The application of the Limberg flap repair technique in the surgical treatment of pilonidal sinus disease

Abstract

Pilonidal sinus disease (PNSD) challenged surgeons for decades. Limberg flap repair (LFR) is a common treatment for PNSD. The purpose of this study was to observe the effect and risk factors of LFR in PNSD. A retrospective study was conducted on the PNSD patients who visited two medical centers and four departments in the People's Liberation Army General Hospital and were taking LFR treatment between 2016 and 2022. The risk factors, the effect of the operation, and complications were observed. The effects of known risk factors on the surgical results were compared. There were 37 PNSD patients: male/female ratio of 35:2, average age: 25.1 ± 7.9 years. Average BMI: 25.2 ± 4.0 kg/m², average wound healing time: 15.4 ± 3.4 days. 30 patients (81.0%) healed in stage one and 7 (16.3%) had postoperative complications. Only 1 patient (2.7%) had a recurrence while others were healed after dressing‐changing. There was no significant difference in age, BMI, preoperative debridement history, preoperative sinus classification, Wound area, Negative pressure drainage tube, prone time (<3d) and treatment effect. Squat defecate and premature defecation were associated with treatment effect, and they were independent predictors of treatment effect in the multivariate analysis. LFR has a stable therapeutic outcome. Compared with other skin flaps, the therapeutic effect of this flap is not significantly different, but the design is simple and is not affected by the known risk factors before operation. However, it is necessary to avoid the influence of two independent risk factors, squatting defecation and premature defecation, on the therapeutic effect.

1. INTRODUCTION

PNSD is a common infectious disease in the sacrococcygeal region, characterised by hirsutism and hair hiding in local sinuses. The aetiology and pathogenesis are still unclear, and there are two theories at present: congenital disease and acquired disease. ¹ Because the disease has the typical feature of “plump hair and fat buttocks”, it is more common in Westerners, while the East Asian yellow people have fewer physical characteristics, so many patients and doctors delay treatment because they know little about the disease. PNSD is mainly formed in the cracks between the buttocks. The main clinical manifestations are cysts or abscesses in the buttock groove. Superficial skin is often ruptured, and serous, purulent, and pyogenic exudations can be seen, and some hair and hair follicles are visible. One or more sinuses can be seen by probing toward the head end. In the acute phase of the disease, if not treated in time or not thoroughly, it will enter the chronic course of the disease, with repeated skin ulceration and sinus tract expansion. Multiple sinus tracts, enlarged lesion areas, and complex infections have made the treatment of pilonidal sinus more difficult. ² , ³

The incidence rate of the disease is 0.026%. It usually occurs after puberty. Young people are the main affected population, while middle‐aged and elderly people rarely get sick. The main pathogenic factors are thick hair, obesity, and occupational and traumatic factors. More than half of the people included in this study are soldiers, drivers, and pilots. ⁴ Because of the above characteristics of PNSD patients, different treatment options are essential reasons for various postoperative complications and recurrence. Therefore, the key to ensuring the therapeutic effect is to thoroughly remove the lesion and select the appropriate reconstruction method. However, it is interesting that there is no gold standard for the treatment of PNSD, which needs to be further agreed upon. At present, medical personnel generally believe that the key postoperative management measures to prevent recurrence are to control the growth of body hair, keep hips clean, avoid sitting for a long time and reduce vigorous and high‐intensity physical activity.

