Limberg Flap Research Articles

Which surgical procedure offers the best treatment for pilonidal disease?

Our aim was to determine the most effective surgical procedure for treatment of pilonidal disease, by comparing different surgical techniques. A total of 354 patients who underwent operation for pilonidal disease were enrolled in this prospective study. The data included patient's demographic characteristics, age, gender, body mass index, occupation, smoking, concomitant diseases, surgeon's experience, wound-healing problems (wound separation and infection), time to return to work, and development of recurrence. Of the 354 patients, total excision + primary closure was performed in 133 (37.6%), D-flap in 101 (28.5%), Karydakis technique in 74 (20.9%), and Limberg flap surgery in 46 (13%). The male/female ratio was 8.5:1, which is a statistically significant difference (p < 0.05). The average follow-up period was 37months (range, 12-97months); during this period, wound-healing problems were observed in 70 (19.7%) patients, and 34 (9.6%) patients developed recurrence. There was no difference in the rate of recurrence of pilonidial disease between procedures done by trainees and staff surgeons. Recurrence rates were similar for all four treatment methods (7.5-13.5%). Wound-healing problems were higher for D-flap than for other methods (p = 0.027). The average time to return to work with the D-flap method was longer than that for the other methods (p < 0.01). Recurrence increased 14.44-fold following the development of wound infection. Higher recurrence rates were also noted in obese patients (8.10-fold) and in females (6.72-fold). Despite the increasing volume of data on the treatment of pilonidal disease, the optimal treatment has yet to be established.

La plastie en LLL : méthode simple pour la couverture des pertes de substance cutanées

Skin defects may be due to several causes: trauma, surgical excision of malignant or benign, even malformative pathologies. The aim of this work is to report the interest of the LLL flap (L for Lozenge) (Dufourmental flap) in the coverage of the skin defects that sometimes may reach high dimensions or being located in areas of lower skin extensibility. We report a study involving 26 patients who all benefited from this technique having skin defects due to different causes and serving in different locations. LLL plasty allowed a first closure in all patients. The cosmetic result was good and no recovery was necessary. LL plasty was first described in 1962 to cover limited skin defects. However, it requires some precision in its execution. This is a simple and reproducible procedure with considerable interest for its potential in the coverage of cutaneous defects in the face and that can reach up than 8cm. The scar would be reduced if we took care to match the areas of sutures with the shaded areas of the face (groove…). While allowing a better distribution of tension, this technique has demonstrated its superiority compared to direct suture, which the indication is limited by the size of the defect and its location (peri-orificial…) and other techniques that are similar as the Limberg flap.

Comparison of excision with primary repair versus Limberg flap

Introduction Pilonidal disease is a common chronic disorder, mostly affecting young adult males. Different hypotheses have been introduced for this disease, but acquired pathogenesis is the most acceptable one. Furthermore, different types of intervention are performed based on its pathogenesis. The aim of this study was to compare excision with primary repair versus the Limberg flap. Materials and methods One hundred patients, who were enrolled in this study were randomly divided into two groups of 50 patients. One group underwent excision with primary repair and the other group rhomboid excision with the Limberg flap. Then the demographic characteristics, early and late complications, comfort and pain score on the first and fourth postoperative day, hospital stay, time of return to work, and patient satisfaction were compared. P < 0.05 was considered statistically significant. Results The mean age was 24 years and the male to female ratio was 4:1. There was no significant difference between the two groups in terms of demographic characteristics, operation time, early complication rate and recurrence. But significant difference was observed in return to work, first pain-free toilet sitting, pain score and patient satisfaction. Conclusion It seems that the Limberg flap has similar complications as the primary repair method, but earlier return to work and less hospital stay, lower pain score and higher comfort and satisfaction were the advantages of the Limberg flap method. Thus, this method is recommended for the treatment of primary pilonidal disease.

Day-Case Limberg Flap for Recurrent Pilonidal Sinus: Does Obesity Complicate the Issue?

