Surgical Management of Pilonidal Sinus: A Comparative Study of Excision, Limberg Flap, and Keystone Flap Reconstruction.

Background Pilonidal sinus is a chronic inflammatory condition predominantly affecting young adult men, with significant recurrence and morbidity. Multiple surgical techniques exist, but no single method has been universally accepted as optimal, particularly for managing recurrence, complications, and quality-of-life (QoL) outcomes. Methods This prospective comparative observational study enrolled 46 patients with pilonidal sinus disease who underwent either simple excision, Limberg flap, or Keystone flap reconstruction at a tertiary care center between February 2024 and July 2025. Patients were followed at one, three, and six weeks postoperatively, and outcomes assessed included operative time, hospital stay, healing duration, complications classified by Clavien-Dindo, recurrence rates, scar quality using the Vancouver Scar Scale, patient satisfaction on a Likert scale, and QoL measured by WHO‑QoL‑BREF. Results The cohort showed male predominance (89.1%) with a mean age of 25.24 ± 6.16 years. Flap procedures were used for more extensive disease and had longer operative time and hospital stay (p < 0.001). Healing duration was comparable, though simple excision showed longer median healing time (p = 0.031). Return to work was earlier with simple excision, but the difference was not statistically significant (p = 0.057). Complications occurred in 43.5% of patients, most commonly seroma (28.3%), with higher rates in flap groups, while recurrence (13.3%) was seen only in the simple excision group (p < 0.001). Flap procedures demonstrated superior scar outcomes (p = 0.014) and higher patient satisfaction (p = 0.002). QoL assessment showed significantly better physical (p < 0.001) and psychological (p = 0.002) scores in flap groups, with no difference in social and environmental domains. Conclusion While flap procedures are associated with longer operative time and hospital stay, they provide superior long-term outcomes in terms of recurrence, cosmesis, patient satisfaction, and QoL. Off-midline flap techniques, particularly Limberg and keystone flaps, are preferable for complex or recurrent pilonidal sinus disease.