In terms of choice of treatment methods, after extensive debridement, the wound was filled with dressing, and after long‐term dressing change and limited resection, the wound was primary closure (PC). Because they need longer treatment time but cannot completely remove the infected tissues, which leads to a higher PNSD recurrence rate and more severe pain for patients, most doctors do not recommend these two methods. Karyadakis flap repair (KFR), LFR, V‐Y flap repair (V‐YFR), Bascom operation, and Z‐plastic are the most commonly used reconstruction methods after lesion resection. ⁵ , ⁶ , ⁷ They have different advantages and disadvantages, resulting in different operation times, hospital stays, complications, and recurrence. Limberg first designed an equilateral rhomboid transfer flap in 1946, which was used for the reconstruction of head and face injuries in the early stage. After that, plastic surgeons made various improvements to LFR. ⁸ LFR used in PNSD treatment can effectively reconstruct large tissue defects, ensure complete resection of lesions, and avoid recurrence caused by residual sinus. The operation method is simple, the length of the flap is equal to the edge of the wound, the suture tension is small, and tension blisters are avoided. The skin flap can completely cover the buttock groove. The middle line of the buttock can form a tension‐free scarless skin flap for healing, which can avoid cracking or infection of the buttock groove due to sweat stains and abrasion, and reduce the recurrence rate. This study is to observe the effectiveness of LFR in the treatment of PNSD, and record the general situation, wound characteristics, treatment time, complications, and long‐term recurrence rate of patients after surgery.

2. MATERIALS AND METHODS

2.1. Inclusion and exclusion criteria

From January 2016 to August 2022, we reviewed and summarised the patients who were hospitalised in the Burn Department and General Surgery Department of the Fourth Medical Center and the Sixth Medical Center of the People's Liberation Army General Hospital and agreed to receive LFR treatment due to PNSD. Patients are selected based on inclusion and exclusion criteria as follows.

Inclusion criteria: All primary PNSD. Gender and age are not limited. The general condition can tolerate surgical treatment. Informed consent on LFR operation.

Exclusion criteria: Patients with diabetes, immune disease, heart disease, and other basic diseases. The wound was in the acute infection stage. Medical history of malignant tumour and mental disease. Patients who refused to accept LFR surgery.

Diagnosis and analysis of the disease: The pilonidal sinus can be diagnosed by colour ultrasound or symptoms. The diagnosis of pilonidal sinus mainly depends on symptoms, signs, and auxiliary examinations. PNSD is most common in young men, followed by hairy patients. The sacrococcygeal region usually has symptoms such as redness, pain and abscess can be touched. After rupture, pus‐like fluid will flow out and recur. Sometimes hard fistula can be felt locally and prominent small external openings can be seen. An auxiliary examination can usually be diagnosed by colour Doppler ultrasound. If the situation is complex, MRI can also be used for auxiliary diagnosis.

The patient's detailed information was collected and included in the list. The basic information and treatment information of patients were analysed and compared with relevant literature.

2.2. Treatment method

Outpatient examination: the patients were initially diagnosed with pilonidal sinus of the sacrococcygeal region by physical examination, anal digital examination, and sacrococcygeal ultrasound, and the possibility of perianal abscess disease was ruled out; Hip MRI was performed to determine the extent and depth of the lesion; The wound bacteria were cultured.

Treatment after admission: (1) Preoperative preparation: Blood routine, C‐reactive protein (CRP), and erythrocyte sedimentation rate examinations were performed, body temperature was measured, and acute infection was ruled out. For patients with acute infection, it is recommended to cut the abscess to drain pus and use antibiotics for symptomatic treatment. After the systemic infection subsides, the surgery should be performed at a selected time. Patients without acute infection can use antibiotics prophylactically one day before the operation. After the results of the bacterial culture are reported, the antibiotic will be changed according to the results of drug sensitivity. On the day before the operation, the patient was prepared for intestinal tract (enema treatment). All hair on the patient's buttocks and the sacrococcygeal region was removed before surgery. (2) Surgical treatment: After epidural anaesthesia, lay the patient prone on the operating table and expose the buttocks to prepare the operation area. Use a needle‐free syringe to inject the diluted methylene blue solution into the sinus tract from the skin rupture, so that all the sinus tracts were dyed blue. The surgical area was designed according to the scope of the lesions displayed on the MRI. (The resection scope is rhombic, with a 60 ° acute angle at the upper and lower ends and a 120 ° obtuse angle at the left and right sides). After all preparations were completed, cut the skin and subcutaneous tissue along the pre‐designed plan. The lesions removed included cysts, sinuses, and all areas that were blue‐stained. This area should be larger than the lesion as much as possible, and the cut specimen should be subject to pathological examination. The lesions removed included cysts, sinuses, and all areas that were blue stained. This area should be larger than the lesion as much as possible, and the cut specimen should be subject to pathological examination. Make an extension line along one side of the vertices on both sides and a parallel line along the lower bottom of one side to form a rhomboid flap. (This kind of flap is simple in design, with good blood supply and low tension in front of the skin when suturing.) The focus is that the wound and the donor area must be carefully stopped bleeding. After confirming that there was no bleeding, the surgical area should be repeatedly flushed with iodophor and normal saline. The negative pressure drainage tube was placed in the operation area, and the subcutaneous tissue and skin were sutured layer by layer (Pressure should be applied during wound covering and dressing.) (Figure 1A,B). (3) Postoperative care: Within 3 days after the operation, the patient lay prone in the hospital bed, reduced the number of defecations, and retained a catheter. The dressing was changed on the third, sixth and ninth days after the operation. When the drainage fluid in the drainage bottle was less than 5 mL, the drainage tube was removed, and the suture was removed 2 weeks after the operation. After discharge, all patients should avoid squatting and strenuous activities within one month. We followed up patients by phone or WeChat for 3 to 12 months. Postoperative hematoma, flap necrosis, dehiscence, infection and recurrence were recorded (Figure 1C).

