title: Distal scar-to-midline distance in pilonidal Limberg flap surgery is a recurrence-promoting factor: A multicenter, case-control study.
abstract: BACKGROUND
  The Limberg flap (LF) procedure is widely performed for the treatment of sacrococcygeal pilonidal sinus (SPS); however, recurrences continues to be observed. The aim of this study was to assess the relationship between LF designs and the risk of SPS recurrence.
  
  
  METHODS
  Sixty-one cases with recurrent disease (study group) and 194 controls, with a minimum of 5 recurrence-free years following surgery (control group), were included in the study. LF reconstructions performed in each group were classified as off-midline closure (OMC) and non-OMC types. Subsequently, the 2 groups were analyzed.
  
  
  RESULTS
  After adjustment for all variables, non-OMC types showed the most prominent correlation with recurrence, followed by interrupted suturing type, family history of SPS, smoking, prolonged healing time, and younger age. The best cut-off value for the critical distance from the midline was found to be 11 mm (with 72% sensitivity and 95% specificity for recurrence).
  
  
  CONCLUSIONS
  We recommend OMC modifications, with the flap tailored to create a safe margin of at least 2 cm between the flap borders and the midline.
authors.affiliation: Department of General Surgery, Bahcesehir University (BAU) School of Medicine, İstanbul, Turkey. Electronic address: dr.kaplan27@gmail.com.
authors.forename: Mehmet
authors.initials: M
authors.lastname: Kaplan
authors.affiliation: Department of General Surgery, Sitki Kocman University School of Medicine, Mugla, Turkey.
authors.forename: Onder
authors.initials: O
authors.lastname: Ozcan
authors.affiliation: Department of General Surgery, Karasu Government Hospital, Sakarya, Turkey.
authors.forename: Ethem
authors.initials: E
authors.lastname: Bilgic
authors.affiliation: MP Research Program, Kemerburgaz University Medical School, Istanbul, Turkey.
authors.forename: Elif Tugce
authors.initials: ET
authors.lastname: Kaplan
authors.affiliation: GAZU Research Program, Gaziantep University Medical School, Gaziantep, Turkey.
authors.forename: Tugba
authors.initials: T
authors.lastname: Kaplan
authors.affiliation: 25-Aralik Health Center, Ministry of Health Republic of Turkey, Gaziantep, Turkey.
authors.forename: Fatma Cigdem
authors.initials: FC
authors.lastname: Kaplan
mesh_terms: D000293:Adolescent; D000328:Adult; D016022:Case-Control Studies; D002921:Cicatrix / Q000473:pathology; D005260:Female; D006801:Humans; D008297:Male; D008875:Middle Aged; D010864:Pilonidal Sinus / Q000601:surgery*; D012008:Recurrence; D012189:Retrospective Studies; D018570:Risk Assessment; D012445:Sacrococcygeal Region; D013524:Surgical Flaps; D055815:Young Adult
keywords: Limberg flap; Modified Limberg; Off-midline closure; Pilonidal disease; Recurrence; Sacrococcygeal pilonidal sinus