Pilonidal sinus disease (PSD) is a chronic inflammatory condition of the sacrococcygeal region, most commonly affecting young adults, and is associated with ingrown hairs and epithelial debris in the natal cleft. It presents with pain, discharge, and recurrent abscesses, significantly impairing quality of life.[1] Male gender, obesity, sedentary lifestyle, and local hirsutism are established risk factors.[2] A wide spectrum of surgical techniques has been described for PSD, ranging from simple excision with primary closure to more complex flap procedures. Though historically common, midline closure is associated with unacceptably high long-term recurrence rates, with one review reporting recurrence rates of up to 67.9% at 20 years.[3] Off-midline flap procedures, including the Karydakis and Limberg flaps, have been shown to reduce recurrence substantially, with rates as low as 0.2–0.6% at two years.[4] A large meta-analysis including over 89,000 patients further highlighted that recurrence rates vary significantly depending on the surgical approach and duration of follow-up.[5] Another widely used method is healing by secondary intention, involving open excision of the tract and allowing the wound to heal by granulation. While this technique requires a longer healing period, studies have demonstrated lower wound complication rates and comparable recurrence rates to closed techniques.[6] In fact, one cohort study found wound complications in 23% of secondary intention cases versus 51% in primary closure, with recurrence rates of 11% and 18%, respectively.[7] Similarly, a comparative study of four different surgical methods showed that open healing had a lower recurrence rate and shorter hospital stay, though results were not always statistically significant.[8] In the Indian context, comparative studies have also evaluated flap versus open excision. One study reported that Limberg flap reconstruction allowed earlier return to normal activities. However, wide excision with secondary intention healing demonstrated acceptable recurrence rates and favorable cosmetic outcomes in selected patients.[9] Therefore, it is interesting to compare cosmetic results and complication profiles across different surgical modalities of pilonidal sinus, with special emphasis on excision and secondary intention healing.

Study Design and Setting This prospective comparative study was conducted in the Department of General Surgery at Vedantaa Institute of Medical Sciences, Dahanu, Palghar, Maharashtra, India. The study was carried out over three months, from February 2025 to April 2025. The primary objective was to evaluate and compare cosmetic outcomes of different surgical treatment methods for pilonidal sinus disease, while also assessing associated complications such as flap rejection, surgical site infection (SSI), postoperative scar formation, and recurrence. Study Population A total of 30 patients presenting with clinically diagnosed pilonidal sinus were included in the study. All patients were admitted through the surgical outpatient department and evaluated for the suitability of operative intervention. Informed written consent was obtained from each participant after explaining the nature of the disease, the surgical procedure, possible complications, and the expected outcomes. Inclusion and Exclusion Criteria Patients aged between 18 and 45 years with primary, uncomplicated pilonidal sinus were included in the study. Exclusion criteria were patients with recurrent pilonidal sinus, those with significant comorbidities such as uncontrolled diabetes mellitus, immunocompromised states, or systemic infections, and patients unwilling or unable to participate in follow-up assessments. Surgical Interventions Patients were allocated to different surgical methods based on the operating surgeon’s discretion and preference. The techniques included conventional flap procedures, primary midline closure, and excision of the tract with healing by secondary intention. In all cases, procedures were performed under spinal or general anesthesia using standard aseptic precautions. Postoperative care and wound management were carried out according to institutional protocols. Outcome Measures The primary outcome assessed was cosmetic result, which was evaluated using scar assessment parameters and patient-reported satisfaction at follow-up. Secondary outcomes included flap rejection, occurrence of surgical site infection (SSI) as per CDC criteria, quality of postoperative scar (hypertrophic, keloid, or satisfactory linear scar), and recurrence within the follow-up period of one to three months. Follow-Up and Data Collection All patients were followed up regularly during the immediate postoperative period and subsequently at one month and three months. Data regarding wound healing, scar appearance, and recurrence were recorded in a structured proforma. Cosmetic assessment was performed objectively by the surgical team and subjectively by the patients to ensure comprehensive evaluation. Statistical Analysis Collected data were tabulated and analyzed using descriptive statistical methods. Frequencies and percentages were calculated for categorical variables, while comparisons between groups were made using the appropriate Chi-square test or Fisher’s exact test. A p-value of less than 0.05 was considered statistically significant.

