Pilonidal Excision Surgeries
Excision treatments involve removal of tissue during surgery, you find them also referred to as a Pilonidal Cystectomy. These surgeries are done under full anesthesia at an outpatient surgical center and range from simple to highly complex.
There are more conservative versions of open and closed excision surgeries where the surgeon doesn’t remove very much tissue and instead locates ALL the sinus tracts and Pits, then removes the Pits and brushes the tracts. These still need to be done under full anesthesia because the surgeon doesn’t know just how extensive the network of sinus tracts might be, he/she needs the patient to be fully sedated in order to find all the tracts.
The one lesson we hope all patients and surgeons will take away from their research at this website is to follow the “best practices” suggested by Bascom and other top surgeons to stay “off-midline” with Pilonidal surgery wherever possible.
Off-midline means is to “stay out of the ditch” of the natal cleft. Wounds directly in the midline of cleft are the hardest to heal due to lack of oxygen. Wounds heal better when out of the midline where the tension is less and they are more likely to be exposed to air. When seated and standing, the buttocks clamp shut and create an air seal that traps debris and bacteria in the area, leading to slower healing and greater incidence of wound breakdown.
Any of 3 major options for surgical treatment will work effectively as long as the surgeon “stays out of the ditch” to greatest degree possible and makes CERTAIN to excise all Pits at the same time. Active Pits left in the midline will delay wound healing indefinitely and ultimately lead to reoccurence.
Excision with Open Healing
You will find this also referred to as: secondary healing, healing from the bottom up, healing from the inside out
What it is – In this procedure the tissues around the abscess and sinuses are completely removed. The resulting wound is left open to heal and fill in naturally from the bottom. Bottom up healing is typical for cavity wounds because it allows the body to replace the tissue removed during surgery. This is the slowest form of healing (8 weeks) but has a lower rate of infection and reoccurence (5-15%) compared to traditional closed wound healing. During healing the wound is normally cleaned out and re-packed with gauze at least twice daily. Some surgeons do not believe in packing – as long as the wound bed is flushed with water twice daily this technique should work as well. The important part is to remove the by-products of healing from the wound bed to keep the healing area as clean as possible, “packing” is simply one method of doing this.
Where it’s done – Excision surgery for Pilonidals is usually done at an outpatient surgical center and takes an average of about 45 minutes; it is typically done under MAC Anesthesia, Spinal Block, or General Anesthesia. You will spend 4 to 5 hours at the clinic and then go home afterwards.
Recovery time – Approx 8 weeks. The first week after the surgery will be the worst and you will need to be home resting during this time because you will not want to sit (trust us on this). You will be advised not to drive for the first few days after surgery (nor will you want to anyway, because, sitting…) Some insurers will actually pay to have a home health nurse come and do your packing changes twice daily. Otherwise, it is possible to do packing changes yourself (I did all my own), but easier if you have a spouse/family member/significant other to help. Most doctors will advise that you can return to work after the first week. In a perfect world, it is best to allow for 2 weeks at home for recovery, but not everyone can do that. You should be back to most normal activities by 4 weeks into healing. Sports should be delayed until healing is complete.
What else you should know – An additional technique called “Marsupializaton” is also sometimes used (the edges of the open wound are stitched all the way around like a button hole) to keep the wound from closing too quickly. This technique speeds up healing time by several weeks.
Resources
Excision with Primary Closure
You will find this also referred to as: closed healing, healing by first intention, sutures, stitches
What it is – In this procedure, the abscess tissue and sinuses are removed and the wound is closed with sutures/stitches. We strongly suggest the surgeon stay out of the midline and keep the incision off to the side where it will have more exposure to oxygen. Closed incisions that run into the lower midline are the hardest to heal and the most likely to fail. The primary benefit of this technique is the faster healing time. The primary negative is the higher rate of infection.
Where it’s done – Excision surgery is usually done at an outpatient surgical center and takes an average of about 45 minutes; it is typically done under MAC Anesthesia, Spinal Block or General Anesthesia. You will spend 4 to 5 hours at the clinic and then go home afterwards.
Recovery time – Approx 4 weeks. The first recovery week after the surgery will be the worst and you really will need to be home resting during this time. Most doctors will advise that you can return to work after the first week, although we suggest two weeks if at all possible. You will be advised not to drive for the first few days after surgery. Stitches typically come out in 10-14 days and it is possible your surgeon may insert a drain to reduce chances of infection.
What else you should know – Excision with primary closure is an option for people who cannot undergo an 8 week healing period. The drawback is that the infection rate is 20-25% for this procedure and if you do get an infection or wound breakdown then you will have to go through open healing anyway. More recent medical techniques are now using Primary Closure with closed-suction drainage and antiseptic flushing of the wound –this seems to greatly reduce the infection rate, be sure to ask your surgeon about this if you are considering Primary Closure. The danger with closed wound incisions (especially those close or on the midline) is that this area of the body moves in many directions during daily life and this movement places a great deal of strain on the sutures, especially those inside the wound.
