ORIGINALCONTRIBUTION

Sacrococcygeal Pilonidal Sinus Treatedby a New Fascio-Cutaneous FlapMajid Lahooti, M.D. � Peymaneh Alizadeh Taheri, M.D. �

Behtash Ghazi Nezami, M.D. � Solmaz Assa, M.D.

Department of Plastic Surgery, Amir-Alam Hospital, Medical Sciences/University of Tehran, Tehran, Iran

PURPOSE: This study reported the technical details andpreliminary clinical outcomes of a new fascio-cutaneoustransposition flap for the surgical treatment of pilonidalsinus.

METHODS: Fifty-two patients with pilonidal sinus weresurgically treated. During the surgical procedure, aninferiorly pedicled, fascio-cutaneous flap with specificgeometric characteristics was prepared and transposed.Postoperative pain, complications, duration of hospitalstay, and time off worked were assessed. Patients werefollowed for eighteen months after surgery.

RESULTS: The mean hospital stay was 2 days. Drains andsutures were removed after 3 and 12 days, respectively.No flap ischemia, wound dehiscence or major complica-tions were observed. Tension on suture lines and painafter surgery were negligible. Wound infections occurredin 4 patients (7.7 percent) and were managed byremoving a few sutures. Seroma was detected in 6 patients(11.5 percent). The mean time patients missed work was7 days. No recurrence was observed during the follow-upperiod of 18 months.

CONCLUSIONS: With no disease recurrence, minimalcomplication rate, time off work, and acceptable aestheticoutcome, this fascio-cutaneous transposition flap tech-nique is a safe and effective method for surgically treatingpilonidal sinus.

KEY WORDS: Pilonidal sinus; Flap; Excision;Primary closure; Fascio-cutaneous.

INTRODUCTION

Pilonidal sinus is a common chronic disease of thesacrococcygeal region, which is often associated withconsiderable discomfort and morbidity. To date severalmethods have evolved for treatment of pilonidal sinus.Apart from nonsurgical and conservative treatmentmodalities, conventional surgical interventions including“excision and primary closure” and “excision and open

management” are associated with high recurrence ratesand high postoperative morbidity.1

In 1944, Dr. Louis Buie recommended that the idealtreatment of pilonidal sinus was removal of the infectedcavity and marsupialization. While this method is stillpracticed, healing of the granulating wound takes timeand requires regular outpatient dressing resulting inconsiderable discomfort.1

As Bose and Candy suggested, the current surgicalaim in pilonidal disease is to obliterate the natal cleft andthereby obliterate the rolling action of the buttocks, acausal factor responsible for the vicious cycle of infectionand recurrence.2 Several surgical techniques such asexcision and Z-plasty, excision and W-plasty and rotation,advancement or transposition flaps are intended toneutralize this causal rolling action.3–5

The use of excision and closure with transpositionflap has received growing attention in recent years; sincelow recurrence rates have been demonstrated with thistechnique.6 Taking advantage of enhanced flap designwith more flexibility and safe coverage, transposition flaphas become a common technique for pilonidal diseasetreatment, although the risk of dehiscence and distalnecrosis still remains.7,8 Based on our experience, excisionof affected tissues along with an appropriate flap design,eliminates the need to completely obliterate the natal cleftand thus avoids patient’s consequent aesthetic dissatisfac-tion. Existing transposition flap designs could be im-proved upon by including underlying fascia and adiposetissue, which will enhance blood supply and possiblyreduce risk of dehiscence and distal necrosis. This paperreports a new fascio-cutaneous transposition flap forsurgical treatment of pilonidal sinus.

METHODS

This prospective study was carried out in 52 consecutivepatients (36 men, 16 women) with sacrococcygealpilonidal sinus treated at Amir-Alam Hospital betweenJanuary 1994 and December1996. All patients wereoperated on by M. L. or under his supervision.

Surgical TechniqueThe operation was carried out under general anesthesia.In all patients the procedure was covered by a single doseof 1 gram of intravenous cefazolin, 30 minutes before skin

Address to correspondence: Majid Lahooti, M.D., Department of PlasticSurgery, Amir-Alam Hospital, Medical Sciences/University of Tehran,Tehran, Iran. E-mail: Lahootim@yahoo.com

DOI: 10.1007/s10350-008-9211-x � VOLUME 51: 588–592 (2008) � ©THE ASCRS 2008 � PUBLISHED ONLINE: 20 FEBRUARY 2008588

incision and 3 doses after surgery every 6 hours. Patientswere placed in the prone, jack-knife position, with thebuttocks strapped apart with the use of adhesive bands.The sacrococcygeal area was shaved right before incisionand cleaned with povidone-iodine. The extent of the sinuswas assessed by a stylet and a small amount of methyleneblue injected into the sinus to outline the cavity. The areato be excised (ABCD) was mapped on the skin in anelliptical pattern (Fig. 1) with the AC axis along the natalcleft. The lateral border of the defect (ADC) was dividedinto two segments, AD=3/5AC and DC=2/5AC. The flapwas prepared by extending the incision to form the DEand EF incision lines (AD=DE=EF). The ADE angle wasequal to the DEF angle and between 45° and 60° (Fig. 2Aand B).

