Pilonidal disease is a chronic skin and subcutaneous infection emanating from the center of the natal cleft, often extending to the buttocks. It is more common in males than females and usually occurs between the time of puberty and 40 years of age. A common theory is that pilonidal disease is caused by ingrown hair at the center of the cleft resulting in inflammation and infection extending to the buttocks. Presentation of the pilonidal disease can range from an asymptomatic cyst, or midline pits to chronically inflamed cyst, large open wounds in the midline, long draining sinus tract, or an acute abscess. Only in exceptionally rare cases is imaging required. Treatment depends on the disease pattern. An acute abscess is treated with drainage and antibiotics, while a complex or recurring infection is treated surgically with either excision of a cyst or unroofing of a sinus tract. Reconstructive flap techniques such as the Bascom cleft lift procedure, Karydakis flap, rhomboid, or Z-plasty can be done to reduce the risk of recurrence by leaving less scar tissue and flattening the region between the buttocks. Recent data has suggested that off-midline incision closure may lead to a lower risk of recurrence.1 Here, we present the case of a male patient who had previously had flap surgery for the pilonidal disease, but experienced recurrence and the development of a sinus tract. Due to the extensive nature of the disease, a deep flap is required to mobilize tissues and close the eventual wound.
Pilonidal disease, coming from the Latin “pilus” meaning “hair” and “nidus” meaning “nest,” is characterized as the presence of sinus tracts or natal cleft “pits.” Thought initially to be a hereditary disease, it is now recognized as being secondary to hair follicle obstruction and subsequent cyst formation and possible rupture with the creation of sinus tracts or abscesses. Although first described in the 1800s, much of the initially reported data on the disease came during World War II, when close to 80,000 U.S. soldiers were treated for the disease. Termed “Jeep riders’ disease,” surgical treatment was associated with dramatically poor outcomes and led to the historically favorable conservative approach. In a cohort study over 17 years, only 23 out of 150 cases (approximately 15%) required an operation, and for those presenting with an acute abscess, over 60% of patients can be managed with simple incision and drainage.2 Almost exclusively presenting initially in young adults, males preferentially over females, it has a calculated incidence of 26 per 100,000 individuals.3 Approaches to treatment vary considerably, leading to an associated inconsistency in outcomes and recurrence rates that range from 0–46% when considering all techniques together.4
Focused History of the Patient
Our patient presented with the recurrent pilonidal disease after having received a described cleft-lift procedure at another facility. Postoperatively, he developed an early recurrence with an associated long sinus tract. Only patients that fail conservative treatment are referred for surgery. Patients are instructed to use hibiclens solution to wash the cleft in the shower daily and perform hair removal in the cleft twice per month. Typically, at least 3 months of non-operative treatment is required prior to scheduling surgery in order to ensure that patients are compliant with the conservative treatment and to see if conservative treatment fails.
A pre-op physical exam is performed two weeks prior to the scheduled surgery date to ensure there is no acute infection. The patients are typically evaluated at least 2 times over a period of at least 3 months to see if surgery is really warranted and to rule out other conditions such as Crohn’s disease or hidradenitis suppurativa. At the time of examination, shaving of the hair around the gluteal cleft should be performed and patients should be provided with antibacterial soap to be used daily.
Typically, a history and physical examination together are sufficient for the diagnosis of a pilonidal cyst, without the need for additional imaging or laboratory evaluation.
For patients with asymptomatic disease, observation with shaving, and attention to hygiene alone is sufficient as most patients will not experience disease progression. Symptomatic disease, however, may be classified and treated according to the level of tissue involvement. Those with an acute pilonidal abscess may be initially treated with simple incision and drainage with healing by secondary intention. Patients with recurrent infections are considered for a definitive operation in the future if failing medical therapy. For more complex disease, including patients with sinus tracts, drainage, or recurrence, surgical excision with off-midline closure should be offered if medical therapy fails. Medical therapy includes local hygiene with hibiclens and hair removal, as well as one or more courses of broad-spectrum antibiotics such as Augmentin.
Options for Treatment
Options for treatment are numerous and controversial, leading many surgeons who are less familiar with pilonidal disease to defer to old or outdated techniques. Broad categories for treatment include excision with open healing, midline closure techniques, off-midline closures, and limited excisions. In addition, novel, minimally invasive approaches have begun to emerge as alternatives to traditional surgical treatment.
Excision with open healing by secondary intention is the most common approach and is often studied in counterpart with excision and primary closure.5 Although healing rates are faster with primary closure, the risk of recurrence also increases.
Midline, primary closure involves a complete excision with primary closure with the goal of accelerating wound healing. This approach, however, is plagued by wound dehiscence, recurrence, and infection, most likely due to the high degree of tension placed on the wound with activation of the gluteal muscles and an environment favorable for bacterial growth. As such, there is most likely little to no place for this technique with the advancement of off midline flap closures.6
Off-midline closures of flap techniques other than primary closure, helping to treat disease by flattening the gluteal cleft and reducing hair accumulation and irritation, can be performed via a variety of techniques, including the Karydakis flap, Limberg, Bascom cleft lift, and V-Y advancement flap. A review article from 2010 by Humphries et al. in Surgical Clinics of North America offers a technical review of the different approaches and interested readers are encouraged to refer to this article for more detail.7 Briefly, the different approaches are largely comparable, and selection be influenced mostly by surgeon preference and experience; although, the Limberg and Karydakis flaps remain the most studied to date. For recurrent disease in particular, however, as in the case presented here, the Bascom cleft lift procedure should be considered.8
Limited excision techniques have shown promise as having low morbidity with acceptable recurrence rates and cosmesis. As opposed to incision and drainage, excision of the entire sinus or deroofing and curettage without complete excision may be an excellent option for patients with limited disease, but as with simple excision, the main drawback to this approach is delayed wound healing with secondary intention.
