed under spinal or general anesthesia. Patients experience minimal discomfort. The wound is completely closed, except for a drain cord, and no packing is required.
Most patients are allowed to return to daily activities including athletics after the drain is removed about 10 days later, and patients can return to full activity in about a month. After a Cleft Lift procedure patients can sit without pain, wear bathing suits and walk in public locker rooms without embarrassment.
How does the cleft lift procedure differ from other flap procedures?
The procedure involves the removal of scarred or pitted midline skin and skin from one side of the natal cleft. The abscess cavity is cleaned out, and the scarred cavity wall is released and rearranged to obliterate the cavity. The skin on the opposite side of the cleft is mobilized (freed from the underlying tissue) out past the edge of the natal cleft on the other side. The deeper tissues of the now exposed buttocks cheeks are drawn and sewn together to ‘shallow the valley’ and to re-contour the cleft. The skin flap is then closed over the ‘shallowed’ valley and sutured to the side outside the cleft. The new natal cleft is less deep and smoothly transitions down toward the anus. Without the valley and divots, debris and hairs can’t collect. The resulting wound is off to the side of the midline so it is exposed to air and can heal well. A temporary drain is placed under the flap of skin to prevent the accumulation of fluid and is generally removed in around one week. During this procedure, the only tissue that is removed is skin. It’s important that no deep tissue is removed, as this can lead to the formation of “dead” or empty space that becomes filled with infected fluid and leads to an early recurrence.
The cleft lift is not like other flap procedures that either remove a lot of deep tissue resulting in disfiguring scars or that are so minimal that the cleft is not shallowed or re-contoured. Some surgeons make their incisions in the center of the deep, diseased area that makes the surgery hard to heal. Or, the flap incisions are often not moved enough to the side and get dragged back into the valley. If this happens, the valley is not reshaped and not shallowed. The persistent deep cleft again allows hair/debris to be trapped, leading to recurrent disease.
The cleft lift removes only the scarred skin, does not remove deep tissue, and puts the incision sufficiently to the side so that it can heal well. Also, the cleft lift procedure is not disfiguring. Most patients find the resulting scar cosmetically acceptable. Data confirms that flap procedures, like cleft lift, resulting in a true lateralized closure are the ‘gold standard’ in the treatment of pilonidal disease. The Cochrane Collaboration review of the surgical treatment of pilonidal disease concluded, “off-midline closure should be the standard management when primary closure is the desired surgical option.
The history of cleft reshaping procedures and the cleft lift
Dr. George Karydakis first developed the concept of asymmetric excision for pilonidal disease and published his experience in 1973. His operation demonstrated some important concepts: wounds off of the midline (where they are exposed to air) will heal, and a shallower cleft (because of his operation) helps prevent recurrent disease (shallow clefts don’t collect debris). The original Karydakis operation required hospitalization and caused a moderate degree of discomfort.
Utilizing the solid concepts of Dr. Karydakis, Dr. John Bascom in Eugene, OR developed a variation of the operation called the cleft lift. Since that time, the operation has evolved and improved to its current form. I had the opportunity to work with Dr. Bascom in 2000 and learned the basic concept of the cleft lift. A few years later, I had the opportunity to visit with Dr. John Bascom and his son Dr. Tom Bascom and observe them performing the cleft lift. I was pleased to learn that we have each developed similar, more contemporary versions of the cleft lift. I continue to refer to the procedure as the ‘cleft lift’ as a tribute to Dr. John Bascom, who has devoted a good portion of his professional life to this underappreciated disease. His hard work, insight, and excellent judgment led to a well-tolerated and reproducible procedure that can be performed in an outpatient setting.
About early disease and acute abscesses
Acute pilonidal abscesses should be treated with prompt surgical drainage. This is an office-based procedure and will yield prompt relief of pain. Don’t worry! The drainage procedure rarely causes significant discomfort and you should feel much better in hours. Antibiotics may be prescribed after a drainage procedure, but rarely should be prescribed without draining the acute abscess.
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Pit excision procedures
After healing from an acute abscess drainage, pits may become visible in the natal cleft midline. What to do at this point in time is controversial. Some surgeons recommend pit excision. While this may help prevent future acute abscesses or progression of pilonidal disease to a chronic abscess, this strategy has not been well researched. Sometimes, pit excision can lead to worse disease. Pit excision or “picking” is only appropriate for those patients who have one or few pits and no sinus.
Each case should be treated individually. Often, conservative and non-excisional care is the best approach.
If recurrent or persistent disease occurs after pit excision, then a cleft lift can be performed with excellent outcomes.
Sometimes too, pilonidal disease skips the early stage and presents for the first time as advanced disease that affects a significant portion of the cleft. In this situation, cleft lift surgery is necessary and can prevent worse disease in the future.
Description of the cleft lift procedure
The following diagrams demonstrate the principles of the cleft lift procedure. The portion of the body pictured here is the buttock area viewed while a person is lying on his/her stomach with the buttocks up facing the viewer and pulled apart to show the valley of the natal cleft.
In the diagram below, the outline represents the contours of the buttocks and anal area. The dashed line is the rim of the natal cleft and is marked while a patient is standing in a relaxed position. When standing, these lines meet. With the patient lying flat on his/her stomach and the buttock cheeks taped apart (as in these diagrams), the valley of the natal cleft is revealed. The red dots within the natal cleft represent dilated pores or ‘pits’. The red dot in the upper left corner is the sinus (tunnel) opening that is often associated with a chronic pilonidal abscess.
In the diagram below, an island of skin is marked to the left of the midline. This purple area is excised and the flap is elevated off the right side of the cleft. The underlying abscessed tissue is unroofed and cleaned. The abscess cavity wall is preserved, as it will heal if in folded on itself. Next, the deep tissues of the ‘valley/cleft’ are sewn together (not shown) to accomplish three goals: 1) to make the cleft less shallow, 2) to re-contour the cleft to remove divots, and 3) to minimize tension on the flap. Minimizing tension on the flap is vital to preventing the incision from being dragged back into the cleft. The arrows show the direction of flap advancement (across at the top and middle of the cleft, and rotated around the anus).
A closed suction drain is inserted during surgery through a small hole at the upper portion of the flap and is placed under the flap. It drains fluid from under the skin flap so that the flap will stick to the underlying tissue. You or your helper will need to drain the fluid from a collection bulb twice a day while the drain is in place and you will need to keep track of how much fluid is being drained each day. The drain is usually removed around 7 – 10 after surgery once there are 2 consecutive days with less than 20 mls of fluid drainage. If you are travelling a significant distance to have surgery, you will be shown how to easily remove the drain yourself.
How do I take care of the drain?
You will receive instructions on how to take care of the drain at the surgery center or hospital.
Please view the drain care video before your surgery, and ensure that you have a care taker who can assist you with the drain procedure for around 8 days. Watch the drain video for instructions.
The Sternberg Clinic shares its instructions for preparing and recovering from the Cleft Lift surgery, including tips for patients and caregivers.
After many years performing major abdominal operations including open and laparoscopic resections for colon cancer, rectal cancer, Crohn’s disease, and Ulcerative colitis, I have chosen to concentrate my efforts in a few highly specialized areas of surgery where I feel I can make the greatest positive impact on patients.
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