Monday, August 16, 2010

Limberg Flap in Treatment of Pilonidal Sinus Disease

MDLinx has once again pointed me to an article I might never have seen.  This one is in the journal Surgery Today and deals with the treatment of pilonidal sinus disease using one of two type of Limberg flap:  the classic and the modified.

Pilonidal sinus disease (PSD) occurs in the cleavage between the buttocks.  The diagnosis of a pilonidal sinus is made by identifying the epithelialized follicle opening (the sinus).

The name pilonidal taken from the Latin, meaning literally 'nest of hairs'.

The onset of PNS is rare both before puberty and after the age of 40. Males are affected more frequently than females. It is also common in obese people and those with thick, stiff body hair.

The article does a good review of the management of PSD which remains controversial. There is currently no “gold standard” treatment. 

Conservative approaches such as weekly shaving of the involved areas may control the progression of PSD, but surgical treatment is often required since supervening infections are inevitable in
most of the cases.

Marsupialization provides a smaller wound to granulate. It is also associated with a low recurrence rate, but the healing time is as long as 4–5 weeks, and patients need to change multiple wound dressings.

The most effective treatment modality is a wide excision of the sinus tract. Excision and primary closure have both advantages and disadvantages, including rapid healing and short time off from work, and increased risk of wound dehiscence and considerable pain at the surgical site. In addition, high recurrence rates of up to 15%–25% have been reported.

Therefore, asymmetric or oblique incision and excision techniques have been introduced during last 2–3 decades to avoid the problems believed to be associated with a midline scar.  ……

The problems related to continuing natal cleft after pilonidal sinus surgeries have prompted surgeons to discover new techniques to eliminate gluteal furrow. To eliminate the natal cleft, various flap techniques such as the Limberg flap, Z-plasty, W-plasty, V-Y advancement flap, and rotating flap have been used.

In all kinds of excision plus flap procedures for PSD, recurrences rates are between 1% and 7% in the literature. cLF has been reported to have lower infection and recurrence rates. However, longer hospital stays, a high maceration rate, hypoesthesia, and an unattractive cosmetic appearance are associated with this
technique.

The authors of the study comparing the modified (mLF) to the classic Limberg flap (cLF)  found the mLF had better clinical results than the cLF group with fewer recurrences (2/205  vs 10/211).  The time to return to work, time to walk without pain, and time to be able to sit on the toilet without pain were longer in the cLF group than in the mLF group.

 

 

REFERENCE

Comparison of the classic limberg flap and modified limberg flap in the treatment of pilonidal sinus disease: A retrospective analysis of 416 patients
Surgery Today, 08/04/2010

Pilonidal Sinus Disease; World Wide Wounds article, November 2009;  David Miller, BMBS MRCS and Keith Harding, MB ChB MRCGP FRC

Pilonidal Disease; eMedicine article, August 24, 2009; James de Caestecker, DO, Barry D Mann, MD, Andres E Castellanos, MD, and Jason Straus, MD

Choosing the Correct Limberg Flap; BORGES, ALBERT F.; Plastic & Reconstructive Surgery. 62(4):542-545, October 1978.  (has nice photos)

Rhombic Flaps; eMedicine article, Feb 12, 2009; Anthony P Sclafani, MD and Michael Fozo, MD

1 comment:

Buckeye Surgeon said...

I think these fancy flaps are useful for recurrent or complex Piloniidal disease but for straight forward cases I just do a wide excision, raise subcu flaps over the gluteals and close in the midline. One infection out of over 50.