Natal Cleft Research Articles

Treatment of recurrent pilonidal sinus by flap technique(Limberg flap)

Background: pilonidal sinus (PNS) is a chronic disease that mostly affects young adults. describes a hair-filled cavity in the subcutaneous fat of the post sacral intergluteal region, known as the natal cleft , its name arises from the Latin terms “pilus” and “nidus” meaning a nest of hair PNS can be asymptomatic, or may be present as a recurrent abscess or as chronic inflamed cavity and local discharge from sinus or sinuses and local pain and discomfort . Materials and Methods: retrospective study was done from (November 2017 to November 2018) at surgical department in Kirkuk General Hospital in 50 patients with recurrent PNS all will be treated with Limberg flap then follow up for one year this surgery done by excision of PNS till we reach fascia overlying sacrum inferiorly and laterally till we reach gluteal fascia and dissection was performed with electro cautery and reconstruction done by flap (Limberg flap) from gluteal area. Results: in 50 patient with recurrent PNS we have 45 (90%) were male and 5 (10%) were female ,30 patient (60%) patients had a familial history of PNS and 42 patients(84%) with etiology-related risk factors to develop PNS then we divided them according first time surgery done either, by excision and primary closure 30 patient(60%) or excision and healing by granulation tissue and secondary intension 20patient (40%) Discussion: pilonidal sinus not classified as dangerous condition but any patients with PNS live in non-comfortable state and may have complications such as abscess formation or discharging sinus even severe pain therefore Limberg flap is commonly used method to treat recurrent PNS and this good result with healing in short period also satisfactory results in long duration but this method with Sacrococcygeal area disfigure mentation as one long duration complications but less recurrence rates and short stay in hospital and better patient tolerability in this way if we compare it to all other methods even with surgical challenge to create a flap but it less wound infection, hematoma ,edema , wound separation if we compare it to other surgical techniques but fluid accumulation in close space under flap is one of important complications in this method and we decrease it by using a drain and putted in site until fluid drainage in area decreased to be less than 50 ml/day . In this method recurrence rate in our study is 2% but reported recurrence rate for Limberg flap are from 0.8 to 2.7% if we compare to 12% recurrent rate in primary closure therefore we have very good recurrence rate Conclusions: the approach for recurrent PNS should be differ from primary PNS flap reconstruction methods in treatment for recurrent PNS is very good and efficient method even with surgical challenge procedure to create flap, personal hygiene are the keystones for preventing recurrence

Severe Disease in Patients With Recent-Onset Psoriatic Arthritis. Prediction Model Based on Machine Learning.

ObjectivesTo identify patient- and disease-related characteristics that make it possible to predict higher disease severity in recent-onset PsA.MethodsWe performed a multicenter observational prospective study (2-year follow-up, regular annual visits). The study population comprised patients aged ≥ 18 years who fulfilled the CASPAR criteria and less than 2 years since the onset of symptoms. Severe disease was defined at each visit as fulfillment of at least 1 of the following criteria: need for systemic treatment, Health Assessment Questionnaire (HAQ) > 0.5, polyarthritis. The dataset contained data for the independent variables from the baseline visit and follow-up visit number 1. These were matched with the outcome measures from follow-up visits 1 and 2, respectively. We trained a logistic regression model and random forest–type and XGBoost machine learning algorithms to analyze the association between the outcome measure and the variables selected in the bivariate analysis.ResultsThe sample comprised 158 patients. At the first follow-up visit, 78.2% of the patients who attended the clinic had severe disease. This percentage decreased to 76.4% at the second visit. The variables predicting severe disease were patient global pain, treatment with synthetic DMARDs, clinical form at diagnosis, high CRP, arterial hypertension, and psoriasis affecting the gluteal cleft and/or perianal area. The mean values of the measures of validity of the machine learning algorithms were all ≥ 80%.ConclusionOur prediction model of severe disease advocates rigorous control of pain and inflammation, also addressing cardiometabolic comorbidities, in addition to actively searching for hidden psoriasis.

