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Reconstruction following excision of sacrococcygeal pilonidal sinus with a perforator-based fasciocutaneous Limberg flap
Journal of Plastic, Reconstructive & Aesthetic Surgery (2010) 63, 1176e1180
Reconstruction following excision of sacrococcygeal pilonidal sinus with a perforator-based fasciocutaneous Limberg flap Abdou M.A. Darwish a,*, A. Hassanin b a b
Plastic and Reconstructive Surgery Unit, Minia University, Minia City, Egypt Surgery Department, Minia University, Minia City, Egypt
Received 3 May 2008; accepted 29 May 2009
KEYWORDS Superiorly based flap; Pilonidal sinus
Summary 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. Patients and methods: 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 4.5 years (range 3e6 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). Results: 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 40 min (ranging between 30 and 45 min 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. Conclusion: 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. ª 2009 British Association of Plastic, Reconstructive and Aesthetic Surgeons. Published by Elsevier Ltd. All rights reserved.
* Corresponding author. Tel.: þ02 086 2344974, 02 0122717874 (mobile); fax: þ02 086 2342015. E-mail address: [email protected] (A.M.A. Darwish). 1748-6815/$ - see front matter ª 2009 British Association of Plastic, Reconstructive and Aesthetic Surgeons. Published by Elsevier Ltd. All rights reserved. doi:10.1016/j.bjps.2009.05.051
Reconstruction following excision
1177
Figure 1 (A) Detection of perforator by Doppler. (B) Mapping of expected defect and flap. (C) The defect after excision. (D) Flap elevation. (E) Flap transposition and wound closure. (F) Same patient in (Figure 1A) after complete healing of the wounds (6 weeks P.O).
1178
A.M.A. Darwish, A. Hassanin
Figure 2
(A) recurrent Pilonidal sinus. (B) Same patient in (Figure 2A) after complete healing (10 weeks P.O.).
The predisposing factors for the development of a pilonidal sinus are a deep natal cleft and the rolling movement of contiguous surfaces of the buttocks.1 In addition, poor hygiene, excessive hairiness and local trauma plays an important role.2 Different techniques for curing pilonidal sinuses have been described. Among these techniques are primary closure,3 lay-open,4 Limberg flap,5 modified Limberg transposition flap,6 elliptical rotation flap7 and rotation advancement fasciocutaneous flap.8 Leow et al. in 2004 described the superior gluteal artery perforator (SGAP) flap in the closure of sacral pressure sores. This flap is reliable and gives the option of further reconstructive possibilities.9 This article presents a study about the use of rhomboid or rhombic (Limberg) flap, which is based on the superior gluteal and sacral perforators for reconstruction of the sacrococcygeal region after excision of recurrent pilonidal sinus.
Patient and methods Between January 2004 and February 2007, 25 male patients (median age, 23; range, 14e29 years) who had recurrent pilonidal sinus underwent surgical treatment by Limberg flap technique. The mean duration of symptoms was 5.2 4.5 years (range: 3e6 years). Written consent was obtained from all patients after explanation of the procedure and expected appearance of the flap in this area. All patients were subjected to complete history taking and routine clinical, local examination and laboratory investigations. Under general anaesthesia, the patients were placed in the prone position. The trunk was slightly jack-knifed at the hips and the buttocks retracted with adhesive tape to allow wide exposure of the operative field. All patients received Ceftriaxone, 1 g intravenous (IV) at induction and postoperatively once daily for the next 5 days. After skin preparation, the anus was excluded from the operative field by surgical drapes. Using a sterile
skin-marking pen, the pathologic area to be excised was mapped on the skin. Then one or two para sacral perforators were identified with a Doppler probe (Figure 1A). The flap design were mapped on the skin (Figure 1B). A rhombic-shaped excision of the sinus-bearing skin and subcutaneous tissue up to the presacral fascia guided by electrocautery was performed (Figure 1C). Elevation of perforator-based Limberg flap (based on the superior gluteal and sacral perforators according to the study done by Koshima et al. 1993 on a cadaver dissection)10 (Figure 1D), in the same manner and the level of dissection was premuscular fascia, good haemostasis was achieved and the adhesive tapes which retracted the buttocks were released to allow suturing of the flap without tension and a suction drain was inserted. The wound was closed in layers. The facial and deep subcutaneous layer was approximated with 4/0 Vicryl sutures, and the skin was closed with 4/0 Prolene sutures (Figure 1E). No special decubetus was advised postoperatively and the patients were allowed to lie freely on the back. The suction drain was removed on the fourth postoperative day, and the sutures were removed between the 8th and 12th postoperative days.
