ORIGINAL ARTICLE

Comparison of the Limberg flap and bilateral gluteus maximusadvancing flap following oblique excision for the treatmentof pilonidal sinus disease

Murat Yildar • Faruk Cavdar

Received: 11 June 2013 / Accepted: 22 August 2013

� Springer Japan 2013

Abstract

Purpose This study was performed to compare the use of

a bilateral gluteus maximus advancing flap (BGMAF)

following oblique incision, which was recently described

for the surgical treatment of sacrococcygeal pilonidal sinus

(SPS) disease, with the widely used Limberg flap (LF)

technique following a rhomboid incision.

Methods A total of 105 patients treated for SPS were

evaluated retrospectively. The patients were evaluated in

terms of their age, body mass index, symptoms, length of

the operation, complications, postoperative hospital stay,

time to return to work, postoperative cosmetic satisfaction

and recurrence rate.

Results Fifty-six of the patients were treated with

BGMAF, while 49 were treated with LF. The mean follow-

up was 20.5 ± 5.4 months. The mean length of the oper-

ation, hospital stay and time to return to work were shorter,

while the cosmetic satisfaction score was higher in the

BGMAF group compared to the LF group. There was no

statistically significant difference between the groups for

the other criteria.

Conclusion The BGMAF appears to be superior to the LF

in terms of the length of the operation, time to return to

work and degree of cosmetic satisfaction. It is preferable

for sinuses not to require wide excision, while the LF is

more appropriate for sinuses with a large post-excision

defect.

Keywords Pilonidal sinus � Limberg flap � Oblique

excision � Advancing flap � Socioeconomic level

Introduction

Pilonidal sinus disease is most common in the sacrococ-

cygeal region and has an incidence of 26/100000. It is

twice as common in males as in females [1]. A foreign

body reaction developing as a result of hair follicles

penetrating the skin following trauma is implicated in the

pathogenesis of the disease [1–3]. The disease is generally

asymptomatic. However, when it becomes symptomatic, it

has a negative impact on the patient’s quality of life.

Due to their high rates of recurrence, conservative

methods of treating symptomatic sacrococcygeal pilonidal

sinus (SPS), such as shaving [4], phenol administration [5]

and cryosurgery [6], have gradually declined in popularity.

Although surgical techniques such as excision, marsupial-

ization and primary closure have lower recurrence rates

than conservative methods, they have gradually given way

to advancement flap techniques, for reasons such as the

need for dressings, prolonged wound healing and wound

infection. The Limberg flap (LF) technique has the lowest

recurrence rate among the flap techniques currently used to

treat SPS. However, recent reports have suggested that this

technique does not achieve good results in terms of the

cosmetic appearance and wound healing [7].

The oblique excision and bilateral gluteus maximus

advancing flap (BGMAF) technique was recently described

for the treatment of SPS, and provides results similar to the

LF in terms of recurrence [8]. However, to date, there have

been no studies comparing this method with other tech-

niques in terms of the length of the operation and the length

of the hospital stay.

M. Yildar (&)

Department of General Surgery, Balıkesir University Medical

School, Balıkesir, Turkey

e-mail: muratyildar@hotmail.com

F. Cavdar

Department of General Surgery, Yalova State Hospital, Yalova,

Turkey

123

Surg Today

DOI 10.1007/s00595-013-0764-5

Therefore, the present study was performed to compare

the results of the LF, which is widely used for the surgical

treatment of pilonidal sinus disease, and the recently

described BMGAF after oblique excision.

Methods

The data for 117 patients surgically treated for SPS at the

Mus and Erzincan State Hospitals in Turkey between

February 2009 and July 2011 were evaluated retrospec-

tively. Twelve patients were excluded due to a lack of data.

The data for the remaining 105 patients who did not have

massive gluteal involvement (diseased area more than

5 cm from the intergluteal sulcus) were included. The

infected sinuses were treated with antibiotics, while

abscesses were treated with surgical drainage and antibi-

otics. Surgery was performed 2–4 weeks after the regres-

sion of the infection. Patients were informed about the

operations to be performed, and signed consent was

obtained. The operations were performed by the authors.

