Failed pilonidal surgery: new paradigm and new operation leading to cures.

HYPOTHESIS Refractory pilonidal disease is due to damage of the epidermis in the deep gluteal cleft by moisture and bacteria, rather than to damage in deep tissues. A new paradigm suggests that a procedure to change the shape of the gluteal cleft will improve results. DESIGN Before-and-after trial. SETTING Community private practice with extensive experience in pilonidal disease, providing ambulatory and hospital care. PATIENTS Thirty-one patients with severe refractory pilonidal disease, with a median follow-up of 20 months in 27 patients (87%). Patients had undergone a total of 141 operations with wounds still open for a combined total of 252 years. INTERVENTION The deep gluteal cleft was reshaped with a skin flap. Deep tissue was left essentially intact. MAIN OUTCOME MEASURES Number healed, time to healing, number of operations required. RESULTS Wounds in all 31 patients healed, 28 after a single procedure. The time to healing was rapid, within 1 week in 22 patients. There were no recurrences. CONCLUSIONS For refractory pilonidal disease, the cleft lift procedure produced rapid results by drawing intact skin over the cleft and bringing the suture line out to open air. The failures of old methods and success of this new one suggest a need for a paradigm shift in our understanding of pilonidal disease. The source of disease is not the deep tissue but rather the epidermis in the moist, hypoxic, and bacteria-laden gluteal cleft. This also has implications for initial treatment of pilonidal disease, where simple, nonoperative treatments are often effective.