What is the efficacy of asymmetrical incisions for treatment of pilonidal disease?

Updated: Jun 11, 2018
  • Author: M Chance Spalding, DO, PhD; Chief Editor: John Geibel, MD, MSc, DSc, AGAF  more...
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Answer

Rather than primarily closing a midline or lateral vertical incision, some physicians advocate the use of asymmetrical [23] or oblique elliptical incisions in an attempt to keep incisions out of the natal cleft. In this way, the procedure can be performed in a midline vertical orientation, with the final incision being lateral to the gluteal cleft.

This operation, often termed the Karydakis procedure, [31, 32] begins with excision of the wound and en-bloc removal of the sinuses with an elliptical specimen of overlying skin. The incision is made off the midline. Once the wound is excised, a full-thickness flap is created on the opposite side from the semilateral incision; this allows the opposite side to be mobilized for primary wound closure, thus avoiding a midline wound. The wound is closed in multiple layers over a closed suction drain.

This technique has been used as a primary procedure for surgical management or for complicated disease. The disadvantage is that the dissection is too extensive for an outpatient setting. The recurrence rate is reported to be 1.3%. Although the use of an incision that crosses the vertical gluteal fold to excise the pilonidal cavity does eliminate a vertical suture line within the gluteal fold, [33] healing times may remain considerable.

Skin flaps have also been described to cover a sacral defect after wide excision. Similarly, this keeps the scar off the midline and flattens the natal cleft. The potential complications include loss of skin sensation in the flap, which is observed in more than 50% of patients, and necrosis of the flap edges. Again, primary healing is achieved in 90% of cases.


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