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Year : 2020  |  Volume : 9  |  Issue : 3  |  Page : 202-207

Closure of excisional defects of pilonidal sinus surgery using a perforator-based island flap

Department of Surgery, College of Medicine, Taif University, Ta'if, Saudi Arabia; Department of Surgery, Damanhour Teaching Hospital, General Organization for Teaching Hospitals and Institutes, Cairo, Egypt

Date of Submission16-Sep-2020
Date of Decision19-Oct-2020
Date of Acceptance27-Oct-2020
Date of Web Publication04-Dec-2020

Correspondence Address:
Samir Ahmad Badr
Department of Surgery, College of Medicine, Taif University, Al-Haweiah, P O Box: 888, Ta'if 21974, Saudi Arabia

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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/sjhs.sjhs_143_20

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Background and Aim of the Work: Pilonidal sinus disease is a common condition in the young adults, which carries significant patient discomfort. There is no consensus regarding the best surgical technique for the treatment of this disease. A controversy is present about the various options for closure of the wound following resection of the affected tissue. In this study, the perforator-based island flap was successfully used for closing the defect left after excising the pilonidal sinus. Methods: Twenty-three patients with a primary complex pilonidal sinus disease were operated upon and followed up in the period from October 2014 to October 2018 at the General Organization of Teaching Hospitals and Institutes hospitals. After wide excision of the pilonidal sinuses, the defects were reconstructed with perforator-based flaps, which were designed with an axis of 45°–90° angle to the vertical axis of the defects. Results: Of the 23 patients included in this study, only three patients developed minor complications (one case of mild seroma and two cases of minor wound infections), and they were treated conservatively. Mean time of hospital stay was <2 days. Mean time to return to normal daily activities was 5 days (range: 3–7). Mean time to complete healing of the wound was 12 days (range: 10–15). Mean time off-work days was14 days (range 12–17). All the patients did not show recurrences during the period of follow-up which continued for at least 9 months postoperatively with a mean time of 10 months (range: 9–15). Conclusions: This study shows that closure of postexcisional defect of pilonidal sinus using a perforator-based island flap is a reliable option for the treatment that fulfill the principles and criteria required to achieve complete cure of the condition in a short period of time.

Keywords: Excisional defects, perforator based island flap, pilonidal sinus disease

How to cite this article:
Badr SA. Closure of excisional defects of pilonidal sinus surgery using a perforator-based island flap. Saudi J Health Sci 2020;9:202-7

How to cite this URL:
Badr SA. Closure of excisional defects of pilonidal sinus surgery using a perforator-based island flap. Saudi J Health Sci [serial online] 2020 [cited 2022 Aug 11];9:202-7. Available from: https://www.saudijhealthsci.org/text.asp?2020/9/3/202/302446

  Introduction Top

Pilonidal sinus disease is a common clinical disorder occurring at the natal cleft in the sacrococcygeal area. The disease is prevailing worldwide, and it seems to be more common in the hot humid areas such as the Middle East region.[1] It is more frequent in the young working population in the third decades of life, with male: female ratio of approximately 4:1.[1],[2] It occurs specially in that people staying a lot of time in sitting position such as office workers and truck drivers.[3]

The pilonidal sinus disease is developed as a result of; the penetration of the shed hair shafts from the hair follicles in the gluteal region crease through the skin, resulting in the formation of a subcutaneous cyst and the existence of a deep natal cleft.[4] In the natural progression of the disease, the pilonidal cyst tries to exude itself, leading to the formation of a pit; in addition, the cyst can get reiterated episodes of infections that cause the creation of deep branched tracks and multiple sinuses in the skin.[5]

A large number of nonsurgical and surgical modalities have been described for the treatment of pilonidal sinus disease. The surgical modalities include excision and leaving the wound to granulate,[6],[7] excision and leaving the wound semi-closed,[8] excision and closure using de-epithelialization technique,[9] minimal excision and primary closure with modified Lord–Miller technique,[10] excision and simple primary closure through midline or asymmetric incisions,[11] excision and primary closure with semilateral elliptic incisions (Karydakis procedure),[12] excision and primary closure with cleft lift (Bascom) technique,[13] or excision and closure using different types of local flaps (including Z-plasty,[14] V–Y flaps,[15] Romboid and Limberg flaps,[16] and perforator based flaps[17],[18]).

