Comparison of the Limberg flap and bilateral gluteus maximus advancing flap following oblique excision for the treatment of pilonidal sinus disease

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ORIGINAL ARTICLEComparison of the Limberg flap and bilateral gluteus maximusadvancing flap following oblique excision for the treatmentof pilonidal sinus diseaseMurat Yildar Faruk CavdarReceived: 11 June 2013 / Accepted: 22 August 2013 Springer Japan 2013AbstractPurpose This study was performed to compare the use ofa bilateral gluteus maximus advancing flap (BGMAF)following oblique incision, which was recently describedfor 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 wereevaluated retrospectively. The patients were evaluated interms of their age, body mass index, symptoms, length ofthe operation, complications, postoperative hospital stay,time to return to work, postoperative cosmetic satisfactionand recurrence rate.Results Fifty-six of the patients were treated withBGMAF, 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 theBGMAF group compared to the LF group. There was nostatistically significant difference between the groups forthe other criteria.Conclusion The BGMAF appears to be superior to the LFin terms of the length of the operation, time to return towork and degree of cosmetic satisfaction. It is preferablefor sinuses not to require wide excision, while the LF ismore appropriate for sinuses with a large post-excisiondefect.Keywords Pilonidal sinus Limberg flap Obliqueexcision Advancing flap Socioeconomic levelIntroductionPilonidal sinus disease is most common in the sacrococ-cygeal region and has an incidence of 26/100000. It istwice as common in males as in females [1]. A foreignbody reaction developing as a result of hair folliclespenetrating the skin following trauma is implicated in thepathogenesis of the disease [13]. The disease is generallyasymptomatic. However, when it becomes symptomatic, ithas a negative impact on the patients quality of life.Due to their high rates of recurrence, conservativemethods of treating symptomatic sacrococcygeal pilonidalsinus (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 ratesthan conservative methods, they have gradually given wayto advancement flap techniques, for reasons such as theneed for dressings, prolonged wound healing and woundinfection. The Limberg flap (LF) technique has the lowestrecurrence rate among the flap techniques currently used totreat SPS. However, recent reports have suggested that thistechnique does not achieve good results in terms of thecosmetic appearance and wound healing [7].The oblique excision and bilateral gluteus maximusadvancing flap (BGMAF) technique was recently describedfor the treatment of SPS, and provides results similar to theLF in terms of recurrence [8]. However, to date, there havebeen no studies comparing this method with other tech-niques in terms of the length of the operation and the lengthof the hospital stay.M. Yildar (&)Department of General Surgery, Balkesir University MedicalSchool, Balkesir, Turkeye-mail: muratyildar@hotmail.comF. CavdarDepartment of General Surgery, Yalova State Hospital, Yalova,Turkey123Surg TodayDOI 10.1007/s00595-013-0764-5Therefore, the present study was performed to comparethe results of the LF, which is widely used for the surgicaltreatment of pilonidal sinus disease, and the recentlydescribed BMGAF after oblique excision.MethodsThe data for 117 patients surgically treated for SPS at theMus and Erzincan State Hospitals in Turkey betweenFebruary 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 havemassive gluteal involvement (diseased area more than5 cm from the intergluteal sulcus) were included. Theinfected sinuses were treated with antibiotics, whileabscesses were treated with surgical drainage and antibi-otics. Surgery was performed 24 weeks after the regres-sion of the infection. Patients were informed about theoperations to be performed, and signed consent wasobtained. 