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.

Pilonidal disease also can arise after trauma, such 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 that are 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 a little more than an hour. You will be in the recovery area for an hour to an hour and a half. 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 a spinal anesthetic. It’s very safe (many women have this type of anesthetic when they deliver babies). Don’t worry, once you’re positioned, you will be sedated, sleep for the procedure and won’t be aware of feeling a thing.

BEFORE SURGERY: You should consider buying the following:

• Black tight-fitting underwear (Fruit of the Loom briefs work well) – they keep the gauze on the wound without tape and don’t reveal the gore.
• Balneol – a great cleanser that helps clean 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.

Patient Resources

Patient Instructions and Forms

Looking for the New Patient History Form and post-operative instructions for Pilonidal Surgery and General and Colorectal Surgery?

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Common Questions After Surgery

What will recovery be like?

Most patients experiencevery little discomfortfrom the operation. Most individuals experience some numbness on the side of the flap that can take around 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). The 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 or 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 with the 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; help you to conquer this disease!

Watch this how-to video to see how to care for the drain.

Can I shower after surgery?

Yes. You can shower the morning following surgery. Make certain to remove all of the gauze first. 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 that we provide to you 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 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 underwear is best to wear while recovering from the cleft lift as it helps hold dressings over the wound and compresses 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 in them) will be placed on the skin across your incision. Don’t remove them. They are intended to support the wound and should be left in place until they fall off or when the drain is taken out.

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)
• 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.

All medications should be taken with food, or they may induce nausea. The Ibuprofen is the more important of the pain relievers as it decreases inflammation. Ibuprofen should be taken three times a day for 10 days, while the narcotic should only be taken every 6 hours if needed (and discontinued once your pain is adequately relieved by the Ibuprofen). Also, narcotics may cause constipation, so you should only take narcotics 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 actually encouraged as it helps push any fluid that accumulates out from under the flap.

What if I become nauseated after surgery?

Nausea for a day or so after surgery is common. On the day of the operation, it’s often due to the anesthetic. Oral anti-nausea medication is often not helpful and has many side effects, so I don’t like to prescribe it. Most commonly, nausea is due to the pain medications oxycodone or 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 and nap. Place a cool, moist cloth on your forehead. You may resume the pain medications with food after the nausea subsides. 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 drain from surgery since fluid will accumulate under the potential space under the surgical flap.  If you have a drain with a tube connected to a bulb, then you have a “closed suction drain”.  Here’s how to take care of it:

Secure the tube and bag inside your clothing with a safety pin.

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

1. Empty your drain at least twice a day into the provided measuring cup and record the volume of fluid to show Dr. Sternberg at your next appointment.
2. Change the dressing around the tube every day.
3. You should remove the dressing when showering and replace it.
4. “Stripping” the tube helps keep blood clots from blocking the tube.  Best to do with an alcohol swab or with soapy fingers (so your fingers slide).
5. Please wash your hands thoroughly (goes 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, then it is not applying 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 that there is no more fluid accumulating under the flap, but it could also mean that the drain is clogged.  You should strip the drain.

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, close to 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 where it comes out of your body and move toward the drainage bulb.  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 removed after it puts out less than 20 cc of fluid each day for 2 days in a row.  This is generally 8 to 10 days after surgery.  Please call Dr. Sternberg before doing so.

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 call Dr. Sternberg.  You should also gently remove the Steri-Strips by peeling them off without pulling aggressively after the drain is removed.

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 the stool softener and Milk of Magnesia if needed (see the next FAQ section)
• Use wet wipes or Balneol (better) to clean 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 definitely lead to constipation, and the prescribed stool softener should be taken regularly. 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.

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

Bruising after the cleft lift is common. It’s very important that you see Dr. Sternberg 24-48 hours after your surgery (this appointment should have been set-up when you scheduled your surgery). The purpose of this appointment is to: 1) insure that your drain-helper is properly performing the drain procedure, and 2) to make certain that a blood clot hasn’t accumulated under the flap the night after surgery (often responsible for bruising). If the latter has occurred, Dr. Sternberg should be able to evacuate the blood clot in the office without difficulty.

The incision separated a bit, what do I do?

This occurs fairly often due to the fragility of the skin in the area (due to infection before or at the time of surgery) and tension from walking and sitting. Despite the skin separation, these wounds will heal, so don’t panic!

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 the rolling procedure with both of you in the office, as it is critical for a good outcome. Also make an appointment for around a week after surgery to have the drain removed. 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. It’s perfectly acceptable, however, to take the week off until your drain is removed.

When can I go back to sports?

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

When returning to physical activity, please avoid anything that causes pain, don’t submerge in the water, and avoid rigorous activities where you could possibly 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 10% of patients may have some minor incisional separation near the anal end of the wound. This is generally not a problem and should not delay recovery.
• An infected fluid collection can occur under the flap but is rare. It may delay your recovery; however, you should still end up with an excellent result. Since changing the type of drain placed at the time of surgery to a ‘passive’ drain, rare complications have occurred.

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 intent of the cleft lift procedure is to prevent recurrent pilonidal disease. In Dr. Sternberg’s last almost 1000 Cleft Lift patients, only 7 required a second operation and all 7 are cured. Those are pretty awesome results.

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