FIGURE 1.

Diagram illustration of the (A) Rhomboid excision, and (B) Limberg flap and construction after rhomboid excision. Arrow direction points to the direction of flap transfer. (C) The third day after the operation. It can be seen that the wound has recovered well, there is no obvious fluid exudation at the skin margin, and there is no tension blister and necrosis of the skin flap.

2.3. Statistical analysis

SPSS 23.0 statistical software was used to process the data. Pearson χ² test and Fisher exact test were used to compare categorical variables, frequency, and percentage data between groups. Mann–Whitney U test and t‐test were used to compare continuous variables. Variables with P‐values<0.05 were analysed using multivariate logistic regression analyses.

3. RESULTS

3.1. General information of patients before the operation

Among the 37 cases, 35 cases were male (94.59%) and 2 cases were female (5.41%). The male‐to‐female ratio was 35:2. The average age was 25.06 ± 7.90 years old. The average BMI of the patients was 25.23 ± 4.01 kg/m² (20.0 ~ 36.1 kg/m2), 11 were overweight and 7 were obese. Before admission, the wound ulceration lasts for at least 5 days and at most 9 years. The admission examination can be divided into five categories according to the wound surface and exudation: (1) 8 patients (21.6%) had no obvious exudation from a single sinus tract; (2) 6 patients (16.2%) had multiple sinus tracts but no obvious exudation; (3) 17 patients (45.9%) had serous exudate in sinus tract; (4) There were 5 patients (13.5%) with purulent exudates in the sinus tract; (5) Only 1 case (2.7%) had hair cyst. Seven patients (19%) were younger than 20 years old, 21 patients (57%) were 20 to 29 years old, 7 patients (19%) were 30 to 39 years old, and 2 patients (5%) were older than 40 years old (Table 1).

TABLE 1.

Preoperative characteristics of the patients studied.

Variable	Frequency	Percent (%)
Age, years (mean ± SD)	25.1 ± 7.9	‐
Sex (male/female)	35/2	94.59/5.41
BMI, kg/m2 (mean ± SD)	25.2 ± 4.0	‐
Preoperative duration of SPND	5d ~ 9y	‐
Clinical presentation
Single sinus and dry	8	21.6
Multiple sinuses and dry	6	16.2
Single sinus + serous discharge	17	45.9
Single sinus + pus discharge	5	13.5
Pilonidal abscess	1	2.7
Age range
<20	7	18.9
20 ~ 29	21	56.8
30 ~ 39	7	18.9
>40	2	5.4

