Pilonidal Cyst & Pilonidal Disease

Understanding Pilonidal Cysts

A pilonidal cyst is a small pocket or cavity that forms near the tailbone (at the top of the crease between the buttocks). It begins when hair and skin debris become trapped in that area, leading to irritation and sometimes infection. Pilonidal disease is common in young adults and can become a recurring problem if not treated effectively.

Sometimes a pilonidal cyst can progress to an abscess. An untreated abscess can be painful and lead to more serious problems. Fortunately, with proper care, most patients achieve long-term relief.

Incision & Drainage — What Patients Should Know

Many patients are referred to surgery after having an incision and drainage (I&D) procedure performed in the Emergency Department or Urgent Care. This is often done when the cyst becomes acutely infected and forms an abscess.

Important points about I&D:

It relieves pain and infection quickly
It does not necessarily cure the underlying problem
Many patients experience recurrence after I&D alone
Definitive surgery is often recommended to reduce the risk of future flare-ups

If you had an I&D recently and are still experiencing symptoms or recurrent abscesses, a consultation for definitive treatment can help prevent further episodes.

Treatment Options for Pilonidal Disease

There are several approaches to treating pilonidal disease, ranging from conservative care to different surgical techniques. Options include:

1. Conservative Management

Warm sitz baths
Hair removal around the area
Local wound care after drainage
This may help mild cases, but many patients with recurrent or persistent disease choose surgical repair.

2. Unroofing / Limited Excision

A surgeon removes the cyst and opens the sinus tracts without extensive reconstruction.

3. Wide Excision

The affected area is removed in a larger wedge-shaped section. Healing may occur by secondary intention (letting the wound close from the inside out) or with closure.

4. Flap Repairs

Reconstructive techniques where adjacent tissue is used to close the defect and flatten the midline, which reduces tension and recurrence risk.

Of the flap options, studies and clinical experience show that off-midline closures like the Karadakis flap have lower recurrence rates and better overall outcomes, especially for patients with recurrent disease. We will tailor the approach to your anatomy, disease severity, and personal goals.

Karadakis Flap Repair — What It Is and Why It’s Effective

The Karadakis flap is a type of off-midline closure designed to reduce tension on the wound and move the scar away from the deepest part of the gluteal crease — where hair, moisture, and pressure can contribute to recurrence. We have had excellent longterm results using this technique.

How It Works

The cyst and sinus tracts are excised
A flap of healthy tissue is mobilized from the side
The flap covers the defect off the midline
The result is a flat, tension-free closure with improved healing

This technique has been shown to have:

Lower recurrence rates compared with midline closures
Faster return to normal activities
Less wound care complexity

Patients typically do not require weeks of open wound management, and the contour of the area is often improved.

Recovery After Pilonidal Surgery

Healing after pilonidal surgery — especially with a flap — involves a short period of adjustment and wound care. Most patients can expect:

Discomfort for a few days (well-controlled with medication)
Limited sitting for the first week or two
Return to light activities within a week
Return to full activity including exercise within several weeks, depending on individual circumstances

We will give you wound care and activity instructions specific to your surgery.

JP Drain Care — What You Need to Know

Most of my repairs include placement of a Jackson-Pratt (JP) drain. This soft tube gently removes fluid that can collect under the wound, helping it heal smoothly.

Daily JP Drain Care

Empty the bulb at twice daily and as needed
- Open the plug, drain fluid into a measuring cup, squeeze the bulb to compress, and reinsert the plug.
Record the output
- Write down the amount (in mL) each time
- Keep a daily log to bring to clinic
Strip the tubing
- Gently squeeze the tubing from the level of where is comes out of the skin and pull down toward the bulb to keep the tube from clogging.
- We will show you this in clinic and in recovery prior to discharge
When to return to clinic
- Come back when the output is less than 30 mL in 24 hours
- This is often the threshold used to decide when the drain can safely be removed

If the drain becomes uncomfortable, blocked, or if you see redness or new swelling, call sooner — we’re here to help.

When to Schedule a Consultation

If you’re experiencing recurrent pain, swelling, or drainage from a pilonidal cyst — especially after prior abscess drainage — we’re here to guide you through your options and help choose the most effective treatment plan for you.