A useful alternative surgical technique to reconstructing large defects following excision of recurrent pilonidal sinus disease in the intergluteal region: An operative approach for the transverse lumbar artery perforator flap

Abstract

The reconstruction of defects in the intergluteal region following pilonidal sinus excision is challenging due to its anatomical location, close proximity to the anus, and being a high-tension area prone to wound-healing problems. Excision and primary closure is known to carry a higher risk of recurrence and subsequent complications compared with using nearby local healthy tissue, such as a flap, to reconstruct defect. Extra due diligence should be given to patient selection and flap choice when deciding the reconstruction of a defect. The senior author, who has briefly reviewed complication rates in previous published literature, prefers the transverse lumbar artery perforator (TLAP) flap for reconstruction following pilonidal sinus excision in the intergluteal region. This paper illustrates the operative approach used by the senior author when raising a TLAP flap.

Keywords: operative approach; pilonidal sinus intergluteal region.

Figure 1

Left: Initial defect following pilonidal sinus excision at the intergluteal region. Right: midline markings (yellow dashed line), lumbar perforators on either sides marked out by hand‐held Doppler device on which the design of the TLAP flap will be based (black arrows)

Figure 2

Option 1 whereby the TLAP flap design is based on the medial lumbar perforator (outline shown in continuous red line). If a greater arc of rotation is desired, the superior incision of the flap crosses the midline by 2 to 3 cm (shown as dotted red lines). The ipsilateral medial lumbar perforator can then be divided, and the entire flap blood supply is based solely on the contralateral medial lumbar perforator. Midline is denoted as yellow dotted lines

Figure 3

(A) Insertion of single drain exiting laterally. Flap was raised and pivoted into defect. A slightly longer superior incision allows for better arc of rotation. (B) TLAP flap inserted into defect. Gluteal skin flap (black arrows) advanced superiorly to close donor site. Flap has a wide arc of rotation (dotted red line). (C) Postoperative on‐table appearance. (D) Seven days postoperatively; patient was discharged on day 7 from hospital and received weekly wound review at our dressings clinic