Pilonidal Surgery FAQ

Common Questions about Your Diagnosis of Pilonidal Disease

I’ve been diagnosed as having coccydynia. Could this be a pilonidal cyst/abscess?

Some patients with pilonidal disease are told that they have a condition called coccydynia. Coccydynia, or tailbone pain, is caused by trauma to the tailbone (also termed the coccyx). The injury can be acute, from a fall, or chronic, from repeatedly sitting on hard surfaces or riding a horse, for instance.

The pilonidal disease also can arise after trauma, such as a fall. Distinguishing between pilonidal disease and coccydynia can be difficult. The key to determining which condition is causing discomfort is to identify the midline pits or pores seen in pilonidal disease. Most of the time, swelling (from an abscess under the skin) is also present in pilonidal disease. Swelling is rare in coccydynia.

Common Questions about Surgery

How long does the cleft lift procedure take?

The operation takes around 90 to 120 minutes, depending on the complexity of your disease. You will be in the recovery area for around an hour. During this time the nurses will go over all of your postoperative instructions and the drainage procedure with you and your helper.

What type of anesthesia will I have?

Most patients receive general anesthesia. This is usually the safest approach, as many of our patients have complicated pilonidal disease. Dr. Sternberg always takes the necessary time to ensure the best results. During the procedure, you will be sedated, allowing you to sleep and ensuring that you won’t feel any pain.

BEFORE SURGERY: You should consider buying the following:

• We recommend wearing snug-fitting athletic compression shorts while the drain is in and for one to two weeks after removal to help support healing. The compression helps the thin skin flap stick to the underlying tissue and prevent fluid from reaccumulating under the flap after the drain is removed. They should fit snugly, so buying a size smaller than you typically wear is best. You may purchase these but any good quality compression shorts that place pressure on your backside are fine.
• Qleanse or Balneol– either is a great cleanser that helps wiping after a BM. Just put a small amount on the TP, and wiping after a BM is easy.
• MOM (Milk of Magnesia) – if you become constipated after surgery, take 2 Tablespoons every 6 hours until you have a BM. Then stop taking it so that you don’t develop diarrhea.

Common Questions After Surgery

What will recovery be like?

Most patients experience very little discomfort from the operation. After surgery, individuals experience numbness on the side of the flap that can take 6-8 weeks to completely go away. The numbness always goes away.

The discomfort is usually well controlled with the two prescribed pain medications: ibuprofen and a narcotic (typically Oxycodone/Acetaminophen). Ibuprofen should be taken regularly, three times a day with meals, and the narcotic pain reliever should be taken only as needed for additional discomfort. Please take all pain medications with food, as they may cause nausea.

Additionally, you will be prescribed an antibiotic for two weeks after the procedure to decrease your chance of developing a postoperative infection.

Do I really need help after the operation?

Having someone help you drain the wound is very helpful, as you will not be able to inspect your incision or take care of the drain easily (it’s all behind you :-)). Drain care is simple, but it’s best done by a helper.

Let’s face it: You’ve decided to have an operation to fix this terrible condition. You can recruit a parent, girlfriend, boyfriend, or roommate to help you conquer this disease!

Watch this how-to video to see how to care for the drain. Please note that the drain has changed slightly. The first bit is hard so the securing suture doesn’t collapse it. In order to strip it you need to squeeze the first soft portion which is 2 inches away from it’s exit site.

Can I shower after surgery?

Yes. You can shower the morning following surgery. Make certain to remove all of the gauze first. Do not remove the steri-strips that are criss-crossed over the wound. They need to stay in place for 10 days or so after your surgery. It’s important to keep the wound dry after showering. Soaking in a bathtub, however, is not permitted for four weeks or until the wound is fully healed. You will find the lanyard we provide very helpful in securing the drain while showering.

Is there any special care for the wound?

I recommend that you try and keep the wound clean and dry. Remove the gauze bandages when having a bowel movement or showering. Please clean the wound carefully after a bowel movement. Wet wipes, Qleanse foam, or Balneol lotion on toilet paper works best. After cleaning or showering, blot the wound and your perianal area carefully with a towel, and then dry completely with a hairdryer on the “low” setting.

Tight-fitting athletic compression shorts are best to wear while recovering from the cleft lift. They help hold dressings over the wound and compresjm s the operative site (discouraging fluid accumulation). The dressing applied after surgery is there to protect your clothing. Don’t use tape to hold gauze in place, as it can injure your incision—instead, use tight-fitting underwear to hold dressings in place.

Steri-strips (thin paper-like tapes with parallel fibers) have been placed on the skin across your incision during surgery. Don’t remove them. They are intended to support the wound and should be left in place until you are instructed to remove them three days after the drain has been removed.

What medications will I prescribe after surgery?

