Reconstruction of the natal cleft with a perforator-based flap

Propeller Flap Reconstruction Following Pilonidal Cyst Excision: A Single-Center Experience With Same-Day Discharge

INTRODUCTION

Reconstruction following pilonidal cyst resection must balance risk of recurrence, healing time, and resumption of functional routine. Propeller flaps provide a reliable and effective reconstructive option. This study highlights our experience with propeller flap reconstruction following pilonidal cyst resection and demonstrates the efficacy of same-day discharge.

METHODS

A single-institution retrospective chart review was performed for propeller flap reconstructions completed from March 2018 to July 2022. Patient demographics, pilonidal cyst details, operative details, and postoperative outcomes were collected. Primary outcomes included flap survival, flap complications, and pilonidal disease recurrence.

RESULTS

Twenty-eight outpatient propeller flap reconstructions following pilonidal cyst resections were identified in 26 patients, with two patients receiving a second propeller flap due to recurrence. Most patients were male (n = 15, 57.7%) with a mean age at time of index operation of 25.5 ± 5.8 years and mean body mass index of 26.5 ± 4.1 kg/m2. Mean symptom duration prior to index surgery was 39.3 months. Mean skin defect size following resection was 28.3 ± 15.3 cm2, with a mean flap size of 44.7 ± 35.5 cm2. Flap survival was 100% (n = 28), with five flaps (17.9%) experiencing minor wound complications and one patient (3.8%) requiring return to the operating room. Mean time to functional improvement was 24.0 ± 22.8 days. Pilonidal disease recurrence occurred in three patients (11.5%). Mean follow-up was 4.1 ± 5.4 months.

CONCLUSIONS

Propeller flaps provide a successful and reliable reconstructive option for pilonidal disease defects. Because patients in our cohort experienced favorable outcomes and functional improvement, we advocate for same-day discharge in order to reduce hospital and patient burden.

Partial Gluteus Muscle Flap for Treatment of Chronic, Recalcitrant Pilonidal Cyst Disease

Background

Pilonidal cyst disease is a challenging condition requiring excision and wound management when it is chronic and symptomatic. Primary closure of the excision site can lead to high recurrence rates, necessitating flap-based reconstruction. This article discusses the use of a partial gluteus maximus muscle flap to address recurrent pilonidal disease and reduce its recurrence.

Methods

From 2014 to 2021, 11 patients aged 14-31 with recurrent pilonidal cysts underwent two-stage surgery involving excision and wound debridement by general surgery, followed by plastic surgery for wound closure using the partial gluteus muscle flap.

Results

Eleven patients were included in the study (four women and seven men). The mean age was 23 ± 5.2, and the average body mass index was 28.59 (±6.7). The mean number of previous procedures was 2.25 (range, 2-3). Operative time was 158.7 ± 37 minutes. The average length of stay when both procedures were done in the same admission was 8 ± 6 days (range 3-21 days) and when procedures were done separately, the length of hospital stay after the wound closure using a partial gluteus muscle flap was 3 days, and the range for reliable follow-up was 1.6-7 years postoperatively. In our study cohort of 11 patients, the majority, specifically seven individuals, experienced uneventful healing. However, a subset of patients encountered complications. Three patients developed an infection recurrence: one was treated conservatively, and one required reoperation with resolution of symptoms, and one patient also experienced wound dehiscence, which was closed with a small procedure.

Conclusion

Partial gluteal muscle flap offers a promising approach for treating recalcitrant, difficult-to-treat pilonidal disease in young adults, enhancing wound healing and reducing the risk of recurrence.

A Dynamic Anatomic Study of Parasacral Perforators: Mapping, Perforasome, and Applications for Buttock Enhancement

BACKGROUND

Due to the lack of knowledge about parasacral artery perforators, flaps from this region cannot be used with complete confidence in their security and effectiveness. Knowledge of the clusters and perforasome of these perforators could help in the design of more reliable flaps and extend the range of applications.

OBJECTIVES

This study aimed to identify the location, number, and density of perforators, and to subsequently analyze the perfusion flow and linking vessel distribution.

METHODS

Five fresh cadavers were harvested and dissected. For the mapping, after injecting lateral sacral arteries with colored latex, perforators with a diameter of >0.5 cm were examined in 5 sacral regions. All data were collected on the suprafascial plane, with an orthonormal coordinate system placed on iliac crests and median lines. For perforasome analysis, 5 perforators and 3 three sacral flaps were injected with radiopaque dye. A dynamic (4-dimensional) computed tomographic angiography completed the analysis.

