Abstract
The most difficult problems that follow surgery for pilonidal disease are persistent unhealed midline wound and recurrence. Various innovations were proposed to deal with these problems. The adipocutaneous flap of Karydakis was devised to shift the natal cleft, while Z-plasty involves fasciocutaneous flap. The present prospective randomized trial was conducted on 50 cases of symptomatic or recurrent pilonidal sinuses divided randomly into two equal groups undergoing Karydakis procedure and Z-plasty. The duration of hospitalization for Karydakis procedure was found significantly lesser than that for double Z-plasty (P < 0.001). Similar observations are obtained for duration of wound healing (P < 0.001), work off period (P < 0.001), and the duration of presence of significant pain postoperatively (P < 0.001). The overall complications were more in double Z-plasty. Recurrence developed in 32% of the cases in double Z-plasty group comparable to no recurrence seen in Karydakis procedure. Thus, Karydakis flap was found superior to double Z-plasty having less seroma formation, no local hematoma, and no flap necrosis. Statistically, this comparison was highly significant (P < 0.001). Karydakis flap has some added advantages over double Z-plasty technique like keeping scar away from the midline and flattening of the natal cleft, thus reducing local recurrence rates.
Highlights
Strong evidence shows that pilonidal disease originates in the epidermis, in a midline stretched hair follicle [1]
On the basis of these observations, a new paradigm of origin emerges that pilonidal disease is exclusively an epidermal problem, rather than a deep tissue problem, which is the theory behind current recommendations for wide excision [2, 3]
In group 2 (Gp 2), Z-plasty was performed by a vertical elliptical incision extended down to the postsacral fascia; complete removal of unhealthy tissue with a rim of normal healthy tissue; two oblique incisions given by making an angle of 60 degrees with the vertical line (Figures 2(a) and 2(b))
Summary
Strong evidence shows that pilonidal disease originates in the epidermis, in a midline stretched hair follicle [1]. Pilonidal changes are amplified due to deep tissue disruption from moisture, anaerobic conditions, hairs, and bacteria. On the basis of these observations, a new paradigm of origin emerges that pilonidal disease is exclusively an epidermal problem, rather than a deep tissue problem, which is the theory behind current recommendations for wide excision [2, 3]. The focus of treatment should be actions to change the conditions that attack epidermis, rather than wide excision which attacks deep and healable tissue. Unlike other flap procedures (i.e., rhomboid flap, Z-plasty, and gluteal rotation flap) which are fasciocutaneous, Karydakis flap is adipocutaneous flap; it is, technically easier, less bloody, and less time consuming; it obviously has a better cosmetic outcome as it leaves a single, lateral, longitudinal scar; and it requires significantly shorter hospital stay. The present study was done to study Karydakis flap reconstruction as a treatment of symptomatic pilonidal sinus disease and to compare Karydakis flap reconstruction and double Zplasty as a treatment of symptomatic pilonidal sinus disease
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