Most people with a pilonidal cyst wish that it would just go away. With the pain, the recurrence, and the awkward location, it is a condition that is difficult to live with and difficult to treat.
Chances are, you have entertained the thought of having pilonidal cyst surgery (or maybe you already have). While I’m not a proponent to surgery (unless absolutely necessary), it has come a long way in recent years. But still the success rates of the different types of pilonidal cyst surgery are not as high as one would hope for.
If you have a cyst that is not responding to conservative, or watch and wait, treatments, you might have to look to the surgeon’s scalpel to get the relief you seek.
Surgery may sound like a scary proposition, but it is better than living with the painful cyst on your backside and doing nothing about it I guess.
Who Should Consider Pilonidal Cyst Surgery?
Surgery is not an option that you should consider lightly. Sometimes, you can treat your pilonidal cyst with more conservative treatments, such as soaking in a hot bath or lifestyle modifications.
For instance, if your cyst is caused by sitting at work or somehow bumping the area, you can choose to sit on a coccyx cushion or eliminate the actions that are responsible for the cyst’s forming.
Proper attention to hygiene in that area can also delay the need for pilonidal surgery. You can keep the area clean by showering regularly, and you can remove any hair in the gluteal cleft that may lead to a further infection.
However, sometimes pilonidal cyst disease can be too painful, too complicated, or too recurring, and you cannot avoid surgery. If you have a very painful cyst, you will likely need to have the abscess drained, at the least.
If you tend to have pilonidal flare-ups multiple times per year or even per month, then something radical needs to occur to help the wound heal. This is where the more invasive surgeries become necessary.
Choosing the doctor to perform your pilonidal cyst surgery will determine your success and decrease the rate of recurrence. When you initially have the pain from your pilonidal cyst, you will likely end up in an emergency room.
While it is true that any surgeon can open a boil or cyst to relieve the pain, you don’t want a non-expert doctor performing surgery on your pilonidal cyst. An ER doctor can simply relieve your pain, but you will likely need to see a more competent surgeon to deal with more complicated pilonidal cysts.
Most experts recommend a colon and rectal surgeon who is well versed on the newest techniques for treating pilonidal cysts. Some surgeons insist on doing the older types of surgeries that are not as effective and have a high rate of recurrence.
You will often find this type of doctor who is merely a general surgeon and has not performed many pilonidal cyst surgeries. Instead, a colon and rectal surgeon is specifically trained in this area of the body and does a great deal of surgeries for pilonidal cysts.
Some procedures are performed in the ER or in the doctor’s office. These are the less invasive, less successful surgeries that are among the older types of procedures. You will likely need to visit a large teaching hospital with a track record in surgical procedures when you have the more invasive types of pilonidal surgery.
Some hospitals are unorganized and unskilled at the type of surgery you need, so shop around for various surgery centers, hospitals, and other facilities to find one you and your surgeon can agree on.
Most surgeries are successful only if you take good care of the surgical site after the procedure. Wound healing can sometimes get tricky with a lesion in the gluteal fold, so it is extremely important that good wound care follows any surgery.
Some of the surgeries below will leave you with a closed wound. You should not get the incision wet for the first 24 hours, but afterward, wash with an antibacterial soap and water.
Many doctors recommend surgical scrubs, such as Hibicleans, to keep all bacteria from growing in the wound. You should even keep the area neatly shaved to prevent hair from getting in the wound and holding bacteria against the skin.
Many of the older style surgeries will leave you with an open wound at the site of your cyst. This is especially true of lancing and incision procedures. Wounds of this nature require more attention to detail so that they can heal on their own.
The idea behind open wounds is that they heal from the inside out. Generally, this means that the depth of the wound will be packed with either ribbon gauze or plain gauze. Sometimes your surgeon will require that you soak the packing in sterile water or some other solution to aid the healing process.
Before packing, flush the wound with normal saline, sterile water, or water from the shower, as your doctor recommends. Pack the wound at least twice per day, although some experts recommend changing the dressing three times per day for the first month.
You WILL have lots of pain after any of these surgeries, especially when sitting up in a chair. Use a coccyx cushion to keep the pressure off of your tailbone in the first stages of healing. You should also consult your doctor regarding pain medications for your incision.
With larger wounds that require a great deal of packing, it can get quite painful. Do not be afraid to ask your doctor to adequately control your pain, especially if it affects how often you change your dressing. Certain medications such as percocets, when taken as directed, are safe, effective treatments for your pain and can make the difference in how your treatment progresses.