Outcomes and cost of medical and surgical treatments of pilonidal disease: A single institution's 10-year review

BackgroundPilonidal disease is a chronic inflammatory skin disorder typically located in the gluteal cleft. Treatment varies from antibiotic therapy to extensive surgical resection and reconstruction; however, complications and recurrence are common. To understand risk factors, outcomes, and costs associated with various treatments, we performed a retrospective chart review of all patients treated for pilonidal disease at a single health care system from 2008 to 2018. MethodsPatients with an ICD diagnosis code associated with pilonidal disease were identified. Charts were reviewed for demographic, clinical, and cost information related to pilonidal disease encounters. Data were analyzed for risk of recurrence by Cox proportional hazards regression and economic burden by Wilcoxon signed-rank test. ResultsDuring the study time frame, 513 patients were diagnosed with pilonidal disease. Primary treatment included 108 patients (21%) with wide excision, 167 (32%) with antibiotics alone, 79 (15%) with incision and drainage, and 109 (21%) with incision and drainage plus antibiotics. The rate of recurrence following antibiotic therapy, incision and drainage, or wide excision was 36.7%, 35.9%, and 21.3%, respectively. Sex, body mass index, obesity, or hidradenitis suppurativa was not associated with recurrence; however, smokers who underwent incision and drainage had a higher risk of recurrence (P < .0001). The median cost of each primary treatment was $3,093 for excision, $607 for incision and drainage, $281 antibiotics alone, and $686 for incision and drainage plus antibiotics. ConclusionPilonidal disease presents with a high degree of heterogeneity and is often managed primarily with antibiotics, incision and drainage, or surgical excision. Risk of recurrence was less in patients who underwent wide excision; however, these patients had higher overall cost compared to patients that had nonoperative management. Level of evidenceLevel III.

Identifying the uncommon solitary fibrous tumour in a rare location - A case report.

Introduction and importanceThe authors describe a case work up of an unusual natal cleft soft tissue tumour which eventually was concluded as solitary fibrous tumour. Solitary fibrous tumour is an uncommon fibroblastic tumour which commonly presents in pleural region and very rarely in extrapleural location such as natal cleft. Accurate identification of this tumour, considering the indeterminate nature of the tumour irrespective of the location, avoided misdiagnosis and played a vital role in follow up management of the patient.Case presentation43 year old female patient presented with a painless lump in the natal cleft region for a short duration of 7 months with no other significant medical or surgical or family or psychosocial history. She was not on any regular medications.Clinical discussionDue to unusual location of the tumour broad range of differential diagnosis including benign and malignant entities were discussed based on histological findings and immunophenotyping. Mammary type myofibroblastoma, glomus tumour, clear cell renal cell carcinoma and clear cell sarcoma of soft tissue were few to note. STAT6 immunohistochemical stain played a crucial role in unravelling this case. Due to gradual increase in size of the lump complete surgical excision was performed with no local recurrence of the tumour.ConclusionIt is important to recognise this rare mesenchymal tumour with intermediate malignant potential occurring at uncommon natal cleft region for which complete surgical enucleation is curative.

Watermelon Slice Flaps — a Novel Technique to Reconstruct the Buttock and Natal Cleft

Watermelon Slice Flaps — a Novel Technique to Reconstruct the Buttock and Natal Cleft

Minimally invasive pilonidal sinus disease (PSD) treatment in pediatric patients: A narrative review.

Pilonidal sinus is a common disease of the natal cleft, which can lead to complications including infection and abscess formation. Various operative techniques are available options for the treatment of this pathology, but the ideal technique is still debatable. Analyzing the literature we found out that more recently minimally invasive approaches have been described. In particular, the mechanism of an endoscopic approach relies on the use of the endoscope without cutaneous tissue damage. Advantages include shorter operative time and time to discharge, which impact resource management in both primary and secondary care: patients undergoing endoscopic technique have a high satisfaction rate, probably due to the low level of postoperative pain and early return to daily activities. Published results of studies of newer approaches have demonstrated a lower short and long-term complication rate compared to open surgery. However, very poor reports are available in literature about pediatric population.