Unfortunately, the traditional midline techniques for pilonidal sinus disease repair give a high rate of wound infection, poor cosmetic results, and a long healing time.[5] In addition, the techniques based on the limitation of excision of the sinus tract and diseased tissue with the use of primary closures have a high rate of recurrence.[19] On the other hand, the techniques based on the wide excision of the sinus tract and the diseased tissue have a higher chance of complete extirpation of the disease with a lower recurrence rate.[20]

Recently, the various flap techniques have become popular worldwide, particularly because of early wound healing, low complication, and low recurrence rates.[21] Of those flaps, the gluteal artery perforator flap has gained its popularity where the dissection of the perforator can lead to a long vascular pedicle (length of 8–10 cm) that allows a greater mobility of the flap and tension-free closure of large defects with displacement of the suture line laterally.[22]

This study aims to evaluate the use of the superior gluteal artery perforator-based flap for closure of the defects created after the excision of the complex pilonidal sinus.

  Methods Top

A total of 23 (no = 23) patients (19 males and 4 females) diagnosed with pilonedal sinus disease were operated upon and followed up for this study at Damanhour and Banha Teaching hospitals, General Organization of Teaching Hospitals and Institutes between October 2014 and October 2018. The ethical board of the hospital approved the study, and informed written consent was taken from the candidates.

All patients were selected with a primary complex disease, i.e., having midline openings and side openings of the sinuses. The patients showing symptoms and signs of acute inflammation or those with recurrent disease after previous surgery were excluded from this study. The preoperative routine investigations and the preoperative assessment of the patients were done. All procedures were performed under general anesthesia and intravenous antibiotics (cefuroxime 1.5 g and metronidazole 500 mg) were given to the patients at the time of induction. The postexcisional defects of all patients were closed with parasacral perforator-based island flap technique.

Technique description

The operation was fulfilled with the patient in a prone, jack-knife position, and to achieve good exposure to the gluteal region, the buttocks laterally separated using adhesive tape. The sacrococcygeal region was shaved under aseptic measures and scrubbed with 10% povidone-iodine. The sinus tracts were delineated using a sterile solution of methylene blue, injected through a plastic cannula into the sinus openings to ensure complete resection of the diseased tissues. The lateral sacral border where credible perforators are located in inside of the middle line was determined using the posterior superior iliac spine and coccyx as the surface landmarks.[23] The perforator-based flap was marked based on one of the perforators of the superior gluteal artery which emerge at the border of the sacrum.[24] The suitable perforators were identified using a sterile Doppler ultrasound probe.

The followings were considered when the flap was designed; it is done with the same vertical and transverse dimensions of the defect, it is based on the superior gluteal artery perforator found adjacent to the defect just lateral to its supralateral edge, and its vertical axis is tilted 45°–90° to the vertical axis of the defect [Figure 1].
Figure 1: Axis of flap tilt 45°–90° to the defect

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The affected area was branded as a vertical ellipse to comprise at a less extent 10 mm of undissected tissue around it if necessary, to facilitate the inclusion of a suitable perforator. This elliptical shape design was useful for directly closing the donor site. Then, the excision of the diseased tissue including the openings of the sinuses, all the tracks, and the overlying skin, was performed and taken beyond the methylene blue-stained areas, and all tissues overlying the presacral fascia were removed and sent for histology. A good hemostasis was achieved with the use of diathermy if needed.

The flap was elevated distally and proximally in the subfascial plane. Caution was practiced near the perforator pedicle in the course of elevation of the proximal portion of the flap, leaving about 10 mm diameter of healthy tissue circumferentially. It was elevated till a tension-free transposition was achieved. Then, the flap was transposed by rotating it for 45°–90°, and emplacement of the scar lines resulted should be delineated with caution to avert making of a midline scar and to attain elimination of the deep natal cleft in the sacrococcygeal region [Figure 2].
Figure 2: Transposition of flap by rotating it for 45°–90°

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A suction drain was inserted to both areas, then the flap was approximated [Figure 3], and fixation of the flap was done with 3/0 Vicryl dermal stitches to the recipient site. The pivot point was closed without tension, but with some undermining if needed and the skin was closed using nonabsorbable sutures with mattress stitches [Figure 4]. The sutures were removed at postoperative day 10.
Figure 3: Approximation of the flap

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Figure 4: Closure of skin with mattress stitches

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Discharge and follow-up

All patients were discharged on the first to the 2nd postoperative days after commenced early postoperative mobilization depending on the clinical status. Discharge instructions included nurse prone or on their sides until the flaps heal, return to normal activities after the 5th postoperative day, and avert intense practice for at least 3 weeks.