The purpose of this study was to analyze the long-term outcome of rhomboid excision with Limberg flap reconstruction (LF) as one-day surgery in treatment of recurrent pilonidal sinus (RPS). The effect of obesity on outcome will be addressed. Forty-nine patients with RPS were treated by rhomboid excision and LF as one-day surgery. Data collected included demographics, body mass index, operative time, flap ischemia, wound infection, length of hospital stay, time of complete healing, and recurrence. Patients' mean age was 33.4 years and mean number of previous operations was 3.4. Operative time ranged from 40 to 70 minutes. Two patients developed sterile seroma (4.1%) and two patients (4.1%) had wound infections. No wound dehiscence or flap ischemia was reported. All patients returned to normal activity within 7 days. No recurrences were reported after a mean follow-up of 32.1 months. Obesity significantly increased the operative time, however, it affected neither the postoperative outcome nor the long-term recurrence. Rhomboid excision and LF as one-day surgery is a safe and reliable method for treatment of RPS. It guarantees low morbidity, short hospital stay, short time off work, and carries low risk of recurrence, even in obese patients.

Auricular reconstruction with the use of a modified rhomboid flap

Sir, We describe a simple, safe one-stage procedure for reconstruction of marginal helical defects. Auricular reconstruction after trauma, burn or local excision of tumours has been a common challenge in plastic surgery. Apart from functional importance, the ear also has great aesthetic value, because it frames the face and provides symmetry. A common defect on the ear is partial loss of the helical margin with or without a cartilage defect. Keeping general principles in mind, one can consider various surgical options, based on a reconstructive triangle approach. One effective solution is the use of the rhomboid flap [1]. The skin defect over the superior part of the ear can be covered by a superiorly based random pattern post-auricular flap designed on the non-hair bearing area, this has the advantage of having the same skin colour as the original auricular skin (Figs. 1, 2, 3 and 4). Although the dimensions and shape of both defect and flap are precise, they are variables in planning, namely which of four potential flaps should be used, and the axis around which the excisional rhomboid is be drawn. It is possible to manipulate these variables in such a way that closure of the secondary defect makes use of the laxity of the skin present (use of Dufourmental instead of Limberg flap). A further advantage of this flap is that the donor site scarring comes to lie behind the ear and is, therefore, inconspicuous. The anterior edge of the flap can be cut along the retroauricular sulcus. The greater skin mobility on the post-auricular surface, coupled with the fact that ear tolerates being set back closer to the head, increases the role of this flap considerably. There is some loss of the curve of the helical margin, but patients tend to be in an older age group and thus the result can be acceptable. For small defects, a simple transposition flap that is designed as a formal rhomboid flap is a useful option (Figs. 5, 6). In this situation, Fortier-Riberdy et al. gave some useful tips [2]:

Comparison of the classic limberg flap and modified limberg flap in the treatment of pilonidal sinus disease: A retrospective analysis of 416 patients

Pilonidal sinus disease (PSD) is usually seen on the sacrococcygeal region in adolescent patients. The current study analyzed the outcome of the rhomboid excision and the Limberg flap procedure (cLF) in comparison to the modified Limberg flap procedure (mlF) for PSD. Four hundred and sixteen patients with PSD were operated on under spinal or general anesthesia by cLF and mlF. The patients were divided into two groups. In Group 1, cLF was performed on 211 patients. In Group 2, mlF was performed on 205 patients. No significant difference was detected between Groups 1 and 2 in terms of sex, age, preoperative disease period, follow-up time, the mean hospital stay, and hypoesthesia. The mlF group had better clinical results than the cLF group. The recurrence rate was statistically higher in the cLF group 1 than in the mlF group (P = 0.036). The time to return to work, time to walk without pain, and time to be able to sit on the toilet without pain were longer in the cLF group (P = 0.001). The maceration and wound infection rate were statistically higher in the cLF group than in the mlF group (P = 0.020 and P = 0.019, respectively). The mlF is a more effective treatment than cLF for the surgical management of PSD.

