Pilonidal cysts frequently recur, though they may not cause any problems for years after the initial infection. Surgery can be done to remove the remaining cyst though this may not be appropriate to do after the first episode of infection. Surgery is not always curative, unfortunately. Recurrence can occur probably up to about 20% of the time, with most of the surgical options. A number of different surgical procedures have been tried through the years, and different surgeons may have different preferences.
One surgical procedure involves the removal of much of the fatty tissue in the area where the infection developed. The skin and surrounding tissue is sewn back together to close the defect. There is a possibility that an infection will occur shortly after the surgery, and this can require that the surgical incision be re-opened. Although the incision will ultimately heal even in this case, the incision will require daily care with cleansing and dressings for several weeks.
Another surgical procedure involves an excision of the skin and fatty tissue in the crease, down almost to the underlying bone. Rather than closing the the incision, it is left open and dressings are used in the open area for 6 weeks or more until it heals on its own. Surgeons who use this technique feel that the success rate is closer to 100%, but it is a very difficult postoperative period for the patient, because of the open area and the need for dressing changes for so many weeks. And in reality, there is still a recurrence risk.
Another surgical technique takes the minimalist approach. This technique has come to be known as the Bascom technique, named after a surgeon in Oregon who has popularized it. This technique is based on the theory that small hair pits directly in the midline of the crease of the buttocks are the root of the problem. Rather than cut out a large amount of skin and underlying tissue here, only the small “pits” are individually removed. A counter incision may be added, placed about 1 inch away from the midline crease to help the underlying infection drain away from the crease. A very distinct advantage of this technique is that it can almost always be done as an outpatient, with local anesthesia. The time to return to normal activities is less. Dr. Bascom does recommend a more “invasive” procedure with excision of tissue for recurrent and more advanced cases.
Since there is a rather high infection risk, a non-surgical approach may be considered after the first episode, reserving surgery for recurrent cases. The area must be kept meticulously clean. The hair in the cleft should be shaved regularly to prevent growth across the cleft. Any pain or drainage should be promptly reported to your surgeon, so that immediate intervention can be made.