Results Primary healing occurred in 22 patients when reviewed at the time of suture removal. Two patients (8%) had seroma with negative bacterial cultures, which eventually healed completely with bedside drainage and conservative treatment (Figures 1F and,2B). Another patient (4%) had superficial wound infection that was treated by appropriate antimicrobial therapy. Complete healing of all cases occurred without recurrence during the follow-up period. The mean operative time was 40 min (ranged between 30 and 45 min according to the size of the lesion and the flap). There was no ischaemia
Reconstruction following excision Table 1
1179
Complications
Complications
Number
Percentage
Seroma Wound infection
2 1
8% 4%
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 and the mean time to return to normal activity was 12.5 days (range: 9e15 days). There was no recurrence during the follow-up, which ranged between 8 and 30 months.
performed superiorly based flap, the mean operative time was 40 min with complete cure of the disease and very low incidence of post operative complications when compared with the previous studies (Table 1). Superiorly based Limberg flap for reconstruction of the defect after excision of recurrent sacrococygeal pilonidal sinus is a reliable technique, easily performed, associated with complete cure and low incidence of post operative complications.
Conflict of interest None.
Discussion
References
With the recent development of perforator flaps, it was found that the major pedicle vessels of skin flaps can be replaced by small perforators, and many muscles in musculocutaneous flaps and major vessels have been preserved without decrease in the skin territories of these flaps.11,12 In 2005, Mu et al.13 studied the numbers, position and course of the superior and inferior gluteal artery perforators in five cases of adult cadavers on both sides. Several main perforators (among 10 and 15) of large calibre were found in the para-ischial and central portion of the gluteal muscle. The length of these vessels varied from 3 to 8 cm, and their diameters from 1 to 1.5 mm. These significant perforators passed through the muscle itself and the fascial portion of the muscle to the overlying skin on the gluteal region. Several series with the rhomboid or rhombic flap technique, including more than 50 cases, have reported recurrence rates of 1% to 7%.1 The flap consists of skin and fat and is constructed by extending the incision to the gluteal muscle fascia. The advantage of this reconstruction is that it flattens the natal cleft with a large, well-vascularised pedicle that can be sutured without tension.14 In 2006, Katsoulis et al.15 presented their experience with the Limberg technique for both primary and recurrent pilonidal sinuses. The sinuses were excised in a rhomboid fashion and the defect closed using a transposition flap (inferiorly based) designed to obliterate the midline cleft. There was a single recurrence (4%) of a pilonidal sinus, which required further surgical excision, and 16% complications in the form of wound dehiscence, haematoma and wound infection in a study formed of 25 patients (same number as our study). In our study, no recurrence and low complication rate (8%) seroma, and superficial wound infection (4%) were observed. Iesalnieks16 studied the long-term results after excision of a pilonidal sinus and primary midline closure compared with the open surgical procedure in 73 patients. There was a high recurrence rate (42%) after excision of pilonidal sinus and primary midline closure. All the previous studies17e19 of Limberge flap rare performed with randompattern inferiorly based flap. In our study, the flap is superiorly based with more anatomical and better cosmetic appearance. In 2008, El-Khatib and Al-Basti20 reported a series of 8 cases of pilonidal sinus reconstructed by bilobed perforator-based flap, the mean operative time was 90 mine so it is time consuming with a long scar. In our study, we