Randomized comparison of Limberg flap versus modified primary closure for the treatment of pilonidal disease

Background The best surgical technique for sacrococcygeal pilonidal disease is still controversial. The aim of this randomized prospective trial was to compare both the results of Limberg flap procedure and primary closure. Methods A total of 260 patients with sacrococcygeal pilonidal disease were assigned randomly to undergo Limberg flap procedure or tension-free primary closure. Results Success of surgery was achieved in 84.62% of Limberg flap patients versus 77.69% of primary closure ( P = .0793). Surgical time for primary closure was shorter. Wound infection was more frequent in the primary closure group ( P = .0254), which experienced less postoperative pain ( P < .0001). No significant difference was found in time off from work ( P = .672) and wound dehiscence. Recurrence was observed in 3.84% versus 0% in the primary closure versus Limberg flap group ( P = .153). Conclusions Our results do not show a clear benefit for surgical management by Limberg flap or primary closure. Limberg flap showed less convalescence and wound infection; our technique of tension-free primary closure was a day case procedure, less painful, and shorter than Limberg flap.

Pilonidalsinus und Analfistel

Proctologic fistulas are divided into pilonidal sinuses affecting the anal cleft and fistula in ano as tracts between the anus and perianal skin. An uncomplicated finding of a pilonidal sinus is treated by minimally invasive excision of the fistula tract using local anesthesia and acute abscesses must be drained prior to excision. Conservative approaches as well as radical excision are no longer recommended. In complicated situations a wide excision with plastic closure by a Limberg flap is the treatment of choice. Fistula in ano must be differentiated into subcutaneous and deep intersphincteral fistulas with no involvement of the anal sphincter and high intersphincteral transphincteral, suprasphincteral and extrasphincteral fistulas. Fistulas in the first group are candidates for fistulotomy with a low risk of incontinence and a high healing rate but the latter group has an increased risk of incontinence and fistula recurrence. Fistulas can be closed by an anal fistula plug without risk of incontinence but with a high risk of recurrence. In the case of recurrence a fistulectomy with closure of the internal opening and an anorectal advancement flap is performed.

Multicenter prospective randomized trial comparing modified Limberg flap transposition and Karydakis flap reconstruction in patients with sacrococcygeal pilonidal disease

Background There is still no consensus as to the optimal treatment for sacrococcygeal pilonidal disease (SPD). Many recommend off-midline closure, if any excisional procedure is to be selected. Methods The authors prospectively studied 145 patients with SPD who presented at 3 hospitals. Patients were randomly assigned to undergo either modified Limberg flap (MLF) transposition (n = 72) or Karydakis flap reconstruction (n = 73). Surgical findings, complications, recurrence rates, and degree of patient satisfaction, evaluated via a standardized telephone interview, were compared. Results Operation time was longer in the MLF group. There were no significant differences between the two groups in terms of complication rate, length of stay, or recurrence rate. Patients in the Karydakis group reported feeling completely healed more quickly postoperatively. The two groups reported similar rates of satisfaction. Mandatory patient withdrawal from a given study arm because of the orifice straying from the midline occurred more frequently in the Karydakis group. Conclusions The MLF technique and the Karydakis procedure appear to generate comparable outcomes. With laterally situated orifices, however, the applicability of the Karydakis method may be limited.

Comparison between karydakis flap repair and limberg flap for surgical treatment of sacrococcygeal pilonidal sinus (short term results)

GIRIS Pilonidal sinus intergluteal bolgede, ozellikle genc erkeklerde daha sik izlenen akut agrili veya kronik sekli olan bir hastaliktir. Pilonidal sinus hastaliginin insidansi 26/100000 olarak bildirilmekte ve erkeklerde kadinlardan 2 kat fazla gozlenmektedir (1). Pilonidal sinus tedavisinde tanimlanmis cok sayida konservatif ve cerrahi yontem olmasina ragmen nuks oranlari hala yuksektir ve ideal bir tedavi arayisi surmektedir (2,3). Tum tedavi seceneklerinin kendisine gore avantaj ve dezavantajlari vardir. Temel cerrahi tedavi eksizyondur. Eksizyon sonrasi defektin kapatilmasi cerrahin tercihine gore; primer kapama, marsupiyalizasyon veya flep (Limberg, Karydakis, V-Y flep, Z-plasti, Rhomboid) yardimi ile olmaktadir. Ancak son zamanlarda yapilan calismalar, flep ile onarim metodlarinin sonuclarinin daha iyi oldugunu gostermektedir (4,5). Bu calismadaki amacimiz, genis bir hasta serisinde primer pilonidal sinus icin uygulanan Karydakis flep teknigi ile rhomboid eksizyon + Limberg flep yonteminin sonuclarinin bildirilmesidir.

