“It used to be considered a congenital disease, but today the prevailing theory is that of acquired growth, where the trapping of hairs in a deep and hairy middle gluteal fissure under stressful conditions (e.g. vehicle drivers), leads to intermittent and chronic fistula formation,” says Dr. Ioannis Dalianoudis, Plastic Surgeon and Scientific Director of Advanced Plastic Surgery.
Causes
The most basic cause of Pilonidal Cyst appearance has been shown to be essentially the fact that the hair “turns” inwards, resulting in inflammation and cyst formation.
The disease can manifest as a simple cyst, abscess or complex with multiple pores. The most common clinical manifestation is a painful inflammatory mass in the sacrococcygeal area with accompanying mild cellulitis often with the presence of stomata (pits). The disease rarely extends into the anus.
If an abscess develops (the cause of which is polymicrobial), drainage through an eccentric incision and cleansing of all hairs is required. Changes are required, dermal baths with topical antiseptics and shaving the area for 3 months; these will cure the disease in 60-70% of cases.
Rarely, chronic recurrent disease leads to the development of carcinoma (squamous cell carcinoma) requiring wide en block excision with fascia and biopsy of swollen lymph nodes followed by radiotherapy, with poor prognosis.
Symptoms
Among the symptoms, in addition to inflammation (pus within the cyst), there is also:
- Pain
- Redness
- Swelling (puffiness)
- Rarely there is also fever or nausea
Wide excision
This is a wide excision of the coccygeal cyst with a 5 mm margin up to the sacrococcygeal fascia. In particular, three methods of wide excision of the coccygeal cyst are described: The closed, the semi-closed and the open method.
In the closed method, after wide excision of the bladder, the wound is first closed with stiches. This technique has the advantage of faster healing and better aesthetic result, but is accompanied by a higher rate of complications, such as recurrence of the cyst, inflammation, wound perforation and rupture, etc.
In the semi-closed method, the wound is first of all closed with stiches, only half of it, in order to facilitate healing, but at the same time to ensure adequate drainage of the wound, so that the risk of perforation, local collection and rupture is significantly reduced. By constantly changing the gauzes on the wound, it is healed in a second way. It has advantages over the closed method in terms of reduced chances of recurrence or perforation and disadvantages in terms of increased healing time.
In the open method, the wound after excision of the coccygeal cyst is left open and healed, after successive changes and use of topical antiseptics. It shows a significantly lower chance of perforation or recurrence, but requires a significantly longer healing time and is often accompanied by a poor aesthetic result.
Marsupialization
Entering a probe through the main duct, opening and communicating all cavities and cleaning by creating a shallow wound that heals more easily. Stitches of marsupialization are applied on the periphery. It has similar healing rates to wide resection.
Techniques without resection
They consist of careful removal of hair and fibre from the pores without excision. It requires long-term monitoring.
Injection of phenol into the bladder
It has high recurrence of rate and is associated with a lot of pain.
Simple resection of the bladder
Consists of resection of the pilonidal cyst alone without other tissue, either through a median incision left open or through a median incision which is then closed. The lateral incision has the advantage of being easier to heal, but it is not always easy, especially in complicated cases.
Flap Reconstruction
The main problem is necrosis and infection of the flap.
Karydakis Flap Procedure
Eccentric ellipsoidal incision (A), removal of the cyst and all pores up to the sacrococcygeal fascia, mobilization of a flap on one side (B) and closure of the wound, thus making the intergluteal fold shallower (C) with placement of a closed drain (recurrence 1%). Main complication is the hematoma.
Cleft closure (Bascom procedure)
This is the closed method with an eccentric incision. We close it by creating a skin flap. There is a subcutaneous drainage.
Local flap
They are divided into full thickness z-flap, rhomboid flap, V-Y flap.
Recurrence
Recurrence is mainly due to infection and incomplete initial technique. Some similar surgery can be performed, but special treatment may be required for deep wounds that fail to close, such as flap transposition of a gluteus maximus flap.
Injection of fibrin glue and the use of VAC (Vacuum assisted closure, a pressure device for treating postoperative infections) seems to reduce recurrence and postoperative hospitalization time, while the use of drains or antibiotics does not affect the progression of the disease.
Prevention of coccygeal cyst consists of following all hygiene rules and removing hair from the back, lumbar and buttocks area. In all cases of pilonidal cyst, laser hair removal of the area is recommended for permanent hair reduction.
FAQ
Pilonidal Cyst
To whom does Coccygeal Cyst most often occur?
The occurrence is more common in men, especially in younger age. Of course, it is not excluded that coccygeal cyst can also occur at older ages, after the age of 20. Pilonidal cyst occurs most often in:
- Men with strong hair growth
- Obese people
- People with a sedentary lifestyle
How is Pilonidal Cyst diagnosed?
The diagnosis is mostly made clinically, by an experienced Plastic Surgeon.
How is the treatment of Pilonidal Cyst with laser performed?
Laser treatment is quick, painless and bloodless and relies on the endoscopic laser for its action. It can be performed in the doctor’s office, without incisions and is completed within 15 to 30 minutes.
What can I do to prevent the appearance of Pilonidal Cyst?
It is necessary to follow all hygiene rules and remove hair from the back, loin and buttocks area. In all cases of pilonidal cyst, laser hair removal of the area is recommended for permanent hair reduction.