TYPES Of SURGERIES
Incision and Drainage
Incision and drainage is often called “lancing” in the medical field. When you have a large abscess, the doctor simply takes a scalpel, cuts into the infected area, and drains the pus and debris that are causing the infection.
This is done under a local anesthetic, which means you won’t be put to sleep. (NOTE: Although an anesthetic is used, most patients do experience a small amount of pain and discomfort during the procedure due to the localized swelling of the cyst.)
Under no circumstances should this procedure occur without local anesthetic.
For some patients, this is the only treatment they need. The wound is left open and packed two to three times per day for a month. Ensure your surgeon performs curettage, or a thorough cleaning of the wound that removes all debris, because 90 percent of those who have curettage with lancing heal within four weeks.
Sometimes your abscess may not be “ripe” for a lancing. This means that it is not close enough to the surface for the surgeon to effectively drain it. Using heating pads, hot baths, and a hot washcloth can help bring the infection to the surface for lancing.
This is a relatively easy procedure that just about any surgeon can perform, but that doesn’t mean you should let any doctor complete this surgery on you. Hospital ERs are capable of lancing a pilonidal cyst, but they are not experts in treating this condition.
In addition, they may not be aware of how to effectively deal with a pilonidal abscess or use proper surgical hygiene. Your best bet is to see a colon and rectal surgeon at an emergency appointment, if you are in a considerable amount of pain. They know how to treat pilonidal cysts and can advise you as to the right course for your condition.
One last note on lancing procedures — it is NOT a cure. It is simply a temporary measure which releases enough of the gunk out of your body just long enough for you to get some much needed relief.
Unfortunately, the pilonidal cyst almost always returns because the actual cause of your pilonidal cyst has not been addressed. You can only fight this disease where it originated from, and no knife or scalpel can do that job effectively.
A cleft lift is the surgery of choice for most experts in the pilonidal field today. It is also called a cleft closure and is closely related to a procedure called the modified Karydakis flap.
Essentially, an ellipse shape is cut from the gluteal cleft, but not actually within the cleft. The incision is made to the side of the deep fold of the buttocks.
The tissue on the opposite side is undercut, and this new flap is pulled over the deep cleft. The incision is made to the side of the cleft for better healing. In the process of the cleft lift, the deep cleft of the buttocks becomes more shallow. This prevents more pilonidal incidents from happening in the future.
Although this pilonidal cyst surgery has many positive points to it, you will likely need to search for a qualified physician in a large city hospital. It has not become as popular yet due to its relative newness. Likewise, many insurance companies refuse to pay for this pilonidal surgery, so you may have to file an appeal if you have a complicated pilonidal case. This surgery will definitely stop recurrences and end the cycle of abscess and lancing.
Pain after this type of pilonidal surgery is usually high. Most of the time, this surgery is done in same day centers, and you will go home to recover. Occasionally, the doctor may require you to stay overnight if you have difficulty waking up from the general anesthesia. You can return to work in two to three weeks and expect the incision to heal completely within four to six weeks.
Excision is a fairly common technique that comes in two different flavors: closed and open healing.
The surgeon actually cuts out the abscess and the tracts that the infection has created. In an open healing wound, the surgical area is left open and needs packing at least twice per day.
Some doctors, however, don’t agree with packing and leave the wound completely open to heal. In this case, it makes sense to flush the area twice per day – such as in a shower – to remove debris that accumulates.
Unfortunately, this technique requires several months for total healing, and the packing twice per day can be very inconvenient (and embarrassing). You should be able to return to work after one month and perform normal activities after two months. Since patients are rarely able to pack their own wound, it is generally easier to have a significant other or home health nurse pack it for you.
A closed excision surgery means that the surgical wound is closed with sutures. This may sound like a better option, but the rate of infection from this procedure is very high. Furthermore, you must make sure your surgeon does not make the incision line in the actual cleft of the buttocks.
The incision should be slightly to the side. This keeps shearing forces from pulling on the sutures and helps to decrease the rate of infection. When this procedure works without the complication of infection, the healing time is six to eight weeks or slightly longer.
You can have this surgery in a same day surgery center or a hospital, depending on your surgeon’s preference. It is usually a same day surgery, but you might need to stay overnight if there are complications with the general anesthesia.
Sometimes this surgery for pilonidal cysts doesn’t need general anesthesia and can be performed with a spinal block, similar to what pregnant women have in labor. The surgery itself takes about 45 minutes, and you will be given pain medications afterward. Taken as directed, these should help the pain you experience while moving, sitting, and changing the dressing.
The success rates for excisions are pretty good, but that’s only because half your ass has been chopped off. There’s no room for another pilonidal cyst to grow. LOL!