Early experience with the use of rhomboid excision and Limberg flap in 16 adolescents with pilonidal disease

Background Rhomboid excision with Limberg flap (RELF) repair has been shown to be effective in the management of pilonidal disease (PD) in adults. Wide excision allows complete removal of diseased tissue, and the rotational flap allows tensionless coverage as well as helps flatten the natal crease, which is believed to contribute to the recurrence of PD. Methods This study is a retrospective review of all adolescents who underwent excision of pilonidal disease using RELF at a single institution for a period of 18 months. Results Sixteen adolescents with PD were treated with RELF during this period. All procedures were completed with no intraoperative complications. Mean operative time and hospital stay were 92 ± 30 minutes and 1.8 ± 0.29 days, respectively. Mean follow-up was 11 ± 6.0 months. One patient had recurrence of his disease, and one needed prolonged wound care after wound breakdown. Six others had minor complications including 4 patients (25%) who had superficial wound separation that resolved promptly with dressing change. One patient had a superficial wound infection. One patient had residual pain. Conclusion Rhomboid excision with Limberg flap is effective in the management of PD in adolescents. The 6% recurrence rate is similar to that reported in the adult literature. Despite the limitations of this study, the low morbidity, hospital stay, and recurrence rate noted with our initial experience are very encouraging.

Reconstruction following excision of sacrococcygeal pilonidal sinus with a perforator-based fasciocutaneous Limberg flap

Many procedures have been proposed for the management of sacrococcygeal pilonidal sinus disease. The aim of this work is to evaluate the superiorly based flap (used before for reconstruction of pressure sore) for reconstruction after excision of sacrococcygeal pilonidal sinus. Between January 2004 and February 2007, 25 male patients of ages between 14 and 29 years(median age: 23 years), who had recurrent pilonidal sinus, underwent surgical treatment by the Limberg flap technique. The mean duration of symptoms was 5.2 + or - 4.5 years (range 3-6 years). Rhombic-shaped excision of the sinus-bearing skin and subcutaneous tissue up to the presacral fascia guided by electrocautery was performed, followed by reconstruction of the defect by perforator-based Limberg flap (based on the superior gluteal and sacral perforators). Primary healing occurred in 22 patients. Two patients (8%) had seroma with negative bacterial cultures, which healed completely with bedside drainage and conservative treatment. Another patient (4%) had superficial wound infection that were treated by appropriate antimicrobial therapy. Complete healing of all cases occurred without recurrence during the follow-up period. The mean operative time was 40min (ranging between 30 and 45min according to the size of the lesion). There was no ischaemia or necrosis of the flaps, and all flaps remained viable. The mean length of hospital stay was 2 days, ranging between 1 and 6 days. The use of superiorly based Limberg flap in reconstruction after excision of sacrococcygeal pilonidal sinus is reliable, easily performed, associated with complete cure and low postoperative complications.

Unroofing and Marsupialization vs. Rhomboid Excision and Limberg Flap in Pilonidal Disease

The aim of the study was to compare clinical outcomes and quality of life in patients undergoing surgery for pilonidal disease with unroofing and marsupialization (UM) or rhomboid excision and Limberg flap (RELP) procedures. One hundred forty consecutive patients with pilonidal sinus were randomly assigned to receive either UM or RELP procedures. A specifically designed questionnaire was administered at three months to assess time from the operation until the patient was able to walk, return to daily activities, or sit without pain, time to return to work or school, and time to healing. Postoperative pain was assessed with a visual analog scale and the McGill Pain Questionnaire. Patients' quality of life was evaluated with the Cardiff Wound Impact Schedule (CWIS). Questionnaires were administered by a clinician blinded to treatment. Compared with RELP, patients receiving UM had significantly shorter duration of operation and hospital stay, shorter time periods to walk, return to daily activities, or sit without pain and to return to work or school, and fewer complications. Time to final healing was significantly shorter and quality of life scores on the CWIS were higher in patients receiving RELP than in those receiving UM. Patients with UM had lower levels of pain one week after surgery. The unroofing and marsupialization procedure provides more clinical benefits in the treatment of pilonidal disease than rhomboid excision and Limberg flap and should be considered the procedure of choice. However, it may be associated with more inconvenience in wound care and longer healing time than rhomboid excision and Lindberg flap.