The patients were attended to the outpatient clinic for physical assessment and take care of the wounds till the occurrence of the complete healing of the wounds and the drains were removed once the drainage was purely serous, and the output was below 20 mL/day.

Follow-up checks were conducted at 1, 3, and 9 months. The patient overall satisfaction was recorded using a scale,[1],[2],[3],[4] with a score of 1 reflected no satisfaction, while a score of 4 reflected the most satisfactory result.

  Results Top

Twenty-three patients were operated upon using parasacral perforator-based island flap technique. Nineteen patients were males (83%) and four patients were females (17%). The mean age of all patients was 28.3 years (range: 19–42).

The average defect size in length and width was 7.5 cm (range: 4–11) and 4 cm (range: 2.5–6), respectively. The average time of surgery was 70 min (range: 50–95 min). Operative time was determined by the time from making the skin incision to the closure of the resulted wound. The wound showed a complete healing in average of 12 days (range 10–15). Patients were mobilized and discharged home after surgery with an average time of hospital stay 36 h (range: 12–48). Hospital stay was determined from the time of the patient's admission to the hospital to the patient's discharge from the hospital. The patients were competent to go back to their normal daily activities after an average of 5 days (range: 3–7) and to their work after an average of 14 days (range: 12–17) postoperatively.

There were three patients showed minor complications; mild seroma occurred in one patient (4%) and minor wound infections in two patients (8%), and they were managed conservatively with aspiration, antibiotics, and daily dressings for few days in the outpatient clinic. The return of sensation at the site of surgery was recorded in six patients (26%). In addition, there were no recurrences during the period of follow-up, which continued for at least 9 months postoperatively, and the mean time of follow-up was 10 months (range: 9–15).

The overall satisfaction of the patients was recorded, where 26% of the patients showed full satisfaction, 61% showed more satisfaction, 13% were to some extent satisfied, and no one showed no satisfaction.

The results present in [Table 1], [Table 2], [Table 3].
Table 1: Characteristics of patients

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Table 2: Perioperative outcomes

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Table 3: Short and long-term outcomes

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  Discussion Top

Closing the defects after surgery for pilonidal sinus is a challenge, and a wide variety of different methods are described for closing of these defects and can be basically categorized into open methods and closed methods. In open methods, the residual cavity after sinus excision is left open to heal by secondary intention. While in closed methods, closure of the cavity can be managed using different techniques including a midline closure, an off-midline closure, or a flap reconstruction.

In general, the ideal surgical treatment should be simple with minimal postoperative pain and low risk of complications, need minimal wound care with rapid wound healing, require minimum hospital stay after surgery, and the patient can return to his work early without recurrence.[25] In pilonidal sinus disease, the fundamentals of treatment are the full eradication of the sinus tracts, the durable and the tension-free closure of the defects resulted from the excision of the diseased tissues with good vascularization of tissues, the elimination and flattening of the natal cleft, and the prevention of the disease recurrences.[26]

The off-midline closure techniques found to be accompanied with significantly fewer recurrence rates when compared with midline closures,[27] and a recent meta-analysis of randomized controlled trials demonstrated that the off-midline Karidakis primary repair and the Limberg flap repair are more eminent to primary midline suture, reducing the disease recurrences, the wound infections, and the wound dehiscences.[28]

In their clinical practice guidelines, the Italian Society of Colorectal Surgery (SICCR) recommended that the patients hirsutism showing massive primary pilonidal sinus disease and deep natal clefts or showing disease recurrences or showing no healing of the midline wounds may be in need for the flap-based techniques for their management.[29] Furthermore, Irkörücü et al.[30] in their proposed classification system for pilonidal disease depend on the anatomical distribution of pits in relation to natal cleft, recommended flap procedures with wide excision for pits on both sides of the natal cleft. In addition, they recommended wide excision and large flap procedures for complex disease with multiple pits on and side of the natal cleft.

