Modified elliptical rotation flap for sacrococcygeal pilonidal

sinus disease

Hayrettin Dizen,* Ömer Yoldas,† Mustafa Yıldız,* Murat Cilekar‡ and Evren Dilektaslı§*Department of General Surgery, Eskisehir Yunus Emre State Hospital, Eskisehir, Turkey†Department of General Surgery, Faculty of Medicine, Izmir University, Izmir, Turkey‡Department of General Surgery, Eskisehir State Hospital, Eskisehir, Turkey and§Department of General Surgery, Bursa Sevket Yılmaz Training and Research Hospital, Bursa, Turkey

Key words

elliptical, modified, pilonidal sinus, rotation flap.

Correspondence

Dr Ömer Yoldas, Department of General Surgery,Faculty of Medicine, Izmir University, Yeni girne bulv.1825 sok Karsıyaka/izmir, Izmir, Turkey.Email: omeryoldas@yahoo.com

H. Dizen MD; Ö. Yoldas MD; M. Yıldız MD;M. Cilekar MD; E. Dilektaslı MD.

Accepted for publication 15 July 2014.

doi: 10.1111/ans.12818

Abstract

Background: Although various surgical procedures have been described for pilonidalsinus disease, the best surgical technique is still controversial. The aim of this studywas to evaluate the short-term results of modified elliptical rotation flap (MERF) forpilonidal sinus disease in terms of post-operative complications, recurrence andquality of life.Method: Data of 121 patients (10 women, 111 men) who were operated on forsacrococcygeal pilonidal sinus disease between 2011 and 2013 were analysed. Ellip-tical rotation flap procedure which was described by Nessar et al. was modified.Complications, quality of life and recurrence were evaluated.Results: The mean operating time was 31 (range, 20–55) min. The mean time forcomplete healing was 2.26 ± 0.72 weeks. The mean time for returning to daily activi-ties was 9.0 ± 2.2 days. There were no flap necrosis and recurrence. Post-operativeinfection developed in five (4.1%) patients, which was managed by removal of a fewskin sutures, drainage and prolonged antibiotic use. Four patients (3.3%) developed aseroma, three of them having a partial wound dehiscence (2.5%). Neither haematomaformation nor complete dehiscence were observed.Conclusion: MERF seems to be an effective and reliable procedure having lowmorbidity rates and no recurrence. Further prospective randomized studies comparingthe MERF with other flap techniques will provide better information about thetechnique.

Introduction

Sacrococcygeal pilonidal sinus is a common disease that is charac-terized by inflammation, sinus formation and recurrent abscesses. Itoccurs in about 0.7% of the population and affects men more thanwomen, with a peak incidence at the age of 16–25 years.1 The idealtreatment for pilonidal sinus should ensure low pain, short hospitali-zation period, low risk of complication, rapid return to normal activi-ties and should have a low recurrence rate. Various surgicaltechniques are described to treat pilonidal sinus, such as excisionand primary closure, excision with marsupialization, simple V-Yadvancement flap, Bascom procedure, limberg flap reconstruction,modified limberg flap (MLF) reconstruction and karydakis flapreconstruction.2–9

Nessar et al. first described the elliptical rotation flap reconstruc-tion for pilonidal sinus disease.10 In this procedure, after a vertical

elliptical excision of the all diseased tissue down to the post-sacralfascia, a cutaneous skin flap of similar size and shape is raisedhorizontally over the gluteus muscle fascia with a 1-cm pivot pointin its lower corner. Its length/width ratio should be 2/1. The flap isthen rotated about its pivot point to the post-sacral defect and suturedsubcutaneously beginning from its lower edge. In this study, wepresent the results of patients in whom the modified elliptical rota-tion flap (MERF) reconstruction was used.

Methods

One hundred and twenty-one consecutive patients withsacrococcygeal pilonidal sinus were operated on by MERF betweenApril 2010 and September 2013. Data of these patients were pro-spectively recorded.

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Operative technique

All patients were admitted to the hospital the day before surgery, andthe gluteal area was shaved on the same day. Patients were operatedon under spinal anaesthesia in the jack-knife position. One gram ofcefazolin was administered intravenously as antibiotic prophylaxis.The buttocks strapped apart by adhesive tapes on the table. Thegluteal and sacral regions were prepared with 10% povidone-iodine.We modified the elliptical rotation flap reconstruction, which wasfirst described by Nessar et al.10 Instead of a vertical elliptical inci-sion, we planned an oblique elliptical incision and an opposite-sidedflap to place the lower edge of the flap 1–2 cm lateral to the natalcleft and to flatten the natal cleft (Fig. 1a,b). An oblique ellipticalincision including all sinus tracts was carried out and after excision,an opposite-sided elliptical transposition flap, with length/widthratio of 2/1, was tailored, fully mobilized and transposed to fulfil thepost-sacral defect without any tension. A vacuum drain was used inall cases. The flap was secured to post-sacral fascia with interrupted2/0 vicryl sutures. Subcutaneous tissues were approximated with 3/0vicryl sutures, and the skin was closed either with 3/0 prolene or skinstaples. Opposite-sided flap is crucial for flattening the natal cleftand for avoiding the occurrence of recurrences (Fig. 2).