A Randomized Clinical Study Evaluating the Need for Drainage After Limberg Flap for Pilonidal Sinus

This prospective randomized clinical study was conducted to evaluate the need for drainage after rhomboid excision and a Limberg flap (RELIF) for the treatment of pilonidal sinus. One hundred one patients undergoing the RELIF procedure were randomly treated with drainage or not. Operating time, postoperative pain assessed on a visual analogue scale (VAS), total amount of intramuscular analgesic administered, hospital stay, complications, recurrence rate, and patient satisfaction were assessed. The mean operating time (P = 0.036), VAS scores on postoperative day 0 (P = 0.039) and day 1 (P = 0.006), intramuscular analgesic requirement (P = 0.009), mean amount of intramuscular analgesic administered (P = 0.025), complication rate (P = 0.027), and mean hospital stay (P = 0.0001) were significantly reduced in the non-drained group. The recurrence rate was similar in the two groups (P = 0.32). This study indicates that drain placement after the RELIF procedure might negatively affect the postoperative outcomes of patients with pilonidal sinus. On the basis of these finding, we suggest that the use of drains may not be necessary after the RELIF procedure for the treatment of pilonidal sinus.

“Reading Man Flap” Design for Reconstruction of Circular Infraorbital and Malar Skin Defects

BACKGROUND Surgical complications such as lid retraction and ectropion from graft or flap scar contracture make reconstruction of skin defects in the malar and infraorbital regions challenging. OBJECTIVE A new flap design, the reading man flap, was used to overcome these problems. The Limberg and bilobed flap were compared with the reading man flap. METHODS The reading man flap consists mainly of a superiorly based quadrangular flap and an inferiorly based triangular flap. Malar and infraorbital circular skin defects measuring 14 × 14 to 40 × 40 mm were reconstructed with a reading man flap in 13 patients. The defects occurred after basal cell carcinoma in all patients. The Limberg flap, bilobed flap, and reading man flap were planned for same-sized defects on the abdominoplasty resection material. The results were compared in terms of total scar area, scar length, and total healthy skin area discarded. RESULTS When comparing the 3 flap designs, the reading man flap was the most suitable flap in terms of total scar area and length. CONCLUSION The reading man flap can be used to reconstruct malar and infraorbital circular defects with good cosmetic results and without creating any tractional forces to the eyelids.

Rhomboid excision and Limberg flap for managing pilonidal sinus: long‐term results in 411 patients

To investigate the results of rhomboid excision and the Limberg flap procedure to treat pilonidal sinus disease. The records of 411 patients with pilonidal sinus disease, who underwent rhomboid excision and Limberg flap procedure, were analysed. All sinus tracks were resected en bloc, and a Limberg flap was prepared from left or right gluteal region. A suction drain was routinely used. The mean follow-up period was 109.2 +/- 4.5 months (range: 12-183 months). Recurrence occurred in 12 (2.91%) patients who were all male. In 42 (10.21%) patients, anaesthesia or hypoaesthesia of the upper portion of the flap occurred; this was temporary in 25 patients. Twelve (2.91%) patients developed a seroma and 15 (3.64%) a wound infection. The average hospital stay was 3.2 days (range: 1-10 days), and the average time of return to work was 12.4 days (range: 7-18 days). The average time to walk without pain was 13.4 days (range: 10-28 days) and the average time to sitting on the toilet without pain was 16.1 days (range: 12-28 days). The Limberg flap procedure is effective and has a low complication rate, short time for returning to normal activity and short hospitalization.

