Keystone Versus Rhomboid Flaps in The Management of The Sacrococcygeal Pilonidal Disease; A Prospective Randomized Trial in A Tertiary Surgical Center

Background: Surgery for pilonidal disease (PND) entails a variety of procedures with no global consensus regarding the optimal procedure for that entity. Surgeons should seek alternative options to improve patient outcomes. The keystone flap has been applied to cover defects involving the trunk and peripheral limbs, with some evidence of success in PND patients. Aim and objectives: Herein, we compared the keystone and rhomboid flaps in the management of patients with primary PND. Methodology: This prospective trial included 108 PND patients who were randomly assigned into two groups; the keystone group and the rhomboid group. The patients were followed for two years after the procedure. Operative time and complications, including recurrence, were recorded. Results: The operative time showed a significant shortening in the keystone approach (52.5 vs. 63.06 minutes in the rhomboid group). Additionally, the keystone patients were able to return to their work earlier than patients in the rhomboid group, although the time needed to walk and sit on the toilet free from pain did not differ between the two groups. The incidence of complications did not differ between the two groups, apart from dehiscence, which was more encountered in the rhomboid approach. Recurrence occurred in 1.9 and 7.4% of the keystone and rhomboid cases, respectively (p = 0.169). Patient satisfaction was significantly better in the keystone group. Conclusion: The keystone flap has more advantages compared to the rhomboid approach, manifested in shorter operative time, earlier return to work, and lower incidence of wound dehiscence.