Finally, while not completely studied, novel techniques such as fibrin glue,9 phenol treatment,10 endoscopic approaches,11 pit picking,12 and negative pressures dressings show promise. For patients unable or unwilling to tolerate an operation, or those looking for a rapid return-to-work time, these approaches may become more relevant as more data emerges. Also, while data is limited, many of these techniques report 80–85% cure rate. Of the 15% that fail, a cleft lift is indicated. The authors have noted a pattern in their own practice that long term disease management is often achieved through noninvasive means in 85% of our patients
Rationale for Treatment
Treatment for pilonidal disease centers around symptom management and psychosocial considerations pertinent to the young demographic most often affected. The morbidity associated with pain and lower quality of life must be balanced against other quality of life measures relevant for this group as well, including return-to-work times, pain associated with the operation itself, time to wound healing, risk of recurrence requiring intervention, and risk for complications.8 Consideration of these factors may alter the treatment approach, as different approaches offer a spectrum of risks vs. benefits as described above. For patients presenting acutely with an abscess, incision, and drainage, all that is needed to achieve a recurrence-free outcome in close to 60% of patients and is primarily intended to reduce pain and risk of sepsis.13
Patients with recurrent disease after surgical treatment are the most likely to require a complex, flap-based reconstruction and should be referred to a specialist who is familiar with treating recurrent disease.
Here we present the case of recurrent pilonidal disease treated with a Bascom cleft lift procedure.
The goal of this procedure is to remove all of the diseased tissue and obliterate the cleft with an off-midline flap creation. Prior to incision, a local anesthetic is injected surrounding the operative field and an elliptical incision is made. The incision comes as close to midline as possible on the affected side and carries out laterally on the affected side in order to encompass all of the diseased tissue. For this particular procedure, the midline incision was moved slightly laterally in anticipation of scar tissue being present and interfering with the dissection. Hemostasis is critical throughout the entire procedure, as the highly vascular and inflamed tissue here increases the risk for hematoma formation and subsequent infection.
The dissection skews towards the affected side, and pattern recognition here is key in terms of identifying a color change from healthy, yellow fat to diseased, purple, or brown tissue. It is essential to remove all of the diseased tissue while ensuring that enough healthy tissue is left behind to facilitate wound healing.
After removal of the diseased tissue, the dissection continues down to the gluteus maximus muscle for fascial release and flap creation. Again, for this highly vascular area, meticulous hemostasis is critical for the prevention of postoperative hematoma. If a fascial release is not enough to maximize tension reduction or pull the flap over, skin or subcutaneous fat flaps can also be created to close the flap and minimize tension. As a general rule, a 5-cm release is adequate, but experience and intraoperative evaluation will, of course, dictate minor alterations or adjustments to ensure adequate flap coverage and tension release. In order to reduce tension, often, a 2–3 cm full-thickness fasciocutaneous release is required on the unaffected side in order to close the wound. While this reduces tension, it also brings the incision close to the midline. The surgeon must take care to do as little mobilization as possible on the unaffected side, while still minimizing tension. The fascial release observed here is, notably, not a traditionally included technical component of the Bascom cleft lift operation and may be considered unnecessary by some surgeons.
Prior to initiation of closing, a 10-Blake drain is placed in the newly created potential space which will be removed between day 5–10 typically. The closure occurs in five layers, beginning with a deep layer involving the deep fat and any released, intact fascia using a 2-0 polydioxanone (PDS) suture to take advantage of monofilament’s reduction in infection risk. Once the initial layer has been brought together and the tension is reduced, the second layer of PDS suture is used in the deep layer to reinforce and further elevate and bring the incision off the midline. Thorough execution, when approximating this deep layer, is of utmost importance in order to fully lift and obliterate the cleft. The deep layer is then followed by a layer of 2-0 Vicryl in the deep dermis, paying close attention to the caudal end of the cleft lift. 3-0 Vicryl on a small needle is used to reapproximate the dermis that is not perfectly aligned with the 2-0 Vicryl. The sutures are cut short to minimize “spitting” from the incision. The final layer of closure is a 3-0 Monocryl for complete approximation and tension reduction.
The wound is dressed in Steri-Strips and padded with gauze and fluffed dressings. The patient is instructed to take sponge-baths only and to leave the dressings and drain in place until the first appointment 5–6 days after surgery. Until this visit, the patient is instructed not to place any pressure on the wound other than when using the bathroom. The drain is typically removed when the drainage is serous and less than 30cc per day.
The Monocryl stitches are removed at the two-week postoperative visit, and the patient is shaved of all hair in the surrounding area, which is a critical component of keeping the wound clean and free from recurrence. At the one-month postoperative visit, patients are allowed to resume all normal activities without restrictions if the wound has healed appropriately. It is anticipated that approximately 80-85% of patients will progress without any complications whatsoever, and 10-15% of patients will have some minor wound opening that can be managed in the office. Follow-up visits will continue at the three-month, six-month, and one-year mark, after which the patient can be discharged. The specifics of postoperative and preoperative care here, however, are largely based on the experience and opinion of the operating surgeon, and may therefore be controversial among some surgeons.
No special equipment was used for this operation.
Nothing to disclose.
Statement of Consent
The patient referred to in this video article has given their informed consent to be filmed and is aware that information and images will be published online.
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