Limberg flap reconstruction for the treatment of pilonidal sinus disease

Introduction
Pilonidal sinus disease is a common chronic disorder characterized by inflammation, abscesses, and sinus formation in the sacrococcygeal region. It has an incidence of 0.7 % in the general population and it affects mainly young male with a peak incidence at the age of 16-25 years (1, 2). There are several theories regarding its etiology and pathogenesis, and it is considered as an acquired lesion. Main predisposing factors are poor hygiene, excessive hairiness, and local trauma in the sacrococcygeal area, as well as the presence of a deep natal cleft. This disease is acquired in the natal cleft and deep intergluteal sulcus as a result of shed hair shafts pushed into skin abrasions by the rotational movements of the buttocks during walking (3, 4). Hair insertion leads to foreign body reaction and the development of an acute or chronically infected site (5). This process is more pronounced in obese patients, in whom the skin overlying the intergluteal sulcus is usually wet and fragile (4).
The ideal treatment strategy would include wide excision of the disease region followed by flattening of the natal cleft to reduce the risk of recurrence (6).
Various surgical techniques have been described, including excision with primary closure (7), excision with open packing (8), excision with marsupialization (9), excision with skin grafting (10), and flap reconstruction (11, 12). The main problems associated with the conventional techniques are the high infection and recurrence rate. On the other hand procedures that flatten the intergluteal sulcus and bring the suture line aside the midline seem to be superior in terms of postoperative morbidity and recurrence rate (13).
The aim of the present study was to analyze retrospectively the results of the surgical management of a group of patients with complicated or recurrent pilonidal sinus
disease using the Limberg transposition flap after rhomboid excision of the diseased area.

Material and Methods
We reviewed the well-documented records of 32 adult patients who underwent wide excision with a Limberg transposition flap for pilonidal sinus disease, in the period between September 2003 and December 2004. All patients were male and were aged between 19-47 years (mean age 26.4+1.6 years). Twenty-three patients (71.9 %) had multiple fistula tracks and chronic discharge (stages 3 and 4) according to Chavoin classification (14)} and 9 patients (28.1 %) had recurrent disease. Five of the patients with recurrence had undergone excision with open packing, 3 marsupialization and one excision with primary closure. None of the patients had been operated on in our clinic.
Surgical procedure
Twenty-eight patients underwent surgery under local anesthesia. The rest 4 patients were operated under general anesthesia. All patients received prophylaxis against infection with 1 g of cefoxitin. At surgery they were placed in the jack-knife position. The sacrococcygeal area was shaved and cleaned with povidone-iodine solution. The extension of sinus was determined using a probe into the sinus tracts. The area to be excised was mapped on the skin in a rhomboid form. Consequently, complete excision of the pilonidal sinus tracks was carried out by rhomboid incision. The upper and lower tips of the incision were placed in the midline in 24 cases (Fig. 1A). However, in 8 most recent cases its inferior tip was transposed laterally to incorporate all fistulous tracts (modified Limberg flap) (Fig. 1B). A right-sided fasciocutaneous rhomboid transposition flap incorporating the gluteal fascia was tailored to fit the size of the rhomboid area. The flap was then transposed medially to fill the rhomboid defect without tension (Fig. 1C). After meticulous hemostasis the surgical wound was closed without drain in all cases. Approximation of the fascial layer and subcutaneous tissues was performed with polyglycolic acid sutures, to prevent dead space. The skin was closed with interrupted polypropylene sutures (Fig. 2).
Follow-up
All patients were released for mobilization after the first 6 hours postoperatively, but were advised for limited extension of the sacral region until they felt completely free of tension and pain. Discharge followed soon after according to senior surgeon's estimation. The patients were advised to keep the sacrococcygeal area clean and shaved. Complica-tion rates, hospitalization, time required to resume daily activities, patient complaints, and recurrence rate were all recorded. Follow-up examinations were done at the end of the first, sixth, and twelfth month after surgery. Beyond the first year the patients were examined with phone calls at every 6 months. The follow-up period ranged between 14 and 28 months (mean follow-up 16 months).