Comparative outcome study between simple closure and flap technique in Pilonidal sinus disease

Introduction: Pilonidal sinus disease (PSD) is a disease of natal cleft in sacrococcygeal region. The main goal of treatment is low recurrence rate, short hospital stays, early return to work and decrease post-operative work. Present study was undertaken to compare and find clinical outcome between simple closure and flap techniques. Methodology: 30 patients of Pilonidal sinus disease (PSD) which were fit to undergo surgery were included. 15 patients undergone simple closure and 15 undergone flap technique (Limberg). Result: Wound Infection, Post-operative discharge and Recurrence rate was found higher in group I patients (20 %, 23.33 %, 30 % and 26.66 % respectively) compared to Group II cases. Difference is statistically significant (p Value 0.03, 0.04, 0.008 and 0.02 respectively). Discussion: Recurrence of the sinus probably depend mainly on the ability of the procedure to obliterate the depth of natal cleft. In the present study we found flap procedures superior in combating the disease recurrence than excision with simple closure. Conclusion: It is recommended that Limberg flap method should be used in the treatment of pilonidal sinus disease over other modalities.

When is a lipoma not a lipoma? Case report presenting a lipoblastoma-like tumor of the gluteal cleft in an older gentleman with literature review.

Introduction and importanceLipoblastoma-like tumors are rare tumors that can be confused with lipoblastomas and liposarcomas but have distinct characteristics. This tumor has previously been identified in the vulva of females, and recently in isolated cases of young males. Given its rarity, we present an instance of this tumor in an older man, demonstrating that this pathology is not limited to a specific age or sex, and surgeons and pathologists must be aware of it in their differential.Case presentationA 58-year-old male presented for evaluation of an enlarging mass in his right gluteal cleft. Prior to referral for surgical evaluation, the patient underwent an ultrasound-guided biopsy of the mass. Histologically, the tumor was a low-grade cellular spindle cell neoplasm in a fibrous to myxoid stroma. Immunohistochemical and molecular workup ruled out several malignant mesenchymal neoplasms, including myxoid liposarcoma, dedifferentiated liposarcoma, melanoma, low-grade fibromyxoid sarcoma, and sarcomatoid carcinoma. The patient initially declined surgery, but the mass continued to grow, and excision was chosen given the uncertain pathology. The tumor was resected with negative margins and histologically characterized as a “lipoblastoma-like lesion”, with features of a myxoid liposarcoma and spindle cell lipoma. Seven months post-resection, there were no signs of recurrence or metastasis.Clinical discussionDespite radiologic and pathologic similarities to malignant lipomatous tumors, lipoblastoma-like tumors are benign and have a good prognosis.ConclusionsClinicians should be aware of this entity despite its rarity as resection with negative margins is curative and may be needed to rule out more aggressive tumors.

Surgical View of Morphological and Pathogenetic Identity of Pilonidal Cysts and Acne Inversa.