1. Peterson S, Koch R, Stelzner S, et al. Primary closure techniques in chronic pilonidal sinus. Dis Colon Rectum 2002;45: 1458e67. 2. Karydakis GE. Easy and successful treatment of pilonidal sinus after explanation of its causative processes. Aust NZ J Surg 1992;62:385e9. 3. Akinci OF, Coskun A, Uzunkoy A. Simple and effective surgical treatment of pilonidal sinus: asymmetric excision and primary closure using suction drain and subcuticular skin closure. Dis Colon Rectum 2000;43:701e6. 4. Gencosmanoglu R, Inceoglu R. Modified lay-open (incision, curettage, partial lateral wall excision and marsupialization) versus total excision with primary closure in the treatment of chronic sacrococcygeal pilonidal sinus: a prospective, randomized clinical trial with a complete two-year follow-up. Int J Colorectal Dis 2005;2:415e22. 5. Eryilmaz R, Sahin M, Alimoglu O, et al. Surgical treatment of sacrococcygeal pilonidal sinus with the Limberg transposition flap. Surgery 2003;134:745e9. 6. Cihan A, Ucan BH, Comert M, et al. Superiority of asymmetric modified Limberg flap for surgical treatment of pilonidal disease. Dis Colon Rectum 2006;49:244e9. 7. Nessar G, Kayaalp C, Seven C. Elliptical rotation flap for pilonidal sinus. Am J Surg 2004;187:3. 8. Schoeller T, Wechselberger G, Otto A, et al. Definite surgical treatment of complicated recurrent pilonidal disease with a modified fasciocutaneous VeY advancement flap. Surgery 1997;121:258e63. 9. Leow M, Lim J, Lim TC. The superior gluteal artery perforator flap for the closure of sacral sores. Singapore Med J 2004;45: 37e9. 10. Koshima I, Moriguchi T, Soeda S, et al. The gluteal perforator based flap for repair of sacral pressure sores. Plast Reconstr Surg 1993;91:678e83. 11. Koshima I, Soeda S. Inferior epigastric skin flap without rectus abdominis muscle. Br J Plast Surg 1989;42:645e8. 12. Angrigiani C, Grilli D, Siebert J. Latissimus dorsi musculocutaneous flap without muscle. Plast Reconstr Surg 1995;96: 1608e14. 13. Mu LH, Yan YP, Luan J, et al. Anatomy study of superior and inferior gluteal artery perforator flap. Zhonghua Zheng Xing Wai Ke Za Zhi 2005;21:278e80. 14. Hull TL, Wu J. Pilonidal disease. Surg Clin North Am 2002;82: 1169e85. 15. Katsoulis IE, Hibberts F, Carapeti EA. Outcome of treatment of primary and recurrent pilonidal sinuses with the Limberg flap. Surgeon 2006;4:7e10.
1180 16. Iesalnieks I, Furst A, Rentsch M, et al. Primary midline closure after excision of a pilonidal sinus is associated with a high recurrence rate. Chirurgia 2003;74:461e8. 17. Mentes BB, Leventoglu S, Cihan A, et al. Modified Limberg transposition flap for sacrococcygeal pilonidal sinus. Surg Today 2004;34:419. 18. Tekin A. Pilonidal sinus: experience with the Limberg flap. Colorectal Dis 1999;1:29e33.
A.M.A. Darwish, A. Hassanin 19. Azab ASG, Kamal MS, Saad RA, et al. Radical cure of the pilonidal sinus by transportation rhomboid flap. Br J Surg 1984; 154:71. 20. El-Khatib HA, Al-Basti HBA. perforator-based bilobed fasciocutaneous flap: an additional tool for primary reconstruction following wide excision of sacrococcygeal pilonidal disease. J Plast Reconstr Aesthet Surg 2008;11: 1e5.
