British Journal of Plastic Surgery (2002) 55, 671-674 92002 The British Association of Plastic Surgeons. Published by Elsevier Science Ltd. All rights reserved. doi: 10.1054/bjps.2002.3943 BRITISH JOURNAL OF [~J PLASTIC SURGERY Reconstruction of the natal cleft with a perforator-based flap A. Garrido, R. Ali, V. Ramakrishnan, G. Spyrou and E R. W. Stanley Department of Plastic and Reconstructive Surgery, Castle Hill Hospital, Cottingham, UK SUMMARY. Recurrent chronic conditions of the natal cleft, such as pilonidal sinuses, are difficult problems to treat. The deep natal cleft and the rolling effect of one buttock surface over the other contribute to the high recurrence rate. Wide excision of the affected area is the treatment of choice; to cover the defect many techniques have been described that flatten the natal cleft and shift the suture line away from the midline to try to reduce recurrence. These techniques include Z-plasties, rhomboid flaps, V-Y flaps, gluteus maximus myocutaneous flaps and others. Five patients with recurrent natal-cleft problems were operated on over a 1 year period. After wide excision of the natal cleft, the defect was reconstructed with a parasacral perforator-based flap. Preoperatively, a perforator situated superolaterally to the defect is identified with a Doppler probe; the flap is then designed horizontally around the perforator and, after eleva- tion, is rotated 90 ~ over the defect. The mean hospital stay was 5 days. Follow-up ranged from 3 months to 15 months, with no signs of recurrence. We believe this to be a simple and reliable technique, with the advantages of placing the scars away from the midline and flattening the natal cleft - factors that help to prevent recurrence. 9 2002 The British Association of Plastic Surgeons. Published by Elsevier Science Ltd. All rights reserved. Keywords: natal cleft, perforator-based flap, pilonidal sinus. Chronic conditions of the natal cleft, such as recurrent pilonidal sinus, unstable scars, chronic inflammation and ulceration, are not uncommon and are difficult to treat. They are associated with considerable morbidity, and have a significant social impact on the affected individuals. Simple pilonidal disease is usually treated by excision of the sinus and healing by secondary intention or direct closure. Recurrence rates following this treatment have been reported to be between 4% and 10%. I'2 Some patients develop recurrent pilonidal disease, which pre- sents a more challenging problem to the surgeon. In order to eradicate the disease, these patients require a wider excision of the affected area, so that the defect created is too big to allow direct closure without tension, and a flap is usually required. Different techniques have been reported, including Z-plasties, W-plasties, rhomboid flaps, V-Y advancement fasciocutaneous flaps, sacral adipofas- cial turnover flaps and gluteus maximus myocutaneous flaps. 3-11 All these techniques have their advantages and disadvantages. In the last decade, perforator-based flaps have gained popularity in soft-tissue reconstruction. Some surgeons have used perforator-based flaps for the reconstruction of lumbosacral defects, mainly after the excision of pressure sores. 12-16 We report our early experience of reconstructing the natal cleft with a perforator-based flap as a treatment for recurrent and complicated disease affecting that region. Presented at the Winter Meeting of the British Association of Plastic Surgeons, London, 28-30 November 2001. Patients and methods Between March 2001 and February 2002 we recon- structed the natal cleft with a perforator-based flap in five patients. All the patients had chronic recurrent disease of the natal cleft (four patients had pilonidal sinuses and one patient had ulcerative colitis with chronic inflamma- tion and ulceration of the natal cleft). The two female and three male patients ranged in age from 22 years to 59 years (mean: 37 years). The duration of the perineal disease ranged from 3 years to 25 years (mean: 12 years), with persistent symptoms of chronic discharge and sore- ness around the affected area. The four patients suffering from recurrent pilonidal sinuses had undergone an aver- age of four previous surgical procedures (range: three to eight procedures) for the same condition (Table 1). Operative technique All patients were anaesthetised and placed prone on the operating table. Prophylactic antibiotics were given. The excision margins of the affected area were marked, and a suitable perforator was identified with a Doppler flow audioscope in an area superior and lateral to the top of the natal cleft. An elliptical island flap was designed around the perforator in a horizontal or slightly oblique direction (Fig. 1A). After wide excision of the diseased tissue down to the presacral fascia, the flap was elevated from lateral to medial. Initial dissection was in a suprafascial plane; when approaching the perforator, the fascial condensation was incised and carefully dissected to isolate and preserve the perforator. The flap was then completely islanded and rotated 90 ~ into the defect (Fig. 1B,C). The donor site was 671