&lt;b&gt;Introduction:&lt;/b&gt; As a rule, the treatment of pilonidal cysts is based on a surgical approach. Surgical treatment depends on the form of the disease and surgeon&apos;s preferences regarding the method. The treatment process does not consider preoperative treatment that would affect the structural components of the skin involved in the pathological process. The results of surgical treatment remain unsatisfactory, leading to a significant number of recurrences and long-term healing of the postoperative wound. &lt;/br&gt;&lt;/br&gt; &lt;b&gt; Materials and methods:&lt;/b&gt; Morphological examination of the pieces of skin with altered sacrococcygeal tissues after radical surgical treatment of 46 patients with pilonidal cyst of the sacrococcygeal region was performed, and 46 patients with acne inversa of the intergluteal cleft, groin and scalp were selected. The sex distribution of patients with pilonidal cysts was as follows: 43 (91.3%) male patients, 3 (6.5%) female patients. Among 46 patients with acne inversa and dissecting cellulitis, the distribution was as follows: 32 (69.6%) male patients and 14 (30.4%) female patients. Patients with pilonidal cysts of the sacrococcygeal region underwent surgical treatment according to the developed method of economical median resection using sutures with internal fixation. &lt;/br&gt; &lt;/br&gt; &lt;b&gt; Results:&lt;/b&gt; Considering and comparing the morphological picture observed in the pathomorphological examination of histological specimens in patients with pilonidal cysts, acne inversa, dissecting cellulitis, the similarity of changes in most patients is noteworthy. "Acne inversa" was first described in 1839 by Velpeau, who originally called the disease "hydradenitis suppurativa", believing that inflammatory changes occur in the sweat glands [1-3]. In 1854, surgeon Verneuil described this disease, and later it was named after him. We observed chronic proliferative inflammation in different layers of the dermis and subcutaneous tissue (the main focus is in the subcutaneous tissue, but closely related to the dermis and epidermis). &lt;/br&gt;&lt;/br&gt; &lt;b&gt;Discussions:&lt;/b&gt; Pilonidal cyst of the sacrococcygeal region, especially without hair in the cavity of the cyst, can be considered as a type of acne inversa with appropriate location. We believe that the use of local and systemic retinoids, namely isotretinoin, in the treatment of patients with this disease other than surgery, together with other groups of drugs traditionally used in the treatment of pilonidal cysts, may be promising in the treatment of pilonidal cysts.

Massive myxopapillary ependymoma of the gluteal cleft.

A 19-year-old male presented with a 2-year history of a progressively enlarging sacrococcygeal mass. Despite the significant size of the mass resulting in disfigurement and difficulty maintaining hygiene, he presented after the development of ulceration of the overlying skin and associated bleeding (Fig. 1). He denied any associated bladder or bowel changes, and had a normal lower limb neurological examination. He had no significant past medical history with no regular medications. Further investigation included a pelvic Magnetic Resonance Image (MRI) (Fig. 2) which showed an 11.4 × 9.9 × 10.3 cm lesion arising from the coccyx extending into the subcutaneous soft tissues of the gluteal cleft, characterized by multiple internal septations, marked T2 hyperintensity and avid Gadolinium enhancement. Histological examination of an image-guided core biopsy was suggestive of a myxopapillary ependymoma. A resection of the sacrococcygeal tumour was performed under general anaesthesia in the prone position. Macroscopically clear margins were achieved with en bloc resection of gluteal muscle, fascia and the coccyx. The wound was closed primarily with interrupted sutures and a suction drain to the resection cavity. Microscopic pathological assessment of the tumour revealed cuboidal tumour cells radially arranged in a papillary manner around vascularized stromal cores, separated by abundant myxoid matrix. The tumour extended beyond the deep fascia and into the marrow of the coccyx. Lymphovascular and perineural invasion were present. The immunocytochemical assessment demonstrated expression of the glial fibrillary acidic protein, but was negative for CK5/6, cytokeratin and SOX10, consistent with the preoperative diagnosis of myxopapillary ependymoma and differentiating the lesion from the more common chordoma. Resection margins were microscopically clear. The patient had an uncomplicated post-operative recovery and was discharged home on Day 7. At 1-year follow-up, he remains well, with no clinical or radiological evidence of recurrent disease. A myxopapillary ependymoma is a slow-growing histological variant of ependymoma that commonly originate within the filum terminale or conus medullaris in the lumbosacral region.1, 2 Virchow3 first identified ependymal tumours in 1865; however, it was not until 1935 when Kernohan and Fletcher-Kerohan4 sub-classified a selection of these tumours as myxopapillary ependymomas. They are currently classified according to the World Health Organization Classification of Tumours of the Nervous System as Grade 1 gliomas.5 Myxopapillary ependymomas are rare, with an incidence of 1 per million person-years.6 The average age of diagnosis of these tumours is 36, however, tumours found in paediatric patients are generally more aggressive and are more likely to metastasise.7 Grossly, these tumours are usually small encapsulated masses with gelatinous interiors. Microscopically, the characteristic features of the tumours are a pseudo-papillary pattern of cuboidal tumour cells around a vascular stromal core that undergoes mucinous degeneration.8 Though considered to have indolent biological behaviour, up to 31.7% of patients will experience disease recurrence. Of these patients, most experience local recurrence (84.5%), however over one-third of patients have non-local disease involving the distant spine and/or brain.8 Surgical resection is the mainstay treatment modality for myxopapillary ependymoma. The role of adjuvant radiotherapy is controversial, but may improve local recurrence, progression-free and overall survival in younger patients, particularly in the setting of subtotal resection.8, 9 Younger age, subtotal or piecemeal resection and larger tumour size (>2 cm) confer poorer prognosis. The prognostic significance of massive tumour size such as in the case presented here remains uncertain due to its rarity, and close clinical and radiological surveillance is warranted. Open access publishing facilitated by University of New South Wales, as part of the Wiley - University of New South Wales agreement via the Council of Australian University Librarians. BJ completed the initial draft. SF, DD, MN & PC were involved in the drafting and editing of the manuscript. All authors viewed the manuscript before submission.