Postoperatively, the patients were examined clinically at 3,

5 and 10 days and 6 months after BGMAF and at 5 and

10 days and 6 months after LF. The final condition of the

patients was determined by a telephone interview. The

cosmetic satisfaction with the surgical results was scored

6 months postoperatively as follows: 1 = poor,

2 = acceptable, 3 = good or 4 = perfect. Patients were

compared in terms of age, body mass index (BMI),

symptoms, length of the operation, complications, post-

operative hospital stay, time to return to work, the post-

operative cosmetic satisfaction score and recurrence.

Statistical analysis

The data are presented as the means and standard devia-

tions, medians and percentages (range). t test was used to

compare normally distributed numerical data between the

groups, and the Mann–Whitney U test was used for non-

normally distributed data. In all analyses, a value of

P \ 0.05 was considered to indicate statistical significance.

Surgical techniques and postoperative care

Following the rectal lavage and shaving of the operation

area on the morning of surgery, all operations were per-

formed under spinal anesthesia in the prone-jackknife

position. One gram of prophylactic cefazolin sodium was

administered 20–60 min before the skin incision.

The Limberg flap was made following the administra-

tion of methylene blue through the sinus opening, in the

classic manner, using a vacuum drainage (Fig. 1). In

BGMAF, an S-type oblique skin incision was made

following the administration of methylene blue through the

sinus opening (Fig. 2a). Diseased tissue, including the

sinus tract, was excised as far as the postsacral fascia

(Fig. 2b). The fascia of both gluteus maximus muscles was

incised vertically from the point of adhesion to the sacrum

and freed 1.5–2 cm from the muscle with hemostasis

established with electrocautery (Fig. 2c). The fascia of

each gluteus maximus was sutured individually to the

postsacral fascia with no. 0 polyglactin sutures (Fig. 2d).

The subcuticular plane was closed with subcutaneous 3-0

polyglactin sutures, and the cutaneous tissue was closed

with 3-0 polypropylene sutures (Fig. 3). No drain was used

in any patient in the BGMAF group. Postoperative pain

was relieved with nonsteroidal anti-inflammatory drugs as

needed.

Patients in both groups were mobilized on the first

postoperative day and told not to sit for the first 7 days.

Drains were removed when the drainage level reached

\20 mL/day. Patients were discharged with appropriate

instructions for wound care and advised to use oral anti-

biotics (co-amoxicillin 1000 mg, once every 12 h) for

5 days. The skin sutures were removed 10–12 days

postoperatively.

Results

A total of 88 of the 105 patients were male while 17 of

them were female; 56 patients were treated with BGMAF

and 49 with LF. Their median age was 25 (range 15–49)

years. There were no significant differences between the

groups in terms of age or gender. The mean follow-up was

20.5 ± 5.4 months. The mean BMI was 25.4 ± 1.9 in the

BGMAF group and 24.5 ± 1.6 in the LF group. Although

there was a significant difference (P = 0.02) between the

groups, this was unlikely to have affected the treatment

results. The patients’ preoperative symptoms were similar

in both groups. The patients’ characteristics and symptoms

are summarized in Table 1.

The mean length of the operation was significantly

shorter in the BGMAF group compared to the LF group

Fig. 1 The final view of the Limberg flap procedure

Surg Today

123

(31.1 ± 3.9 vs. 48.3 ± 5.0, P \ 0.001). Wound dehis-

cence was seen in seven (12.5 %) patients in the BGMAF

group and three (6.1 %) patients in the LF group in the

early postoperative period; there were no significant dif-

ferences between the groups in terms of dehiscence

(P = 0.267) or in the total complication (P = 0.154) rates.

Wound dehiscence was treated conservatively. Seromas

developed in two (3.6 %) patients in the BGMAF group

and hematomas developed in two (4.1 %) patients in the

LF group. The seromas were aspirated, while the hemato-

mas were drained under local anesthesia.

The mean hospital stay and time to return to work

were shorter in the BGMAF group (2.1 ± 0.3 and

12.6 ± 2.6 days, respectively) compared to the LF group

(2.5 ± 0.6 and 14.0 ± 2.1 days, respectively) (P \ 0.001

and P = 0.003, respectively), and the cosmetic satisfaction

score was higher in the BGMAF group than in the LF

group (3.2 ± 0.5 vs. 2.9 ± 0.5, respectively, P \ 0.001).

Drainage was not used in the group treated with BGMAF.

In the LF group, the drainage time was the same as the

hospital stay (2.5 ± 0.6 days). Recurrence was seen in four

(7.1 %) patients in the BGMAF group and three (6.1 %) in

the LF group (P = 0.834). The effects of the treatment

modality on the clinical results are shown in Table 2.

