Int Surg 2016;101:503–509

DOI: 10.9738/INTSURG-D-15-00198.1

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A Comparison of the Results of the Karydakis
Flap Procedure and Primary Closure in the
Treatment of Pilonidal Sinus Disease Over the
Short and Long Term: A Randomized Clinical
Study
Murat Kendirci, Tezcan Akin, Merve Akin, Hüseyin Berkem, Süleyman Hengirmen,
Bülent Cavit Yüksel

Department of Colon and Rectum/General Surgery, Ankara Numune Training and Research Hospital,
Ankara, Turkey

In the current prospective study, we compared the results of the Karydakis flap procedure
(KFP) and primary closure (PC). This study compared the short and long-term results of
the KFP and PC techniques. The sample of this study was a total of 352 patients (302
male: 85.7%; median age: 24 years) who underwent reconstruction after pilonidal sinus
excision in our clinic. The reconstruction was performed using the KFP (group 1, n ¼ 176,
50%) or PC (group 2, n ¼ 176, 50%). The following data on the patients was obtained; sex,
age, body mass index (BMI), duration of operation and hospital stay, length of time
patient could walk without pain, length of time patients could sit on toilet without pain,
complications (e.g., infection, recurrence). No significant difference was found between
groups 1 and 2 with respect to sex, age, BMI, and duration of operation. Moreover, length
of time patients could walk and sit on toilet without pain was similar in both groups. On
the other hand, the rate of recurrence was significantly lower in group 1 (n ¼ 4, 2%)
compared with group 2 (n ¼ 20, 11%, P , 0.001). KFP is preferable to PC since it is easier to
learn and perform and has lower complication and recurrence rates.

Key words: Pilonidal sinus – Primary closure – Karydakis operation

Corresponding author: Bülent C. Yüksel, MD, Ankara Numune Training and Research Hospital, General Surgery, Sıhhıye, 06680,
Ankara, Turkey.
Tel.: þ90 532 6342056; Fax: þ 90 312 418 27 60; E-mail: bulentcyuksel@yahoo.com.tr

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P ilonidal sinus disease (PSD) is a common

chronic disease of younger ages, which is often
associated with considerable discomfort and mor-
lopes that were opened in order when assignments
were made. An independent observer undertook
the randomization and allocation of patients to the
bidity. Although various surgical techniques are groups, and the surgeon was informed of the type
currently used for the treatment of PSD, no clear of surgery to be performed at the time of induction
consensus as to optimal treatment has so far been of anesthesia.
reported in the literature.1,2 Despite controversy
about the best surgical technique for the treatment Study population

