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Gluteus maximus myocutaneous flap for the treatment of recalcitrant pilonidal disease

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  • Gluteus Maximus Myocutaneous Flap for the Treatment of Recalcitrant Pilonidal Disease

    JOSE A. PEREZ-GURRI, M.D., WALLEY J. TEMPLE, M.D., ALFRED S. KETCHAM, M.D.

    Perez-Gurri JA, Temple WJ, Ketcham AS. Gluteus maximus myocu- taneous flap for the treatment of recalcitrant pilonidal disease. Dis Colon Rectum 1984;27:262-264.

    The treatment of a patient for multiple recurrent pilonidal disease failed all forms of conventional therapy. After re-excision, a gluteus maximus myocutaneous flap, measuring 15 X 15 cm and based on the superior gluteal artery, was swung to cover the defect. Complete relief from severe pain was obtained immediately. No recurrence is noted after two and one-half years of follow-up. [Key words: Pilonidai dis- ease, multiple recurrences; Gluteus maximus myocutaneous flap]

    THE MULTITUDE OF TREATMENT STRATEGIES for p i lon ida l disease reflects in par t its p ropens i ty for recur-

    rence, t-4 For tunate ly , most pat ients are cured by wide

    surg ica l exc is ion w i th or w i thout pr imary closure. Th is

    remains the s tandard w i th wh ich any new t reatment must

    be compared . 1,5-7 More d i f f i cu l t cases have been hand led

    by pr imary closures us ing rotat iona l or Z-plasty f lap techni -

    ques 7-xl w i th reasonab le success. A l though promis ing ,

    the i r complex i ty d i scourages the i r acceptance as in i t ia l

    t reatment . On the o ther hand, they prov ide exce l lent

    t reatment for most recurrences. Th is repor t focuses on a

    rare exper ience and fo l low-up of a pat ient w i th obdurate

    p i lon ida l disease. Repeated acceptab le therapeut ic maneu-

    vers fai led, leav ing a major sacral defect w i th recur rent

    p i lon ida l disease. F ina l ly , a myocutaneous f lap success-

    fu l ly c losed the defect and exce l lent long- term resul ts were obta ined.

    Repor t o f a Case

    A 32-year-old moderately hirsute white man, who sat for prolonged periods of time as a disc jockey, presented with recurrent pilonidal disease dating back to 1967. During this time he had had innumerable incisions and drainages and five maj or attempts at definitive treatment, including excision with primary closure in 1969, excision and marsup- ialization in 1971, and two excisions with healing by secondary inten- tion in 1977 and 1978. In 1980 wide excision was performed at our

    Received for publication August 24, 1983. Address reprint requests to Dr. Temple: Tom Baker Cancer Centre,

    1331 - 29th Street N.W., Calgary, Alberta T2N 4N2 Canada.

    From the Department of Surgery, University of Miami School of Medicine,

    Miami, Florida

    institution six weeks prior to his present admission. He required large amounts of narcotic medication for pain relief and was unable to sit. Past medical history was unremarkable, except for Charcot-Marie- Tooth disease and a history of occasional drug abuse.

    On physical examination he had changes consistent with Charcot- Marie-Tooth disease, with wasting interossei and distal leg muscula- ture and an associated distal sensory loss. Examination of the sacral area revealed a deep 7 )< 5 cm defect in the presacral area, with a scarred base and surrounding hypertrophic tissue (Fig. 1). It was essentially unchanged from the time of his last discharge. At the time of his present admission, the patient was placed on an intensive wound care pro- gram, with frequent dressing changes and debridements, but significant healing was not seen.

    The patient was taken to the operating room for excision and cover- age of the defect, using a gluteus maximus myocutaneous flap. Under general anesthesia, he was placed in the prone jackknife position. The densely scarred and hypertrophic granulating tissue was excised to normal surrounding fat and sacrum (Fig. 2). A rotational buttock flap, measuring 15 X 15 cm, was raised, incorporating skin and the underly- ing superior portion of the gluteus maximus muscle. After traversing the skin and subcutaneous tissue of the buttock, the upper portion of the gluteus maximus was transected down to the gluteus medius and piriformis muscles, taking great care to protect the sciatic nerve (Fig. 3). The superior gluteal vessels were not identified, but active bleeding from the muscle edges indicated an intact vascular pedicle. The myocu- taneous flap was then rotated into place (Fig. 4), a suction drain inserted (Fig. 5), and the wound closed in layers. The patient was not allowed to lie on the flap for one week, and primary healing was obtained (Fig. 6). He was then discharged and is free of recurrence and pain at a two and one-half year follow-up.

