Treatment of the Chronic Pilonidal Sinus Wound with a Local Perforator-Assisted Transposition Flap

Abstract

Sir: Treatment of chronic pilonidal sinus wounds is associated with a high failure rate. Transposition and perforator-assisted transposition flaps can be useful for closure of chronic pilonidal sinus wounds, providing well-vascularized skin with tension-free margins and a flattening of the buttock cleft. We present two cases of successful closure of chronic pilonidal sinus wounds with a local transposition flap, the first of which was augmented in its vascular supply with two superior gluteal artery perforators. A 40-year-old man was referred for treatment of a pilonidal sinus chronic wound that had developed a biopsy-proven 4 × 4-cm squamous cell carcinoma at the superior margin of the wound. The wound extended from the top of the buttock cleft to 2 cm above the anus. The cancer and the pilonidal sinus wound were excised with clear margins, and the defect was reconstructed with a superiorly based transposition flap (15 cm superior to inferior, and 8 cm at its widest at the superior portion), with two intact perforators from the superior gluteal artery to augment the blood supply to the flap. The very tip of the flap had excellent bleeding. The flap survived entirely and healing was complete primarily (Fig. 1). There have been no complications at 2 years postoperatively.Fig. 1.: Complete survival without complications after reconstruction with two superior gluteal artery perforators assisting a transposition flap (15 × 8 cm) after excision of a 4 × 4-cm squamous cell cancer arising at the superior part of a chronic pilonidal sinus wound extending to 2 cm above the anus.In our second case, a 27-year-old woman was referred after two previous unsuccessful attempts at excision and closure of a pilonidal sinus wound. The wound was excised and closed with a simple transposition flap smaller and similar in construction to the flap in Figure 1, which healed completely. Although we could have included them, no perforators were required in this flap, as it was smaller and quite well vascularized without perforator augmentation. There have been no postoperative complications at 3 years (Fig. 2).Fig. 2.: Complete survival without postoperative complications with a simple transposition flap of a pilonidal sinus wound that had been operated on twice.Successful outcome in chronic pilonidal wound management is difficult because of a number of factors, including high tension and shearing forces with excision and primary closure, high moisture and contamination rates, and difficulty with skin graft take and instability in this region. Gluteal island perforator flaps have been used for successful repair of sacral defects for more than a decade.1–3 The provision of extremely well-vascularized skin with a tension-free closure provides a logical solution to some of the problems of pilonidal disease. In a large wound such as in the first case, the blood supply to such a large flap (8 × 15 cm) would have been less robust if either the base of the flap (venous outflow) or the perforators (arterial inflow and venous outflow) had been severed. Keeping the base of the transposition flap intact not only provided increased venous outflow to the perforator flap but also prevented kinking of the perforators themselves, which can lead to island perforator flap necrosis and failure. The orientation of the transposition flap allows for tension-free closure on either side of the midline and flattening of the buttock cleft; both of these factors decrease the risk of pilonidal sinus wound recurrence. Rebecca Nelson, M.D. Don Lalonde, M.D. Dalhousie University Saint John, New Brunswick, Canada DISCLOSURES This project was not commercially funded and uses no commercial products. There are no commercial or financial affiliations or gains.