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of PSD, an ideal operation should be simple, not
requiring a prolonged hospital stay, have a low Eligible participants were patients presenting with
recurrence rate, cause minimal pain, and have a PSD treated in the surgical unit of the department of
short course of wound care to reduce the time spent colon and rectum/general surgery from January
off work.2–5 Over the past few decades, surgeons 2001 to February 2008. Patients with acute inflam-
have increasingly come to appreciate the importance mation and/or abscess formation were treated with
not only of flattening the natal cleft but also of antibiotics and drainage, and then taken into
achieving an off-midline closure for the prevention surgery. Definitive surgery was performed no less
of midline recurrences in the management of than 3 weeks after evident sepsis had been
PSD.2,6–8 Oblique or asymmetric closure techniques eradicated. Both KFP and PC were thoroughly
such as the Karydakis flap procedure(KFP) are explained to all patients, together with the benefits
based on these principles.6,7 The use of excision and risks involved. Written informed consent was
and closure using transposition or advancement obtained from patients who agreed to receive either
flaps has received growing attention in recent years of the procedures and participate in the study.
due to the low recurrence rates that have been Patients who declined to undergo either procedure
reported using these techniques.4,8–10 were excluded from the study. The other exclusion
In the comparison of the results of PSD surgery, criteria were: being younger than 15 years of age
important parameters include complications during and having a collagen tissue disease. In addition,
the early period and recurrences during the late one patient who had bilaterally generalized sinus
period. To our knowledge, no study has been pore out of the navicular area was excluded.11
conducted to compare the long-term results of the
KFP and primary closure (PC) techniques. There- Surgical technique
fore, in the current prospective randomized con-
trolled study, we compared the short and long–term All patients received spinal or epidural anesthesia
results of the management of PSD using KFP and PC with the patient in the jackknife position and the
methods. buttocks strapped apart. The buttocks were shaved
immediately before surgery and the surgical area
Patients and Methods was disinfected with 10% povidone-iodine solution.
All patients were administered a single dose of
Study design cefazolin 1 g parenterally 30 minutes before the skin
This was a prospective randomized controlled trial incision.
using the parallel-group and balanced randomiza- KFP was performed with an initial asymmetric
tion methods [1:1]. The study was conducted in the elliptical incision. The ellipse was based on the side
department of colon and rectum of Ankara Nu- of any secondary opening; if the sinus was entirely
mune Training and Research Hospital, Ankara, central, either side was chosen. The ellipse included
Turkey. The local ethical approval was obtained, all the openings and was placed 2 cm lateral of the
and the study was conducted according to the midline. The area thus marked was then excised full
tenets of the Declaration of Helsinki (2006/1275). thickness up to the sacral fascia (Fig. 1a), with a
The patients were randomly assigned to 2 groups. straight edge on the side of flap mobilization and a
Patients who underwent KFP (n ¼ 176, 50%) were sloping edge on the other side (Fig. 1b). This was
included in group 1 and those who underwent PC followed by mobilization of the flap across the
(n ¼ 176, 50%) were included in group 2. Random- midline. The medial side of the wound was then
ization was performed using a pseudorandom undermined just superficial to the underlying
number generator with individual assignments gluteus muscle fascia to produce a flap for a
concealed in sequential numbered sealed enve- distance of at least extending the full length of the

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COMPARISON OF THE RESULTS OF THE KARYDAKIS FLAP PROCEDURE AND PRIMARY CLOSURE KENDIRCI

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Fig. 1 Flap mapping onto the skin (a),
the flap starts by excising all sinuses
down to the presacral fascia using an
asymmetric elliptical incision and
creating a new cutaneous-subcutaneous
flap; (b) postoperative appearance of the
Karydakis flap (c).

wound. This allowed the flap to reach the contra- After their discharge, patients were instructed to
lateral side without tension. A layer of interrupted pay meticulous attention to hygiene rules and not to
absorbable Vicryl 0/0 sutures (Ethicon Endo-Sur- sit or be in a semi-sitting position for 2 weeks.
gery, Cincinnati, Ohio) were used to suture the Walking was not restricted. In addition, the follow-
deepest tissue of the flap to the underlying fascia ing recommendations were made: to use talc
and the corresponding tissue on the fixed side. powder to prevent moisture, then after complete
Then, the subcutaneous tissue was sutured directly healing to use depilatory cream for 6 months to
to the lateral edge of the tissue. Finally, interrupted remove hairs from the operation site, to avoid
vertical polypropylene mattress 2/0 sutures (Ethi- prolonged sitting and not to ride a horse or bicycle
con Endo-Surgery) were used for skin closure (Fig. for 6 weeks after the operation. Sutures were
1c). removed on postoperative day 14, and the patients
Excision and PC was performed as described by were allowed to return to work by postoperative
Soligher.12 The sinus tract was totally excised up to day 21.
the presacral fascia via a symmetric elliptic incision
in the midline, and a layer of interrupted absorbable Data collection and outcome measures
Vicryl 0/0 sutures (Ethicon Endo-Surgery) were
used to suture the deepest tissue. Finally, skin Data on sex, age, and body mass index (BMI, kg/
closure was undertaken using interrupted vertical m2), as well as history of previous treatment (when
polypropylene mattress 2/0 sutures (Ethicon Endo- applicable), was obtained from all patients.
Surgery). Duration of operation was defined as the time
A closed suction drain was placed in the resultant from the start of skin incision to the end of the last
dead space and sufficiently extended laterally stitch. Duration of hospital stay was noted. Postop-
through a separate stab incision. The suction drain erative complications such as seroma, wound
was removed when the effluent was less than 20 mL dehiscence, and wound infection were noted. A
for 24 hours. postoperative wound assessment was undertaken

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KENDIRCI COMPARISON OF THE RESULTS OF THE KARYDAKIS FLAP PROCEDURE AND PRIMARY CLOSURE