Obviously, the wide excision of the diseased pilonidal sinus tissue with good margins of healthy tissue specifically in the primary complex disease can result in the complete eradication of the disease with low or without recurrences.[31] Unfortunately, this wide excision creates a defect that large enough to prevent its safely closure, so the flaps should to be used.[18] However, the use of parasacral perforator-based flaps for closing the defects created after excision of pilonidal sinus disease enables the transfer of large and well-vascularized tissue that allow elevation of natal cleft, tension-free closure of the defect, obliteration of dead space, and shift of the scar away from the midline.[18],[31]

In this study, the defects created after wide excision of the primary complex pilonidal sinus diseases were covered using perforator-based flaps with satisfactory results. Out of the total 23 patients, 83% were male and 17% were female with a prominent male predominance, and the mean age of 28.3 years (19–42) was within the third decades indicate the natural characteristics of pilonidal sinus disease that have been known for years.[21] The little representation of female patients can be referred to the relatively lower incidence rate of pilonidal sinus disease in females, because the occurrence of hirsutism is less in females than males.[25]

Akinci et al.[32] have measured the depth of the natal clefts of the healthy volunteers and patients with pilonidal disease. They founded that the patients with pilonidal disease demonstrate significantly deeper natal cleft than in the healthy volunteers. In the present study, the natal cleft found to be deep in 70% of the patients, whereas the remaining (30%) showed a shallow natal cleft.

The blood supply of the flaps is robust, and in the present study, the mean length of the flap was 7.5 cm (range: 4–11) and the mean width was 4 cm (range: 2.5–6). While in the study of Venus and Titley,[31] the mean length of the flap was 12.6 cm (range: 5–23) and the mean width was 3.8 cm (range: 2.8–6).

The operative time was recorded for the technique used in this study from the start of the skin incision to the closure of the resulted wound, and the mean operative time was 70 min. This was more than recorded by Acartürk et al.[17] (45 min) and less than recorded by Venus and Titley[31] (140 min).

This study presented a less perioperative complications including one case (4%) of minimal seroma and two cases (8%) of minor wound infections, and they were treated using minimally invasive methods such as simple aspiration, proper antibiotic therapy, and good wound dressings. The information that seroma accumulation will generally be less in flaps that are fed better[33] can explain the finding of less seroma occurrence in the present study.

Postoperative regional loss of sensation that was seen in the patients in the present study did not to the extent causing any distress that would impair the quality of life in the patients. It is believed that the loss of sensation is related to the width of the diseased tissues removed surgically.[33] However, the return of sensation to the area was recorded in 26% of the affected patients.

The quality of life in patients operated for pilonidal sinus disease can be determined by some important factors including the length of hospital stay, the time taken for occurrence of complete healing of the wound, the time taken for patient to resume his routine activities, and the work-off days. Generally, these periods are short in this study where the mean length of hospital stay was 36 h, the mean time of complete healing was 12 days, the mean time to resume the routine activities was 5 days, and the mean work-off days was 14. These findings are near to that reported in the literature of Acartürk et al.,[17] except the mean time of complete healing that was not recorded and the mean time off work that was 10 days.

When performing flap-based procedures, the patient's satisfaction should be measured as recommended in the guidelines of the SICCR.[29] In this study, 26% of the patients involved showed full satisfaction, 61% of the patients showed more satisfaction, 13% of the patients were to some extent satisfied, and no one showed no satisfaction.

There are no recurrences recorded in this study at a mean follow-up period of 10 months, which was similar to the follow-up period of the study of Acartürk et al.[17] that also was an average of 10 months without recurrences and faraway of the results of the study of Venus and Titley[31] that was three recurrences at a long mean follow-up period of 33 months.

  Conclusions Top

This study indicates that the repair of postcomplex pilonidal sinus excisional defect using the perforator-based island flap is a feasible technique. The study had a limited period of follow-up, although no recurrences were recorded.


I am thankful to hospitals staff, residents, and nurses for their help. Special thanks to Prof Dr. Abd Elhafez M. Elsheweal for his sincerely support.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.

  References Top

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  [Figure 1], [Figure 2], [Figure 3], [Figure 4]

  [Table 1], [Table 2], [Table 3]

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