3.2. Postoperative treatment effect on patients

The average hospitalisation time of all patients was 23.2 ± 14.7 days. The average wound healing time was 15.35 ± 3.35 days. There were no complications in 30 patients (81%) after the operation. There were 2 cases of serious mass formation in the operation area (5.4%), 1 case of hematoma formation (2.7%), 2 cases of superficial wound infection in the operation area (5.4%), 1 case of proximal local skin necrosis and partial incision cracking (2.7%), and 1 case (2.7%) recurred in half a year (Table 2). The combined analysis of postoperative complications and preoperative wound conditions showed that the patients with preoperative wounds accompanied by purulent secretion had hematoma, seroma, infection, and surgical site cracking respectively; Preoperative recurrence occurred in patients with multiple sinus tracts. In addition, one patient with serous exudation on the wound before the operation had seroma complications after the operation, and the patient with a hair cyst had a postoperative infection in the operation area (Table 3). All patients with postoperative complications recovered by dressing change.

TABLE 2.

Postoperative condition of patients.

Variable	Frequency	Percent (%)
Time to healing, days (mean ± SD)	15.4 ± 3.4	‐
Hospital stay, days (mean ± SD)	23.2 ± 14.7	‐
Complications
Nil	30	81.0
Seroma	2	5.4
Hematoma	1	2.7
Wound infection	2	5.4
Dehiscence	1	2.7
Recurrence	1	2.7

TABLE 3.

Complications in various patients according to preoperative status of pilonidal sinus.

Complications	Sinus					Total
	Single and dry	Multiple and dry	Single + Serous discharge	Single sinus + Pus discharge	Sinus + Abscess
Nil	8	5	16	1	0	30 (81%)
Seroma	0	0	1	1	0	2 (5.4%)
Haematoma	0	0	0	1	0	1 (2.7%)
Wound infection	0	0	0	1	1	2 (5.4%)
Dehiscence	0	0	0	1	0	1 (2.7%)
Recurrence	0	1	0	0	0	1 (2.7%)
Total	8	6	17	5	1	37

3.3. Analysis of risk factors related to surgical healing

None of the variables were different between the age (P = 0.246), BMI (P = 0.125), preoperative debridement + PNWT (P = 1.0), sinuses (P = 0.977), wound area (P = 0.540), negative pressure drainage tube (P = 0.658), prone time (<3d) (P = 0.608) and postoperative complications. There was no correlation between the known risk factors of PNSD and LFR efficacy in our study (Table 4). There was a significant difference in squat defecate (P = 0.037), premature defecation (P = 0.027), and treatment effect (P < 0.05) (Table 4). Further multi‐factor Logistic regression analysis showed that squat defecate (P = 0.049) and premature defecation (P = 0.038) were independent predictors of complications after LFR (Table 5).

TABLE 4.

Correlation between complications and risk factors

Observations	No complications (n = 30)	Complication (n = 7)	χ2/t	P
Age (years)	25.7 ± 8.5	21.9 ± 1.5	0.001	0.246
BMI (kg/m2)
Normal (BMI < 24)	13	1	3.078	0.125
Overweight (BMI > 24)	12	3
Obesity (BMI > 28)	5	3
Preoperative debridement + PNWT	13	3	0.001	1
Wound area (cm2)	14.8 ± 8.6	12.7 ± 6.3	0.619	0.540
Sinus
Single and dry	6	2	0.468	0.977
Multiple and dry	5	1
Single + serous discharge	14	3
Single sinus + Pus discharge	4	1
Sinus + Abscess	1	0
Squat defecate	2	3	6.360	0.037
Defecation time (<48 h)	4	4	6.428	0.027
Negative pressure drainage tube	17	4	0.001	0.658
Prone time (<3d)	13	4	0.436	0.608

TABLE 5.

Single factor binary logistic correlation analysis.

