When Is It Time For Pilonidal Cyst Removal?

Once a diagnosis of tailbone-area pilonidal disease is established, when is the time to have to have surgery to treat or cure it?  At our Center, we have established 5 criteria that each indicate that the “time is now” for our curative gluteal cleft-lift procedure. Here they are, in no particular order..

1. Two or more subcutaneous abscesses requiring drainage.  Because many patients with one such abscess will not develop a second, yet each subsequent abscess increases the chance for further abscesses, we have decided it most reasonable to move ahead with cleft-lift recommendation once a patient has reached a threshold of 2 such abscesses.  We also understand that nonspecialist drainage procedures can be exquisitely painful for our patients and thus seek to minimize them.
2.   One or more chronically draining pilonidal sinus tracts.  Because permanent pus drainage in this area is both nonhygienic and socially impactful, we move ahead with cleft-lift recommendation once one or more such tracts have developed.  Further, there is a small but existent chance of cancerous transformation of a longstanding and untreated pilonidal sinus tract. Finally, sinus tracts can advance progressively lower and perianal in location if cure is not provided to stop the process.
3. A nonhealing surgical wound from a previously failed pilonidal excisional surgery, often by a nonspecialist!  As one can imagine, the permanent inflammation and cellular turnover here set the stage for cancerous transformation in a longstanding and nontreated surgical wound.  Not to mention the pain and chronic drainage of such wounds.
4. Chronic coccydynia in the absence of undrained pilonidal abscess.  Stay with me, because this one can get tricky!  Some patients with the diagnostic midline pits complain of chronic tailbone pain, worse with sitting.  Here, another reason to cure with cleft-lift!  We do, however, like to first make sure that no undrained chronic pilonidal abscess is present before making the recommendation here.  We have seen multiple patients who have such an abscess as the cause of pain, and simple abscess drainage was all that was needed to render them pain-free, thus avoiding cleft-lift in these cases.

Okay how about our Minimally Invasive Pilonidal Treatment (MIPiT) protocol… are the criteria the same? Great question…  The criteria are roughly the same with several exceptions

1. Because incisions are kept tiny with our Gips Procedure and laser pilonidoplasty, we are a bit more permissive with regards to abscess, offering the minimally invasive option to both patients with only one such abscess requiring drainage and even offering it to pilonidal patients who have never had any abscess but wish a proactive approach, to prevent a  painful drainage procedure from ever being needed at all.  Makes sense!
2. We do not offer the minimally invasive protocol to patients with nonhealing surgical wounds or ultralow sinus tracts because results are deemed unsatisfactory in these situations.