RESULTS

A mean [standard deviation] of 8.4 [1.36] perforators per corpse, with a mean diameter of 0.72 [0.14] mm, were identified. There was a higher density of parasacral perforators close to the median line and 7.6 cm above the iliac crests. This pattern was not a random distribution (P < 0.05). The perfusion area was preferentially in the superior gluteal region. Perfusion flow was permitted by the dominant direct-linking vessels towards adjacent lumbar perforators, oriented diagonally upward and outward to the midline.

CONCLUSIONS

Parasacral perforator flaps appear to be a useful procedure in reconstruction and in aesthetic surgery, especially in gluteal augmentation. Their reliability depends on sound anatomic knowledge, with accurate preoperative perforator mapping.

[Perforating flap for covering sacro-coccygeal cysts: About 8 cases]

INTRODUCTION

Multiple surgical revisions (exeresis and directed healing) of recurrent pilonidal cysts are sources of unstable scars. Chronic ulcerations often appear with or without authentic recidivism. A local fasciocutaneous perforating flap based on the parasacral arteries would bring healthy tissue and avoid the disadvantages of conventional techniques (musculo-cutaneous or random).

MATERIALS AND METHODS

A series of 8 cases of transposition flap covering based on parasacral perforators, in multi-operated patients. The perforators are identified by Doppler probe before the gesture, then the flap is traced obliquely according to the size of the loss of substance. The gesture is short, not morbid and accessible to all by a technique that excludes fine dissection of the pedicle. The duration of hospitalization is 2days.

RESULTS

Despite two minor and resolving complications (a hematoma and a disunion of the donor sit) the healing was complete and without recurrence in all patients at 2years, with 100% satisfaction.

CONCLUSION

This reliable and reproducible simple flap becomes the reference technique in our department for the sequelae of recurrent sacro-coccygeal cyst.

Comparison of 'Excision and Primary Repair' with 'Bascom's Technique' in the Surgical Treatment of Pilonidal Sinus

Introduction

The management of the chronic pilonidal disease is variable and the principles of treatment are aimed to eradicate the sinus tract, promote wound healing, prevent disease recurrence, and improve the quality of life of the patient. This study aims to compare the effectiveness of excision and primary closure, and Bascom’s technique in the management of pilonidal sinus disease.

Methods 

The study was performed at a tertiary hospital from April to October 2011. All patients with chronic pilonidal sinus were included in the study (n=60) and randomly allocated into Group A - undergoing excision and primary closure (n=30) and Group B - undergoing Bascom’s repair. Comparative outcomes of interest were duration of hospital admission, post-operative pain, wound infection, wound-healing and disease recurrence. 

Results

The mean age of presentation was 24.18±5.6 years. A higher number of patients in Group A were discharged within 24 hours compared to Group B (p = 0.001). Group B had significantly less post-operative pain by the first postoperative week (p = 0.049). Group B had lower infection rates with clean wounds observed in 28 (93.3%) patients compared to 23 (76.7%) in Group A by the first postoperative week (p = 0.07). Recurrence rate during 12-week follow-up was observed in one (3.3%) patient in Group B, and five (16.7%) in Group A (p= 0.085).

Conclusions

Patients who underwent Bascom's operation had less postoperative pain, lower infection rates and disease recurrence, and better wound healing. Therefore, in our patient cohort, we conclude Bascom’s repair appears to be superior to primary excision and repair in reducing patient morbidity.

Management of Pilonidal Sinus Disease with the Aesthetically Shaped Parasacral Perforator Flap: Multicenter Evaluation of 228 Patients

BACKGROUND

The management of pilonidal sinus disease is still not standardized. Currently, the two main procedures are a lay-open excision procedure with secondary healing or coverage with local flaps. The authors present their experience with a one-stage excision-coverage with an innovative parasacral artery perforator flap propeller designed to respect the aesthetic unity of the buttocks.

METHODS

Study patients were managed with this procedure in the Toulouse, Montpellier, and Rennes university hospitals between 2012 and 2018. Data were collected on clinical and surgical details, immediate and late postoperative complications, and long-term recurrence. Aesthetic satisfaction was evaluated with a self-evaluation questionnaire.