Risk factors	P	OR	95%CI
Squats defecate	0.049	10.364	1.006 ~ 106.812
Defecation time (<48 h)	0.038	8.574	1.125 ~ 65.356

4. DISCUSSION

PNSD occurs mostly in males after puberty and is more common in Arabs/Europeans and Americans. It is not common in East and Southeast Asia, especially in females. It is also called the “Jeep cyst” because it was often found among American soldiers who used to ride jeeps during World War II. ⁸ , ²⁴ Because this disease is not common among yellow people, treatment is often delayed due to misdiagnosis. ²⁵ The author found that the ratio of men to women was 35:2. In the past five years, only 37 cases were admitted by four departments of two medical centers, and nearly half of the patients were soldiers. The longest course of the disease can reach 9 years, and most patients mistakenly believe that perianal abscess or buttock sebaceous gland cyst come to our hospital for treatment. What needs to be explained is that the hospital where the author works is one of the largest comprehensive hospitals in China, with multiple treatment centers. PNSD is very similar to a perianal abscess, but the sinus of the pilonidal sinus in the sacrococcygeal region mostly spreads to the head end, not to the anus. Therefore, we need to differentiate it from perianal abscesses before choosing a treatment method. PNSD is mainly treated by surgery, and the choice of the best surgical method is still controversial. However, no matter what treatment method is selected, early treatment and complete removal of cysts and sinuses are key to the success and recurrence of the operation. ²⁶

The regular treatment includes ¹ , ²⁶ : (1) Incision and drainage of lesions cannot completely clear the lesions, with a high recurrence rate and long healing time. (2) After the focus is removed, the wound is opened and tamped for a long‐term dressing change. This method takes a long time to heal the wound, causing great pain to the patient, and the scar hyperplasia is obvious after healing. (3) After the enlarged resection of the lesion, the skin flap was transferred to seal the wound. This kind of method was widely used. The choice of surgical methods was broad (LFR, KFR, V‐YFR), but there was a risk of complications such as hematoma, seroma, and flap failure. (4) The advantages and disadvantages of other new methods, such as PRP treatment after lesion resection and microparticle skin grafting, need to be further confirmed by a large number of clinical cases.

All along, PNSD has had a high recurrence rate. Early recurrence is mainly caused by wound infection or cracking. In late recurrence cases, incomplete resection and residual hair on the buttocks are the main causes of secondary infection. ²⁷ In all the surgical methods, the complications and recurrence rate of flap transfer are low. In all skin flap operations, the skin tension in the operation area of LFR is small, the wound is smooth, it is not easy to produce residual or new sinus, and the scar hyperplasia is the least obvious. ⁹ Chopadet al. ²⁸ compared LFR reconstruction with secondary repair after debridement and found that the pain time, wound healing time, and complications in the secondary repair group were significantly higher than those in the LFR reconstruction group. In early clinical research, we found that LFR has obvious advantages over PC in terms of operation time, hospital stay, and recurrence. ¹¹ Hussain et al. ²¹ performed surgical resection and primary sutures on 59 male PNSD patients. The proportion of hematoma and seroma after surgery accounted for 1.69% and 3.39% respectively. The wound infection rate was 6.78% and the recurrence rate was 3.39%. In our study, the proportion of hematoma and seroma was 2.7% and 5.4%, the infection rate was 5.4%, and the recurrence rate was 2.7%. The high proportion of hematoma and seroma in our cases may be related to the larger debridement area. In our case, the area of wound resection was 5 × 4 cm ~ 14 × 7 cm, plus the skin donor area of the same size, so the hemostatic area was large. Therefore, compared with direct sutures, hematoma and seroma are more likely to occur. To avoid affecting blood supply and avoiding skin edge necrosis, all surgical patients do not use hemostatic drugs and get out of bed early. Hematoma that occurred in one patient after surgery may be caused by premature “squatting defecation”. Two patients with seroma after surgery are obese patients. We consider the reason is that obese patients have thicker subcutaneous fat, which is more prone to fat liquefaction after infection and surgical stimulation. The patient with hematoma removed the distal suture, recovered after 1 week of VSD negative pressure suction and compression, and the patient with seroma was relieved after compression and bandaging. Arnous et al. ¹⁶ also confirmed in a comparative study between PC and LFR that LFR is an effective method for the treatment of pilonidal sinus. The recurrence rate is extremely low, and the complication rate and hospital stay are similar to those of PC. Kanlioz et al. ²⁹ followed up on 476 patients admitted to the hospital for PNSD and receiving PC and LFR for at least 2 years. They found that 23 patients (7.87%) in the LFR group had relapsed, including 5 women and 18 men; In the PC group, 39 patients (21.19%) recurred, including 15 women and 24 men. LFR is superior to PC, and the female recurrence rate is higher. However, in this study, we also found the defects of LFR in the process of postoperative rehabilitation. It is inconvenient to change dressing due to the pressure bandage on the wound. Premature defecation leads to contamination of wound dressing, and failure to change wound dressing was an important cause of wound infection.