This study included 30 patients with pilonidal sinus disease who underwent surgical management using different treatment modalities. Patients were divided into three groups based on the type of procedure: flap techniques (n = 10), primary midline closure (n = 10), and excision with healing by secondary intention (n = 10). Outcomes assessed included flap rejection, surgical site infection (SSI), postoperative scar quality, and recurrence during follow-up. Patient Demographics The mean age of the study population was 26.4 years (range 19–42 years). The majority of patients were male, reflecting the well-documented male predominance of pilonidal sinus disease. Distribution of age and sex across treatment groups was comparable (Table 1). Table 1. Demographic characteristics of patients in different surgical groups Variable Flap (n=10) Midline Closure (n=10) Secondary Intention (n=10) Total (N=30) Mean age (years) 27.1 25.9 26.3 26.4 Male: Female 8:2 9:1 8:2 25:5 Flap Rejection and Surgical Site Infection Flap rejection was observed only in the flap group, whereas no rejection occurred in patients undergoing midline closure or secondary intention healing. Surgical site infection was most frequent in the midline closure group, while secondary intention demonstrated the lowest infection rate (Table 2). Table 2. Distribution of flap rejection and surgical site infection across groups Outcome Flap (n=10) Midline Closure (n=10) Secondary Intention (n=10) p-value Flap rejection 2 (20%) 0 0 0.04 SSI 2 (20%) 3 (30%) 1 (10%) 0.21 Postoperative Scar Assessment Scar quality was assessed both objectively and subjectively. Hypertrophic scars were more common in the flap and midline closure groups, whereas patients undergoing secondary intention reported superior cosmetic outcomes with predominantly linear or inconspicuous scars (Table 3). Table 3. Postoperative scar characteristics in different groups Scar type Flap (n=10) Midline Closure (n=10) Secondary Intention (n=10) Hypertrophic 3 (30%) 4 (40%) 1 (10%) Keloid 1 (10%) 1 (10%) 0 Linear/satisfactory 6 (60%) 5 (50%) 9 (90%) Recurrence Rates Recurrence was observed in both flap and midline closure groups but not in patients treated with secondary intention healing, which showed zero recurrence within the follow-up period (Table 4). Table 4. Recurrence of pilonidal sinus across surgical groups Group Recurrence (n) Percentage Flap 2 20% Midline Closure 1 10% Secondary Intention 0 0% Overall Comparison of Outcomes When all outcomes were compared, excision with healing by secondary intention consistently demonstrated superior cosmetic acceptability, absence of recurrence, and lower complication rates compared with flap procedures and midline closure (Table 5). Table 5. Consolidated comparison of surgical outcomes Outcome Flap Midline Closure Secondary Intention Flap rejection Present Absent Absent SSI 20% 30% 10% Unsatisfactory scar (hypertrophic/keloid) 40% 50% 10% Recurrence 20% 10% 0%

Pilonidal sinus disease (PSD) continues to pose a surgical challenge due to its chronic nature, recurrence risk, and cosmetic implications. The ideal operative technique should minimize recurrence and infection while ensuring rapid recovery and acceptable cosmetic outcomes, especially since PSD mainly affects young adults.[10] In our study, excision with secondary intention healing emerged as the most favorable technique, with no recurrence, fewer wound complications, and superior scar cosmesis. These findings align with earlier meta-analyses showing high recurrence with midline closure[10] and improved outcomes with alternative techniques.[4] Flap procedures, although effective in reducing deep natal cleft and recurrence,[11] were associated with flap rejection in our series, a complication also described in previous studies.[12] Cosmetic outcome has increasingly been recognized as an important determinant of patient satisfaction. In our cohort, hypertrophic and keloid scars were more common with flap and midline closure, whereas secondary intention healing yielded linear or inconspicuous scars in 90% of patients.[13] Similar results have been reported in other cohorts, where secondary intention had fewer wound complications (23% vs. 51%) compared to primary closure and comparable recurrence rates.[14] This advantage may be attributed to the absence of suture-line tension and natural healing by granulation, which reduces scarring.[15] Importantly, surgical site infections were also lowest in the secondary intention group, supporting findings from comparative analyses that reported reduced wound problems with open healing.[16] In the Indian context, comparative studies such as Chopade et al. reported faster recovery with Limberg flaps but acceptable outcomes with wide excision and secondary intention healing.[9] Our results strengthen this evidence by highlighting cosmetic superiority of secondary intention, despite the trade-off of longer healing duration. Limitations of the present study include its small sample size and short follow-up, which restrict generalizability and long-term recurrence assessment. Nonetheless, the findings suggest that secondary intention healing is a safe, effective, and cosmetically advantageous for primary PSD, while flap techniques may still be reserved for complex or recurrent cases.

Excision of pilonidal sinus with healing by secondary intention demonstrated superior cosmetic outcomes, fewer wound complications, and no recurrence in this study compared with flap procedures and primary midline closure. While flap techniques remain useful for complex or recurrent cases, secondary intention healing appears to be a safe and cosmetically favorable option for managing primary pilonidal sinus disease.