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Fig. 2 CONSORT 2010 Flow Diagram

using the asepsis method, in which an overall value , 0.05 was considered significant. Values were
above 20 indicated that the wound was infected.13 expressed as median (range).
All patients were physically examined on post-
operative days 3 and 14 for wound inspection after Results
surgery. Patients were invited to the hospital for a
short follow-up 3 months after surgery. They were A flow diagram of patient disposition is shown in
asked about the length of time they could sit on Fig. 2. Of the 377 patients screened, 15 did not meet
toilet without pain and length of time they could the inclusion criteria, and 10 refused to participate
walk without pain. The responses were documented in the study. As a result, a total of 352 patients
including 302 men (85.7%) and 50 women (14.2%)
and analyzed. The long-term follow-up after 3
were randomly allocated to 2 treatment groups.
months was performed either by interviewing the
Patient age ranged from 13 to 59 years with a
patients every 3 months on the phone or in person at
median of 24 years.
the outpatient clinic to check for recurrences. Table 1 presents the patient characteristics of each
Patients were followed for 12 to 96 months (median: treatment group. No significant differences were
56.8 months). observed between the groups regarding age, sex
distribution, BMI, and history of recurrent disease.
Statistical analyses As shown in Table 2, the difference in operative
time and length of time patients could walk and sit
Power calculations were performed to test the
hypotheses related to the comparison between the Table 1 Patient demographics and operation features
treatment groups. The sample sizes of the KFP (n ¼
KFP PC
170) and PC groups (n ¼ 171) required a power of
(n ¼ 170) (n ¼ 171) P value
approximately .0.80 to compare the 2 groups.
Statistical analysis was carried out using statistical Sex, n (%)
Male 147 (86 ) 149 (87) 0.6
software (SPSS, version 18, IBM-SPSS, Chicago,
Female 23 (14) 22 (13)
Illinois). The Mann-Whitney U test and Student’s Age, y, median (range) 25 (15–56) 24 (13–59) 0.2
t-test were used to compare 2 groups in terms of the BMI, kg/m2, median (range) 24 (22–28) 24 (22–27) 0.1
continuous variables; and the v2 and Fisher’s exact Recurrent disease, n (%) 29 (17) 27 (15) 0.62
test were used for categorical variables. A value of P P values , 0.05 were considered statistically significant.

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COMPARISON OF THE RESULTS OF THE KARYDAKIS FLAP PROCEDURE AND PRIMARY CLOSURE KENDIRCI

Table 2 Analysis postoperative period for PSD in KFP versus PC groups in terms of subcutaneous fluid collection
KFP PC
(Table 2).
(n ¼ 170) (n ¼ 171) P value There was no statistically significant difference
between the groups in the length of time patients
Duration of operation, could walk and sit on the toilet without pain.
min, median (range) 31 (25–35) 26 (22–31) 0.32
Time to walk without pain,
However, a statistically significant difference was
d, median (range) 7 (5–9) 7 (5–10) 0.87 observed in terms of number of complications (P ,
Time to sitting on toilet 0.05). The clinical outcomes of both group treatment