Reconstruction following excision of sacrococcygeal pilonidal sinus with a perforator-based fasciocutaneous Limberg flap Abdou M.A. Darwish a,*, A. Hassanin b a b
Plastic and Reconstructive Surgery Unit, Minia University, Minia City, Egypt Surgery Department, Minia University, Minia City, Egypt
Received 3 May 2008; accepted 29 May 2009
KEYWORDS Superiorly based flap; Pilonidal sinus
Summary 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. Patients and methods: 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 4.5 years (range 3e6 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). Results: 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 40 min (ranging between 30 and 45 min 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. Conclusion: 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. ª 2009 British Association of Plastic, Reconstructive and Aesthetic Surgeons. Published by Elsevier Ltd. All rights reserved.
* Corresponding author. Tel.: þ02 086 2344974, 02 0122717874 (mobile); fax: þ02 086 2342015. E-mail address: [email protected] (A.M.A. Darwish). 1748-6815/$ - see front matter ª 2009 British Association of Plastic, Reconstructive and Aesthetic Surgeons. Published by Elsevier Ltd. All rights reserved. doi:10.1016/j.bjps.2009.05.051
Reconstruction following excision
1177
Figure 1 (A) Detection of perforator by Doppler. (B) Mapping of expected defect and flap. (C) The defect after excision. (D) Flap elevation. (E) Flap transposition and wound closure. (F) Same patient in (Figure 1A) after complete healing of the wounds (6 weeks P.O).
1178
A.M.A. Darwish, A. Hassanin
Figure 2
(A) recurrent Pilonidal sinus. (B) Same patient in (Figure 2A) after complete healing (10 weeks P.O.).
The predisposing factors for the development of a pilonidal sinus are a deep natal cleft and the rolling movement of contiguous surfaces of the buttocks.1 In addition, poor hygiene, excessive hairiness and local trauma plays an important role.2 Different techniques for curing pilonidal sinuses have been described. Among these techniques are primary closure,3 lay-open,4 Limberg flap,5 modified Limberg transposition flap,6 elliptical rotation flap7 and rotation advancement fasciocutaneous flap.8 Leow et al. in 2004 described the superior gluteal artery perforator (SGAP) flap in the closure of sacral pressure sores. This flap is reliable and gives the option of further reconstructive possibilities.9 This article presents a study about the use of rhomboid or rhombic (Limberg) flap, which is based on the superior gluteal and sacral perforators for reconstruction of the sacrococcygeal region after excision of recurrent pilonidal sinus.
Patient and methods Between January 2004 and February 2007, 25 male patients (median age, 23; range, 14e29 years) who had recurrent pilonidal sinus underwent surgical treatment by Limberg flap technique. The mean duration of symptoms was 5.2 4.5 years (range: 3e6 years). Written consent was obtained from all patients after explanation of the procedure and expected appearance of the flap in this area. All patients were subjected to complete history taking and routine clinical, local examination and laboratory investigations. Under general anaesthesia, the patients were placed in the prone position. The trunk was slightly jack-knifed at the hips and the buttocks retracted with adhesive tape to allow wide exposure of the operative field. All patients received Ceftriaxone, 1 g intravenous (IV) at induction and postoperatively once daily for the next 5 days. After skin preparation, the anus was excluded from the operative field by surgical drapes. Using a sterile
skin-marking pen, the pathologic area to be excised was mapped on the skin. Then one or two para sacral perforators were identified with a Doppler probe (Figure 1A). The flap design were mapped on the skin (Figure 1B). A rhombic-shaped excision of the sinus-bearing skin and subcutaneous tissue up to the presacral fascia guided by electrocautery was performed (Figure 1C). Elevation of perforator-based Limberg flap (based on the superior gluteal and sacral perforators according to the study done by Koshima et al. 1993 on a cadaver dissection)10 (Figure 1D), in the same manner and the level of dissection was premuscular fascia, good haemostasis was achieved and the adhesive tapes which retracted the buttocks were released to allow suturing of the flap without tension and a suction drain was inserted. The wound was closed in layers. The facial and deep subcutaneous layer was approximated with 4/0 Vicryl sutures, and the skin was closed with 4/0 Prolene sutures (Figure 1E). No special decubetus was advised postoperatively and the patients were allowed to lie freely on the back. The suction drain was removed on the fourth postoperative day, and the sutures were removed between the 8th and 12th postoperative days.