Results
All patients stayed in the outpatient ward for a few hours and then they were discharged as soon as they could be mobilized. Four patients who chose to undergo general anesthesia stayed in hospital for 24 to 32 hours. Thus the mean duration of hospital stay was 12 hours (range 6 hours to 32 hours). There was minimal pain or tension in the sacrococcygeal area after surgery. Hair shafts were present in the cavities of all patients. Postoperative short-term complications were: a minimal superficial infection in one case (3.12 %), and seroma in 3 cases (9.4 %). These cases were treated conservatively. Purulent wound infection, hema-toma or flap necrosis did not develop in any patient. In all cases we had good maintenance of the flap.
The convalescence period was short in all patients. They returned to work within 4 to 12 days (mean time to return to work was 9 days). No recurrence or any other complication was detected during the follow-up period. Our patients were satisfied with the cosmetic appearance after surgery, since most of them had already extensive disease with fistulous tracks and/or scars.

Discussion
Pilonidal sinus disease is considered as a chronic, intermittent, inflammatory process rarely occurring in congenital cases as extensions of sinus and dura to neural canal (15, 16). Lately the theory for congenital etiology has been superseded by a theory involving hair insertion to the natal cleft (9, 17). A deep natal cleft is an environment favoring sweating, hair penetration, and bacterial contamination. During walking, the buttock movements help hairs to penetrate the skin and cause a foreign body reaction and infection. This gradually leads to pilonidal abscess and/or sinus formation (18, 19).
Pilonidal sinus disease occurs more often in adolescent or young males. In our study we selected only male patients; their mean age was 26.4 years. Indeed in most reports there is a male preponderance, which is a further indication supporting the theory for acquired etiology, and the mean age is close to ours (5, 15). There is also an increased incidence in Caucasians and decreased in African and Asian races, depending mainly on hair distribution and growth (5). It is encountered more frequently in obese patients due to increased perspiration and gluteal friction and in patients with poor hygiene and local hirsutism (20).
There is considerable controversy regarding the optimal treatment of this common disease. Surgical interventions are generally preferred against conservative treatment.
However, a long list of surgical techniques reflects the inability to find an efficient mode of treatment approved by all surgeons. Excision of the diseased tissue down to the presacral fascia is generally accepted, but the management of the remaining space is still a matter of debate. Primary suturing after resection leads to a resultant dead space, which is actually a continuing natal cleft. This predisposes to infectious complications and a high recurrence rate approaching 20 % (15, 20, 21, 22). Other conventional methods, such as the "lay open" technique with continuous cleansing of the wound and packing until granulation occurs, and the "semi-open" techniques, i.e., closing the wound with partial sutures and marsupialization, are all associated with long-term wound care and high rate of recurrence (13, 22). Hodgson and Greenstein reported that cases treated by incision and drainage or excision with marsupialization had a recurrence rate of 40 % (3). Others reported that marsupialization is associated with a lower recurrence rate of 1.2 %-8 %, but a long healing period of 3-5 weeks (9, 23). In addition, patients complain of increased pain and discomfort in the wound area, especially if the closure of the defect has been done under tension. Also, the large areas of scar tissue in the open or semi-open techniques may cause tension, especially on sitting, even years after surgery (24).
Since most recurrences occur in the intergluteal sulcus, methods that flatten the intergluteal sulcus would eradicate the etiology and eliminate the risk of recurrence (5, 20, 25). Complete closure of the defect without tension is only provided by reconstructions such as the Z-plasty, the W-plasty, the V-Y plasty, and fasciocutaneous advancement flaps, such as the Karydakis and Limberg flap reconstruction (5, 13, 19, 26). Flap surgery enables the surgeon to excise tissue as widely as required, and then to close the defect using a reconstructive procedure.
The Z-plasty technique has been described by Monro and MacDermott in 1965 (27). This was one of the first efforts to eliminate the causative factors of the disease. However, this technique had a quite high recurrence rate (1.6%- 10 %), as well as flat tip necrosis in 20 % of cases (3, 22). The W-plasty technique has been introduced by Roth and Moorman in 1977 (28), but it also carried a quite high recurrence rate (0-16.7 %) (29). The V-Y flap technique was first described by Khatri (30), and was modified later by Schoeller et al (31). This technique was based on the use of an elliptical excision with closure of the defect through unilateral or bilateral advancement of the flap. The Schoeller modification was based in deepithelialization of the medial flap and an attempt at destroying all hair follicles and skin glands near the natal cleft, an aggressive procedure against recurrence (26).