1. Karydakis GE. Easy and successful treatment of pilonidal sinus after explanation of its causative process. Aust N Z J Surg. 1992 May;62(5):385–9. 2. Cai Z, Zhao Z, Ma Q, Shen C, Jiang Z, Liu C, et al. Midline and off‐midline wound closure methods after surgical treatment for pilonidal sinus. Cochrane Database Syst Rev [Internet]. 2022 May 31 [cited 2025 Sept 4];2022(5):CD015213. Available from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC9153062/ 3. Stauffer VK, Luedi MM, Kauf P, Schmid M, Diekmann M, Wieferich K, et al. Common surgical procedures in pilonidal sinus disease: A meta-analysis, merged data analysis, and comprehensive study on recurrence. Sci Rep. 2018 Feb 15;8(1):3058. 4. Doll D, Haas S, Faurschou IK, Hackmann T, Heitmann H, Braun-Münker M, et al. Pediatric pilonidal sinus disease: Recurrence rates of different age groups compared to adults. Surg Open Sci. 2025 Jan;23:50–6. 5. Huang Z, Li S, Kou Y, Huang L, Yu T, Hu A. Risk factors for the recurrence of diabetic foot ulcers among diabetic patients: a meta‐analysis. Int Wound J [Internet]. 2019 Sept 6 [cited 2025 Sept 4];16(6):1373–82. Available from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7949075/ 6. Chhabra S, Chhabra N, Kaur A, Gupta N. Wound Healing Concepts in Clinical Practice of OMFS. J Maxillofac Oral Surg [Internet]. 2017 Dec [cited 2025 Sept 4];16(4):403–23. Available from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5628060/ 7. Cai Z, Zhao Z, Ma Q, Shen C, Jiang Z, Liu C, et al. Midline and off‐midline wound closure methods after surgical treatment for pilonidal sinus. Cochrane Database Syst Rev [Internet]. 2024 Jan 16 [cited 2025 Sept 4];2024(1):CD015213. Available from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC10790338/ 8. Ekici U, Kanlıöz M, Ferhatoğlu MF, Kartal A. A comparative analysis of four different surgical methods for treatment of sacrococcygeal pilonidal sinus. Asian J Surg. 2019 Oct;42(10):907–13. 9. Chopade SP, Adhikari GR. Comparative Study of Limberg Flap Reconstruction With Wide-Open Excision and Healing by Secondary Intention in the Management of Pilonidal Sinus: Our Experience at a Tertiary Care Center in India. Cureus [Internet]. [cited 2025 Sept 4];14(6):e26396. Available from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC9337795/ 10. Onder A, Girgin S, Kapan M, Toker M, Arikanoglu Z, Palanci Y, et al. Pilonidal Sinus Disease: Risk Factors for Postoperative Complications and Recurrence. Int Surg [Internet]. 2012 [cited 2025 Sept 4];97(3):224–9. Available from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3723218/ 11. Petersen S, Koch R, Stelzner S, Wendlandt TP, Ludwig K. Primary closure techniques in chronic pilonidal sinus: a survey of the results of different surgical approaches. Dis Colon Rectum. 2002 Nov;45(11):1458–67. 12. Søndenaa K, Andersen E, Nesvik I, Søreide JA. Patient characteristics and symptoms in chronic pilonidal sinus disease. Int J Colorectal Dis. 1995;10(1):39–42. 13. Limandjaja GC, Niessen FB, Scheper RJ, Gibbs S. Hypertrophic scars and keloids: Overview of the evidence and practical guide for differentiating between these abnormal scars. Exp Dermatol [Internet]. 2021 Jan [cited 2025 Sept 4];30(1):146–61. Available from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7818137/ 14. Abraham MN, Raymond SL, Hawkins RB, Iqbal A, Larson SD, Mustafa MM, et al. Analysis of Outcomes in Adolescents and Young Adults With Pilonidal Disease. Front Surg [Internet]. 2021 Feb 25 [cited 2025 Sept 4];8:613605. Available from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7947800/ 15. Hull TL, Wu J. Pilonidal disease. Surg Clin North Am. 2002 Dec;82(6):1169–85. 16. Surgical site infections: prevention and treatment [Internet]. London: National Institute for Health and Care Excellence (NICE); 2020 [cited 2025 Sept 4]. (National Institute for Health and Care Excellence: Clinical Guidelines). Available from: http://www.ncbi.nlm.nih.gov/books/NBK542473/