The DE and EF incisions were deepened through thefascia of the underlying muscle, forming a fascio-cutaneous flap, which was separated from muscle withhemostasis using electrocoagulation. The fascio-cutaneousflap was then transposed medially to cover the defectwithout tension (Fig. 2C) and skin was closed in one layerwith simple 4–0 nylon sutures. Separate sutures on thefascia layer were not necessary, since the low tensionimposed on transposed flap allowed the flap to fully restin the wound bed and fill the defect. In order to preventfluid collection, a single multiple-hole, closed suctiondrain was laid in the bed of the wound before closure andbrought out through a separate stab incision (Fig. 3).

Post-Operative CareNo postoperative restrictions on resting position orpatient activity were made. The dressing was changed

and patients were encouraged to walk on the firstpostoperative day.

AssessmentsPost-surgical pain of patients was assessed subjectivelyand graded from 0 (no pain) to 4 (severe pain) (Table 1).Early wound complications, duration of hospital stay,elapsed time needed to return to active work, and diseaserecurrence were recorded. Follow-up examinations weremade on an outpatient basis after two weeks and then, onthe first, sixth and eighteenth months after operation.Patients were recommended to return if they had anycomplication after eighteen months.FIGURE 1. Configuration of the flap.

FIGURE 2. Flap mapping onto the skin (A) and transpositon to coverthe defect after excision of the sinus (B and C).

LAHOOTI ET AL.: NEW FLAP TECHNIQUE FOR PILONIDAL SINUS 589

RESULTS

Patients’ ages ranged from 16 to 38 years (mean 25 years).Nine patients (17.3 percent) had the history of acuteabscess resulting in drainage and 12 patients (23 percent)had previously undergone one of the conventionalprocedures for pilonidal sinus. The other 31 cases werefirst visiting patients without history of abscess orprevious surgical management for pilonidal disease.

Postoperatively, 7 patients (13.5 percent) had mod-erate pain (grade 3), which was managed with non-narcotic analgesics. The remaining 45 patients experi-enced either slight or mild pain. No patients reportedsevere pain. No incidences of flap ischemia, necrosis orwound dehiscence occurred postoperatively. Woundinfection was developed in 4 patients (7.8 percent),mainly based on clinical symptoms and signs, such aserythema, swelling, puss leakage and pain. These patientswere managed by removing a few sutures and drainage ofthe wound without further antibiotic therapy. Seroma wasdetected in 6 patients (11.5 percent) needing aspiration(once in 4 cases and twice in 2 others) without anysubsequent complications. The drains and skin sutureswere removed at the third and twelfth postoperative day,respectively. The average hospital stay was 2 days, rangingfrom 1 to 3 days. The mean time off work was 7 days (3–14 days) with those with undemanding jobs returning towork right after discharge.

Primary healing was achieved in all patients withsatisfactory aesthetic appearance and no recurrence wasobserved during the eighteen-month follow-up period.

DISCUSSION

The treatment goals for pilonidal disease are cure with alow recurrence rate while causing minimal complicationsand inconvenience for the patient including minimizinghospital stays and time lost from work. In our study, thefifty-two patients, who were surgically treated, experi-enced no disease recurrence, considerably lower pain andmorbidity after surgery and 7.7 percent rate of postoper-ative wound infections. We propose that at least part ofthe improved treatment outcomes were due to theinclusion of underlying fascia into flap structure, sincefascia and subcutaneous adipose tissue play a pivotal rolein supplying the overlying skin and thus decreasing therisk of distal necrosis when applied in flap fabrication.

An important predisposing factor for pilonidaldisease is the existence of a deep natal cleft and thepresence of hair within the cleft, which prepares afavorable environment for sweating, maceration andbacterial contamination.2,9–11 The most likely hypothesisabout the etiology of pilonidal disease is that infectionoriginates within a natal cleft hair follicle. The folliclebecomes distended with keratin and inflamed resulting infolliculitis and edema, which blocks its outlet. Theobstructed follicle in turn expands and finally rupturesinto the underlying subcutaneous fat to form a pilonidalabscess.12,13

Conservative treatment modalities including frequenthair removal, injection of sclerosing chemical agents suchas phenol, and electrocauterization are associated withhigh disease recurrence rate.5 Excision and direct woundclosure is usually associated with extensive tension andpain and long period of postoperative care. Moreover,high recurrence rates of up to 30 percent have beenreported.9,12,14–18 Kronborg et al. reported the results ofexcision, excision with suture, and excision with suture andantibiotic coverage; the recurrence rates were 13 percent,25 percent and 19 percent, respectively.19