Pilonidal sinus and use of Limberg flap: a three years’ experience from two tertiary care centres of Northern India

Background: Pilonidal sinus is a common chronic inflammatory anorectal condition that arises usually in the natal cleft of the sacrococcygeal region. This disease leads to deterioration not only in professional life of young adults but in their personal life as well. The Limberg flap reconstruction is a frequently used procedure in pilonidal sinus. This aim of this study was to observe the usefulness of Limberg flap technique in treatment of pilonidal sinus in our setup.Methods: This study enrolled a total of 50 patients who underwent Limberg flap surgery for sacrococcygeal pilonidal sinus over a period of 6 years in two different tertiary care hospitals of northern India. Various factors were studied in this study which included age group, gender, operative time, length of hospital stay, post-operative complications, recurrence and time required for return to normal work and activities. All the data was tabulated and analysed.Results: In this study we found that the maximum number of patients were young males in their third decade of life who presented with complaints of discharging sinus, pain and infection. The Limberg flap technique was used in these patients which showed a good outcome as far as complication rates and recurrence rates were concerned. Also return to work in these patients was quite early when compared with other methods in literature.Conclusions: In this study, we can conclude that this procedure is relatively easy to perform with a shorter learning curve, fewer complication rates, faster healing and is associated with a shorter hospital stay.

Sacro-coccygeal Epidermoid Cyst: A Case Report from Tertiary Care Centre in India

Localization of primitive neoplasms the retrorectal or presacral space is rare in adults as most of these tumors are congenital. Developmental cysts are included within the group of retrorectal congenital cystic neoplasms and are slowly-progressive cystic neoplasms. Because of their localization, their manifestation is delayed, despite their congenital nature. Their form of presentation is varied and is caused by compression of the surrounding organs or infectious complications of the cyst. In the present case, we have 55 yr old female with complain of low back painand pus dyscharge from perineal region. Further examination reveal 84*54*49mm lesion in posterior perianal region on either side of natal cleft with cutaneous opening within natal cleft. Post operative biopsy suggestive of epidermoid cyst.

Single Case Study on Pilonidal Sinus Using Madhu SaindhavAragwadhadi Kshar Sutra, A Minimally Invasive Treatment.

