Pilonidal sinus disease (SPSD) is a global problem with a propensity for recurrence that causes significant problems if not dealt with appropriately in the primary setting. A higher incidence of the disease is noted among males and army recruits.[1] Early pilonidal changes are amplified due to deep tissue disruption from moisture, anaerobic conditions, hairs, and bacteria.[2,3].

The focus of treatment should be actions to change the conditions that attack epidermis, rather than wide excision, which attacks deep and healable tissue excision with midline closure, oblique excision and asymmetric closure, Karydakis and z plasty procedures. Karydakis procedure is a gluteal advancement flap [2]. Z-plasty is a fasciocutaneous flap; Karydakis flap is an adipocutaneous flap; it is, therefore, technically easier, less bloody, and less time consuming; it has a better cosmetic outcome, a single, lateral, longitudinal scar; and it requires a significantly shorter hospital stay.

It has been proved that flap procedures are superior to traditional methods of excision of the tract to prevent recurrence of the lesion.[1,4]. The procedure of choice, however, remains debatable [4]. The principle of the Karydakis procedure being flattening of the natal cleft and lateral shift of midline (scar), which prevents lodging of hair in the natal cleft and hence recurrence [5,6]. Flap procedures are often accused of being time-consuming and technically demanding.

The present study was undertaken as a prospective study from May 2019 to June 2021. All patients subjected to the Karydakis procedure, Z plasty into two divided groups for PSD at our centre were included in the study whether presenting with primary or recurrent disease. A single surgical unit performed all procedures. The sample size was decided according to the experience of cases of pilonidal sinuses and local guidelines. The cases are randomised based on the hospital registration number by the initial part. The screening personnel did not get involved in the operative procedure.

Inclusion Criteria: Patients aged between 20 to 40yrs Includes both males and females

Exclusion Criteria: It doesn't include pregnant women.

Fig: Immediate postop After suture removal

The Z-plasty involves the transposition of two triangular flaps, A and B. The limbs of the Z must be equal in length to the central limb but can extend at varying angles (30–90 °) depending on how much length is required. The classic Z-plasty has an angle of 60 ° and provides a 75% theoretical gain in length of the central limb by recruiting lateral tissue. The depth of the incision is to the fascia, to allow a pre fascial cutaneous and subcutaneous flap. The flaps are suitable interdigitated and sutured in three layers according to the depth of the wound to avoid negative spacing. MacDermott proposed that the suture line be shifted laterally away from the midline gluteal fold to reduce the recurrence rate by modifying local conditions.[7] All patients were asked to pay attention to hygiene rules, not to sit or use a semi-sitting position for 15 days, and to depilate hairs around their gluteal region as necessary every 3months beginning after hospital discharge.

The age of patients ranged from 18 to 56 years with a mean age of 26.45 years, with the majority (18 out of 30-75.72%) in the 21to 40 year's age group. The incidence in male patients was nine times more than that in females. In both groups, the incidence was more common in patients with coarse body hair density (80–84%) and patients with a deep natal cleft (88%). Grossly, the primary disease was present in 82% of the patients, among which 87.8% Recurrent disease was present in 20% of patients, and all of them are males, and all these patients have a deep natal cleft.

Similar to our study, Chintapatla et al. showed a male preponderance of this disease [8]. Awad and Saad reported that 56.3 % of pilonidal disease patients had coarse hair density and deep natal cleft [9]. This may be mainly due to their more hirsute nature. There were four recurrent cases in group 2 and Nil in group 1. In both groups, the common clinical presentations were small pus discharging sinus (56%), multiple discharging sinuses (28%), and swelling with pus discharging sinus (16%).

Four of these patients had recurrent disease and had undergone a primary procedure like excision and curettage or excision and primary midline closure. All cases were found to have these openings within 4 cm cranial or caudal to the primary opening, and secondary openings situated laterally were within 2 cm on one side of the midline. In patients with the serous collection, the collection was let out, following which wounds healed within two weeks of regular dressings. In patients with wound infection, pus was drained, and they were administered appropriate antibiotics and underwent regular dressing.

In five patients, the wounds healed by secondary intention within 3-4 weeks. Only one patient in the above group had to be taken up for secondary suturing at the end of 4 weeks, and healing was complete in another three weeks. This was an obese patient who had recurrence twice following excision and primary midline closure and underwent the Karydakis procedure the 3rd time.

Table 1: Complications observed in both groups

In contrast, in the Z-plasty technique, the mean days of wound healing were 30 days the number of days in which pain lasted postoperatively was 37 days, and work off periods were 40 days; hence the meantime of healing in the Karydakis flap was less than 15 days Complications: the overall complication rates were maximum for the Z-plasty group commonest were tip necrosis (56%), loss of sensation 50%, Infection (8%), seroma formation (4%), and wound dehiscence (4%). Loss of local sensation is a known complication following Z-plasty because, in this technique, flaps are transposed in such a way as to avoid a suture line in the midline. [11,12]. To achieve this, we have to make an incision, thereby cutting cutaneous nerves.

In Z-plasty, to minimise the tip necrosis, we have observed and advise to do the following:

(i) the incision to achieve transposition of flaps should be in full depth, having deeper tissues along with the skin;

(ii) approximation of soft tissue (subcutaneous and deeper) should be meticulous by vicryl suture;

(iii) the cautery should be minimally used.

Similarly, the experience of 15 cases with the Karydakis procedure, reported among early complications loss of local sensation in 4%, seroma in 12%, wound infection in 16.7% and wound dehiscence in 0.3%. flap necrosis and wound dehiscence were significantly less common.[7]. None of the patients had any recurrence, which is comparable to other studies like Kitchen (4%),[13] Anyanwuet al. (0%)[14]. and Amir (0%).[15].

In both groups, wound dehiscence and infection were more common in cases having deep natal cleft and coarse body hair density. This is because, as the perineum to be the most contaminated area of our body, with the mid natal cleft being the bacterial harbour where maximum bacterial colonisation occurs, dense body hair adversely affects the maintenance of proper hygiene, thus increasing the infection rate. So, it is evident that not only are risk factors for the causation of the disease but also complicate the procedure done, increasing the infection, necrosis, and wound dehiscence rate.

Recurrences have led to a variety of procedures being practised, from simple excision to complicated flap procedures.