Background
This page is not intended to offer a major scientific discussion about a troublesome and sometime embarrassing condition but more to provide a bit of background information on the condition and give some insights into why I do what I do to treat it. It is fair to say that I have made this condition into something of a special interest over the years and have written several papers and presentations about it which can be easily found on-line if anyone wishes to. I will try to make this into the sort of information that you might want to know if you were coming to a consultation with the condition. I have been managing this disease for more than 20 years now and "seen it all" and I might say that I know how to manage it when things go wrong which is always an advantage! I have successfully treated a professional Snowboarder, an Olympic yachtsman and a Modern Pentathlete and I imagine that most people's needs are less demanding than those: if they can have successful outcomes, then so can most others! This disease mostly affects people younger than 40-years-old but it can present at any age.

Causative factors
Pilonidal disease of the natal cleft is largely a result of three physical attributes:

• The nature of the hair (which often comes from the head hair rather than natal cleft hair)
• The robustness of the skin to resist the sharp hairs sticking in to it
• The anatomy or depth of the natal cleft where the infection that results from hair and bacteria that accumulate under the skin after it has been broken

It is seldom possible to affect surgically (or otherwise) the first two elements of these but changing the anatomy of the natal cleft by making it shallow and stopping the tendency for hair to penetrate it is what I aim to do. At this point, most people look somewhat horrified that their natal cleft will be eliminated but be reassured - the results of surgery are very cosmetically acceptable!

The operation (Bascom's Cleft Closure)
Many, many operations and treatments have been invented for pilonidal sinus disease which, if nothing else, tells us that not one of them is a universal success!
The most common operation that I do is called the Bascom Cleft Closure (he calls it a cleft lift) which is the one that flattens off the natal cleft. John Bascom is an American surgeon whose disciple I have become in this regard.
In essence, I remove a portion of the natal cleft skin under a general anaesthetic; this piece of skin is shaped like a boat sail and allows the cleft to be stitched together and the skin too with the bottom flatter and the wound to one side. After this, a drain is needed for three days to suck away excess liquid that accumulates and I usually aim to see patients after 2 weeks to remove stitches - usually expecting to see the wound neatly healed!
The general principle of this is that the natal cleft is "built up" rather than excised which is, I am sure, the reason for the success of the surgery. As I said, the scientific results from these procedures can been seen in the medical literature but suffice it to say, I can get rapid and near complete healing at 2 weeks with a very low rate of return of the infection of less than 2% in my latest series.

Other operations
I mentioned other operations but don't want to go into great detail here because there are so many! The operation that I used to do a lot is also a Bascom invention - I call it simple Bascom's procedure where the sepsis is drained to one side and the "pits" that allow the hair and infection in are cut out and closed with stitches. This operation leaves a wound that needs some dressings - though these are done by the patient and not a nurse -and healing is usually complete by 4 weeks or so. I have almost given this operation up in favour of the Cleft Closure because the latter heals better, is more comfortable and has less recurrence. Better all round!

So, when should it be done.....?
Pretty much all cases that come to the clinic are suitable for cleft closure at the next opportunity, either from the waiting list in the NHS or booked directly as a Private Patient. If the infection presents as an acute abscess, which is by no means uncommon, the abscess should be drained urgently and the infection allowed to settle which should take a couple of weeks at most.

Why such major surgery for a simple condition...?
Over the years I have seen almost all ways of managing pilonidal sinus disease from the "laying open" operations of yesteryear (which need sometimes many weeks of dressings afterwards) to the more major excisional treatments that leave quite extensive scars on the buttock which may be quite uncosmetic. It has been my distinct impression that the biggest problems in pilonidal sinus disease are in those unfortunate patients who have had recurrences of operations, or multiple infections or just neglected disease, which often happens as a consequence of not realising it for what it is, or simple embarrassment.
It seems to me that the best solution for this tricky problem is to offer a solution that is simple and secure and has a minimal rate of recurrence. In my view, therefore, the likelihood is that I would offer the Cleft Closure option to almost any disease severity. I do this because it deals with the problem at hand simply and effectively and will prevent people having troubles later in life.
I have noticed that, having done pretty much all of the definitive pilonidal surgery at St. Richard's Hospital in Chichester for some 10 years, that I seldom see very complicated or recurrent disease - unless it has come from another part of the country! So, in my view, the evidence that I can see is that treating the primary disease effectively prevents later difficulties.

Is Cleft Closure the only option?
No, it isn't. There may well be some patients who don't want or need a more major operation for simple disease and I am quite happy either to do nothing or the simple Bascom's operation as needed. Also, there are people for whom the disease has become very close to the anus (which is almost always due to previous surgery or severe infection) and for these, other procedures may be needed, e.g. rotational flap operations. These are rare however, but the important part is to know what operation is needed and when, which I have spent many years in learning!

If you need an opinion on your pilonidal sinus - let me know - I'd be happy to help!