| "Is surgery the only option?" - To a
degree, yes. But this doesn't always mean wide and deep
excision, there are conservative techniques that are much better and
much less invasive. Pilonidals will not be
cured by Herb Compotes, Colloidal Silver Concoctions, Tea Tree Oil
or any other potion. Some people have a mild enough case that they
can live with their Pilonidal, if this is you, count yourself very lucky.
Most people who have had a nasty flare-up and a lancing are in for
more problems.
"Should I get surgery or not?" - We can't answer that for
you. Since Pilonidals range from mild to severely aggressive, what
we
suggest is that you read through the entire site very carefully and
then make a decision knowing the facts and the risks. You can visit
4 surgeons and get 4 different answers as to what to do, so it's up
to you to make the choice. You may never have a major flare up and
might be able to go through life and have no problems. You can
choose to take a wait and see approach but you must understand the
risks and how Pilonidals tend to progress. The risk that you have to consider
is that while you may not be showing any symptoms, the cyst could be
tunneling away deep inside and getting larger. You are also asking
your immune system to be constantly on-the-go against the infection,
which may wear it down and leave you more vulnerable and less able
to defend against other infections. And you have to know that if
you see even one new sinus hole show up, that you need to high-tail
it in to the surgeon.
"I'm freaking out! All I see on the forums
here are recurrences
and problems!" - The forums are not an appropriate
yardstick to measure Pilonidal surgery by. To get a better view,
spend some time reading the Personal Stories pages. Message boards,
in general, only appeal to a certain segment of people who are
comfortable with them and usually the people posting on message
boards are those having problems and needing support. The bigger
problems they are having, the more they post.
"What is a lancing?" - A lancing (aka Incision & Drainage) is
where the doctor cuts open the top of the cyst (usually under local
anesthesia) and drains out the pus/hair inside. Usually, the top is
left open and stuffed with gauze but some surgeons don't like gauze
and just leave it open to heal -- both methods can work. The gauze is repacked daily and
healing is complete within about 2 weeks. Lancing, by itself, only
works approx 40% of the time. Usually the abscess becomes infected
again and full removal is required.
"How is a lancing different from excision (full removal)?" -
With a lancing, the abscess is just cleaned out but the deep tissues
and "pits" are still there. Full excision
means removal of the abscess area all the infected tissue around it. There
are newer techniques that leave the deep tissue intact and
brush the abscess cavity and sinuses out, then remove the "pits". It
is well worth your time to find a surgeon that does this less
invasive technique first and save more invasive surgery as a second
choice.
"What are all these other special surgeries (Z-Plasty, Karydakis,
Limberg)?" - These advanced procedures are methods to correct
failures of the first operation (excision). The basis of most of
them is to flatten out the gluteal fold and move the incision off to
the side - this helps to get the wound out from inside the cleft so
more oxygen can get to it and help it heal. There are several kinds
of "Flaps" that can be done and these surgeries are very
complicated.
"There's a lot of talk about the Bascom procedure?"
- Dr.'s
John and Thomas Bascom have pioneered a surgery called the
CLEFT LIFT. They
are having great success with unhealed wounds and people who have
had multiple surgeries fail. We have a listing of surgeons in
the USA that have requested information or are practicing the Cleft
Lift/Pit Removal procedures,
which is in PDF
form and can be
downloaded here.
"What is the difference between open healing and closed healing?"
-
- Open healing (aka, healing from the bottom up,
healing by secondary intention) involves leaving the wound open
- no stitches. The wound heals by filling itself in from the
bottom. Average healing time is about 8 weeks. Open healing
involves packing the wound at least twice a day for 8 weeks; it
is a long, tedious process but it's also the one with the
highest cure rate. The infection/recurrence rate for open
healing is 5% - 10%.
- Closed healing (aka, stitches, sutures, primary closure,
healing by first intention) involves stitching the wound
closed after surgery. Average healing time is less than 4 weeks.
The drawback is that the infection rate goes up to 20% and if
you do get an infection the remedy is to re-open the wound and
let it heal from the bottom up. However, there is a new
technique that is showing great promise. It involves using a
closed-suction drain and flushing the wound with antiseptic
solution - the drain is removed after about 9 days and the
infection rate drops to about the same as with Open Healing.
"What about the anesthesia?"- Excision surgery is best done
under MAC (managed care anesthesia) which is very heavy sedation
with local anesthesia or a Spinal Block. You do also have the option
of having General Anesthesia. You may think that you would prefer to
be awake during your surgery but with this operation you will be
face down, looking at the shoes of your medical team, while you are
in the "jack knife" position bent at the waist with your rear end
stuck in air.
If this is your first surgery or you are very nervous you can ask
for a sedative in your IV - this is a post from the message board:
"a surgical nurse suggested that I ask the anesthesiologist for
Versed which she called the "happy to go with you" drug. He was
happy to give it to me in my IV. I was scared and crying before I
got the drug, but afterwards, I was giggling and happy as a clam.
Wheel me away whoo hoo! Anyway... I was glad to get something to
help me relax. No matter what anyone says, surgery is scary!"
Also read the "Anesthesia"
page....
"I've heard about some kind of blue dye used in surgery?"-
The dye is called Dilute Methylene Blue, and some surgeons inject it
into the wound just prior to surgery. It stains all the infected
tissue a blue color, thus making it easier for the surgeon to
identify and removed ALL the bad stuff. The dye should show all the
offshoots and chambers of the cyst that might be missed. If you are
planning surgery, be sure to ask your surgeon about it.
"Why a Colon & Rectal Surgeon?" - Pilonidal Disease is
officially classified by the medical establishment as being a
disease of the Colon & Rectum, even though it affects neither. The
only doctors whom you can expect to have a brochure in their waiting
room on this disease are Colon & Rectal Surgeons. Almost all of the
major research and articles on this disease have been done/written
by Colon & Rectal specialists.
However, if your general surgeon can discuss the various techniques
and explain them to you, then you can feel more confident that
they've done their homework. Ask any surgeon who you are considering
to explain the difference between open healing and closed. Ask them
to explain Marsupializaton, Flap Surgery and Follicular Occlusion.
Ask them about the dye that can be injected into the cyst to
identify the infected tissue. If your surgeon can't explain these
things to you then find another doctor who is up on the current
treatments and surgeries.
A small number of people are truly born with an obvious
sinus opening, this is technically called a Sacral Dimple and is not
actually related to Pilonidal Disease as discussed on this site. If you are not one of those people (just ask your
mom, she'll remember if you had a hole in your bottom at birth) and
your doctor is adamant that Pilonidal Disease is something you were
born with, this should be a big red flag that it's time for you to
find another doctor.
"Where do I find a Colon & Rectal Surgeon?" - The best place
to start is at their web site:
www.fascrs.org.
Interview as many doctors as you need until you find one you are
comfortable with. The FASCRS site lists doctors from around the
world. Look for a surgeon who is ABCRS Certified. The discussion
board also has listings of qualified surgeons.
If you are in the UK you also might try contacting the Wound Healing
Research Unit at the University of Wales College of Medicine
(Cardiff) for some references.
http://www.whru.co.uk/index1.asp
Lastly, we have special forum on the message boards that features
surgeon recommendations.
"What should I ask a prospective surgeon during a consultation?"
- here is a basic list to judge surgical fitness for Pilonidal
Excision Surgery
(Doctor
Questions). This won't cover every question you will want to ask,
it was meant to be a guide for a patient to gauge how well a surgeon
has kept up on their Pilonidal Cyst homework. You should know all
the answers to these questions before you walk into any surgeon's
office...
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