Karydakis used an asymmetric excision and closure with an advancement flap to avoid hair penetration into the natal cleft (11). Since the incisional scar has been transferred laterally from the midline the recurrence rate with this technique was quite low (4 %), and the mean hospital stay was 3 to 4 days (32). Bascom, on the other hand supported that the actual source of the disease are the hair follicles and proposed another alternative technique comprising excision of hair follicles and a lateral drainage (33). All the above reconstruction techniques are not generally indicated in patients with extensive or complicated pilonidal disease (19, 34).
The rhomboid transposition flap was introduced by Dufourmentel to cover skin defects (35) and then was introduced in the treatment of pilonidal disease by Azab et al (36). The use of rhomboid excision and closure of the defect with a gluteal transposition flap, the so-called Limberg flap, has gained growing attention in the recent year as a means to manage complicated or recurrent pilonidal sinus disease.
According to this technique a rhomboid shaped excision including all sinuses and tracks is carried out. A lateral (right or left) fasciocutaneous transposition flap, incorporating the gluteal fascia, is fully mobilized on its inferior part and transposed medially to fill the rhomboid defect. In case of extensive disease with sinus tracks close to the inferior midline we may place the inferior apex of the rhomboid excision 1-2 cm lateral to the midline on the side opposite to the donor area (13). The defect is closed with interrupted sutures without tension to permit full blood supply to the flap (Fig. 1). Since all free space in the gluteal region is covered, there is no need for a drainage tube (37).
The Limberg flap repair has several advantages: it is a very efficient method to flatten the natal cleft and with simple modifications it may displace the incision scar from the midline (2, 19). Thus skin maceration and debris accumulation is diminished and sweating resulting from frictional movements of the buttocks is decreased. If all sinus tracks are removed, then all predisposing factors are eliminated and the recurrence rate is very low (0-7 %) (2, 5, 12, 19, 38). Since most of these recurrences occur in the midline, a modification of the Limberg flap technique has been used by several authors (39, 40). According to the latter technique, the wound and all suture holes are taken away from the midline, and the lower pole of the incision is placed on the contralateral side of the elevated flap. This way there is no incision in the lower intergluteal sulcus.
In our series the immediate postoperative outcome after the procedure was outstanding. The majority of our patients were managed in an outpatient basis. They did not have any pain or considerable tension in the sacrococcygeal area and were able for mobilization as soon as 4 to 6 hours after surgery. A few patients who elected to undergo general anesthesia stayed in hospital for less than 32 hours. The convalescence period was also short: patients were able to return to regular daily activities within 4 to 12 days, with a mean time 9 days, a much shorter period than the one reported elsewhere (41). Only minor complications were encountered in a few patients (morbidity rate 12.5 %). No flap ischemia or necrosis was noted. The above results are equivalent or even better than the ones reported elsewhere (2, 5, 13). No recurrences were detected in a follow-up period ranging between 14 and 28 months. A zero recurrence rate for the modified Limberg flap procedure is also reported by Mentes, Cihan and Tekin (2, 13, 39, 40). Although we did not have any recurrences or other problems with the classical Limberg flap procedure so far, we recently introduced the modified Limberg flap technique, since it is now considered as the most reliable technique.
As regards the cosmetic appearance after surgery it is well known that plasty techniques leave a considerable surgical scar, and not all patients are satisfied from this point of view (19). For that reason we were reluctant to select female patients for this type of surgery. However, on the long-term none of our patients had a serious complaint about the cosmetic appearance of the scar, because they all had extensive involvement in the sacrococcygeal area, or had already scars from previous surgery.
In conclusion, the Limberg procedure has been proven to be a safe and advantageous technique in the treatment of complicated/ recurrent pilonidal sinus disease, offering minimal postoperative pain, a low complication rate, a quick healing time, short hospitalization and disability and a very low recurrence rate.

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