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without pain, d, median modalities are given in Table 2.
(range) 6 (5–9) 7 (5–9) 0.86
Number of complications,
The median duration of the long-term follow-up
n (%) 17 (10) 27 (15) ,0.05 in both study groups was 56.8 months (range, 12–
Seroma, n 5 5 0.90 96). A striking difference was observed between the
Wound dehiscence, n 2 treatment groups in terms of recurrence. PSD
Full–thickness 0 8 0.003
recurred only in 4 patients (2%) in the KFP group,
Cuticular 5 3 0.33
Need to resuture 0 8 0.003 whereas recurrence was seen in 20 patients (11%) in
Wound infection, n 5 10 0.07 the PC group (P , 0.001; Table 2). When the patients
Long-term analyses with recurrence were evaluated, it was seen that sex;
Recurrences, n (%) 4 (2) 20 (11) ,0.001 BMI; ASEPSIS (additional treatment, serous dis-
P values , 0.05 were considered statistically significant. charge, erythema, purulent exudate, separation of
deep tissues, isolation of bacteria, stay duration as
on the toilet without pain was not statistically inpatient) score; drainage; and follow-up duration
significant between the KFP and PC groups. did not affect the recurrence, and only the type of
However, a statistically significant difference was operation had a statistically significant effect on
observed between the 2 groups in terms of recurrence.
postoperative complication (P , 0.05) and recur-
rence (P , 0.001). Discussion
No patients in the KFP group had a full-thickness
wound dehiscence, but this complication occurred In the present randomized controlled study, KFP
in 8 patients in the PC group (P , 0.05; Table 2). The and PC were compared in the surgical management
full-thickness wound disruption resulted in loss of of PSD, and a significant difference was found
alignment between the edges of the wound, which between the 2 groups in terms of the short-term
occurred following postoperative days 6 and 9. In results regarding full-thickness wound dehiscence
these 8 patients, resuturing was performed under and long-term results regarding recurrence.
The main problem encountered in the treatment
local anesthesia. However, resuturing was not
of PSD is that currently no procedure can fully
successful in any of the patients, and the full
prevent recurrence. Factors that increase the fre-
thickness wound dehiscence occurred again within
quency of the recurrence of the disease include:
1 week. In these patients, healing by secondary
inadequate excision, presence of dead space, deep
intention took a median of 6 weeks (range, 7–9). The
natal cleft, having a large amount of body hair and
groups did not significantly differ in terms of the
bad hygiene, early wound infections, wound sepa-
occurrence of cuticular disruption in the wound. ration, increased wound pressure, and obesity.14
This condition was managed with daily dressing Various flap procedures—such as Limberg flap, Z-
and eventually healed completely. plasty, W-plasty, D-flap, rotation flap, muscular
Patients in the KFP group also did not differ gluteus maximus flap, adipofascial migrating flap,
significantly from those in the PC group with regard V-Y flap, and KFP—have been described to reach
to wound infections, which were treated with these aims. However, since these procedures cause
antibiotics along with daily dressing and did not several problems, they have been modified.4,10 The
lead to wound breakdown in any of the patients in flap procedures have less recurrence rates compared
this study. In the KFP group, the drain remainder for with secondary healing, marsupialization, incision-
a median of 2.1 days (range, 1–4) compared with a curettage, and PC,10,14 which are more complex and
median of 2.7 days (range, 1–7) in the PC group. No take longer time, often resulting in local complica-
significant difference was found between the 2 tions such as wound infection, separation, and

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KENDIRCI COMPARISON OF THE RESULTS OF THE KARYDAKIS FLAP PROCEDURE AND PRIMARY CLOSURE

ischemia as well as other less desirable esthetic One of the important points in the management
outcomes.2,4,15 of PSD is the time to return to normal daily activity.
PSD is a disease frequently affecting those of a Ertan et al20 compared the Limberg flap procedure
younger age with a high rate of morbidity, which with PC with respect to sitting on a toilet without
results in extended absence from work. It is a pain, and concluded that flap procedures are more
chronic inflammatory process of the skin caused by beneficial.20 In our study, patients were asked how
hair, keratin plugs, and debris.16 It is known that the long they could sit on a toilet and walk without
PSD incidence varies across countries and races. The pain. No statistically significant difference was