The majority of patients will be prescribed the following medications:

• Ibuprofen, a NSAID that relieves pain and decreases inflammation
• A narcotic pain reliever (typically Oxycodone with Acetaminophen)
• And, an antibiotic for two weeks.
• If you end up taking the narcotic pain medication, it may constipate you, so having a bottle of Milk of Magnesia (an over-the-counter laxative readily available at all pharmacies) around is helpful. The proper dose is 2 tablespoons 3 times a day until you have a bowel movement. Stop as soon as you do have a bowel movement, or you will have diarrhea. This is likely different than the instructions on the bottle.

All medications should be taken with food, or they may induce nausea. Ibuprofen is the most important pain reliever as it decreases inflammation. It should be taken three times a day for 10 days, while the narcotic should only be taken every 4 hours if needed (and discontinued once the ibuprofen adequately relieves your pain). Also, narcotics may cause constipation, so you should only take them if you need to.

Please let Dr. Sternberg or his office staff know if you have any allergies or prior reactions to the medications listed above well in advance of surgery.

Can I sit down immediately after the procedure?

Yes. Sitting is encouraged as it helps push any fluid that accumulates out from under the flap. But please don’t sit if it is too painful.

What if I become nauseated after surgery?

Nausea for a day or so after surgery is common. It’s often due to the anesthetic on the day of the operation. Oral anti-nausea medication is often not helpful and has many side effects, so I don’t like to prescribe it. Nausea may be due to the pain medications oxycodone, hydrocodone, or Ibuprofen. Please make certain that you never take any pain medication on an empty stomach.

Should you develop nausea, please hold your pain medications for several hours and try to nap. Place a cool, moist cloth on your forehead. You may resume the pain medications with food after the nausea subsides. It’s best to just take the ibuprofen and avoid the narcotic (oxycodone or hydrocodone). Remember, never take any of your prescribed medications on an empty stomach. A small amount of food, such as bread or toast, will help settle your stomach!

How do I take care of the drain?

You have a closed suction drain from surgery since fluid will accumulate under the potential space under the surgical flap. Here’s how to take care of it:

Secure the tube and bulb inside your clothing with a safety pin or with the attached clip (if present).

It may be uncomfortable for you to sleep on your back for the 8 days the drain is in.

1. Empty your drain twice a day into the provided measuring cup and record the fluid volume in CCs (also termed MLs) on the provided log sheet.
2. Change the dressing around the tube every day.
3. You should remove the dressings when showering and replace them. No tape is required. Just have the tight-fitting underwear hold them in place.
4. “Stripping” the tube helps prevent blood clots from blocking it. It is best to do this with an alcohol swab or soapy fingers (so your fingers slide).
5. Please wash your hands thoroughly (go for a helper if you have one, too) before emptying the drain!
6. The bulb should be partially compressed at all times. If the bulb is full and round, it does not apply suction and should be re-compressed.

Emptying the bulb:

1. Get your measuring cup ready.
2. Clean your hands well with soap and water or with an alcohol-based cleanser.
3. Open the bulb cap.
4. Empty the fluid into the measuring cup and record the date and the time for Dr. Sternberg.
5. Squeeze the suction bulb and hold it flat.
6. While the bulb is squeezed flat, close the cap.
7. Flush the fluid down the toilet.

What if there is no fluid draining into the bulb?

This may mean no more fluid accumulating under the flap, but it could also mean that the drain is clogged.  You should strip the drain. If there is little or no drain fluid for the first day after surgery, don’t be concerned and there is no need to call. You will be seeing Dr. Sternberg the day after surgery and he will make certain that your drain is not clogged.

1. If you see a blood clot or obstruction in the drain, squeeze the tubing there to help break it up.
2. Grip the drain with your fingers at the first soft portion, around 2 inches from where it exits your body and compress the tube to occlude it.  With your other hand squeeze down the length of the tube with an alcohol pad or with soapy fingers (so they slide). Start at the first soft portion of the tube.  Keep the stripping fingers compressing the tube and release the fingers compressing the tube where it exits your body. Do this several times until fluid is draining into the bulb.

The drain is typically removed after the drainage is less than 15 cc of fluid each day for 2 days in a row after it’s in place for 8 days. Please text Dr. Sternberg before removing it. If you have a complicated case or a large abscess, you may be asked to wait until the drain output is lower. Being patient is important. If the drain is removed prematurely, fluid can reaccumulate, and that is not an easy problem to fix.

Removing the drain is simple.  Simply cut the suture holding it to the skin at the skin level and gently pull the drain out.  The drain is approximately 15 cm or 7 inches long.  It should slide out easily and not hurt.  Before removing the drain, please text Dr. Sternberg.  You should also gently remove the Steri-Strips 3 days later by peeling them off without pulling aggressively.