We summarised and compared the literature on PNSD treatment in recent 7 years (Table 6). In addition to LFR repair, many scholars applied different skin flap repair methods to repair the pilonidal sinus and confirmed the advantages of skin flap surgery in the treatment of pilonidal sinus. Afridi et al. ¹⁷ found in the reference of Bascom operation in PNSD treatment that the average hospital stay of this type of operation was about 3.32 ± 1.61 days, the average wound healing time was 12 ± 2.16 days, the postoperative infection rate was 4 cases (7.9%), seroma 3 cases (5.7%), hematoma 2 cases (3.8%), and only 2 cases (3.8%) recurred after discharge. Although it has a good effect on PNSD treatment, it is slightly lower than in this study in terms of complications and recurrence. Gündoğdu et al. ¹³ reported that 186 patients with pilonidal sinus were treated with oval fascia rotary flap, with satisfactory results, few complications, and no recurrence. Several articles have compared the advantages and disadvantages of LFR and other types of flaps (such as KFR, V‐YFR, etc.) in the treatment of pilonidal sinus from different angles, and found that LFR has lower complications and less recurrence rate than other flap treatment techniques (Table 6). Emile et al. ³⁰ found in a meta‐analysis of randomised controlled trials comparing KFR and LFR in the treatment of PNSD that there was no statistical significance in the comparison of the incidence of complications and recurrence rates of the two groups of surgery, as well as the length of hospital stay, pain score, and wound healing time, but the incidence of seroma and infection rate of LFR was lower, and the recovery time was shorter. As shown in Table 6, the therapeutic effects of various skin flaps were compared with those of LFR in this study, and the incidence of complications and recurrence rates were similar. Erkent et al. ¹⁸ compared the characteristics of PC, KFR, and LFR technology in their research. In all cases, women patients mostly chose PC, while patients with recurrence chose LFR technology. The results after comparison showed that the cosmetic effect of PC patients was the best (P < 0.05), and the complication rate (P < 0.01) and recurrence rate (P < 0.05) of the KFR group were the lowest. However, due to too much consideration of aesthetic factors in female patients, the lesion was not completely removed, so the recurrence rate was high. LFR or KFR should be preferred on the premise of reducing recurrence, but KFR should be the preferred treatment for doctors and patients when considering low recurrence rate, patient comfort, and cosmetic effect. The author collected 37 cases of pilonidal sinus of the sacrococcygeal region treated with LFR. After follow‐up, only one case (2.7%) had a relapse as of the date of publication, and the recurrence rate after LFR was reported to be 0% to 8% in the previous literature (Table 6).

TABLE 6.

The operative method and complications were discussed.