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incidence is also affected by factors such as driving, found between the 2 groups who reported that they
personal hygiene, and obesity.17 There are two were able to walk without pain in approximately 7
conflicting theories of PSD pathogenesis: congenital days. Time to sit on a toilet without pain was 6 days
and acquired. It is very important to understand the in the KFP group and 7 days in the PC group,
difference between these two since each requires indicating no statistical difference.
different principles of treatment.18 Recently, the The most important parameter in the manage-
acquired theory has been widely accepted. Available ment of PSD is the recurrence rate of procedures. Da
evidence strongly supports the view that the classic Silva15 reported that reconstructive procedures have
PSD seen in adults is an acquired condition as a lower recurrence rates. Mahdy21 surgically treated
result of a hair insertion process.6,18 60 patients with PSD between 2003 and 2006, and
Karydakis6 reported that hair insertion at the found no difference in the recurrence rates between
depth of the natal cleft, the raphe, is the real cause of flap procedures, and the overall results were better
PSD. The author described 3 main factors that than those obtained from PC. McCallum et al22
contribute to the hair insertion process: (1) the conducted a meta-analysis in 2008 and reported that
invader (the loose hair as H factor); (2) the force, closures made off the midline have lower recurrence
which causes hair to insert (the depth and narrow- rates compared with midline closure. To overcome
ness of the natal cleft together with friction this problem, Berkem et al10 modified the V-Y plasty
movements between its sides as F factor); and (3) technique described. The authors laterally located
the vulnerability of the raphe as V factor. 18 the incision and detected no recurrence.10 Karyda-
Karydakis6 suggested that these factors should be kis18 reported the largest series about the procedure
decreased or neutralized to vulnerability of the in 1992, in which he treated 7451 patients and
raphe with replacement to healthy skin, and the reported only 55 recurrences, which was less than
midline wound scar should not be at the depth of 1%.18 The latest study on KFP was by Ates et al,23
the natal cleft. who reported that KFP should be preferred to other
The rate of wound dehiscence reported in earlier flap techniques due to the lower postoperative
studies comparing KFP and PC ranges from 0% to complication rates and recurrences.
12%.19 In the present study, no patients in the KFP In our study, the median follow-up duration was
group and 8 patients in the PC group had a full- 56.8 months (range, 12–96), during which recurrence
thickness wound dehiscence. was seen in 24 patients, all within the first
The different findings regarding full-thickness postoperative year. One of the causes of early
wound dehiscence can be explained by the mor- recurrence can be penetration of hair into the
phologic differences between the two procedures. midline wound. To prevent this possibility, the
PC is not a tension-free operation in which part of midline can be deviated and the natal cleft can be
the cutaneous and subcutaneous tissues are at- flattened. Kitchen24 pointed out the problems
tached to the underlying strong fascial. Walking experienced with midline wounds. The authors
may induce either traction on the sutured edges or suggested that the location of the wound at midline
strong friction between the edges and recipient side and the depth of natal cleft are the most important
edges of the wound, which may lead to dehiscence causes of early migrations of the wound away from
in some patients. In contrast, KFP involves only the midline. Therefore, KFP, in which the natal cleft
removing skin and subcutaneous tissue from the can be flattened at least 2 cm away from the midline
underlying gluteal muscle and fascia and laterally and heal without tension, has lower complication
advancing it for a distance of at least 2 cm from the and recurrence rates. This way, flap complications
suture line. In such design, the forces on the suture such as ischemia and necrosis can be minimized.
line produced by walking may not be strong enough The only factor influencing recurrence was the
to disrupt the wound. type of operation. Age, sex, BMI, drainage, infection,

508 Int Surg 2016;101

COMPARISON OF THE RESULTS OF THE KARYDAKIS FLAP PROCEDURE AND PRIMARY CLOSURE KENDIRCI

and follow-up period were found to have no 12. Soligher JC. Surgery of Anus, Rectum and Colon. 5th ed. London:
significant impact on recurrence. Wound infection Bailliere Tindal; 1984:256–276
was observed more in the PC group than in the KFP 13. Akin T, Akin M, Topaloglu S Berkem H, Yüksel B, Hengirmen
group, but this effect was not significant. S et al. External validation of SENİC and NNIS scores for
In conclusion, this study has shown that KFP has predicting wound infection in colorectal surgery. Surgical
several advantages and is superior to the PC method Science 2011;2(2):73–76
in the treatment of PSD. The closure of the excised 14. Singh R, Pavithran NM. Adipo-fascio-cutaneous flaps in the
area with a tension-free, off-midline, and well- treatment of pilonidal sinus. Experience with 50 cases. Asian J