    Discuss ion

    Exper ience w i th the g lu teus max imus myocutaneous

    f lap has been descr ibed 1>15 for the cover ing of i sch ia l and

    sacral sores, but th is app l i ca t ion is un ique for p i lon ida l

    disease. The vast ma jor i ty of pat ients w i th recur rent or

    extens ive p i lon ida l d isease can be hand led by random

    pat tern ro ta t iona l sk in f laps. However , in this case where

    these f laps wou ld have been inadequate to cover the

    defect w i thout delay, a myocutaneous f lap a f forded safe

    pr imary c losure.

    262

  • Volume 27 Number 4 PILONIDAL DISEASE 263

    FIG. 1. Large postsacral defect is seen with undermined edges and hypertrophic granulation tissue. Design of gluteus maximus myocu- taneous flap is also seen.

    FIG. 2. Densely scarred and hypertrophic tissue has been excised down to the sacrum and elevation of flap has begun.

    FIG. 3. The flap has been elevated to show tile superior portion of the gluteus maximus muscle that will be utilized for coverage. FIG. 4. The myocutaneous flap is then rotated to cover the presacral

    defect.

    FiG. 5. The wound is closed primarily and a closed suction drain FIG 6. The wound is shown on the tenth postoperative day with system is left in place, primary healing.

  • Dis. Col. ge Rect, 264 PEREZ-GURRI, ET AL. April 198'~

    myocutaneous f~. ,1 - - \ f

    (~ , f~ / / \ superior / ~ /~/ / x ,g lu tea l vesse{s / Y /~ '~/ b ~ 8" nerve

    1 ;-,,no o, owiform is -- FTt i t / t ;~- \ i

    l/I/I ,' "' , /~ /~/~/ ' / "~gluteal vessels

    ~'~/ ' /~ , / , /', / ' - - 8- nerve

    / / '

    FIG. 7. The gluteus maximus myocutaneous flap, using the upper half of the muscle, is marked out(-) along with the defect. Blood supply is provided by the superior gluteal vessels which exit about 5 cm lateral to the midline sacrum, above the sciatic nerve and superior to the piriformis muscle.

    To avoid funct ional disturbance in the mobi le patient, only one-half of the muscle based either on the superior or inferior gluteal vessels should be used. The superior gluteal vessels exit above the pir i formis, just lateral to the sacrum. The inferior gluteal vessels are located approx- imately 5 cm from the mid l ine of the sacrum, medial to the sciatic nerve (Fig. 7). Identi f icat ion of these vessels depends on the extent of mobi l izat ion necessary to cover the defect. However, caution must be exercised to avoid damage to the sciatic nerve, which exits below the pir- i formis muscle, a long with the inferior gluteal vessels. Th is flap has the distinct advantage of transferring a large amount of tissue for pr imary closure, which effec- tively enhances the blood supply of the area and provides an excellent sacral cushion.

    For smaller defects, good results have been obtained using rotat ional skin flaps for pr imary closure and are reported to have less than 2 per cent recurrence. 9 A

    number os authors credit the success of skin flap closures, us ing either a rotat ional f lap or W- or Z-plasty tech- niques, to the obl i terat ion os the natal cleft. Th is elim- inates one of the predisposing elements for recurrence in this disease, s,16

    We still advocate pr imary excision with closure by secondary intent ion as the time-tested technique. Th is has the lowest recurrence rate, with less than 2 per cent in one review of approx imate ly 4500 patients. 5 Why it was not effective in this pat ient is a matter of conjecture. It

    wou ld be reasonable to suggest that the previous mult i - ple surgical interventions caused extensive local fibrosis, d imin ish ing both the blood supply and the abil ity for the tissues to undergo wound contracture. The latter process is critical in the heal ing of these defects.

    Th is pat ient continues to be free of disease at two and one-hal f years, The natural history of recurrence of this disease is not wel l -documented, but in one series of 126 patients, 98 per cent of recurrences had appeared by two yearsY In a second series, 66 per cent of all recurrences occurred wi th in two years of pr imary closure. 7 A third report documented two-thirds of all recurrences in the first year. In view of these data and the history of repeated breakdowns with in a few months of our patient's pre- vious procedures, we are opt imist ic as to the permanent success of this procedure. It is also noteworthy that the pat ient has no residual weakness attr ibutable to the operation.

    References

    1. Golz A, Argov S, Barzilai A. Pilonidal sinus disease: comparison among various methods of treatment and a survey of 160 patients. Curr Surg 1980;37:77-85.

    2. Goodall P. The etiology and treatment of pilonidal sinus: a review of 163 patients. Br J Surg 1961;49:212-8.

    3. Kooistra HP. Pilonidal sinuses: review of the literature and report of three hundred fifty cases. Am J Surg 1942;55:3-17.

    4. Patey D