Discussion

The first surgical techniques used to treat pilonidal sinus

included laying open the sinus, marsupialization, excision

Fig. 2 The BGMAF procedure.

a An S-shaped oblique skin

incision was made; b the sinus

area was obliquely excised;

c the advancing flap was

prepared; d the fascia of

bilateral gluteus maximus

muscles was sutured

individually to the postsacral

area

Fig. 3 The final view of the BGMAF procedure

Table 1 Patient characteristics

Characteristics BGMAF

(n = 56)

LF (n = 49) P*

Age (years) 26.7 ± 7.9 24.1 ± 5.1 0.217

Sex (M/F) 47/9 41/8 0.944

Mean body mass index (kg/m2) 25.4 ± 1.9 24.5 ± 1.6 0.020

Patients with recurrent PS (n) – 1 (2 %) 0.283

Preoperative symptoms

Pain 19 (33.9 %) 15 (30.6 %) 0.717

Discharge 33 (58.9 %) 30 (61.2 %) 0.811

Pain ? discharge 4 (7.1 %) 4 (8.2) 0.844

Data are expressed as the mean ± SEM or numbers (percentage)

* P values \0.05 were considered to be statistically significant

Surg Today

123

and primary closure techniques. The high recurrence rates

associated with these techniques led to the development

of new treatment modalities, such as advancement flap

techniques.

The ideal treatment of pilonidal sinus disease consists of

flattening the natal cleft and lateralization, while reducing

wound tension will reduce the morbidity by preventing

wound dehiscence and scar formation [3, 8]. The ideal

method for treating SPS must have a low recurrence rate.

The technique must also be simple, require brief hospital-

ization, increase the postoperative patient comfort, have an

efficient wound healing time and provide cosmetic satis-

faction. Techniques such as the Limberg and Dufourmentel

flaps were reported to have lower recurrence rates among

the flaps used to treat SPS that flatten the natal cleft and

remove the incision line and scar tissue from the central

line. The reported long-term recurrence and total early

complication rates are 1.6–6.9 and 4.7–25.7 %, respec-

tively, for the LF technique, which was first described for

the surgical treatment of pilonidal sinus disease by Azab

et al. [9–13]. Mentes et al. [14] modified the LF by later-

alizing the margin close to the anus, and reported even

lower rates of recurrence and complications with this

modification. The LF technique has not been previously

investigated in terms of parameters such as the length of

the operation, length of hospital stay and cosmetic satis-

faction. Various techniques used for the surgical treatment

of SPS and their outcomes are shown in Table 3.

The search for perfect patient satisfaction, while mini-

mizing the rates of recurrence and complications, in the

treatment of pilonidal sinus disease continues. Recent

studies have shown that the excision techniques used in

primary closure management, which involve a shorter

hospital stay and less surgical scarring, also reduce the

recurrence rates [3, 15, 16]. It was recently hypothesized

that the depth of the intergluteal sulcus, the vacuum effect

developing between the buttocks and the incision scar in

Table 2 Clinical outcomes of the treatment modalities

Outcomes BGMAF

(n = 56)

LF

(n = 49)

P*

Length of operation (min) 31.1 ± 3.9 48.3 ± 5.0 \0.001

Duration of drainage (days) – 2.5 ± 0.6 NA

Length of hospital stay

(days)

2.1 ± 0.3 2.5 ± 0.6 \0.001

Complications 9 (16.1 %) 5 (10.2 %) 0.154

Seroma 2 (3.6 %) –

Hematoma – 2 (4.1 %)

Wound dehiscence 7 (12.5 %) 3 (6.1 %)

Return to work (days) 12.6 ± 2.6 14.0 ± 2.1 0.003

Cosmetic satisfaction 3.2 ± 0.5 2.9 ± 0.5 \0.001

Follow-up period (months) 19.6 ± 5.2 21.6 ± 5.5 0.064

Recurrence 4 (7.1 %) 3 (6.1 %) 0.834

Data are expressed as the mean ± SEM or numbers (percentage)

* P values \ 0.05 were considered to be statistically significant

Table 3 Various flap techniques and outcomes

Operation Flap type Year N Drain MOT

(min)

LOH

(days)

Follow-up

(years)