The Bascom Technique is very similar to the cleft lift. In this surgery, the surgeon cuts out the abscess, but leaves the deeper tissue behind. This is not as invasive as the cleft lift and leaves a great deal of supporting tissue behind.
However, it is important to remove all the abscess and trouble locations to prevent a recurrence. Again, an ellipse shaped area is removed to the left or right of the midline fold. The surgeon creates a flap of skin on the opposite side and pulls the incision closed.
As with the cleft lift, this creates a more shallow gluteal cleft and moves the incision to the side for better healing. This technique was first introduced by Drs. John and Thomas Bascom, and they report low recurrence rates when using this technique.
Since this is a newer procedure, you will likely need to find a specialized doctor in a large city to have this surgery performed. Insurance companies may not cover it, but if you can get them to agree to the cleft lift, the Bascom Technique is not that much different that the insurance company will balk.
The healing time is within four to six weeks, and the incision does not require much after care other than bathing. The rate of infection and recurrence with this technique is minimal, which makes it a great option for a complicated pilonidal case. General anesthesia is used, and most patients go home the same day.
Pitting is also known as “picking pits.” A pilonidal cyst develops in a hair follicle that stretches out too far and starts to collect debris. These present as small holes, or pits, that the doctor can easily see and surgically remove.
When you have an abscess, the surgeon will lance it and release the pus and debris that is contained in the infection. After ten days when the swelling has reduced to a normal level, the surgeon can examine your gluteal fold to see what pits you might have in the cleft. Using local anesthesia, the surgeon cuts out the small holes and sutures the surrounding skin back together.
There are several problems associated with this technique. First, it is not always successful, and if you have a complicated pilonidal case, your abscesses will usually return.
Second, it is often difficult for the doctor to see all the pits. If even one is left, it can cause a new pilonidal cyst. A way to prevent this is for the surgeon to pull down on the buttocks to spread the cleft vertically. This simulates the pull of gravity when you are standing, and it helps the pits become more apparent.
Since the cutting is performed on the midline, or in the cleft, sometimes the wounds do not heal very well. The incisions are very small, though, and keeping them superficial helps to minimize this side effect. Sometimes the pilonidal cysts return despite the most focused pit picking, and you will need to have a surgery, such as a cleft lift, to fully cure yourself of the recurrence of pilonidal cysts.
Flap surgery is the oldest type of surgery and not recommended by most experts anymore. This is because most of the underlying tissue is removed along with the abscess, and this creates an unstable wound bed that does not heal well.
In addition, this pilonidal cyst surgery is often performed in the midline where wound healing is not as easy. Some of the names for this surgery include the Limberg flap, Z-plasty, and rotational flap. This is a very invasive surgery with a low success rate.
The Limberg flap removes all of the abscessed tissue, the pits in the cleft, and the surrounding tissues below it. The surgeon then cuts a flap of skin and deep fat from the buttocks and pulls it to cover over the resulting cavity. If the Limberg flap incision is made to the side of the cleft, you can expect better outcomes from this than from other flap surgeries.
Rotational flaps involve loosening the skin of the buttocks and rotating tissue into the cleft space. Z-plasty creates two flaps in an N-shaped formation and pulls them together to form a Z-shaped incision.
When you have pilonidal flap surgery, you will likely need to stay in the hospital for three to five days. You will be under general anesthesia, and you need hospital care to ensure there are no complications. Pain is expected, and can be controlled with narcotic pain relievers when taken as directed.
You could return to work within two to three weeks with total healing expected by four to six weeks. Insurance companies usually cover these procedures, but they are not as desirable as the cleft lifts.
Phenol is also known as carbolic acid, and it can destroy tissue, muscle, and fat with frightening speed. It is injected into a pilonidal cyst and expected to create scar tissue in the area that is prone to the abscesses. With scar tissue, no pores are available for the collection of debris and infection.
Unfortunately, this treatment is not effective and has generally been discredited. At first, researchers thought that it was a viable treatment option, but as more studies were completed, they found that it had a high recurrence rate for the cysts. Most doctors do not consider this a viable treatment anymore, and it is mainly used in Europe.
These injections are very easy to administer and can be done simply in a doctor’s office. Most people experience healing of the pilonidal cyst within a few days of treatment, and it is not considered a painful procedure. If it was actually effective for pilonidal cysts, it would be the ideal treatment because it does not require the invasive surgeries of the other options.
If you opt for this option, be aware that it may solve the problem short-term, but you will likely have a recurrence of the abscess and one of the other procedures will be necessary.