Results Primary healing occurred in 22 patients when reviewed at the time of suture removal. Two patients (8%) had seroma with negative bacterial cultures, which eventually healed completely with bedside drainage and conservative treatment (Figures 1F and,2B). Another patient (4%) had superficial wound infection that was treated by appropriate antimicrobial therapy. Complete healing of all cases occurred without recurrence during the follow-up period. The mean operative time was 40 min (ranged between 30 and 45 min according to the size of the lesion and the flap). There was no ischaemia
Reconstruction following excision Table 1
1179
Complications
Complications
Number
Percentage
Seroma Wound infection
2 1
8% 4%
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 and the mean time to return to normal activity was 12.5 days (range: 9e15 days). There was no recurrence during the follow-up, which ranged between 8 and 30 months.
performed superiorly based flap, the mean operative time was 40 min with complete cure of the disease and very low incidence of post operative complications when compared with the previous studies (Table 1). Superiorly based Limberg flap for reconstruction of the defect after excision of recurrent sacrococygeal pilonidal sinus is a reliable technique, easily performed, associated with complete cure and low incidence of post operative complications.
Conflict of interest None.
Discussion
References
With the recent development of perforator flaps, it was found that the major pedicle vessels of skin flaps can be replaced by small perforators, and many muscles in musculocutaneous flaps and major vessels have been preserved without decrease in the skin territories of these flaps.11,12 In 2005, Mu et al.13 studied the numbers, position and course of the superior and inferior gluteal artery perforators in five cases of adult cadavers on both sides. Several main perforators (among 10 and 15) of large calibre were found in the para-ischial and central portion of the gluteal muscle. The length of these vessels varied from 3 to 8 cm, and their diameters from 1 to 1.5 mm. These significant perforators passed through the muscle itself and the fascial portion of the muscle to the overlying skin on the gluteal region. Several series with the rhomboid or rhombic flap technique, including more than 50 cases, have reported recurrence rates of 1% to 7%.1 The flap consists of skin and fat and is constructed by extending the incision to the gluteal muscle fascia. The advantage of this reconstruction is that it flattens the natal cleft with a large, well-vascularised pedicle that can be sutured without tension.14 In 2006, Katsoulis et al.15 presented their experience with the Limberg technique for both primary and recurrent pilonidal sinuses. The sinuses were excised in a rhomboid fashion and the defect closed using a transposition flap (inferiorly based) designed to obliterate the midline cleft. There was a single recurrence (4%) of a pilonidal sinus, which required further surgical excision, and 16% complications in the form of wound dehiscence, haematoma and wound infection in a study formed of 25 patients (same number as our study). In our study, no recurrence and low complication rate (8%) seroma, and superficial wound infection (4%) were observed. Iesalnieks16 studied the long-term results after excision of a pilonidal sinus and primary midline closure compared with the open surgical procedure in 73 patients. There was a high recurrence rate (42%) after excision of pilonidal sinus and primary midline closure. All the previous studies17e19 of Limberge flap rare performed with randompattern inferiorly based flap. In our study, the flap is superiorly based with more anatomical and better cosmetic appearance. In 2008, El-Khatib and Al-Basti20 reported a series of 8 cases of pilonidal sinus reconstructed by bilobed perforator-based flap, the mean operative time was 90 mine so it is time consuming with a long scar. In our study, we