CS

(S/TS)

Morbidity

%

Recurrence

%

Asymmetric incision Advancement

Karydakis [3] 1992 6545 N – 3 2–20 – 8.5 \1

Ates et al. [13] 2011 135 Y 42.3 3.43 26.2 (months) 2.2/10 11.1 3.1

Limberg flap Transposition

Azab et al. [9] 1984 30 Y – 10 0.5–3 – 20 0

Kapan et al. [11] 2002 85 Y – 5.3 69.3 (months) – 4.7 3.5

Topgul et al. [10] 2003 200 Y – 3.1 5.1 – 6 2.5

Mentes. et al. [17] 2008 353 N – 4.5 24 – 10.4 3.1

Akin et al. [12] 2010 411 Y – 3.2 109.2 (months) – 10.2 2.9

Muzi et al. [20] 2010 130 Y 60.6 4.9 45.7 (months) – 13.1 0

Muller et al. [7] 2011 70 Y 57.4 – 1.4 16.4/24 25.7 1.6

Ates et al. [13] 2011 134 Y 50.1 3.80 26.6 (months) 3.2/10 20.8 6.9

Current 2013 49 Y 48.3 2.5 21.6 (months) 2.9/4 10.2 6.1

Gluteus Maximus flap Advancement

Krand et al. [8] 2009 278 N 42.8 – 66 (months) – 7.2 0.7

Current 2013 56 N 31.1 2.1 19.6 (months) 3.2/4 16.1 7.1

N number of patients, MOT mean operation time, LOH length of hospitalization, CS cosmetic satisfaction, Y yes; N no, s score, TS total score

Surg Today

123

the midline affect recurrence [17]. The recurrence rates

associated with primary midline closure after excision are

20–42 % [18, 19], while the rate is reduced to 0.9–5.6 %

with primary closure after oblique excision [8, 15].

In a series of 278 patients, Krand et al. [8] reconstructed

the oblique excision with BGMAF and reported total

complication (seroma, infection and wound dehiscence)

and recurrence rates of 7.2 and 0.7 %, respectively. Mentes

et al. [17] reported complication and recurrence rates of

10.4 and 3.1 %, respectively, in a study of 353 patients

treated using the LF technique, while Ates et al. [13]

reported rates of 20.8 and 6.9 % in a 134-patient study

using the same technique. Muzi et al. [20] compared

modified tension-free primary closure with the LF tech-

nique in a study of 260 patients, and reported complication

and recurrence rates of 25.4 vs. 13.1 and 3.8 vs. 0 %,

respectively. They did not perform a statistical analysis of

the total complication rate, but found no significant dif-

ferences between the groups in terms of wound infection or

wound dehiscence. The total complication rates in our

series were 16.1 % in the BGMAF group and 10.2 % in the

LF group, while the recurrence rates were 7.1 and 6.1 %,

respectively; the differences between the groups were not

significant. Although the differences were not significant,

we attribute the increased complication rate in the BGMAF

group, particularly in wound dehiscence, to the flap tech-

nique being unable to sufficiently reduce the wound ten-

sion, thus leading to a delay of wound healing.

The recurrence and complication rates in our patients

treated with the BGMAF technique were higher than

those reported by Krand et al. [8] using the same tech-

nique. We ascribe this difference more to the socioeco-

nomic level of our subjects, rather than surgical factors,

because Krand et al. [8] studied patients living in the top

province in terms of socioeconomic development,

according to the State Planning Authority’s classification

of Turkey’s 81 provinces (SEGE 2011), while our

patients lived in the 45th and 81st provinces. Our

recurrence and complication rates in the LF group were

similar to those cited in some reports, but were higher

than the values in others [13, 17, 20]. Our literature

review did not reveal any comprehensive research on the

effects of socioeconomic development on recurrence and

morbidity. Anderson et al. [21] postulated that the out-

comes of pilonidal surgery may be affected by patient-

associated factors, and reported that cigarette use

increased morbidity. However, as their patients were

from relatively high socioeconomic levels, the effects of

various factors in patients with a low socioeconomic

status on the surgical outcomes could not be determined.

Krand et al. [8] reported a mean operation time for

BGMAF of 42.8 ± 4.2 min; Kirkil et al. [22] reported

mean operation times for LF of 79.5 and 65.5 min in

groups without and with drains, respectively. Ates et al.