RESULTS

The authors operated on 228 consecutive patients for pilonidal sinus disease with an aesthetically shaped parasacral artery perforator flap. The median patient age was 23.5 years, the median operative time was 46 minutes, the median flap length was 9.3 cm (range, 6.5 to 14 cm), and the median flap width was 4.1 cm (range, 4 to 6.5 cm). There were five distal necroses but no complete flap necrosis. There were six postoperative hematomas, 11 infections, and 18 wound dehiscences. The median follow-up period was 27.9 months. Median hospital length of stay was 4.2 days. Three recurrences of pilonidal sinus disease and six instances of hidradenitis suppurativa were detected. Approximately 82 percent of the women and more than 85 percent of the men were "satisfied" or "very satisfied" with the aesthetic outcome, without significant differences between the sexes (p = 0.901).

CONCLUSIONS

The aesthetically shaped parasacral artery perforator flap combines very satisfactory results regarding recurrence and postoperative recovery with cosmetic outcome. This procedure is technically more demanding than other flap procedures, although it is accessible to numerous surgeons as the first-line treatment for pilonidal sinus disease after initial learning.

CLINICAL QUESTION/LEVEL OF EVIDENCE

Therapeutic, IV.

Pilonidal Sinus—Plenty of Literature yet Lack of Direction: A Pooled Analysis

A systematic analysis was conducted to compare various surgical treatment modalities and evaluate the short- and long-term outcomes in the management of sacrococcygeal pilonidal disease. Pilonidal sinus is a common and debilitating condition often requiring a surgical approach to treatment, of which many are available. Despite numerous treatment methods, no universal decision has been made as to the most efficient and effective surgical treatment. All randomized control trials published between January 1, 2003 and January 8, 2013 were accessed. Interventions included classic and modified Limberg flap, Karydakis flap, primary closure, and healing by secondary intention. Primary outcome measures included rate of surgical site infection, recurrence, and length of hospital stay. Secondary outcome measures were hematoma or seroma, and return to work. The search identified 22 articles suitable for inclusion in this review totaling 3693 patients. Analysis showed a 50% reduction in the rate of infection and recurrence in patients receiving closure with flaps compared with primary midline closure and healing by secondary intention. The Karydakis flap was shown to be more favorable cosmetically; however, it failed to compete with the classic and modified Limberg flap in treatment of complicated disease. No significant difference was noted between the modified Limberg and Limberg flap. These results show that the Karydakis flap, classic, and modified Limberg flap demonstrate significant benefits over healing by secondary intention and primary closure.

Common surgical procedures in pilonidal sinus disease: A meta-analysis, merged data analysis, and comprehensive study on recurrence

We systematically searched available databases. We reviewed 6,143 studies published from 1833 to 2017. Reports in English, French, German, Italian, and Spanish were considered, as were publications in other languages if definitive treatment and recurrence at specific follow-up times were described in an English abstract. We assessed data in the manner of a meta-analysis of RCTs; further we assessed non-RCTs in the manner of a merged data analysis. In the RCT analysis including 11,730 patients, Limberg & Dufourmentel operations were associated with low recurrence of 0.6% (95%CI 0.3-0.9%) 12 months and 1.8% (95%CI 1.1-2.4%) respectively 24 months postoperatively. Analysing 89,583 patients from RCTs and non-RCTs, the Karydakis & Bascom approaches were associated with recurrence of only 0.2% (95%CI 0.1-0.3%) 12 months and 0.6% (95%CI 0.5-0.8%) 24 months postoperatively. Primary midline closure exhibited long-term recurrence up to 67.9% (95%CI 53.3-82.4%) 240 months post-surgery. For most procedures, only a few RCTs without long term follow up data exist, but substitute data from numerous non-RCTs are available. Recurrence in PSD is highly dependent on surgical procedure and by follow-up time; both must be considered when drawing conclusions regarding the efficacy of a procedure.

Use of Perforator-Based Fasciocutaneous Flaps for Pressure Sore Reconstruction: Single-Perforator-Based Versus Multiple-Perforator-Based Flaps

BACKGROUND

A perforator-based fasciocutaneous flap is an alternative type of flap for pressure sore reconstruction. The aim of the present study was to determine whether a single-perforator-based flap or a multiple-perforator-based flap is better for pressure sore reconstruction.

METHODS

We reviewed the general data and postoperative complications in patients who received single-perforator-based or multiple-perforator-based fasciocutaneous flaps for pressure sore reconstruction between July 2009 and July 2012.

RESULTS

No differences in general data, comorbidities, wound locations, flap sizes (73.9 vs. 67.0 cm(2), P = 0.455), and operative times were noted between the single-perforator-based and multiple-perforator-based flap groups. The flap rotation arc was larger in the single-perforator-based flap group than in the multiple-perforator-based flap group; however, the difference in the rotation arc was not significant (99.2° vs. 55.5°, respectively; P = 0.199). Two patients had total flap necrosis and one had partial flap necrosis in the single-perforator-based flap group. None of flap necrosis was noted in the multiple-perforator-based flap group; however, no significant differences in major complications were noted between the two groups. All donor sites underwent primary closure.