New surgical techniques, with lower recurrence rates,aim to reduce the depth of natal cleft. These surgicaltechniques include excision and Z-plasty, excision and W-plasty, V-Y advancement flaps and transposition flaps(such as gluteal myocutaneous and Limberg flap).4,10,20

The reported recurrence rates for Limberg flap repair varyfrom 0 percent to 5 percent.7,8,21,22 The Limberg flap notonly reduces the depth of the natal cleft, but alsotransposes the incision scar from the midline. Thus,frictional movements of the buttocks are decreased andcomplicating factors such as skin maceration and debrisaccumulation are eliminated. However, the wide angle of

Table 1. Subjective grading of postoperative pain

Grade Description

0 No pain1 Slight pain, no need to use analgesics2 Mild pain, oral analgesics3 Moderate pain, nonnarcotic analgesics (IM)4 Severe pain, narcotic analgesics (IM)

IM: intra muscular

FIGURE 3. Postoperative appearance of the flap.

LAHOOTI ET AL.: NEW FLAP TECHNIQUE FOR PILONIDAL SINUS590

the extended incision in the Limberg flap ends in tensedsuture lines and less desirable aesthetic outcome.6 Z- andW-plasty are associated with disadvantages such as necrosisof the flap tips and unsatisfactory scars.3–5 Z-plasty,originally as a tissue rearrangement method, is used forlengthening small linear scars and contractures by rearran-ging the existing tissue to relieve the tension and makingmore tissues available in one direction. For this purpose,the defect is put in central limb of the Z, along which theadditional length is desired.23 So it may look in contrary tothe purpose of a safe coverage in pilonidal disease, in whichthe defect is literary under a transverse tension and henceZ-plasty is not recommended in patients with complicatedor extensive pilonidal disease.5,11,24

In our fascio-cutaneous transposition flap technique,after proper sinus excision and flap transposition, thedepth of the cleft is decreased but not completelyeliminated and the scar is finely deviated from midline,as a result of the low-tensioned flap transposition and itsappropriate thickness. If all sinus tracts are excised, themain predisposing factor is eliminated, and the recur-rence rate is very low. In our study we had no recurrenceduring the follow up period of 18 months. These resultsmay be argued due to our relatively short follow up,however we do not expect considerable changes in theseresults, as our patients, mostly local residents, wereadvised to report new incidence of complication orrecurrence.

Notaras reported that the average time off work aftersimple wound closure was 6 weeks.9 Flap techniques suchas Z-plasty and especially Limberg flaps have significantlyreduced patient time off work and thus the techniqueshave received growing attention in recent years.3,5–7,11,21

In our study, patients were discharged 2 days after surgeryand returned to work after 7 days with no incidence ofwound dehiscence.

We found several differences between our methodand Rhomboid or Limberg flaps which explains oursuperior results over other flap techniques.25 The rhom-boid flap by definition is made by converting the initialdefect into an equilateral parallelogram with fixed 60° and120° angles. One face of the rhomboid constitutes the firstside of the flap (BC line in Fig. 4), which should bealigned along the line of maximum extensibility, and theextending incision (BE) is made outward the shortdiagonal of the rhomboid, for a distance equal to it. Theextending incision in our method, starting from the wallof the defect, originates from the point which divides thewall into two sections with the ratio of two-fifths andthree-fifths. The angle between this incision and thedefect wall is consequently between 45° and 60° versus the120° in rhomboid flaps (Fig. 4). The proposed narrowangles in our technique was achieved by enhancedcirculation in flap as a result of including the underlyingfascia which leads to more flexible flaps and relaxed

transposition. On the other hand the ADE portion isconsiderably diminished in length and has gained accept-ably wide pedicle, which adds to the flap’s blood supply(Fig. 4).

CONCLUSIONS

In conclusion, minimum postoperative morbidity andpain, short hospital stay and reduced time off work,satisfying aesthetic outcome, and no disease recurrencemake the proposed fascio-cutaneous transposition flap, anappropriate method for treatment of sacrococcygealpilonidal sinus especially in patients with recurrentdisease. With low risk of complications and a simple flapdesign, the fascio-cutaneous transposition flap is a safeand easily reproducible method for surgical treatment ofpilonidal sinus.

FIGURE 4. Comparison between the proposed fascio-cutaneous flap(A) and conventional Limberg flap (B). The curved arrow linesindicate the required transposition range.