[13] reported a mean operation time of 50.1 min for LF

using drainage and Muzi et al. [20] reported mean opera-

tion times of 28 min for modified primary closure and

60.6 min for LF with drainage. The mean lengths of the

operations in our study were 31.1 ± 3.9 min in the

BGMAF group and 48.3 ± 5.0 min in the LF group. Thus,

the operation was significantly shorter in the BGMAF

group, which was attributed to the preparation of the

advancement flap being easier than that of the full-thick-

ness flap, which is used in LF.

Drainage was not used in the BGMAF group. The mean

hospital stay was 2.1 ± 0.3 days. In the LF group, the

mean drainage and hospital stay were both 2.5 ± 0.6 days.

There was a significant difference between the groups in

terms of the hospital stay time. The most important reason

for the longer duration in the LF group was drainage

monitoring. However, in a study of 353 patients in whom

drainage was not used during LF, Mentes et al. [17]

reported a mean hospital stay of 4.5 days. Kirkil et al. [22]

reported a mean hospital stay of 3.3 days in a non-drainage

patient group and 3.1 days in a group in which drains were

used. Although a lack of drain usage seems to have

increased the length of the hospital stay in previous studies,

our results demonstrated that there is a positive relationship

between using a drain in the LF procedure and a prolonged

hospital stay. We believe that this difference between our

study and the previous studies depended on the variations

in the surgical techniques.

Krand et al. [8] reported a mean return-to-work time

after BGMAF of 12 ± 2 days, Unalp et al. [23] reported a

period of 15.2 days after LF, Ertan et al. [24] reported

15.8 days after LF and Mentes et al. [17] reported a mean

return-to-work time of 17.2 days after LF. The time to

return to work in our study was 12.6 ± 2.6 days in the

BGMAF group and 14.0 ± 2.1 days in the LF group

(P = 0.003). Our findings suggest that the shorter hospi-

talization contributes to shortening of the time to return to

work, and the BGMAF procedure was associated with a

shorter hospitalization and a shorter time to return to work

than LF.

Krand et al. [8] did not score the cosmetic satisfaction

after BGMAF. Muller et al. [7] evaluated the cosmetic

results in a study using the LF technique, and performed a

comparison with the scores in studies involving laparo-

scopic procedures and medial laparotomy; they concluded

that the score for the LF technique was intermediate

between those for laparoscopic procedures and median

laparotomy. We found a higher cosmetic satisfaction score

in the BGMAF group compared to the LF group in the

present study (3.2 ± 0.5 vs. 2.9 ± 0.5, P \ 0.001). The

better cosmetic score was likely associated with the shorter

incision scar in the BGMAF group.

Surg Today

123

Conclusion

Although BGMAF achieved similar outcomes to LF in

terms of recurrence, it had a higher rate of wound dehis-

cence; but ultimately, the difference was not significant.

We attribute the high level of dehiscence in BGMAF to

increased wound tension associated with the greater width

of the excision in advancement flaps compared to trans-

position flaps. BGMAF appears to be superior to LF in

terms of the length of the operation, length of hospital stay,

time to return to work and the cosmetic satisfaction, and

may be preferred for sinuses not requiring wide excision.

We believe that the LF technique, which better reduces

tension, is preferable for sinuses with a large post-excision

defect.

Acknowledgments We thank Prof. Said Bodur for the statistical

analysis of the data.

Conflict of interest None.

References

1. Al-Khamis A, McCallum I, King PM, Bruce J. Healing by pri-

mary versus secondary intention after surgical treatment

for pilonidal sinus. Cochrane Database Syst Rev. 2010;Jan

20;(1):CD006213.

2. Surrel JA. Pilonidal disease. Surg Clin North Am. 1994;74:

1309–15.

3. Karydakis GE. Easy and successful treatment of pilonidal sinus

after explanation of its causative process. ANZ J Surg. 1992;

62:385–9.

4. Armstrong JH, Barcia PJ. Pilonidal sinus disease: the conserva-

tive approach. Arch Surg. 1994;129:914–9.

5. Schneider IHF, Thaler K, Kockerling TF. Treatment of pilonidal

sinus by phenol injection. Int J Colorectal Dis. 1994;9:200–2.

6. Gage AA, Dutta P. Cryosurgery for pilonidal disease. Am J Surg.

1977;133:249–54.