CONCLUSION

This is the first clinical patient-matched research that considered the number of perforators and the rotation arc in applying perforator-based fasciocutaneous flaps in wound reconstruction. The results showed that the number of perforators is not the determinant factor of surgical outcome of the use of perforator-based fasciocutaneous flaps in pressure sore reconstruction. Thus, whether a single- or a multiple-perforator-based fasciocutaneous flap is used for flap perfusion does not jeopardize the operation. These results emphasize the reliability and convenience of using freestyle design of perforator-based flaps for pressure sore reconstruction. The design and clinical utility of the flaps have the advantage of being versatile.

LEVEL OF EVIDENCE IV

This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

Outcomes in the repair of pilonidal sinus disease excision wounds using a parasacral perforator flap

INTRODUCTION

The ideal treatment for pilonidal sinus disease has yet to be defined. There are many approaches described in the literature.

METHODS

Thirty-five consecutive patients who underwent wide excision of pilonidal sinus disease had the wound repaired using a parasacral perforator flap. Outcomes were assessed by case notes analysis and follow-up telephone and postal questionnaires.

RESULTS

There were ten minor complications including six minor wound edge dehiscences. There were two ischaemic complications, with one flap loss. There were 3 recurrences of pilonidal disease at a mean follow-up of 33 months, giving a 5-year recurrence free rate of 86%. Of the patients questioned, all would recommend the procedure to someone else despite 69% being dissatisfied with the cosmetic outcome.

CONCLUSIONS

This series indicates that the parasacral perforator flap technique is able to repair pilonidal sinus excision wounds successfully with minimal morbidity and a low recurrence rate at a mean of follow-up of 33 months. The study suggests that it may be a technique best reserved for recurrent cases of pilonidal sinus disease. Patients feel the procedure is successful despite reservations regarding the cosmetic outcome.

Effectiveness of a drain in surgical treatment of sacrococcygeal pilonidal disease. Results of a randomized and controlled clinical trial on 803 consecutive patients

PURPOSE

The aim of this study was to evaluate the influence of cavity drainage in the surgical treatment of sacrococcygeal pilonidal sinuses.

METHODS

The study was prospectively carried out in 803 patients randomized into two groups of respectively 401 and 402 patients. In the first group, primary excision and closure were associated with drainage of the wound; in the second group, the wound was not drained. We have analyzed time off work, time to walk without pain, time to sitting on the toilet without pain, recurrences, and wound infections. We have also evaluated the satisfaction rate and esthetic results.

RESULTS

On comparing time off work, time to walk without pain, and time to sitting on toilet without pain postoperatively, there were no significant differences between the two groups. A significant difference between the two groups with regard to wound infection rates (p = 0.5) and recurrence rates (p = 0.6) was not observed. In order to prevent prolonged inpatient stay and social intolerance, this study suggests that the post-operative period is tolerated by a few when a drain was used. The visual analog scale (VAS) in the drained group was 3.2 ± 0.9, and VAS in the non-drained group was 3.5 ± 0.9 with a significant statistical difference (p = 0.0001). As regards the cosmetic appearance of the scar after surgery, we achieved a high satisfaction rate among patients in either group with 82.9% good cosmetic results.

CONCLUSIONS

The use of a drain, in our experience, appears to be useless in achieving a quick healing of the sacral wound; in addition, it has a low satisfaction rate.

The modified gluteal sliding plication closure in the treatment of chronic pilonidal sinus

BACKGROUND

The surgical approach to pilonidal sinus disease is open to debate with no ideal treatment. The aim of this work is to present the efficacy of the modified gluteal sliding plication closure technique in treatment of pilonidal sinus disease as regards the complication and recurrence rates, while maintaining a more cosmetically acceptable midline scar.

PATIENTS AND METHODS

All patients between the year 2000 and 2008 with symptomatic pilonidal disease were treated by the modified gluteal sliding plication closure method, except for recurrent cases after previous flap surgery. Outcome measures included wound complications, recurrence rate, follow-up period, and functional recovery. Patient esthetic satisfaction rates as regards the scar and shape of the buttocks were included on a scale of good, fair, or bad.