Also note, surgical wound infections can be very dangerous (as in, fatal) so if you see drainage, redness, odor or swelling get to your doctor ASAP.
Resources
Cleft Lift / Modified Karydakis
You will find this also referred to as: Cleft Closure, Bascom Procedure
What it is – These are both very similar procedures developed in line with theories by Karydakis about the origins of pilonidal disease. In the Cleft Lift, the actual shape of the cleft is changed to be more shallow and allow for better healing. The surgery was originally developed to deal with surgeries that had failed to heal or continued to recur and is now being done more and more as a first surgery.With the both techniques, the surgeon removes an ellipse as he/she excises the pilonidal. To cover the “cavity” the surgeon undercuts the other side and pulls across the midline a flap of skin and thick fat becomes shallow and the single suture line lies in open air to the left of the midline. By almost flattening the cleft, the gathering of loose hairs is less likely, and the there is no portal of entry left for hair entry (they always enter a midline hole, not one on the side), thus greatly reducing the risk of recurrence.. The now less-deep cleft is also less of a happy harbor for anaerobic bacteria. One of the key elements to both the Cleft Lift and the Modified Karydakis are that all incisions are made to the side of the midline, never right down the middle. All wounds are closed with sutures and tissue removal is minimal.
Where it’s done – Hospital or Outpatient Surgical Center. Usually scheduled as a day surgery with the patient going home that evening. In some cases and overnight stay may be suggested.
Recovery time – Patients usually return to work after 2 weeks. Healing is usually complete within 4 weeks.
What else you should know – Finding a surgeon doing this technique is challenging, you may need to travel to a major city. Also, your insurer may not cover the surgery, be prepared to fight for it. We have the proper codes for your doctor to use on the Insurance page. If your local surgeon doesn’t know this technique, he/she may be willing to learn! We have videos of the surgery in the Medical Professionals Resource section and Dr. Tom Bascom is willing to consult long distance with your doctor.
Drs. John and Tom Bascom created a presentation overview of the Cleft Lift surgery:
Cleft Lift Overview
We maintain a list of known Cleft Lift surgeons worldwide here.
Resources
Other Flap Surgeries
Limberg Flap, Z-Plasty, Rotational Flap
**Note** is our general opinion that these surgeries are less effective choices and anyone considering them should first search for a surgeon doing either Modified Karydakis or Cleft Lift. These surgeries can remove large amounts of tissue, which destabilizes the area and leaves very few options to the patient if they fail. It is our opinion to exercise caution when suggesting removal/movement of large amounts of tissue, especially when there are better techniques that preserve tissue. The underlying tissue of a Pilonidal is not the problem, the depth of the cleft and Pits (follicle blockage) is the problem.
What it is – To treat pilonidals with a Limberg flap, the surgeon removes an oblong-shaped plug containing pilonidal abscess, skin and fat, thus creating a “cavity.” To fill the “cavity” the surgeon extends the cut laterally then downwards and mobilizes a block or flap of skin and thick fat, from the buttock beside and below the cavity. The surgeon swings the flap into the center and pulls together the edges with sutures. The re-positioned plug makes the cleft become shallow but leaves a more complex suture line than after the Karydakis. The Limberg flap works well if sutures are positioned out of the cleft. Rotation flaps loosen the entire buttock and rotate it to move tissue into the midline cavity. Z-plasty loosens triangular flaps on each side of the midline to fill the cavity, with points of the flaps toward the head and foot. The surgeon crosses the pointed flaps to cross the midline in a horizontal direction, thus converts an N shaped incision to a Z shaped closure.Textbooks suggest the source of pilonidal failure-to-heal is a “cavity” unfilled. Bascom reviewed failed operations and found otherwise. Instead, pilonidal operations fail when a surgeon leaves a suture line or an overhang within a cleft, especially a deep and tight one. Operations succeed when a surgeon reshapes the cleft, changes deep to shallow, and when he/she moves the cleaned-out chronic abscess walls in place. Cleft Lift thus creates no cavity. The Cleft Lift operation, like a face lift operation, moves flaps, but of skin only, not fat or muscle. Cleft Lift excises excess tissue, but skin only, and covers the walls of the cleaned-out abscess with a thin flap; leaving the abscess wall in place where it will heal. The resulting wound, like the Karydakis operation, ends up with a vertical scar to one side of a shallower midline. Because of its similarity in appearance it is sometimes called a modified Karydakis operation.
Where it is done – Hospital, average stay of 3 to 5 days. This is a major surgery that requires an overnight stay.
Recovery time – Patients usually return to work after 2 weeks. Healing is usually complete within 4 weeks.
Resources
This page last updated: January 4, 2019
