4 Options for Simple Home Treatment of Early Pits 1) Use tweezers to remove hairs (pull out at surface)2) Currette out keratin. Use the eye of a darning needle. Allows pit to shrinkThis simple move will cure ~ 30 % of early pilos.You will never start trouble if you begin with this.
5 When I am asked how to deal with simple pilonidals, in contrast to complex problems that call for cleft lift,I focus on the source, the stretched and elongated hair follicle,the PIT.And recommend simple control.Local anesthetic, in office if possible.
6 List 2 points to remember on pilos 1________________________ 2 _______________________PICK ALL PITSSTAY OUT OF THE DITCH
23 If a cavity is present it is a CHRONIC ABSCESS: Insight! STAY OUT OF THE DITCH
24 Prevent Early Abscesses To prevent earlyabscess re-seal,cut out skin plug..,a painless alternative to packingScrub out the abscess cavitythrough an incisionlateral to the midline --Keep long incisionsout of the ditch!
25 What is this Opening we call a Pit? Pit “Nursery”
26 The “Pit” Nursery Single hair in normal follicle Crud gathering around hairs in stretched follicles
27 The Pilonidal Pistol ABSCESS ! ! ! Shoots a hole in the Saran Wrap (epidermis)Drives hair and crud into fat,Which puts bacteria in fat to start aABSCESS ! ! !PILONIDAL
28 Growing a Pilonidal Pistol - GUN BARREL = Follicle stretching tobecome a pitBULLET = HairGUNPOWDER = Keratin
34 …And Pick (Out) Early Pits Keep it simple!Learn to avoid trouble!
35 2 Points to Remember on Pilos 1________________________ 2 _______________________PICK ALL PITSSTAY OUT OF THE DITCH
36 Curing Complex Problems When you ask “How can I cure complex pilonidal problems?”I reply, “Cleft Lift.”(Overlooked simple care or failed previous surgery often starts these complex problems.)
37 Here anaerobic bacteria A Small Tragedy21 yr old after--Four years of disease & Five operations ( 2 were huge Rotation Flaps )Learn to PREVENT these WRECKSThis is a SEWER!Here anaerobic bacteriadestroyskin & suture lines.If you held your fingerhere for 4 years,its skin wouldrot off too!Insight!Red tissue is normaland healable!Give em AIR!!
38 All 31 healed after 1 cleft lift 623 PatientsOut of 623 Pilonidal patients we treated, we located charts on the 31 WORSTThese 31 had endured--141! Prior operations252! Years of open woundsAll 31 healed after 1 cleft lift
39 Cleft Lift--Result After 4 yrs and Pre-op 1 week post operative Ready for dressing
40 Failure to heal-reasons in our 31 patients In 16 Surgeon left a deep cleftIn 7 Surgeon left an overhangIn 5 Surgeon left pits (or new ones grew)In 3 Scar too tight, not enough skin left
42 Clues from a Case That Failed to Heal…. Incision healed OK when in airIncision healed OK where cleft was shallowDeep cleft seals inpus. Yet offers big flap for cleft lift operation.
43 Squirts thru fat, makes tunnel & new opening. Insight!A pit pumps pusSquirts thru fat, makes tunnel & new opening.Sit squeezesSit sealsWhen patient stands, the cavity sucks in debris.When patient sits ……Fig. 6. Ingestion of hair by a chronic pilonidal abscess cavity. Scales on hair convert the in and out flow of cavity contents to a steady inward motion of the hair. Left, standing; right, sitting
44 Processes that keep wounds open for years…. 1. Tight scargenerates…2. a hidden overhang.3. Debris collects,anaerobes eata new hole inskin4. Primary openingcollects pus and debris.It pumps pusand hair upward.
45 Would heal without treatment Exit--secondary openingWould heal without treatmentonce youheal the entrance!TunnelEntrance –primary opening
46 Push buttocks together and mark the outer line of contact. TechniquePush buttocks together and mark the outer line of contact.
47 Incise Incise through the heavy red line first, then elevate all skin tinted blue. Plan to remove the skin tinted pink.
48 Flaps Turned Back, Red is exposed abscess cavity-- 1. We often scrub clean where others would excise
49 What to Save 2. Skin to save for new, shallow cleft 3. Save fat for padding