Pain, pain go away.
I can’t deal with pain from this pilonidal cyst one more day.

A pilonidal cyst is a sac-like structure beneath the skin that forms in between the buttocks at the tailbone. This is a closed, walled-off structure that usually contains hair and skin debris. In a sense, it is a pimple! This can become infected, now it is an abscess when the skin becomes red and swollen. Sometimes the pilonidal cyst will open up and drain foul-smelling material.

Pilonidal cyst tracks develop when a pilonidal cyst drains and then the body heals and closes the opening. Then the cyst drains somewhere else in the skin and closes. This process keeps repeating itself. The pilonidal cyst continues to enlarge under the skin and multiple draining areas to the skin form. This creates tunnels under the skin and causes more infections. This becomes a very troubling situation that can get worse and worse.

Both males and females can be affected by a pilonidal cyst. However, males tend to be affected more. Usually, these occur in a younger patient population. These are patients that are of dating age and this diagnosis can affect a person’s confidence and can cause emotional turmoil. These are also patients that are of the age of the workforce and can cause a decrease in work efficiency and an increase in days absent from work. People that tend to develop a pilonidal cyst are those that sit for long periods of time; taxi cab driver or trucker. Or they have a sedentary or inactive lifestyle. These patients tend to sweat more than the typical person. Usually, patients are overweight and very hairy.

If a pilonidal cyst develops there are several things that a person can do to minimize the symptoms and/or prevent an abscess from forming. Improved hygiene with keeping the area as clean as possible will decrease the bacteria in the area. Losing weight will decrease the skin of the buttocks from being compressed against each other. This in turn will decrease moisture and bacterial load in this area. Changing one’s occupation or lifestyle to increase activity level and decrease sitting will also prevent the complications of a pilonidal cyst.

These measures will not get rid of the pilonidal cyst once it has formed. If the pilonidal is acutely infected then the patient may need antibiotics, and they may need an incision and drainage procedure. Once the acute process is better under control then surgical intervention may be indicated.
There are several proposed surgical procedures to treat a pilonidal cyst.

The first is excision of the pilonidal cyst and direct closure of the skin edges. Sometimes if the skin cannot be closed then the wound is left open for healing by secondary intention. This means that the area is packed with gauze or a wound VAC is used, and the open area is allowed to close over time. Another procedure that can be performed is a VY advancement flap where tissue from the buttocks is moved to close the open wound. The procedure I have found to be the most effective is called the cleft lift procedure. This procedure will borrow skin from one butt cheek and move it to the other butt cheek.

There are 2 main reasons why it is sometimes hard to treat a pilonidal cyst surgically. The first is that it occurs in the midline where there is tension on the surgical closure. The second is that the buttocks can form a deep cleft (this is typically what is seen in a patient with a pilonidal cyst) that traps moisture and bacteria. The cleft lift procedure eliminates both of these concerns. This procedure will borrow skin and subcutaneous tissue from one buttock and move it across the midline to the other side. Skin is removed from the second buttocks to accommodate the advancement of the other side’s skin. What this will do is decrease the depth of the cleft between the buttocks and decrease the tension that is placed on the skin closure. I have seen a dramatic decrease in the complication rate and recurrence rate using the cleft lift procedure. For this reason, patients that present to my office will most likely be offered the cleft lift procedure to treat a pilonidal cyst.

Adam T. Silverman MD, MS, FACS