A pilonidal sinus is a tract in the cleft above the buttocks, driven by hair working its way into the skin. Treating the infection is easy. Preventing it coming back is the whole problem, and that is decided by how the wound is closed.
Pilonidal sinus surgery removes the infected tracts and the pits that feed them. How the resulting wound is closed matters more than the excision: leaving it open heals slowly over months, closing it in the midline recurs often, and an off midline flap closure such as a Limberg or Karydakis repair heals faster and recurs least. An abscess is drained first and definitive surgery done once the infection has settled.
A pilonidal sinus starts with loose hair being worked into the skin of the natal cleft by movement and pressure. The body treats the hair as foreign, a cavity forms, and small pits appear in the midline with tracts running under the skin. Infection follows, sometimes as a sudden painful abscess.
Removing the disease is straightforward. The difficulty is what to do with the hole that is left, and this is where outcomes are decided.
Leaving the wound open to heal from the bottom up works, and recurrence is reasonably low, but it means dressings for one to three months and a considerable interruption to normal life. Closing it directly in the midline is quick, but the scar sits in the depth of the cleft where it is moist, under tension and exposed to hair again, and recurrence rates are the highest of the options.
The better answer is to close the wound off the midline and flatten the cleft at the same time, using a flap of adjacent skin and fat. A Limberg rhomboid flap or a Karydakis type closure does exactly that. Healing is faster, the scar lies away from the depth of the cleft, and recurrence is substantially lower.
Timing matters: definitive surgery is done when the tissue is quiet, not during an acute abscess.
Any abscess is drained and allowed to settle. Operating through actively infected tissue leads to breakdown.
The pits and tracts are identified, sometimes with dye, so that all diseased tissue is included.
The sinus, its tracts and the involved skin are removed down to healthy tissue over the sacral fascia.
A rhomboid or advancement flap of adjacent skin and fat is planned so the final scar lies off the midline.
The flap fills the defect and reduces the depth of the cleft, which is what removes the environment the disease needs.
A small drain is usually left for a few days and the wound closed in layers without tension.
Drain removed once output settles. Sit on a soft cushion and avoid prolonged direct pressure. Keep the area clean and dry.
Wound largely healed. Most people return to desk work. Avoid heavy lifting and long drives.
Normal activity resumes. Begin regular hair removal from the area once the wound is fully healed.
Scar matures. Continue hair control and hygiene, which is where long term prevention lies.
Flap closure heals in around two to three weeks rather than the two to three months an open wound takes, and recurrence is considerably lower than after midline closure. It is not zero. Recurrence remains possible, particularly where hair control and hygiene lapse, and where the patient smokes. The scar is longer than a simple excision would leave and sits to one side of the cleft, which is deliberate. A temporary drain is usual and some fluid collection is common.
This area is warm, moist and mobile, which is what makes wound problems the main concern.
Hair control and keeping the area dry do as much to prevent recurrence as the operation itself.
That is one option and it works, but flap closure heals in weeks with lower recurrence than midline closure. Open healing is no longer the only reasonable choice.
Wider excision does not reliably reduce recurrence. Where the scar ends up does. A wide midline excision closed in the midline still recurs.
Hair, friction and the depth of the cleft are the main factors. Hygiene and hair control help prevent recurrence, but the condition is not a verdict on cleanliness.
Recurrence is much less likely after off midline flap closure, but it remains possible, particularly if hair control lapses or the patient smokes.
Pilonidal disease is treated badly far more often than it is treated well, usually by repeated midline excisions that keep recurring. Flattening the cleft and moving the scar off the midline is a reconstructive decision, and it is what changes the long term result.
Surgery for recurrent pilonidal disease is commonly covered by health insurance and by government schemes. Cost depends on whether a simple excision or a flap reconstruction is performed and on the length of stay. A written estimate follows assessment.
Most of these come from people who have already had one operation elsewhere.
Ask your question →Most often because the wound was closed in the midline. That scar sits in the moist depth of the cleft, under tension and exposed to hair again. Moving the scar off the midline and flattening the cleft is what changes that.
Most people manage with a soft cushion within a few days and sit normally by two to three weeks. Long drives are best avoided for the first fortnight.
Yes. Hair working into the skin is what causes the condition in the first place. Regular removal from the area is one of the few things shown to reduce recurrence, and it is part of the treatment rather than an optional extra.
An abscess can be drained, which relieves the acute problem but does not cure the sinus. Some very limited disease can be managed with minimal procedures. Recurrent disease with established tracts generally needs excision.
Longer than a simple excision would leave, and placed to one side rather than in the depth of the cleft. That placement is the point of the operation, and it is what makes recurrence less likely.
Seeing patients from across the city and beyond: read about the practice on the plastic surgeon in Surat page, or check what a written estimate covers on the costs and insurance page.