Pilonidal sinus (PNS) is a fissure between the buttocks (natal cleft) that can cause pain, embarrassment, and employment disruption. Men are more prone than women (because of the fact that men have more hair). Excision and primary closure, along with excision with reconstructive flap, are the most often adopted surgical methods for this condition. However, there is a substantial threat of recurrence or wound infection following the operation. In addition, the patient will have to stay for a longer period of time in the hospital, and the operation will be expensive. The Pilonidal sinus resembles the Shalya Nadi Vranamentioned in the Sushruta Samhita.Sushrutahas stated a less invasive para-surgical treatment for Nadi Vrana, known as the Kshar sutratechnique.For a Vrana Shoshanna and Ropana activity for wound healing, Acharya Sushruta reviewed several herbs or herbo-mineral combinations. Among them drugs of aragwadhadi gan were used to prepare the kshar sutraalong with madhu(honey), saindhav(himalayan salt)to lessen microbial burden, eliminates the unhealthy slough, necrotized tissue, and maintenance of wound moisture.As a result, this treatment was tested in the Pilonidal sinus, and the results are documented in this case report. The Kshar sutraprocedure not only reduces recurrence and complications but also allows patients to return to work faster with less discomfort, has a significant effect on self-esteem &amp; body image and is less expensive.

Prevalence of inverse psoriasis subtype with immune checkpoint inhibitors.

SummaryBackgroundCutaneous immune-related adverse events (irAEs) are the most common irAEs caused by immune-checkpoint inhibitors (ICI). Psoriasiform eruptions, both de novo and flares, may occur. Evidence is lacking on inverse psoriasis subtype.MethodsA retrospective study was conducted at Dana-Farber Cancer Institute/Mass General Brigham through February 2020 using databases. Confirmed inverse psoriasis cases pre-/post-ICI initiation either independently or in conjunction with other psoriasis subtypes were included. Known psoriasis cases without flare post-ICI were excluded.ResultsA total of 262 (3%) individuals with any ICI-mediated psoriasiform cutaneous irAE were identified out of the 8683 DFCI ICI-treated patients. Of these, 13 (5% of psoriasis patients) had inverse psoriasis (mean age 68.7 years; 7/13 male sex). Median (range) time from ICI initiation to inverse psoriasis development or flare was 7 (4–12) and 3.5 (2–6) weeks, respectively. Pruritus occurred in 12/13 (92.30%) cases. 11 (85%) had inguinal involvement; other sites included gluteal cleft (6; 46%), inframammary (3; 23%), perianal (2; 15%), axilla (2; 15%), umbilicus (2; 15%), and infra-abdominal folds (1; 8%). Most (9/13) individuals had more than one site involved. The Common Terminology Criteria for Adverse Events severity was 1 in 10 (76.92%) individuals and 2 in 3 (15.38%) individuals. Six (46.15%) patients were treated initially by oncology with topical (nystatin, econazole, or clotrimazole) or systemic antifungals (fluconazole) for median (range) of 3.5 (1–7) months without improvement, for presumed candida intertrigo.ConclusionPatients on ICI may develop inverse psoriasis, which may be initially confused for fungal intertrigo. Delayed diagnosis can prolong symptoms, while patients are treated ineffectively with topical/systemic antifungals for presumed candida infection. Oncologist and dermatologist awareness is important to improve diagnosis of ICI-mediated inverse psoriasis, its management and affected patients’ quality of life.

Psoriatic arthritis among Egyptian patients with psoriasis attending the dermatology clinic: prevalence, comorbidities, and clinical predictors.