Once the drain is out, we want the hole in the skin that the drain came out of to scab over.  Please allow 3 or 4 days until it stops leaking.  Then the patient can start to exercise with the caveat that they should not ride a bike, fall on their backside, or submerge in water.  Squats are also not a great idea but lifting weights and walking or running is fine.  Please have the patient call Dr. Sternberg a month after drain removal so I know they are okay.

That incision looks like it comes pretty darn close to the anus. Will having a bowel movement be a problem?

In patients with long clefts and in those patients with pits or unhealed wounds approaching the anus, the surgical incision needs to end close to the anus. Nonetheless, having a bowel movement shouldn’t be much of a problem. Several pointers:

• Don’t get constipated! Take a fiber supplement to help prevent constipation such as Konsyl or take Milk of Magnesia to relieve constipation if it happens (see the next FAQ section)
• We recommend using Qleanse foam or Balneol lotion on toilet paper as it works best for cleaning after a bowel movement for several weeks after surgery.
• Showering (not bathing) after a bowel movement is a good idea for the first several days after surgery.

Will I become constipated?

Not as a result of the procedure. But taking a narcotic can lead to constipation. If you go for a day without a bowel movement, please buy Milk of Magnesia. It is available over the counter. Take 2 tablespoons every 8 hours until you have a BM. Then stop taking it to avoid having diarrhea.

My buttocks are black and blue! What do I do?

Bruising after the cleft lift is common. You must see Dr. Sternberg the day after your surgery (this appointment should have been arranged when you scheduled your surgery). The purpose of this appointment is to 1) ensure that your drain helper is properly caring for and emptying the drain and 2) make certain that a blood clot hasn’t accumulated under the flap and clogged the drain. If the latter has occurred, Dr. Sternberg often can easily evacuate the blood clot in the office.

The incision separated a bit. What do I do?

This occurs in around 20% of patients and is due to 1) infection, 2) fragility of the skin from an abscess at the time of surgery, or 3) tension, as many patients with pilonidal issues have very tight clefts. Don’t panic as even with incisional separation, these wounds will heal usually heal but may require some extra care.

1. Please let us know and Dr. Sternberg will likely want you to send us a photo of the incision. Not all separations are significant enough to require extra care.
2. If the separation is significant enough, we will likely advise applying Medihoney Gel to the area twice daily (cover with gauze afterward). Please don’t dry the open portion of the incision with a hair dryer anymore, as you want to prevent a scab from developing. Should a scab develop, please stop using the Anacept and apply Vaseline petroleum jelly twice daily until the area appears healed.
3. We will want you to update us weekly until the healing appears to be headed in the right direction.

Other Common Questions

Do I need to make a follow-up appointment one day after surgery?

Yes! Please make an appointment to see Dr. Sternberg for the day following surgery and bring your drain helper. I will want to go over proper drain care and removal as it is critical for a good outcome. If you live far from San Francisco, I will show you and your helper how to remove the drain yourself so you can travel back home. Don’t worry; removing the drain is super easy and doesn’t hurt at all!

Will I have a scar?

15-22 cm (6-8 inches) in length, depending on the length of your natal cleft.

When can I return to work?

Most patients can return to work four days or so after surgery. However, it’s perfectly acceptable to take the week off until the drain is removed.

When can I go back to sports?

Please don’t exercise while the drain is in place. Walking is okay. You can sit on the operative site immediately after surgery (it helps push fluid from under the flap). Once the drain is removed, you may begin to gently exercise.

When returning to physical activity, please avoid anything that causes pain, deep squats, riding a bike, don’t submerge in the water, and avoid rigorous activities where you could fall on your bottom (skiing and snowboarding are bad early activities)for a month after the drain is removed.

For those patients that have had a prior failed operation or very complex pilonidal disease (a large wound close to the anus), I often ask them to refrain from sports for a few weeks more. 

What is the likelihood of a complication?

• Around 20% of patients may have some incisional separation near the anal end of the wound. If this occurs, it may delay your recovery, but it usually heals well.
• An infected fluid collection can occur under the flap, but it is rare. It may delay your recovery; however, you should still end up with an excellent result.

Should I regularly shave the area or have laser hair removal?

Shaving before or after a cleft lift operation is not advised and it may cause problems. You should know that:

• The disease is not caused by ingrown hairs.
• Hairs that deposit in pilonidal wounds are shed hairs that may come from areas other than the buttocks and natal cleft.
• The skin of the natal cleft is sensitive, and small nicks and cuts from shaving can contribute to infections. Chemical hair removers are very irritating.
• Once you have undergone a successful cleft lift procedure, you are no longer at significant risk of developing a recurrent pilonidal abscess.
• Laser hair removal is expensive, time-consuming, embarrassing, and unnecessary for the above reasons.

Will I be cured?

Most likely! The cleft lift procedure intends to prevent recurrent pilonidal disease. In Dr. Sternberg’s last 1,300 Cleft Lift patients, only 11 required a second operation, and all were cured. Those are pretty awesome results.

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