Surgical Treatment of the Pilonidal Disease: Primary Closure or Flap Reconstruction After Excision

Controversy still exists regarding the best surgical technique for the treatment of pilonidal disease in terms of minimizing disease recurrence and patient discomfort. The present study analyzes the results of excision with primary closure and excision with flap reconstruction in the surgical treatment of sacrococcygeal pilonidal disease. From January 2003 to January 2006, 60 consecutive patients with primary pilonidal sinus disease received surgical treatment in the form of either excision and primary closure (group I, n = 20 patients) or excision and flap reconstruction (group II, n = 40 patients; modified Limberg flap n = 20, classic Limberg flap n = 10 and adipo-fasciocutaneous flap n = 10). Times for complete healing and return to work were recorded. To evaluate patient comfort, all patients were asked to complete a questionnaire including visual analog scale, time to sitting on toilet without pain, and time to walking without pain 3 months after surgery. Mean follow-up was 21 months. A significant difference was observed between the two groups in terms of length of hospital stay (P < 0.003), time to complete healing (P < 0.001), time off work (P < 0.001), wound infection (P < 0.01), recurrence rates (P < 0.01), times to sitting on toilet without pain (P < 0.002), and walking without pain (P < 0.001). The mean (standard deviation) postoperative visual analog scale scores were 6.1 (1.2) in the primary closure group vs. 7.4 (1.3) in the flaps groups (P < 0.001). In the modified Limberg flap, no wound infection, wound breakdown, or recurrence of the disease occurred. Flap reconstructions were superior to primary closure after excision of pilonidal sinus and that modified Limberg flap was superior with regard to wound infection and recurrence.

“Reading Man Flap” Design for Reconstruction of Circular Infraorbital and Malar Skin Defects

Surgical complications such as lid retraction and ectropion from graft or flap scar contracture make reconstruction of skin defects in the malar and infraorbital regions challenging. A new flap design, the reading man flap, was used to overcome these problems. The Limberg and bilobed flap were compared with the reading man flap. The reading man flap consists mainly of a superiorly based quadrangular flap and an inferiorly based triangular flap. Malar and infraorbital circular skin defects measuring 14 x 14 to 40 x 40 mm were reconstructed with a reading man flap in 13 patients. The defects occurred after basal cell carcinoma in all patients. The Limberg flap, bilobed flap, and reading man flap were planned for same-sized defects on the abdominoplasty resection material. The results were compared in terms of total scar area, scar length, and total healthy skin area discarded. When comparing the 3 flap designs, the reading man flap was the most suitable flap in terms of total scar area and length. The reading man flap can be used to reconstruct malar and infraorbital circular defects with good cosmetic results and without creating any tractional forces to the eyelids.

Reconstruction of an Extended Defect in the Axilla Using a Thoracodorsal Fasciocutaneous Perforator Flap

Ectopic primary carcinoma of breast tissue is a rare entity, and its diagnosis often is delayed. The axilla is the most common site involved. The Limberg flap as a random flap is easy and practicable for coverage of many defects including those involving the axilla. In the reported case, the vascularity of the flap was improved by including a thoracodorsal artery perforator. This report presents the clinical features of a case of ectopic breast carcinoma in the axilla and an alternative tension-free Limberg thoracodorsal artery perforator flap for reconstruction of the extended defect after excision of the tumor. The flap survived and healed without further problems. A good functional and aesthetic result was obtained. Ectopic primary carcinoma of breast tissue is a rare entity. Correct early diagnosis should be made. A tension-free fasciocutaneous flap according to Limberg, supercharged using a thoracodorsal artery perforator, can provide skin and soft tissue coverage for extended defects in the axilla with a satisfactory outcome. The operative procedure is easy and reliable. This is a further surgical option for soft tissue extended reconstruction in the armpit.

Treatment of skin necrosis after radiation synovectomy with yttrium-90: a case report

Chronic synovitis, unresponsive to systemic medical therapy including agents, anti-inflammatory drugs and remission-inducing agents, and intra-articular administration of corticosteroids can be treated with surgical, chemical and radiation synovectomy. We reported a case of a 23 years old male. Skin radiation necrosis (4 x 5 cm) developed after an injection of Yttrium-90 (Y-90). Full-thickness skin graft had been applied but we were not able to succeed. Skin radiation necrosis was treated with Limberg's flap. As a result we recommend flap surgery instead of skin graft in skin radiation necrosis.