Pilonidal Disease: Classic and Contemporary Concepts for Surgical Management

Pilonidal disease (PD) is a recalcitrant condition associated with significant morbidity. It affects 26 in 100,000 individuals; however, there is no consensus on optimal surgical treatment, and up to half of patients struggle with recurrence. This review appraises the current literature on techniques and outcomes of PD surgery, to better guide decision making.

A literature review using directed search terms was performed to identify studies addressing PD management, in accordance with the PRISMA guidelines. Data on techniques, outcomes, and complications were collected.

Open healing remains the most widely used treatment method and achieves reliable outcomes at the expense of prolonged wound healing, between 21 and 71 days. Asymmetric closure reduces healing time to 10 to 23 days and produces significantly fewer recurrences relative to midline closure (P < 0.05). Outcomes are similar between various asymmetric techniques; the Bascom cleft lift, Karydakis flap, and Limberg transposition are commonly used approaches which all demonstrate recurrence rates under 6%. Deroofing is associated with a significantly lower rate of complications than any closure procedure at 1.4% (P < 0.05), with recurrence in only 1% to 10% of patients, and represents a favorable treatment alternative.

Despite the heterogeneous nature of studies on PD, certain techniques have been consistently shown to optimize postoperative outcomes. Deroofing sinuses and allowing secondary healing results in low rates of recurrence with minimal morbidity. When closure is preferred, off-midline flaps provide more effective coverage than midline repair. Treatment recommendations should be guided by individualized patient preferences and be grounded in high-quality data.