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 and10 days and 6 months after LF. The final condition of thepatients was determined by a telephone interview. Thecosmetic satisfaction with the surgical results was scored6 months postoperatively as follows: 1 = poor,2 = acceptable, 3 = good or 4 = perfect. Patients werecompared 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 analysisThe data are presented as the means and standard devia-tions, medians and percentages (range). t test was used tocompare normally distributed numerical data between thegroups, and the MannWhitney U test was used for non-normally distributed data. In all analyses, a value ofP \ 0.05 was considered to indicate statistical significance.Surgical techniques and postoperative careFollowing the rectal lavage and shaving of the operationarea on the morning of surgery, all operations were per-formed under spinal anesthesia in the prone-jackknifeposition. One gram of prophylactic cefazolin sodium wasadministered 2060 min before the skin incision.The Limberg flap was made following the administra-tion of methylene blue through the sinus opening, in theclassic manner, using a vacuum drainage (Fig. 1). InBGMAF, an S-type oblique skin incision was madefollowing the administration of methylene blue through thesinus opening (Fig. 2a). Diseased tissue, including thesinus tract, was excised as far as the postsacral fascia(Fig. 2b). The fascia of both gluteus maximus muscles wasincised vertically from the point of adhesion to the sacrumand freed 1.52 cm from the muscle with hemostasisestablished with electrocautery (Fig. 2c). The fascia ofeach gluteus maximus was sutured individually to thepostsacral fascia with no. 0 polyglactin sutures (Fig. 2d).The subcuticular plane was closed with subcutaneous 3-0polyglactin sutures, and the cutaneous tissue was closedwith 3-0 polypropylene sutures (Fig. 3). No drain was usedin any patient in the BGMAF group. Postoperative painwas relieved with nonsteroidal anti-inflammatory drugs asneeded.Patients in both groups were mobilized on the firstpostoperative 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 appropriateinstructions for wound care and advised to use oral anti-biotics (co-amoxicillin 1000 mg, once every 12 h) for5 days. The skin sutures were removed 1012 dayspostoperatively.ResultsA total of 88 of the 105 patients were male while 17 ofthem were female; 56 patients were treated with BGMAFand 49 with LF. Their median age was 25 (range 1549)years. There were no significant differences between thegroups in terms of age or gender. The mean follow-up was20.5 5.4 months. The mean BMI was 25.4 1.9 in theBGMAF group and 24.5 1.6 in the LF group. Althoughthere was a significant difference (P = 0.02) between thegroups, this was unlikely to have affected the treatmentresults. The patients preoperative symptoms were similarin both groups. The patients characteristics and symptomsare summarized in Table 1.The mean length of the operation was significantlyshorter in the BGMAF group compared to the LF groupFig. 1 The final view of the Limberg flap procedureSurg Today123(31.1 3.9 vs. 48.3 5.0, P \ 0.001). Wound dehis-cence was seen in seven (12.5 %) patients in the BGMAFgroup and three (6.1 %) patients in the LF group in theearly 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. Seromasdeveloped in two (3.6 %) patients in the BGMAF groupand hematomas developed in two (4.1 %) patients in theLF group. The seromas were aspirated, while the hemato-mas were drained under local anesthesia.The mean hospital stay and time to return to workwere shorter in the BGMAF group (2.1 0.3 and12.6 2.6 days, respectively) compared to the LF group(2.5 0.6 and 14.0 2.1 days, respectively) (P \ 0.001and P = 0.003, respectively), and the cosmetic satisfactionscore was higher in the BGMAF group than in the LFgroup (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 thehospital stay (2.5 0.6 days). Recurrence was seen in four(7.1 %) patients in the BGMAF group and three (6.1 %) inthe LF group (P = 0.834). The effects of the treatmentmodality on the clinical results are shown in Table 2.DiscussionThe first surgical techniques used to treat pilonidal sinusincluded laying open the sinus, marsupialization, excisionFig. 2 The BGMAF procedure.a An S-shaped oblique skinincision was made; b the sinusarea was obliquely excised;c the advancing flap wasprepared; d the fascia ofbilateral gluteus maximusmuscles was suturedindividually to the postsacralareaFig. 