Pilonidal Cyst Case Presentation: Update Course 2015

So continuing our trend of gross skin and soft tissue infections. You see a 12-year-old patient following up with you in clinic. One week previously, you did an I&D for an acutely infected cyst, which are acutely infected pelonidal cysts, and this patient has no other medical comorbidities. So at what point are you going to attempt a more definitive treatment other than just performing an I&D on these patients? When do you operate? When it comes back, Aaron, when do you operate? After 2. After 2 or 3 I transferred to David. I usually tell them after one, but I stretch it out as long as possible. After 1, well, after the 2nd, 2nd 1, the next one comes back, but I discourage what it looks like does not make you go to the opera noon on the 1st 1. If it's a big thing, you still wait for a 2nd episode, OK. So I bought hook, line and sinker into the best gum technique. This is a group of note organ, uh, taking, taking up pits. And then only operating if they have bigger draining sinuses doing a layered off center off off center midline closure. OK, I know we're way over time, but I tell me how you do this. So you excise out the pits under local, just take an 11 blade and cut out and they're 1 millimeter pits just at skin level, sub subcu tissue, and let them heal by secondary intent, and that by their data 70% are never come back and that they might not come back anyway. They don't have a control group, so. And then if there's a large after the first episode, after the 10 days after incision and drainage, after it's subsided, you bring them back and take out the pits, right? OK. And then what were you saying about, and then if that, if they recur or if they have larger draining sinuses, then they go to the OR for a formal excision of the entire affected area off midline layered closure with a drain. Sorry, adaptation of it, yeah, it's, and it's um, it takes a miserable operation. Situation makes it a lot less miserable. It's still miserable. Are we jumping ahead on your a little bit? That's sorry. So are there, we're trying to save time. Yeah, I don't know I've been tempted to try it. Let's see what, what do you got? So, uh, along those lines, are there any factors that would manage or that would affect your management, either timing and treatment or what type of operation? Any of those things change what you just told us, or no? Their age, their body habitus. Recurrence. That's what I wait for recurrence, OK, but there are some patients who just have, you know, such high risk factors. They look, you know, they have a deep gluteal fold, lots of a ton of hair. Those patients, it's, it's a miserable process. So potentially physical exam findings, potentially, yeah. So you guys touched on this a little bit earlier, which operation would you perform for definitive management? Would anyone open it and leave it open? If it's really nasty, you would, if it's really nasty with wet to dry dressing change or a wound back back back, OK. OK, and then you guys talked about some other off midline closures, right? Anyone do a rhomboid flap? We just tried one. Sort of, OK, so looking at the literature, I was gonna say just briefly looking at the literature, the Kradais flap was superior to excision only and pretty comparable to this modified Lindbergh flap, and then the less data on the modified elliptical rotation flap, but in the short term it has been shown to have comparable results to the Lindbergh and the Kraakas. What's the nuclear weapon? So when they keep coming back, you've had 3 recurrences. What's the nuclear weapon? Is it marsupialization? Is it a skin graft? Is it a, I think it's post-op management. You put them on a bed prone for until the wound heals. It's a wound healing problem. And when I think. That typically is the biggest it's sitting on it afterwards, yeah, and you can do some sort of flap to get good tissue over it, but unless you get them off of it post-op, and that's what our plastics guys will do, you know, when it finally comes to the I can't do this anymore, send them to plastics, they do a flap, leave them on their belly, um, for that's my laser hair removal, my completely unatta substantiated feeling, OK. So yeah, like you said, has anybody used or recommended laser hair removal for any of their patients? I have. and the patient came back to me and said it was the most painful thing they had ever had, and he got through like one half a session and said he would never go back again. So having not had it done myself, I was willing to take his word for it, and I have not recommended it since. I haven't had that experience. I've sent a few and they haven't really complained. It's been decent. I've had to almost draw out for the laser hair removal list. Um, where to go because I don't think they're going wide enough or extensive enough, um, and I've even encouraged to try to submit for insurance, um, reimbursement, but have not been successful in that part yet because it is expensive. What's next