Study	Hematoma			Seroma			Infection			Dehiscence			Failure
	PC	OFR	LFR	PC	OFR	LFR	PC	OFR	LFR	PC	OFR	LFR	PC	OFR	LFR
Zubair et al. 9	NA	NA	4 (8.6%)	NA	NA	2 (4.3%)	NA	NA	2 (4.3%)	NA	NA	NA	NA	NA	1 (2.1%)
Calisir et al. 10	NA	1 (1.9%)	1 (1.4%)	NA	4 (7.5%)	5 (7%)	NA	3 (5.7%)	4 (5.6%)	NA	5 (9.4%)	17 (23.9%)	NA	1 (1.9%)	2 (2.8%)
Song et al. 11	NA	NA	NA	3 (8.1%)	NA	0	10 (27%)	NA	0	10 (27%)	NA	0	9 (24%)	NA	1 (2.5%)
Elhiny et al. 12	NA	0	0	NA	0	0	NA	8 (29.6%)	1 ( (3.7%)	NA	11 (40.7%)	3 (11.1%)	NA	6 (22.2%)	0
Gündoğdu et al. 13	NA	NA	NA	NA	7 (3.8%)	NA	NA	2 (1%)	NA	NA	5 (3.2%)	NA	NA	NA	NA
Destek et al. 14	NA	1 (1.9%)	1 (1.2%)	NA	4 (7.5%)	3 (5.9%)	NA	2 (3.8%)	1 (2%)	NA	2 (3.8%)	1 (2%)	NA	4 (7.5%)	3 (5.9%)
Alvandipour et al. 5	NA	0	0	NA	13 (35.1%)	0	NA	3 (8.1%)	1 (3.7%)	NA	1 (2.7%)	0	NA	1 (2.7%)	0
Kanlioz et al (2019) 15	NA	NA	NA	NA	NA	NA	NA	NA	NA	NA	NA	NA	39 (21.2%)	NA	23 (7.9%)
Arnous et al. 16	NA	NA	NA	3 (10%)	NA	2 (6.6%)	6 (20%)	NA	1 (3.3%)	2 (6.6%)	NA	1 (3.3%)	6 (20%)	NA	0
Afridi et al. 17	NA	2 (3.8%)	NA	NA	3 (5.7%)	NA	NA	3 (5.7%)	NA	NA	NA	NA	NA	2 (3.8%)	NA
Erkent et al. 18	NA	NA	NA	43 (8.6%)	8 (6.3%)	28 (9.3%)	13 (2.9%)	2 (1.5%)	8 (2.6%)	44 (8.8%)	3 (2.3%)	23 (5.6%)	54 (10.8%)	5 (3.16%)	24 (8%)
Chen et al. 19	NA	NA	1 (9.09%)	NA	NA	3 (27.27%)	NA	NA	0	NA	NA	3 (27.27%)	NA	NA	0
Abdelnaby et al. 20	NA	1 (1%)	3 (3.2%)	NA	6 (6.3%)	16 (17%)	NA	2 (2.1%)	6 (6.4%)	NA	8 (8.4%)	13 (13.8%)	NA	3 (3.1%)	7 (7.4%)
Hussain et al. 21	1 (1.69%)	NA	NA	2 (3.39%)	NA	NA	4 (6.78%)	NA	NA	NA	NA	NA	2 (3.4%)	NA	NA
Khan et al. 22	NA	0	0	NA	20 (22.2%)	6 (6.66%)	NA	30 (33.3%)	11 (12.2%)	NA	0	0	NA	NA	NA
Bahadır et al. 23	NA	NA	NA	NA	2 (8%)	3 (9%)	NA	2 (8%)	1 (3%)	NA	1 (4%)	2 (6%)	NA	1 (4%)	0

Abbreviations: LFR, Limberg flap; NA, not available; OFR, other flaps; PC, primary closure.

In conclusion, according to the author's previous research and relevant literature on PNSD treatment, the complications and recurrence of LFR are significantly lower than those of PC. The LFR has no comprehensive advantages over other flap reconstruction methods. Each flap has its own feature that can be a treatment choice according to different patients’ specific conditions. However, the LFR flap design is relatively simple, the operation time is short and the blood supply of the flap is good. Meanwhile, the non‐plastic surgeon can still easily master it. It is a good supplement to PNSD treatment and is worth recommending to clinicians.

FUNDING INFORMATION

This study was supported from the Major Program of Healthcare Special Project (22BJZ35), the Program of National Natural Science Foundation of China (82072169, 82272279), the Major Program of Military Logistics Research Plan (ALB18J001), and the Innovation Cultivation Fund(CXPY201732).

CONFLICT OF INTEREST

The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.

Song Y, Zang Y, Chen Z, et al. The application of the Limberg flap repair technique in the surgical treatment of pilonidal sinus disease. Int Wound J. 2023;20(6):2241‐2249. doi: 10.1111/iwj.14105

DATA AVAILABILITY STATEMENT

Further information and requests for reagents may be directed to and will be fulfilled by the Lead Contact: Chuan'an Shen (shenchuanan@301hospital.com.cn)