3 The final view of the BGMAF procedureTable 1 Patient characteristicsCharacteristics BGMAF(n = 56)LF (n = 49) P*Age (years) 26.7 7.9 24.1 5.1 0.217Sex (M/F) 47/9 41/8 0.944Mean body mass index (kg/m2) 25.4 1.9 24.5 1.6 0.020Patients with recurrent PS (n) 1 (2 %) 0.283Preoperative symptomsPain 19 (33.9 %) 15 (30.6 %) 0.717Discharge 33 (58.9 %) 30 (61.2 %) 0.811Pain ? discharge 4 (7.1 %) 4 (8.2) 0.844Data are expressed as the mean SEM or numbers (percentage)* P values \0.05 were considered to be statistically significantSurg Today123and primary closure techniques. The high recurrence ratesassociated with these techniques led to the developmentof new treatment modalities, such as advancement flaptechniques.The ideal treatment of pilonidal sinus disease consists offlattening the natal cleft and lateralization, while reducingwound tension will reduce the morbidity by preventingwound dehiscence and scar formation [3, 8]. The idealmethod 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 anefficient wound healing time and provide cosmetic satis-faction. Techniques such as the Limberg and Dufourmentelflaps were reported to have lower recurrence rates amongthe flaps used to treat SPS that flatten the natal cleft andremove the incision line and scar tissue from the centralline. The reported long-term recurrence and total earlycomplication rates are 1.66.9 and 4.725.7 %, respec-tively, for the LF technique, which was first described forthe surgical treatment of pilonidal sinus disease by Azabet al. [913]. Mentes et al. [14] modified the LF by later-alizing the margin close to the anus, and reported evenlower rates of recurrence and complications with thismodification. The LF technique has not been previouslyinvestigated in terms of parameters such as the length ofthe operation, length of hospital stay and cosmetic satis-faction. Various techniques used for the surgical treatmentof 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 thetreatment of pilonidal sinus disease continues. Recentstudies have shown that the excision techniques used inprimary closure management, which involve a shorterhospital stay and less surgical scarring, also reduce therecurrence rates [3, 15, 16]. It was recently hypothesizedthat the depth of the intergluteal sulcus, the vacuum effectdeveloping between the buttocks and the incision scar inTable 2 Clinical outcomes of the treatment modalitiesOutcomes BGMAF(n = 56)LF(n = 49)P*Length of operation (min) 31.1 3.9 48.3 5.0 \0.001Duration of drainage (days) 2.5 0.6 NALength of hospital stay(days)2.1 0.3 2.5 0.6 \0.001Complications 9 (16.1 %) 5 (10.2 %) 0.154Seroma 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 0.003Cosmetic satisfaction 3.2 0.5 2.9 0.5 \0.001Follow-up period (months) 19.6 5.2 21.6 5.5 0.064Recurrence 4 (7.1 %) 3 (6.1 %) 0.834Data are expressed as the mean SEM or numbers (percentage)* P values \ 0.05 were considered to be statistically significantTable 3 Various flap techniques and outcomesOperation Flap type Year N Drain MOT(min)LOH(days)Follow-up(years)CS(S/TS)Morbidity%Recurrence%Asymmetric incision AdvancementKarydakis [3] 1992 6545 N 3 220 8.5 \1Ates et al. [13] 2011 135 Y 42.3 3.43 26.2 (months) 2.2/10 11.1 3.1Limberg flap TranspositionAzab et al. [9] 1984 30 Y 10 0.53 20 0Kapan et al. [11] 2002 85 Y 5.3 69.3 (months) 4.7 3.5Topgul et al. [10] 2003 200 Y 3.1 5.1 6 2.5Mentes. et al. [17] 2008 353 N 4.5 24 10.4 3.1Akin et al. [12] 2010 411 Y 3.2 109.2 (months) 10.2 2.9Muzi et al. [20] 2010 130 Y 60.6 4.9 45.7 (months) 13.1 0Muller et al. [7] 2011 70 Y 57.4 1.4 16.4/24 25.7 1.6Ates et al. [13] 2011 134 Y 50.1 3.80 26.6 (months) 3.2/10 20.8 6.9Current 2013 49 Y 48.3 2.5 21.6 (months) 2.9/4 10.2 6.1Gluteus Maximus flap AdvancementKrand et al. [8] 2009 278 N 42.8 66 (months) 7.2 0.7Current 2013 56 N 31.1 2.1 19.6 (months) 3.2/4 16.1 7.1N number of patients, MOT mean operation time, LOH length of hospitalization, CS cosmetic satisfaction, Y yes; N no, s score, TS total scoreSurg Today123the midline affect recurrence [17]. The recurrence ratesassociated with primary midline closure after excision are2042 % [18, 19], while the rate is reduced to 0.95.6 %with primary closure after oblique excision [8, 15].In a series of 278 patients, Krand et al. [8] reconstructedthe oblique excision with BGMAF and reported totalcomplication (seroma, infection and wound dehiscence)and recurrence rates of 7.2 and 0.7 %, respectively. Menteset al. [17] reported complication and recurrence rates of10.4 and 3.1 %, respectively, in a study of 353 patientstreated using the LF technique, while Ates et al. [13]reported rates of 20.8 and 6.9 % in a 134-patient studyusing the same technique. Muzi et al. [20] comparedmodified tension-free primary closure with the LF tech-nique in a study of 260 patients, and reported complicationand recurrence rates of 25.4 vs. 13.1 and 3.8 vs. 0 %,respectively. They did not perform a statistical analysis ofthe