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Surgeons frequently debate the most effective surgical approach for pilonidal sinus disease (PSD). Traditionally, many centers relied on midline closure (MC) or excision with healing by secondary intention (EHSI). However, recent evidence strongly supports the Karydakis flap for pilonidal sinus as a superior reconstructive option. This technique aims to move the surgical scar away from the midline, thereby reducing tension and moisture in the natal cleft.
Researchers recently conducted a comprehensive systematic review and meta-analysis to compare these methods. This study included 15 randomized and comparative cohort studies involving 3,108 patients. Specifically, the analysis evaluated 1,257 Karydakis flap procedures against 1,593 midline closures and 258 secondary intention cases. Consequently, the findings provide clear clinical direction for modern surgical practice.
The primary finding of the meta-analysis is the significant reduction in recurrence rates. The Karydakis flap showed a 70% reduction in recurrence compared to midline closure (OR 0.30). Furthermore, it outperformed EHSI with an even more impressive odds ratio of 0.17. These results suggest that off-midline flap techniques are essential for long-term success in PSD treatment.
In addition to lower recurrence, the Karydakis flap significantly reduces postoperative complications. Patients experienced fewer surgical site infections and a lower incidence of seroma formation. Although the flap procedure typically takes 14 minutes longer than midline closure, the recovery benefits are substantial. Notably, patients treated with the Karydakis flap returned to work approximately two weeks earlier than those undergoing secondary intention healing. Therefore, the flap technique offers better efficiency for both patients and healthcare systems.
The Karydakis flap shifts the surgical wound away from the deep natal cleft. This maneuver flattens the cleft and reduces the accumulation of hair and moisture, which are the primary drivers of recurrence.
Yes. Compared to excision with secondary intention, patients undergoing the Karydakis flap procedure return to daily activities nearly 14 days sooner. It also results in shorter hospital stays compared to open healing methods.
Disclaimer: This content is for informational and educational purposes only... Refer to the latest local and national guidelines for clinical practice.
References
Hussein A et al. Comparative study of the Karydakis flap versus conventional surgical techniques for pilonidal sinus disease: a systematic review and meta-analysis. Updates Surg. 2026 Mar 19. doi: 10.1007/s13304-026-02585-y. PMID: 41854814.
Keshava A et al. Management of pilonidal sinus disease. ANZ Journal of Surgery. 2018;88(5):454-460.
Keshvari A et al. Karydakis flap versus excision-only technique in pilonidal disease. J Surg Res. 2015;198(1):260-6.
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