ObjectivesEarly diagnosis and treatment of psoriatic arthritis (PsA) help to prevent progressive joint involvement and disabilities. There is a problem in the early diagnosis of PsA worldwide, which may be attributed to the dermatologists missing PsA symptoms and signs and a lack of effective screening tools.Aim of the studyThe current study was designed to assess the prevalence, comorbidities, and clinical predictors associated with the development of PsA in psoriasis patients.Material and methodsA cross-sectional observational study was performed. Screening questionnaires – the Psoriasis Epidemiology Screening Tool (PEST) and Early Arthritis for Psoriatic Patients (EARP) – were applied to 200 psoriasis patients; among them n = 22 (11% of all tested patients) were in developmental age. Those with positive questionnaires were classified as having PsA or not according to the classification for psoriatic arthritis criteria. Body surface area, psoriasis area and severity index, and psoriasis disability index tools were used for assessing psoriasis patients. A full rheumatological and dermatological evaluation were carried out for PsA patients.ResultsThe prevalence of PsA was found to be 30%, with a mean age of 45.48 ±10.79 years. Further, psoriasis preceded the onset of PsA in 46 patients (76.6%), arthritis began before psoriasis in 6 individuals (10%), and both psoriasis and arthritis coincided in 8 (13.3%) patients. Obesity (OR 7.0, 95% CI: 2.61–18.85), nail psoriasis (OR 5.02, 95% CI: 2.02–12.476), and intergluteal cleft site (OR 12.659, 95% CI: 4.302–37.255) were associated with increased risk of PsA. However, classic plaque psoriasis (OR 0.149, 95% CI: 0.051–0.433) and flexure site (OR 0.238, 95% CI: 0.076–0.746) were linked with a decreased risk of PsA development.ConclusionsScreening for PsA in patients with psoriasis revealed a significant number of undiagnosed cases of PsA that should be treated early. Obesity, nail psoriasis, and psoriasis at the intergluteal sites can help predict the PsA development.

Nevus lipomatosus cutaneous superficialis presenting as papilloma: A case report

Nevus Lipomatosus Cutaneous Superficialis (NLCS) is an uncommon hamartomatous lesion of the skin. NLCS is classified into two clinical forms classic and solitary. Some authors consider this lesion as a type of connective tissue nevus. We report a rare case of solitary NLCS in a 69 year old male with a long history of pedunculated swelling in the right gluteal cleft with review of literature. On gross appearance the lesion was a grey brown, exophytic, cerebriform, smooth skin covered soft tissue mass measuring 4.5 cms in the largest dimension with a broad peduncle attached. On histopathological examination the lesion showed superficial and deep dermal infiltration of the adipose tissue with distortion of the dermal collagen.

Comparison of two Different Surgical Modalities in the treatment of Pilonidal Sinus (Primary Closure and Open Technique)

Background: Pilonidal sinus is disease of young age andits prevalence is higher in men compared to women (almost twice).It is a disease that arises from hair follicles particularly present in the natal cleft. It occurs commonly in Jeep Drivers and hence gets the name from there “Jeep Drivers Disease” and also commonly occurs in Barbers. It leads to formation of abscesses and chronic wounds with discharge and pain. Disease can have huge impact on social life and quality of life. In most cases the treatment is incision and drainage. Study design: It is a case series study. Place and duration of study: Department of General Surgery at Shaikh Zayed Hospital Lahore from January 2019 to January 2021. Aim: To compare the relative effects of open and closed surgical techniques on the recurrence rate, rate of infection and time of healing for pilonidal sinus. Methodology: Patients with pilonidal sinus disease from January 2019 to January 2021 received surgical treatment either excision followed by primary closure as in closed technique (group A) or excision followed by leaving the wound open for healing by secondary intention as in open technique (group B). Surgical management is widely based upon two techniques open and closed. In open technique wound is left open and heals by secondary intention while in closed technique it is closed primarily and heals by primary intention. The better choice between these two techniques is still a topic of debate. Results: The most common age group for pilonidal sinus was between 16-25 years of age. The mean age came out to be 26.7 years. The mean healing time was 15 days in group A and 42 days in group B. The duration of hospital stay ranged between 2-8 days for group A and 5-16 days for group B. Early postoperative complications seen was infection in 1 patient (7.69%) in group A and 5 patients (35.71%) in group B and these cases were managed conservatively.1 (7.69%) case of aseptic gaping of wound after stitch removal was seen in group A and was managed with closed technique. Recurrences reported in group A was 1 case (7.69%) at 6 months and was surgically managed by open technique. There were a total of 4 (28.57%) recurrences which were left open to heal by granulation. Conclusion: It is concluded that better management option for pilonidal sinus disease is primary closure of defect. So it is suggested that management of pilonidal sinus disease should be individualized but preference must be given to closure of wound after excision. Keywords: Pilonidal sinus, Primary Closure, Open Technique.