Downloaded from http://meridian.allenpress.com/international-surgery/article-pdf/101/11-12/503/2200836/intsurg-d-15-00198_1.pdf by Egypt user on 31 March 2024

vascularized flap produces better results and reduc- Surg 2005;28(3):198–201
es complication and recurrence rates. 15. Da Silva JH. Pilonidal cyst: cause and treatment. Dis Colon
Rectum 2000;43(8):1146–1156
16. Søndenaa K, Pollard ML. Histology of chronic pilonidal sinus.
References
APMIS 1995;103(4):267–272
17. Fitzpatrick EB, Chesley PM, Oguntoye MO, Maykel JA,
1. Hull TL, Wu J. Pilonidal disease. Surg Clin North Am 2002;
Johnson EK, Steele SR. Pilonidal disease in a military
82(6):1169–1185
population: how far have we really come? Am J Surg 2014;
2. AL-Khamis A, McCallum I, King PM, Bruce J. Healing by
207(6):907–914
primary versus secondary intention after surgical treatment
18. Karydakis GE. Easy and successful treatment of pilonidal
for pilonidal sinus. Cochrane Database Syst Rev 2010:CD006213
sinus after explanation of its causative process. Aust N Z J Surg
3. Akinci OF, Coskun A, Uzunköy A. Simple and effective
1992;62(5):385–389
surgical treatment of pilonidal sinus. Dis Colon Rectum 2000;
19. Can MF, Sevinc MM, Yilmaz M. Comparison of Karydakis flap
43(5):701–706
reconstruction versus primary midline closure in sacrococcy-
4. Yüksel BC, Berkem H, Özel H, Hengirmen S. A new surgical
geal pilonidal disease: results of 200 military service members.
method of pilonidal sinus treatment: a bilaterally parallel
Surg Today 2009;39(7):580–586
elliptic fascio-cutaneous advancement flap technique. Bratisl
20. Ertan T, Koc M, Gocmen E, Aslar AK, Keskek M, Kılıc M. Does
Lek Listy 2012;113(12):728–731
technique alter quality of life after pilonidal sinus surgery? Am
5. Eryilmaz R, Sahin M, Alimoglu O, Dasiran F. Surgical
J Surg 2005;190(3):388–392
treatment of sacrococcygeal pilonidal sinus with the Limberg
21. Mahdy T. Surgical treatment of the pilonidal disease: primary
transposition flap. Surgery 2003;134(5):745–749
closure or flap reconstruction after excision. Dis Colon Rect
6. Karydakis GE. New approach to the problem of pilonidal 2008;51(12):1816–1822
sinus. Lancet 1973;2(7843):1414–1415 22. McCallum IJ, King PM, Bruce J. Healing by primary closure
7. Öz B, Akcan A, Emek E, Akyüz M, Sözüer E, Akyldiz H, versus open healing after surgery for pilonidal sinus:
Aydin H. A comparison of surgical outcome of fasciocuta- systematic review and meta-analysis. BMJ 2008;336(7649):
neous V-Y advancement flap and Limberg transposition flap 868–871
for recurrent sacrococcygeal pilonidal sinus disease. Asian J 23. Ates M, Dirican A, Sarac M, Aslan A, Colak C. Short and long-
Surg 2015;(15):00121–00129 term results of the Karydakis flap versus the Limberg flap for
8. Unalp HR, Derici H, Kamer E, Nazlı O, Onal MA. Lower treating pilonidal sinus disease: a prospective randomized
recurrence rate for Limberg vs. V-Y flap for pilonidal sinus. Dis study. Am J Surg 2011;202(5):568–573
Colon Rectum 2007;50(9):1436–1444 24. Kitchen PR. Pilonidal sinus: experience with the Karydakis
9. Mentes O, Bagci M, Bilgin T, Özgül O, Özdemir M. Limberg flap. Br J Surg 1996;83(10):1452–1455
flap procedure for pilonidal sinus disease: results of 353
patients. Langenbecks Arch Surg 2008;393(2):185–189 Ó 2017 Kendirci et al.; licensee The International College of
10. Berkem H, Topaloglu S, Ozel H, Avsar FM, Yıldız Y, Yüksel BC Surgeons. This is an Open Access article distributed under the
et al. V-Y advancement flap closures for complicated pilonidal terms of the Creative Commons Attribution Non-commercial
sinus disease. Int J Colorectal Dis 2005;20(4):343–348 License which permits use, distribution, and reproduction in any
11. Tezel E. A new classification according to navicular area medium, provided the original work is properly cited, the use is
concept for sacrococcygeal. pilonidal disease. Colorectal Dis non-commercial and is otherwise in compliance with the license.
2007;9(6):575–576 See: http://creativecommons.org/licenses/by-nc/3.0

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