How is recurrent pilonidal disease treated?

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

The techniques developed for recurrent disease and unhealed wounds generally involve the use of a flap procedure to achieve primary closure and to obliterate the deep natal cleft. This relocates hair follicles away from the midline and prevents the frictional forces associated with the principal etiologic factors in the development of pilonidal disease. Flap closure should be reserved for complex or recurrent pilonidal disease that has failed to respond to the simple, conservative operative techniques that are initially used to treat chronic pilonidal disease.

A wound that has not responded to initial therapy must be reexcised down to the sacrococcygeal fascia. The reexcision must include the unhealed wound, scar, and granulation tissue. A flap procedure [34, 35, 36, 37, 38] is then performed to achieve primary wound closure. The techniques available include the following:

  • Cleft closure
  • Advancement flap (Karydakis procedure [31, 32] )
  • Local advancement flap (3-plasty rhomboid flap [34] or V-Y advancement flap)
  • Rotational flap (gluteus maximus myocutaneous flap)

The cleft closure technique involves excising the wound with a triangular incision, with the apex of the incision lateral to the apex of the natal cleft. The inferior margin becomes crescent-shaped, with its point positioned towards the anus. A skin flap involving only the dermis is created on the convex side of the lower wound margin.

Before the procedure is begun, the line of contact of the buttocks is marked to define the lateral edge of the raised skin flap. The two skin edges are then overlapped, and the excess skin is excised. This creates a primary closure that is off the midline and obliterates the intergluteal cleft. The wound is closed in multiple layers over a closed suction drain. The recurrence rate is reported to be 3.3%.

The advancement flap or Karydakis procedure [31, 32] (described earlier) can be used as a primary procedure or for the treatment of recurrent complicated disease.

Local advancement flaps (eg, the 3-plasty rhomboid flap and the V-Y advancement flap) are used to cover defects resulting from recurrent pilonidal disease. However, such flaps in the pilonidal area may be at risk for compromised vascularity as a consequence of continued infection, external compression, cigarette smoking, and tension on the flap. Accordingly, whenever an advancement flap is contemplated, a myocutaneous flap should be considered.


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