Selection of Site for Harvesting Dermal Grafts as a Spacer in the Correction of Eyelid Retraction.

Several materials can serve as spacer grafts in the repair of retracted lower eyelids. However, previous studies did not reveal any of these to be superior to the others. From our perspective, autologous dermal grafts are ideal because they are biologically compatible and abundantly available. However, the absorption of these grafts is an issue, and the thickness of the dermal grafts is crucial. We evaluated the dermal thickness at five potential donor sites using ultrasonography and the efficacy and safety of the posterior neck dermis as a spacer graft in the correction of retracted lower eyelids. In 20 healthy volunteers, the dermal thickness was assessed using ultrasonography and compared between the posterior neck, upper arm, inguinal area, intergluteal cleft, and gluteal sulcus. Between January 2018 and June 2021, eight retracted lower eyelids in eight patients were repaired using a posterior neck dermal graft. The surgical results of these grafts were also evaluated. The mean age of the volunteers was 37.8 years, and the mean body mass index was 24.45kg/m2. The intergluteal cleft provided the thickest dermis followed by the posterior neck and gluteal sulcus, which were not significantly different. The upper arm and inguinal area had the thinnest dermis without significant differences between them. The mean marginal reflex distance 2/iris ratio decreased by 0.15 (p=0.008). The mean cosmetic score (0-10) for evaluation of lower eyelid reconstruction increased by 3.38 (p=0.011). The mean Vancouver Scar Scale score for evaluation of donor site scarring was 3.21. Although the posterior neck dermis is the second thickest, it is an ideal spacer graft in the reconstruction of retracted lower eyelids. Adequate thickness, uncomplicated methods, and a closer surgical field are its advantages. Additionally, donor site morbidity is minimal, with acceptable scarring. 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 .

Lumbar Skin Lesion in a Term Infant.

Lumbar Skin Lesion in a Term Infant.

International survey on the management of lumbosacral cutaneous stigmata in infants with suspected occult spinal dysraphism.

Occult spinal dysraphism (OSD) is a common pediatric neurosurgical diagnosis rife with controversy surrounding both the screening of asymptomatic infants and the threshold to offer a prophylactic detethering operation. The authors sought to clarify international practice patterns with a survey of pediatric neurosurgeons. A survey asked pediatric neurosurgeons whether they would perform imaging in patients with a variety of cutaneous stigmata associated with OSD and whether they would offer prophylactic detethering surgery for asymptomatic patients with a variety of imaging findings on the OSD spectrum. Completed surveys were received from 141 pediatric neurosurgeons. Broad consensus was demonstrated on the need for obtaining images in sample patients with more severe stigmata ranging from large lipoma with a skin appendage to focal dysplastic skin in the lumbar midline. Ninety percent of respondents would perform MRI for these patients. In contrast, for patients with a low-sacral dimple, flat hemangioma, and symmetric (Y-shaped) splaying of the intergluteal cleft, opinion on the need for imaging varied considerably (between 57% and 89% recommended imaging). Respondents differed on the type of imaging that they would perform, with 31% to 38% recommending ultrasound screening. The responses reflected less consensus on when to offer surgery to patients with simple spinal tethering (low-lying conus medullaris and fatty filum terminale). Both a lower level of the conus and increased thickness of the filum terminale affected decision-making. The results of this survey showed significant consensus on the recommendation for screening imaging in patients with more dramatic cutaneous stigmata, although these stigmata are the rarest. A significant variance in opinions was reflected in the recommendation for imaging of the most common cutaneous stigmata. Consensus was also lacking on which lesions deserve prophylactic detethering surgery. Significant equipoise exists for future study of screening imaging and of surgical decision-making in patients with asymptomatic OSD and associated cutaneous stigmata.