Chronic Pain After Cleft-lift Procedure 

The gluteal cleft-lift procedure has been established as the superior treatment for tailbone-area pilonidal disease (The Data Mounts: 261 Cleft Lifts for Complex Pilonidal Disease and Excisional Failures – PubMed),(The Bascom Cleft Lift as a Solution for All Presentations of Pilonidal Disease – PubMed).  Nevertheless, it is not perfect.  A subset of patients will unfortunately develop chronic pain at the surgical scar in the years following operation. What can be done?

1.   Rule out recurrent pilonidal disease.  Although the rates were still negligible in the aforementioned studies, a few recurrences were reported; naturally then, a thorough repeat examination must be performed to assess for this. As reported, repeat cleft-lift by same specialist was shown to be the answer in all of these cases.
2. Rule out longterm wound complications.  They are similarly infrequent, as reported in the above PTCNJ study (https://pubmed.ncbi.nlm.nih.gov/38077680/).  Again, thorough repeat examination must first be performed to assess for these complications.  One such complication is suture granuloma, which is persistence of and infection of non-absorbed suture material.  This is usually responsive to tailored oral antibiotic therapy and watchful waiting; minor surgical intervention is rarely required.  Another such conplication is scar ulceration, a sequellum of thinner weaker skin tissue at an area of repeated shear forces like rubbing of tight clothing . At PTCNJ, we have found this lesion to be very responsive to one of several topical creams..no worry warranted!
3. When recurrence and wound issues are ruled out and yet the scar pain persists for more than 18 months following operation and healing, we attribute this pain to the regeneration of microscopic nerve endings at the site of pilonidal excision. Although not yet formally studied, we at the PTCNJ have anecdotally observed that this neuropathic pain is more prevalent among those cleft-lift recipients who had undergone previous operations and failed; this observation bolsters the argument for seeking out a cleft-lift specialist first after diagnosis is established, rather than in a salvage role following failure. Fortunately , we have found chronic neuropathic pain following cleft-lift to sometimes be responsive to a certain oral medical regimen.  Of course, sitting habits must first be modified and the use of a coccyx pillow insured. Our favorite pillow is this one 

            If all else fails for the post-cleft neuropathic pain sufferer, we will attempt intralesional injection of a corticosteroid at the scar or flap site of greatest pain; the rationale for this treatment is suppression of inflammatory pain signals around these new nerve endings.  If any success is seen, these injections can be repeated in other areas of the scar/flap and up to 4 -6 times in a year.  We have seen modest success with this modality, but it is a quick office procedure with minimal risk and no downtime; potential benefit certainly outweighs risk.  I would not let potential chronic neuropathic pain deter pilonidal sufferers from moving ahead with cleft-lift; the risk of this development is exceptionally low, only 0.4% in our studied cohort.