LAHOOTI ET AL.: NEW FLAP TECHNIQUE FOR PILONIDAL SINUS 591

REFERENCES

1. Aydede H, Erhan Y, Sakarya A, Kumkumoglu Y. Compar-ison of three methods in surgical treatment of pilonidaldisease. ANZ J Surg 2001;71:362–4.

2. Bose B, Candy J. Radical cure of pilonidal sinus by Z-plasty. Am J Surg 1970;120:783–6.

3. Mansoory A, Dickson D. Z-plasty for treatment of disease ofthe pilonidal sinus. Surg Gynecol Obstet 1982;155:409–11.

4. Roth RF, Moorman WL. Treatment of pilonidal sinus andcyst by conservative excision and W-plasty closure. PlastReconstr Surg 1977;60:412–5.

5. Hodgson WJ, Greenstein RJ. A comparative study betweenZ-plasty and incision and drainage or excision withmarsupialization for pilonidal sinuses. Surg Gynecol Obstet1981;153:842–4.

6. Eryilmaz R, Sahin M, Alimoglu O, Dasiran F. Surgicaltreatment of sacrococcygeal pilonidal sinus with theLimberg transposition flap. Surgery 2003;134:745–9.

7. Urhan MK, Kucukel F, Topgul K, Ozer I, Sari S. Rhomboidexcision and Limberg flap for managing pilonidal sinus:results of 102 cases. Dis Colon Rectum 2002;45:656–9.

8. Erdem E, Sungurtekin U, Nessar M. Are postoperativedrains necessary with the Limberg flap for treatment ofpilonidal sinus? Dis Colon Rectum 1998;41:1427–31.

9. Notaras MJ. A review of three popular methods oftreatment of postanal (pilonidal) sinus disease. Br J Surg1970;57:886–90.

10. Schoeller T, Wechselberger G, Otto A, Papp C. Definitesurgical treatment of complicated recurrent pilonidaldisease with a modified fasciocutaneous V-Y advancementflap. Surgery 1997;121:258–63.

11. Monro RS, McDermott FT. The elimination of causalfactors in pilonidal sinus treated by Z-plasty. Br J Surg1965;52:177–81.

12. Allen-Mersh TG. Pilonidal sinus: finding the right track fortreatment. Br J Surg 1990;77:123–32.

13. Bascom J. Pilonidal disease: long-term results of follicleremoval. Dis Colon Rectum 1983;26:800–7.

14. Sondenaa K, Nesvik I, Andersen E, Soreide JA. Recurrentpilonidal sinus after excision with closed or open treat-ment: final result of a randomised trial. Eur J Surg1996;162:237–40.

15. al-Hassan HK, Francis IM, Neglen P. Primary closure orsecondary granulation after excision of pilonidal sinus?Acta Chir Scand 1990;156:695–9.

16. Khaira HS, Brown JH. Excision and primary suture ofpilonidal sinus. Ann R Coll Surg Engl 1995;77:242–4.

17. Al-Jaberi TM. Excision and simple primary closure ofchronic pilonidal sinus. Eur J Surg 2001;167:133–5.

18. Spivak H, Brooks VL, Nussbaum M, Friedman I. Treat-ment of chronic pilonidal disease. Dis Colon Rectum1996;39:1136–9.

19. Kronborg O, Christensen K, Zimmermann-Nielsen C.Chronic pilonidal disease: a randomized trial with acomplete 3-year follow-up. Br J Surg 1985;72:303–4.

20. Manterola C, Barroso M, Araya JC, Fonseca L. Pilonidaldisease: 25 cases treated by the Dufourmentel technique.Dis Colon Rectum 1991;34:649–52.

21. Bozkurt MK, Tezel E. Management of pilonidal sinus withthe Limberg flap. Dis Colon Rectum 1998;41:775–7.

22. Cubukcu A, Gonullu NN, Paksoy M, Alponat A, Kuru M,Ozbay O. The role of obesity on the recurrence of pilonidalsinus disease in patients, who were treated by excision andLimberg flap transposition. Int J Colorectal Dis 2000;15:173–5.

23. Disa JJ, Halvorson EG, Hidalgo DA. Surface reconstructionprocedures. In: Souba WW, Fink MP, Jurkovich GJ, KaiserLR, Pearce WH, Pemberton JH, et al., eds. ACS Surgery:Principles and Practice. Elmwood Park, NJ: WebMDProfessional Publishing, 2004:227–30.

24. Dylek ON, Bekereciodlu M. Role of simple V-Y advance-ment flap in the treatment of complicated pilonidal sinus.Eur J Surg 1998;164(12):961–4.

25. Nivatvongs S. Pilonidal disease. In: Nicholls RJ, Dozois RR,eds. Surgery of the Colon & Rectum. 1st ed. NewYork:Churchill Livingstone; 1997:250.

LAHOOTI ET AL.: NEW FLAP TECHNIQUE FOR PILONIDAL SINUS592