Post-operative care and follow-up

All patients were discharged on the first post-operative day withantibiotics and pain medication. One hundred milligrams ofdiclofenac sodium was advised twice a day for pain medication. Thedrains were removed when the drainage decreased to ≤20 mL/day.Patients were examined routinely on the surgical ward on post-operative days 2, 7, 10 and 14 for wound inspection and removal ofsutures, and on post-operative at 1, 3, 6 and 12 months. Operationtimes, wound complications (infection, seroma, wound dehiscence),time required for returning to daily activities, time for completehealing and recurrences were recorded. All data were collected andanalysed using the Statistical Package for the Social Sciences (SPSS)for Windows 20.0 computer software (SPSS Inc., Chicago, IL, USA).

Results

Of the 121 patients, 111 (91.7%) were men, and 10 (8.3%) were women.The mean age was 22.6 ± 5.6 (range: 14–49) years. The mean follow-upperiod was 17 (range: 3–34) months. The mean operating time was 31(range,20–55) min.Themean timeforcompletehealingwas2.26 ± 0.72weeks.The mean time for returning to daily activities was 9.0 ± 2.2 days.

(a)

(b) Fig. 1. Demonstration of the obliqueelliptical excision and opposite-sidedflap lines (a) and of the suture linesafter modified elliptical rotation flap (b).

(a) (b)

(c) (d)

Fig. 2. Operative images of modifiedelliptical rotation flap (a–d).

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There were no flap necrosis and recurrence. Post-operative infectiondeveloped in five (4.1%) patients, which was managed by removal of afew skin sutures, drainage and prolonged antibiotic use. Four patients(3.3%) developed a seroma, three of them having a partial wounddehiscence (2.5%) away from the lower pole. Neither haematoma for-mation nor complete dehiscence was observed.

Discussion

Various surgical techniques were described for sacrococcygeal pilonidalsinus disease, but the ideal method is still under debate. An ideal opera-tion should be simple, should require a short hospital stay, should havelow recurrence rate, and should be associated with low complication rateand minimal pain. Complete excision of the sinus is widely practised, butcontroversy remains about what to do with the wound after excision.11

Excision with reconstructive procedures such as V-Yadvancement flaps,Z-plasties and W-flaps have been reported with low recurrence rates of0–9.5%, 1.6–10.0%, 0–16.7%, respectively.12–16 Karydakis used anasymmetric excision and primary closure with a recurrence rate of 1%.17

Although the number of patients were limited, Nessar et al.10 identifiedthe elliptical rotation flap with a recurrence rate of 0%, and short hospitalstay. Most of the flap reconstruction techniques have acute angled endpoints and these are the source of tissue ischaemia, wound dehiscenceand infection. Elliptical rotation flap has the advantage of having nocorners ending with acute angle, providing a better tissue healing and lessscar tissue. The weak point of elliptical rotation flap is having an endpoint in the intergluteal sulcus which provides maceration and prolongedwound healing. We have been performing elliptical rotation flap since2007 but besides high patient satisfaction and good cosmetic results, werealized that wound dehiscence, wound infection and recurrences wereoften occurred at the lower pole of the elliptical excision and we thereforehave modified the elliptical rotation flap. Instead of a vertical ellipticalincision an oblique elliptical incision and an opposite-sided flap wasperformed.The lower pole of the flap is removed from intergluteal sulcuswith MERF procedure. The most important predisposing factors for thedevelopment of pilonidal sinus are the existence of a deep natal cleft andthe presence of hair within the cleft.18,19 ‘Flattening the natal cleft’ is themost significant point for the surgical technique of choice because itdecreases both early post-operative period complications and recurrencerates.20–22 MLF procedure is one of the off-midline rotation flap-basedtension-free procedures, and it also flattens the natal cleft. Sit et al. foundMLF superior to the classic limberg flap and Karydakis flap. They foundMLF to have lower maceration, infection, dehiscence and recurrencerates.23 MERF is also an off-midline rotation-based tension-free proce-dure and additionally has the advantage of having no corner points whencompared with MLF.

The opposite-sided flap in MERF provides flattening of the natalcleft. We did not observed any recurrences in our study group;however, recurrence is a complication with a rate that increases overtime rather than being observed during the early period aftersurgery.24 Therefore, a short follow-up period is not sufficient forevaluation, and longer follow-up periods are essential.

Taking consideration of the results of our study, MERF seems tobe an effective and reliable procedure with having low morbidityrates and no recurrence rates. Further, prospective randomized

studies comparing the MERF with other flap techniques will providebetter information about the technique.

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