7. Muller K, Marti L, Tarantino I, Jayne DG, Wolff K, Hetzer FH.

Prospective analysis of cosmesis, morbidity, and patient satis-

faction following Limberg flap for the treatment of sacrococ-

cygeal pilonidal sinus. Dis Colon Rectum. 2011;54(4):487–94.

8. Krand O, Yaltı T, Berber I, Kara VM, Telliıglu G. Management

of pilonidal sinus disease with oblique excision and bilateral

gluteus maximus fascia advancing flap: result of 278 patients. Dis

Colon Rectum. 2009;52:1172–7.

9. Azab AS, Kamal MS, Saad RA, Abou al Atta KA, Ali NA.

Radical cure of pilonidal sinus by a transposition rhomboid flap.

Br J Surg. 1984;71(2):154–5.

10. Topgul K, Ozdemir E, Kilic K, Gokbayir H, Ferahkose Z. Long-

term results of Limberg flap procedure for treatment of pilonidal

sinus: a report of 200 cases. Dis Colon Rectum. 2003;46(11):

1545–8.

11. Kapan M, Kapan S, Pekmezci S, Durgun V. Sacrococcygeal

pilonidal sinus disease with Limberg flap repair. Tech Colo-

proctol. 2002;6(1):27–32.

12. Akin M, Gokbayir H, Kilic K, Topgul K, Ozdemir E, Ferahkose

Z. Rhomboid excision and Limberg flap for managing pilonidal

sinus: long-term results in 411 patients. Colorectal Dis. 2008;

10(9):945–8.

13. Ates M, Dirican A, Sarac M, Aslan A, Colak C. Short and long-

term results of the Karydakis flap versus the Limberg flap for

treating pilonidal sinus disease: a prospective randomized study.

Am J Surg. 2011;202(5):568–73.

14. Mentes BB, Leventoglu S, Cihan A, Tatlicioglu E, Akin M, Oguz

M. Modified Limberg transposition flap for sacrococcygeal

pilonidal sinus. Surg Today. 2004;34(5):419–23.

15. Mentes O, Bagci M, Bilgin T, Coskun I, Ozgul O, Ozdemir M.

Management of pilonidal sinus disease with oblique excision and

primary closure: results of 493 patients. Dis Colon Rectum. 2006;

49(1):104–8.

16. Kim JK, Jeong JC, Lee JB, Jung KH, Bae BK. S-Plasty for

pilonidal disease: modified primary closure reducing tension.

J Korean Surg Soc. 2012;82:63–9.

17. Mentes O, Bagci M, Bilgin T, Ozgul O, Ozdemir M. Limberg flap

procedure for pilonidal sinus disease: results of 353 patients.

Langenbecks Arch Surg. 2008;393(2):185–9.

18. Al-Hassan HK, Francis IM, Neglen P. Primary closure or sec-

ondary granulation after excision of pilonidal sinus? Acta Chir

Scand. 1990;156(10):695–9.

19. Iesalnieks I, Furst A, Rentsch M, Jauch KW. Primary midline

closure after excision of a pilonidal sinus is associated with a high

recurrence rate. Chirurg. 2003;74(5):461–8.

20. Muzi MG, Milito G, Cadeddu F, Nigro C, Andreoli F, Amabile

D, Farinon AM. Randomized comparison of Limberg flap versus

modified primary closure for the treatment of pilonidal disease.

Am J Surg. 2010;200(1):9–14.

21. Anderson JH, Yip CO, Nagabhushan JS, Connelly SJ. Day case

Karydakis flap for pilonidal sinus. Dis Colon Rectum. 2008;

51(1):134–8.

22. Kirkil C, Boyuk A, Bulbuller N, Aygen E, Karabulut K, Coskun

S. The effects of drainage on the rates of early wound compli-

cations and recurrences after Limberg flap reconstruction in

patients with pilonidal disease. Tech Coloproctol. 2011;15(4):

425–9.

23. Unalp HR, Derici H, Kamer E, Nazli O, Onal MA. Lower

recurrence rate for Limberg vs. V-Y flap for pilonidal sinus. Dis

Colon Rectum. 2007;50(9):1436–44.

24. Ertan T, Koc M, Gocmen E, Aslar AK, Keskek M, Kilic M. Does

technique alter quality of life after pilonidal sinus surgery? Am J

Surg. 2005;190(3):388–92.

Surg Today

123