1. Peterson S, Koch R, Stelzner S, et al. Primary closure techniques in chronic pilonidal sinus. Dis Colon Rectum 2002;45: 1458e67. 2. Karydakis GE. Easy and successful treatment of pilonidal sinus after explanation of its causative processes. Aust NZ J Surg 1992;62:385e9. 3. Akinci OF, Coskun A, Uzunkoy A. Simple and effective surgical treatment of pilonidal sinus: asymmetric excision and primary closure using suction drain and subcuticular skin closure. Dis Colon Rectum 2000;43:701e6. 4. Gencosmanoglu R, Inceoglu R. Modified lay-open (incision, curettage, partial lateral wall excision and marsupialization) versus total excision with primary closure in the treatment of chronic sacrococcygeal pilonidal sinus: a prospective, randomized clinical trial with a complete two-year follow-up. Int J Colorectal Dis 2005;2:415e22. 5. Eryilmaz R, Sahin M, Alimoglu O, et al. Surgical treatment of sacrococcygeal pilonidal sinus with the Limberg transposition flap. Surgery 2003;134:745e9. 6. Cihan A, Ucan BH, Comert M, et al. Superiority of asymmetric modified Limberg flap for surgical treatment of pilonidal disease. Dis Colon Rectum 2006;49:244e9. 7. Nessar G, Kayaalp C, Seven C. Elliptical rotation flap for pilonidal sinus. Am J Surg 2004;187:3. 8. Schoeller T, Wechselberger G, Otto A, et al. Definite surgical treatment of complicated recurrent pilonidal disease with a modified fasciocutaneous VeY advancement flap. Surgery 1997;121:258e63. 9. Leow M, Lim J, Lim TC. The superior gluteal artery perforator flap for the closure of sacral sores. Singapore Med J 2004;45: 37e9. 10. Koshima I, Moriguchi T, Soeda S, et al. The gluteal perforator based flap for repair of sacral pressure sores. Plast Reconstr Surg 1993;91:678e83. 11. Koshima I, Soeda S. Inferior epigastric skin flap without rectus abdominis muscle. Br J Plast Surg 1989;42:645e8. 12. Angrigiani C, Grilli D, Siebert J. Latissimus dorsi musculocutaneous flap without muscle. Plast Reconstr Surg 1995;96: 1608e14. 13. Mu LH, Yan YP, Luan J, et al. Anatomy study of superior and inferior gluteal artery perforator flap. Zhonghua Zheng Xing Wai Ke Za Zhi 2005;21:278e80. 14. Hull TL, Wu J. Pilonidal disease. Surg Clin North Am 2002;82: 1169e85. 15. Katsoulis IE, Hibberts F, Carapeti EA. Outcome of treatment of primary and recurrent pilonidal sinuses with the Limberg flap. Surgeon 2006;4:7e10.
1180 16. Iesalnieks I, Furst A, Rentsch M, et al. Primary midline closure after excision of a pilonidal sinus is associated with a high recurrence rate. Chirurgia 2003;74:461e8. 17. Mentes BB, Leventoglu S, Cihan A, et al. Modified Limberg transposition flap for sacrococcygeal pilonidal sinus. Surg Today 2004;34:419. 18. Tekin A. Pilonidal sinus: experience with the Limberg flap. Colorectal Dis 1999;1:29e33.
A.M.A. Darwish, A. Hassanin 19. Azab ASG, Kamal MS, Saad RA, et al. Radical cure of the pilonidal sinus by transportation rhomboid flap. Br J Surg 1984; 154:71. 20. El-Khatib HA, Al-Basti HBA. perforator-based bilobed fasciocutaneous flap: an additional tool for primary reconstruction following wide excision of sacrococcygeal pilonidal disease. J Plast Reconstr Aesthet Surg 2008;11: 1e5.