Idea and innovation: Secure fixation between dermis and periosteum using perforator flap to prevent recurrence of pilonidal sinus disease

Abstract

In the past decades, numerous surgical techniques and conservative treatments for pilonidal sinus disease (PSD) had been discussed and published. There is still no consensus yet of the best techniques because of high recurrence rates and prolonged wound healing. In the case of complicated discharging sinus or recurrent PSD resistant to treatment with antibiotics, we recommend radical excision followed by a regional flap, which can obliterate the dead space with well-vascularised tissue. In this article, we presented the technique of snug suture fixation between the dermis and periosteum using a superior gluteal artery perforator (SGAP) flap. The study demonstrates a few key concepts on the prevention of PSD recurrence, an off-midline, well-perfused flap that allows flattened natal cleft and obliteration of gluteal cleft and eventually showed good aesthetic results. We aim to demonstrate a reliable surgical technique for wound closure of recurrent pilonidal sinus after radical excision followed by reconstruction with an SGAP flap. The history, surgery, and images are described, and the literature is reviewed. The pitfalls of disease recurrence will be discussed in this literature. Keys to successful treatment will be elaborated. An 18-year-old female with recurrent pilonidal sinus disease over right medial gluteal region presented with sacral pain and infection. She developed progressive swelling and burst of abscess from several sinus tracts and did not respond to the treatment with antibiotics alone. After radical excision of the entire pilonidal sinus and adjacent fibrotic tissue, a deep and large defect was measured. A superior gluteal perforator flap was designed based on three perforators from the superior gluteal artery. A medial 3 cm of the SGAP flap was de-epithelised to provide soft tissue bulk to obliterate the deep cavity. Strong sutures were applied to secure the flap to the periosteum. There was no recurrence at 3 years of follow up. The patient stood the operation well and had prompt recovery.

Figure 1

Soft‐tissue sonography showing residual sinus in the subcutaneous region of the buttock [Colour figure can be viewed at wileyonlinelibrary.com]

Figure 2

Radical excision of the pilonidal sinus and deep defect over the middle gluteal region [Colour figure can be viewed at wileyonlinelibrary.com]

Figure 3

A fasciocutaneous rotation flap was designed from the right buttock in a V‐Y fashion. The skin incision was made accordingly, and the perforators were identified with careful dissection [Colour figure can be viewed at wileyonlinelibrary.com]

Figure 4

A, Deep cavity after radicle excision. B, Perforator was identified with Doppler. C, Fasciocutaneous flap was elevated. D, De‐epithelised to form soft tissue filling into the cavity [Colour figure can be viewed at wileyonlinelibrary.com]

Figure 5

Snug suture fixation was applied using 3–0 and 2–0 PROLENE. The dead space is obliterated. Secure fixation of the dermis to the periosteum prevents disease recurrence

Figure 6

The medial 3 cm skin was de‐epithelised. The remaining defects in the right gluteal area were closed with advancement of the tissue above and below the flap [Colour figure can be viewed at wileyonlinelibrary.com]

Figure 7

Two weeks after the surgery, patient had stiches removed [Colour figure can be viewed at wileyonlinelibrary.com]