total complication rate, but found no significant dif-ferences between the groups in terms of wound infection orwound dehiscence. The total complication rates in ourseries were 16.1 % in the BGMAF group and 10.2 % in theLF group, while the recurrence rates were 7.1 and 6.1 %,respectively; the differences between the groups were notsignificant. Although the differences were not significant,we attribute the increased complication rate in the BGMAFgroup, 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 patientstreated with the BGMAF technique were higher thanthose 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 topprovince in terms of socioeconomic development,according to the State Planning Authoritys classificationof Turkeys 81 provinces (SEGE 2011), while ourpatients lived in the 45th and 81st provinces. Ourrecurrence and complication rates in the LF group weresimilar to those cited in some reports, but were higherthan the values in others [13, 17, 20]. Our literaturereview did not reveal any comprehensive research on theeffects of socioeconomic development on recurrence andmorbidity. Anderson et al. [21] postulated that the out-comes of pilonidal surgery may be affected by patient-associated factors, and reported that cigarette useincreased morbidity. However, as their patients werefrom relatively high socioeconomic levels, the effects ofvarious factors in patients with a low socioeconomicstatus on the surgical outcomes could not be determined.Krand et al. [8] reported a mean operation time forBGMAF of 42.8 4.2 min; Kirkil et al. [22] reportedmean operation times for LF of 79.5 and 65.5 min ingroups without and with drains, respectively. Ates et al.[13] reported a mean operation time of 50.1 min for LFusing drainage and Muzi et al. [20] reported mean opera-tion times of 28 min for modified primary closure and60.6 min for LF with drainage. The mean lengths of theoperations in our study were 31.1 3.9 min in theBGMAF group and 48.3 5.0 min in the LF group. Thus,the operation was significantly shorter in the BGMAFgroup, which was attributed to the preparation of theadvancement 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 meanhospital stay was 2.1 0.3 days. In the LF group, themean drainage and hospital stay were both 2.5 0.6 days.There was a significant difference between the groups interms of the hospital stay time. The most important reasonfor the longer duration in the LF group was drainagemonitoring. However, in a study of 353 patients in whomdrainage 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-drainagepatient group and 3.1 days in a group in which drains wereused. Although a lack of drain usage seems to haveincreased the length of the hospital stay in previous studies,our results demonstrated that there is a positive relationshipbetween using a drain in the LF procedure and a prolongedhospital stay. We believe that this difference between ourstudy and the previous studies depended on the variationsin the surgical techniques.Krand et al. [8] reported a mean return-to-work timeafter BGMAF of 12 2 days, Unalp et al. [23] reported aperiod of 15.2 days after LF, Ertan et al. [24] reported15.8 days after LF and Mentes et al. [17] reported a meanreturn-to-work time of 17.2 days after LF. The time toreturn to work in our study was 12.6 2.6 days in theBGMAF 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 towork, and the BGMAF procedure was associated with ashorter hospitalization and a shorter time to return to workthan LF.Krand et al. [8] did not score the cosmetic satisfactionafter BGMAF. Muller et al. [7] evaluated the cosmeticresults in a study using the LF technique, and performed acomparison with the scores in studies involving laparo-scopic procedures and medial laparotomy; they concludedthat the score for the LF technique was intermediatebetween those for laparoscopic procedures and medianlaparotomy. We found a higher cosmetic satisfaction scorein the BGMAF group compared to the LF group in thepresent study (3.2 0.5 vs. 2.9 0.5, P \ 0.001). Thebetter cosmetic score was likely associated with the shorterincision scar in the BGMAF group.Surg Today123ConclusionAlthough BGMAF achieved similar outcomes to LF interms 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 toincreased wound tension associated with the greater widthof the excision in advancement flaps compared to trans-position flaps. BGMAF appears to be superior to LF interms of the length of the operation, length