A pilonidal cyst is a chronic skin infection forming a small pocket near the tailbone, at the top of the buttocks crease, often containing hair and skin debris. This condition commonly affects young adults and those who sit for long periods, causing pain, swelling, and drainage. While initial treatment may involve draining an abscess, definitive resolution typically requires surgery to remove the cyst and prevent recurrence. Finding the right medical expert is a crucial first step, as the surgeon’s specialization and preferred technique significantly influence the outcome.
The Primary Surgical Specialists
The question of which doctor performs pilonidal cyst surgery generally points to two main specialties: the General Surgeon and the Colorectal Surgeon. A General Surgeon is trained to perform a wide range of common surgical procedures, including those involving the skin and soft tissues. They are a common provider for initial pilonidal cyst excisions, possessing the necessary skills for incision, drainage, and basic excision techniques.
Colorectal Surgeons, also known as proctologists, focus on conditions affecting the lower gastrointestinal tract, including the colon, rectum, and anus. Given the anatomical location of pilonidal disease near the perianal area, these specialists receive extensive training in managing complex and recurrent diseases of this region. For patients with chronic, complex, or recurrent pilonidal disease, a Colorectal Surgeon is frequently preferred due to their specialized focus and experience with advanced flap procedures. Their expertise in the surrounding anatomy often positions them as a leading choice for definitive treatment, even though pilonidal disease is technically a skin condition.
Understanding Surgical Approaches
The specific surgical approach chosen is often more important than the surgeon’s general title, as different techniques have vastly different healing times and recurrence rates. One of the oldest methods is Wide Excision, where the entire affected tissue is removed, leaving a large cavity. This wound is then either left open to heal from the bottom up (secondary healing) or closed with sutures (primary closure).
Healing an open wound by secondary intention can take several months and requires extensive daily wound care, though it may be necessary if infection is present. Primary closure aims for a faster recovery but carries a higher risk of wound breakdown and recurrence, with recurrence rates around 15–20%. The challenge with these midline techniques is that the surgical scar remains in the deep natal cleft, which is the underlying cause of the condition.
Newer, minimally invasive techniques attempt to address the infected pits and sinus tracts with less tissue removal. These include Bascom’s Pit Excision and video-assisted procedures, which offer faster healing and return to normal activity. However, these approaches do not change the shape of the deep natal cleft, leading to variable long-term success. Some reports indicate high recurrence rates, such as one study predicting a 62% recurrence at five years for pit picking.
The Cleft Lift Procedure, a flap-based technique, is often considered the most effective long-term solution for pilonidal disease. This procedure involves excising the diseased tissue and reconstructing the area by moving a flap of skin to flatten the deep natal cleft, shifting the incision away from the midline. This re-contouring addresses the mechanical cause of the disease: the tight, deep cleft. Studies comparing the cleft lift to traditional wide excision show significantly better outcomes, with recurrence rates as low as 2.5–3% compared to over 20% for wide excision.
Selecting the Right Surgeon
When selecting a surgeon, the patient should look beyond the general specialty and focus on the surgeon’s experience specifically with pilonidal disease. A surgeon with a high volume of pilonidal cases, regardless of whether they are a General or Colorectal Surgeon, is a better choice. Patients should ask the surgeon directly about the number of pilonidal procedures they perform annually and their success rates with different techniques.
Patients should specifically inquire about the surgeon’s proficiency with modern, off-midline techniques like the Cleft Lift procedure, as this indicates an understanding of the condition’s underlying cause. If a surgeon only offers traditional wide excision with primary or secondary healing, seeking a second opinion from a specialist experienced in flap procedures is prudent. For complex or recurrent pilonidal disease, finding a surgeon who dedicates a significant portion of their practice to these specific procedures offers the best chance for a definitive cure.