Volume 64, Issue 1 , Pages 138-140, January 2011
A perforator solution for excisional defects of pilonidal sinus
Article Outline
Pilonidal sinus is a chronic inflammatory disease that originates from invagination of hair follicles into the skin fold. It periodically causes an inflammatory reaction, associated with abscess formation. Although it is a benign disease, the clinical symptoms of chronic irritation and discharge of the coccyx cause discomfort.
Primary closure and secondary intention are associated with high rates of recurrence and infection. Recent literature proposes that the ideal reconstruction method with the lowest recurrence rates is excision and flap coverage of the pilonidal sinus.1, 2, 3 They recommend displacement of the suture line to the lateral side of the gluteal fold to prevent recurrence.1, 2, 3 We introduce a design for the perforator based island flap which is well suited for reconstruction of excisional defects of pilonidal sinus.
Surgical technique and refinements
The posterior superior iliac spine and coccyx are marked and serve as the surface landmark of the lateral sacral border along which reliable perforators are located in inside of the middle line.4 Included in the flap design was the consideration for primary closure of donor. The design incorporated the perforator adjacent to the defect and involved transposition of the donor tissue along a rotation arc of 45°–90°. Elliptical shape designs are useful for directly closing the donor site. After simulating closure of the donor defect, the apparent recipient shape changed. Flap length required is usually longer and wider in width (Figure 1, above left).
Figure 1
The posterior superior iliac spine (PSIS) and coccyx were marked and this was the surface landmark of the lateral sacral border along which numerous constant and reliable perforators are located in inside of the middle line. The design incorporated the perforator along the lateral sacral border and involved transposition of the donor tissue along a rotation arc of 45°–90°. The apparent defect shape changed and the length required was usually longer after donor site closure (Above, Left). The flap was then elevated disto-proximally in the subfascial plane (Above, Right). Flap was elevated till a tension-free transposition was achieved (Below, Left). Closure of the donor site was commenced following which the flap was inset under negative suction drainage (Below, Right).
The flap is elevated disto-proximally in the subfascial plane (Figure 1, above right). During elevation of the proximal portion of the flap, caution is exercised near the perforator pedicle, leaving a 1
cm radius of undissected tissue around it. Pedicle isolation is not performed. Flap is elevated till a tension-free transposition is achieved (Figure 1, below left). After flap is elevated, the pivot point is closed without tension. This serves as the key suture for primary closure of the donor site, following which the remaining areas are closed (Figure 1, below right).
Discussion
V–Y advancement flaps for reconstruction of pilonidal sinus defects are effective as they require less dissection and are associated with a lower incidence of hematoma.1, 2 A shorter skin incision and large skin bridge reduce the risk of fecal contamination and result in a short operative time.1, 2 However, V–Y advancements result in creation of midline scars with the inherent risk of recurrence. The establishment of a perforator concept serves to provide customized flaps with low donor morbidity and wider options for flap design. The gluteal region has rmulitple redundant perforators as described by Koshima et al.4
Superior gluteal artery perforator flaps have been used in reconstruction of large defects of the pilonidal sinus.3 They avoid midline closure, which results in flattening of the intergluteal sulcus. The most lateral perforators are selected, as a long vascular pedicle is required for transposition of these flaps. Pedicle isolation is a tedious and risky procedure which is often prone to congestion and ischaemia.2, 3 However, the perforator based flap has overcome the drawbacks of the conventional perforator flap, as there is no necessity to isolate perforators, averting postoperative venous congestion and kinking of the vascular pedicle by providing a cushion of soft tissue around the perforator.
In this article, we distinguish the term ‘perforator flap’ from ‘perforator based flap’. We use the term ‘perforator based’ when the source artery is spared. According to the concept, the term ‘Parasacral perforator flap’, ‘Pedicled perforator flap’ and ‘perforator pedicled propeller flaps’ would be more aptly named as the ‘Gluteus Maximus perforator based island flap (GM-PBIF)’ (It does not matter what the source artery is, proximal portion of the flap pedicle along the lateral sacral border always includes numerous’ micro-perforators’ which penetrates the Gluteus Maximus).5 Our concept is compatible with the report of Acartürk TO et al,2 In comparison, our flaps were designed at 45-90° angle to the vertical axis of the defect (Figure 1, Figure 2). The distal end of the triangular flap was often prone to ischaemia when the design incorporated a narrow angle and the donor site was closed under tension. The flap length required is usually longer and wider in width after primary closure of the donor defect. More dissection around the proximal portion of the flap pedicle, leaving a 1cm radius of undissected tissue can lead to tension-free closure after transposition of the donor flap.
Figure 2
(Left) A 29-year-old man suffered chronic and recurred pilonidal sinus. (Center) Schematic figure shows the design of PBIF. P: perforator 1/2: middle line between posterior superior iliac spine (PSIS) and coccyx. (Right) The wound healed well and he is shown at 11 months postoperatively.
Perforator-based island flaps (PBIF) are simple and easy to harvest compared to other techniques utilizing perforator flaps, which require isolation of the perforator. In addition, this flap can be utilized for various sizes of pilonidal sinus defects.
Disclosure
None of the authors has any financial interest in any medical devices, drugs or products mentioned in this article.
References
- V-Y rotation advancement fasciocutaneous flap for excisional defects of pilonidal sinus. Plast Reconstr Surg. 2006;117:2448–2454
- Superior gluteal artery perforator flap in the reconstruction of pilonidal sinus. J Plast Reconstr Aesthetic Surg. 2010;63:133–139
- Reconstruction of extensive pilonidal sinus defects with the use of S-GAP flaps. Ann Plast Surg. 2008;61:197–200
- The gluteal perforator-based flap for repair of sacral pressure sores. Plast Reconstr Surg. 1993;91:678–683
- . New nomenclature concept of perforator flap. Br J Plast Surg. 2005;58:431–440
PII: S1748-6815(10)00321-9
doi:10.1016/j.bjps.2010.05.021
© 2010 British Association of Plastic, Reconstructive and Aesthetic Surgeons. Published by Elsevier Inc. All rights reserved.
Volume 64, Issue 1 , Pages 138-140, January 2011
