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 pi lonidal 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 fol low-up. [Key words: Pilonidai dis- ease, multiple recurrences; Gluteus maximus myocutaneous flap]

T H E MULTITUDE OF TREATMENT STRATEGIES fo r

p i l o n i d a l d i sease ref lects i n p a r t i ts p r o p e n s i t y for recur -

rence , t-4 F o r t u n a t e l y , m o s t p a t i e n t s are c u r e d b y w i d e

s u r g i c a l e x c i s i o n w i t h o r w i t h o u t p r i m a r y c losure . T h i s

r e m a i n s t he s t a n d a r d w i t h w h i c h a n y n e w t r e a t m e n t m u s t

be c o m p a r e d . 1,5-7 M o r e d i f f i c u l t cases h a v e b e e n h a n d l e d

by p r i m a r y c losures u s i n g r o t a t i o n a l or Z-plas ty f l ap t echn i -

q u e s 7-xl w i t h r e a s o n a b l e success. A l t h o u g h p r o m i s i n g ,

t h e i r c o m p l e x i t y d i s c o u r a g e s t h e i r a c c e p t a n c e as i n i t i a l

t r e a t m e n t . O n t h e o t h e r h a n d , t hey p r o v i d e e x c e l l e n t

t r e a t m e n t for m o s t r ecu r r ences . T h i s r e p o r t focuses o n a

r a re e x p e r i e n c e a n d f o l l o w - u p of a p a t i e n t w i t h o b d u r a t e

p i l o n i d a l disease. R e p e a t e d a c c e p t a b l e t h e r a p e u t i c m a n e u -

vers fa i led, l e a v i n g a m a j o r sac ra l defect w i t h r e c u r r e n t

p i l o n i d a l d isease . F i n a l l y , a m y o c u t a n e o u s f l ap success-

fu l l y c l o s e d the defect a n d e x c e l l e n t l o n g - t e r m r e s u l t s

were o b t a i n e d .

R e p o r t o f a C a s e

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.

D i s c u s s i o n

E x p e r i e n c e w i t h t he g l u t e u s m a x i m u s m y o c u t a n e o u s

f l a p h a s b e e n d e s c r i b e d 1>15 fo r t he c o v e r i n g of i s c h i a l a n d

sac ra l sores , b u t t h i s a p p l i c a t i o n is u n i q u e for p i l o n i d a l

d isease . T h e v a s t m a j o r i t y of p a t i e n t s w i t h r e c u r r e n t o r

e x t e n s i v e p i l o n i d a l d i s ease c a n b e h a n d l e d b y r a n d o m

p a t t e r n r o t a t i o n a l s k i n f laps . H o w e v e r , i n th i s case w h e r e

t he se f l a p s w o u l d h a v e b e e n i n a d e q u a t e to cove r t h e

defec t w i t h o u t de l ay , a m y o c u t a n e o u s f l a p a f f o r d e d safe

p r i m a r y 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 l u t e a l vesse{s / Y / ~ ' ~ / b ~ 8" nerve

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

l/I/I ,' "' , / ~ / ~ / ~ / ' / "~g lu tea l 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.

T o avoid func t iona l d is turbance in the mobi l e pat ient ,

on ly one-ha l f of the musc le based ei ther on the super ior

or infer ior g lu tea l vessels shou ld be used. T h e super ior

g lu tea l vessels exit above the p i r i formis , just lateral to the

sacrum. T h e infer ior g lu tea l vessels are located app rox -

imate ly 5 cm f rom the m i d l i n e of the sacrum, media l to

the sciatic nerve (Fig. 7). Iden t i f ica t ion of these vessels

depends on the extent of mob i l i za t ion necessary to cover

the defect. However , cau t ion mus t be exercised to avoid

d a m a g e to the sciatic nerve, w h i c h exits be low the pir-

i formis muscle, a l ong wi th the infer ior g luteal vessels.

T h i s f lap has the dis t inct advan tage of t ransferr ing a

large a m o u n t of tissue for p r ima ry closure, wh ich effec-

tively enhances the b lood supply of the area and provides

an excel lent sacral cushion.

For smal ler defects, good results have been obta ined

us ing ro ta t iona l skin flaps for p r i m a r y closure and are

repor ted to have less than 2 per cent recurrence. 9 A

n u m b e r os au thors credit the success of skin flap closures,

u s ing e i ther a ro t a t iona l f lap or W- or Z-plasty tech-

n iques , to the ob l i t e ra t ion os the natal cleft. T h i s e l im-

inates one of the p red i spos ing e lements for recurrence in

this disease, s,16

We still advocate p r ima ry excis ion wi th closure by

secondary i n t en t ion as the t ime-tested technique. T h i s

has the lowest recurrence rate, wi th less than 2 per cent in

one review of a p p r o x i m a t e l y 4500 patients . 5 Why it was

no t effective in this pa t i en t is a mat te r of conjecture. It

w o u l d be reasonable to suggest that the prev ious mul t i -

ple surgical in te rvent ions caused extensive local fibrosis,

d i m i n i s h i n g bo th the b lood supply and the abi l i ty for

the tissues to undergo w o u n d contracture. T h e latter

process is cri t ical in the hea l ing of these defects.

T h i s pa t i en t con t inues to be free of disease at two and

one-ha l f years, T h e na tu ra l h is tory of recurrence of this

disease is no t we l 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 w i t h i n two years of p r imary closure. 7 A third

repor t d o c u m e n t e d two-thirds of all recurrences in the

first year. In v iew of these data and the his tory of repeated

b reakdowns w i t h i n a few m o n t h s of our pa t ient ' s pre-

vious procedures , we are op t imis t i c as to the p e r m a n e n t

success of this procedure. It is also no t ewor thy that the

pa t i en t has no residual weakness a t t r ibutable to the operat ion.

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