of hospital stay,time to return to work and the cosmetic satisfaction, andmay be preferred for sinuses not requiring wide excision.We believe that the LF technique, which better reducestension, is preferable for sinuses with a large post-excisiondefect.Acknowledgments We thank Prof. Said Bodur for the statisticalanalysis of the data.Conflict of interest None.References1. Al-Khamis A, McCallum I, King PM, Bruce J. Healing by pri-mary versus secondary intention after surgical treatmentfor pilonidal sinus. Cochrane Database Syst Rev. 2010;Jan20;(1):CD006213.2. Surrel JA. Pilonidal disease. Surg Clin North Am. 1994;74:130915.3. Karydakis GE. Easy and successful treatment of pilonidal sinusafter explanation of its causative process. ANZ J Surg. 1992;62:3859.4. Armstrong JH, Barcia PJ. Pilonidal sinus disease: the conserva-tive approach. Arch Surg. 1994;129:9149.5. Schneider IHF, Thaler K, Kockerling TF. Treatment of pilonidalsinus by phenol injection. Int J Colorectal Dis. 1994;9:2002.6. Gage AA, Dutta P. Cryosurgery for pilonidal disease. Am J Surg.1977;133:24954.7. 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):48794.8. Krand O, Yalt T, Berber I, Kara VM, Telliglu G. Managementof pilonidal sinus disease with oblique excision and bilateralgluteus maximus fascia advancing flap: result of 278 patients. DisColon Rectum. 2009;52:11727.9. 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):1545.10. Topgul K, Ozdemir E, Kilic K, Gokbayir H, Ferahkose Z. Long-term results of Limberg flap procedure for treatment of pilonidalsinus: a report of 200 cases. Dis Colon Rectum. 2003;46(11):15458.11. Kapan M, Kapan S, Pekmezci S, Durgun V. Sacrococcygealpilonidal sinus disease with Limberg flap repair. Tech Colo-proctol. 2002;6(1):2732.12. Akin M, Gokbayir H, Kilic K, Topgul K, Ozdemir E, FerahkoseZ. Rhomboid excision and Limberg flap for managing pilonidalsinus: long-term results in 411 patients. Colorectal Dis. 2008;10(9):9458.13. Ates M, Dirican A, Sarac M, Aslan A, Colak C. Short and long-term results of the Karydakis flap versus the Limberg flap fortreating pilonidal sinus disease: a prospective randomized study.Am J Surg. 2011;202(5):56873.14. Mentes BB, Leventoglu S, Cihan A, Tatlicioglu E, Akin M, OguzM. Modified Limberg transposition flap for sacrococcygealpilonidal sinus. Surg Today. 2004;34(5):41923.15. Mentes O, Bagci M, Bilgin T, Coskun I, Ozgul O, Ozdemir M.Management of pilonidal sinus disease with oblique excision andprimary closure: results of 493 patients. Dis Colon Rectum. 2006;49(1):1048.16. Kim JK, Jeong JC, Lee JB, Jung KH, Bae BK. S-Plasty forpilonidal disease: modified primary closure reducing tension.J Korean Surg Soc. 2012;82:639.17. Mentes O, Bagci M, Bilgin T, Ozgul O, Ozdemir M. Limberg flapprocedure for pilonidal sinus disease: results of 353 patients.Langenbecks Arch Surg. 2008;393(2):1859.18. Al-Hassan HK, Francis IM, Neglen P. Primary closure or sec-ondary granulation after excision of pilonidal sinus? Acta ChirScand. 1990;156(10):6959.19. Iesalnieks I, Furst A, Rentsch M, Jauch KW. Primary midlineclosure after excision of a pilonidal sinus is associated with a highrecurrence rate. Chirurg. 2003;74(5):4618.20. Muzi MG, Milito G, Cadeddu F, Nigro C, Andreoli F, AmabileD, Farinon AM. Randomized comparison of Limberg flap versusmodified primary closure for the treatment of pilonidal disease.Am J Surg. 2010;200(1):914.21. Anderson JH, Yip CO, Nagabhushan JS, Connelly SJ. Day caseKarydakis flap for pilonidal sinus. Dis Colon Rectum. 2008;51(1):1348.22. Kirkil C, Boyuk A, Bulbuller N, Aygen E, Karabulut K, CoskunS. The effects of drainage on the rates of early wound compli-cations and recurrences after Limberg flap reconstruction inpatients with pilonidal disease. Tech Coloproctol. 2011;15(4):4259.23. Unalp HR, Derici H, Kamer E, Nazli O, Onal MA. Lowerrecurrence rate for Limberg vs. V-Y flap for pilonidal sinus. DisColon Rectum. 2007;50(9):143644.24. Ertan T, Koc M, Gocmen E, Aslar AK, Keskek M, Kilic M. Doestechnique alter quality of life after pilonidal sinus surgery? Am JSurg. 2005;190(3):38892.Surg Today123Comparison of the Limberg flap and bilateral gluteus maximus advancing flap following oblique excision for the treatment of pilonidal sinus diseaseAbstractPurposeMethodsResultsConclusionIntroductionMethodsStatistical analysisSurgical techniques and postoperative careResultsDiscussionConclusionAcknowledgmentsReferences

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