RESULTS

Fifty-six patients, 41 male and 15 females, with 23 years median age (range, 17-45 years) were treated. After a median follow-up period of 12 months (range, 6-84 months), the incidence of recurrence was 1.8%, infection rate of 10.7%, paresthesia and seroma accumulation in 3.6% of cases. The median functional recovery achieved was 12 days (range, 10-45 days), while the esthetic satisfaction rates were good in 78.57%, fair in 17.86% and bad in 3.5% of cases.

CONCLUSION

This study presents a successful modified technique of primary closure which allows an extensive en bloc removal of diseased tissues and permits a safe and complete primary closure without undue tension and with respect of cosmetic principles.

Sinus excision, release of coccycutaneous attachments and dermal-subcuticular closure (XRD procedure): a novel technique in flattening the natal cleft in pilonidal sinus treatment

INTRODUCTION

The objective of this study was to analyse, prospectively, the outcome of a new technique - excision of pilonidal sinus and flattening the natal cleft by division of the coccycutaneous attachments at the lower end of the incision.

PATIENTS AND METHODS

Sixty-six consecutive patients with chronic pilonidal sinuses were treated between 1995 and 2001. The procedure consisted of an elliptical, wide, local excision, release of the coccycutaneous attachments and primary closure using dermal-subcuticular closure (XRD). Suction drains were used until drainage was minimal. The height of skin level at the lower angle of the wound from the coccyx was measured intra-operatively before and after division of the coccycutaneous attachments. Postoperatively, patients were assessed for hospital stay, return to normal activity, complications and recurrence.

RESULTS

Sixty-four patients (97%) were males, median age 27 years. The height of skin level rose from a mean of 1.8 cm (95% CI, 1.78-1.85) to a mean of 3.8 cm (95% CI, 3.77-3.88; P < 0.001). Morbidity affected 12 patients (18%), epidermal separation of the lower wound angles (6 patients), seromas (5 patients) and 1 wound dehiscence at 2 weeks. All other wounds healed primarily without dehiscence. There were no recurrences after a median follow-up of 22.5 months (range, 12-38 months).

CONCLUSIONS

Release of the coccycutaneous attachments is an easy technique to learn, which seems to be an effective way of flattening the natal cleft and may result in lower recurrence rate. This technique should be tried in uncomplicated pilonidal sinus disease before more complex procedures are attempted.

A New Flap for Reconstruction of Pilonidal Sinus

BACKGROUND

"Adipofascial turnover flap" is a well-known procedure, but it is generally not used for the surgical treatment of pilonidal sinus disease. The "lumbar adipofascial turnover flap" has been used in this study for the reconstruction of uncomplicated pilonidal sinus disease.

METHODS

Ten cases (8 male and 2 female patients) were operated on by this technique. The reconstruction was performed with the lumbar adipofascial turnover flap. The flap sizes ranged from 4 x 7 cm to 5 x 9 cm (mean, 4.5 x 8 cm), and they were elevated with length-to-base ratio below 2:1. The follow-up period was 14 to 26 months.

RESULTS

Postoperative magnetic resonance imaging, computed tomography scan, and power Doppler ultrasound examinations revealed viability of the flaps in all patients. There was no distortion of anatomic landmarks in any of the cases. The esthetic results were satisfying for all patients as well. There was no recurrence in any cases.

CONCLUSIONS

The hospital stay and mean time off work were shorter compared with other methods of reconstruction and there was no recurrence. We advocate that the lumbar adipofascial turnover flap is an excellent choice for reconstruction of cases with uncomplicated pilonidal sinus disease.

Successful treatment of recurrent pilonidal sinus with laser epilation

BACKGROUND

Pilonidal disease is a chronic disease of the natal cleft. Recurrent follicular infection is the causative factor. Surgical treatment has a significant failure rate, and recurrence is common. Laser removal of hair in the natal cleft could be an alternative to surgery.

OBJECTIVE

To determine the effectiveness of laser hair removal in the natal cleft on pilonidal disease.

METHODS

Six young men with recurrent pilonidal disease were treated with laser epilation in our clinic from 2000 to 2003. Most patients had a history of one or more surgical treatments in the area, and all patients had suffered recurrent folliculitis for years. An alexandrite laser was mostly used, although, occasionally, an intense pulsed light device was used. The number of epilation treatments ranged from 3 to 11, performed at 6- to 8-week intervals.

RESULTS

All patients experienced progressive resolution of the folliculitis with the laser epilation treatments. No more surgical treatments have been needed. The treatments were simple and quick, and there were no complications.

CONCLUSION

Laser epilation of the natal cleft should be considered a first choice treatment for recurrent pilonidal disease. Preventive laser epilation of the natal cleft in patients with recurrent folliculitis could avoid future surgery.