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Karydakis flap for pilonidal disease

Published 13 March 2026 ·Last reviewed 13 March 2026 by the editorial team ·How we create our content

At a glance

The Karydakis flap is a well-established surgical technique for pilonidal disease that excises the diseased tissue and closes the wound using an asymmetric skin flap placed off the midline. This off-midline closure is the key to its effectiveness — midline wounds in the natal cleft are prone to breakdown and recurrence, and the Karydakis technique avoids this.

How it works

The principle

The natal cleft midline is a problem area for wound healing. It is deep, moist, and subject to friction and shearing forces. Wounds closed directly in the midline have high rates of breakdown and disease recurrence.

George Karydakis developed his technique based on the observation that moving the wound off the midline dramatically improved outcomes. The procedure achieves this through:

Asymmetric excision — an elliptical excision that is slightly off-centre, removing all diseased tissue
Flap mobilisation — the skin on one side is undermined to create a flap
Off-midline closure — the flap is advanced to close the wound with the suture line positioned off the midline
Cleft flattening — the closure results in a shallower cleft in the operated area

The procedure

Performed under general or spinal anaesthesia
The diseased tissue is excised in an asymmetric ellipse
A skin flap is mobilised from the deeper side
The wound is closed in layers with the scar line off the midline
A suction drain is usually placed
The procedure typically takes one to two hours

Who it is suitable for

The Karydakis flap is suitable for:

Primary pilonidal disease — as a definitive first treatment
Recurrent disease — when previous treatments have failed
Moderate complexity — disease that is too extensive for pit-picking but does not require a full cleft lift
Multiple sinuses — the excision can encompass several tracts

Recovery

Week 1

Drain typically removed within two to three days
Limited sitting — a cushion is helpful
Wound care involves keeping the closure clean and dry
Pain is usually well managed with standard pain relief
Light walking is encouraged

Weeks 2 to 3

Sutures or staples removed
Gradual return to normal sitting
Most people return to desk work during this period
The wound should be healing well along the off-midline closure

Weeks 3 to 6

Full activities resume for most people
The wound continues to strengthen
Follow-up to confirm complete healing

Long term

Hair removal in the area is commonly recommended
Regular hygiene of the natal cleft
Low but not zero recurrence risk
The area may feel different — slightly flatter on the operated side

Compared to other techniques

Technique	Wound type	Recovery	Recurrence rate
Wide excision (open)	Open wound	Weeks to months	Higher
Bascom pit-picking	Minimal	1-2 weeks	Moderate
Karydakis flap	Closed, off-midline	2-4 weeks	Low
Cleft lift	Closed, off-midline	2-4 weeks	Low
Limberg flap	Closed, rhomboid	2-4 weeks	Low

The Karydakis flap and cleft lift share similar principles and outcomes. The choice between them often depends on surgeon preference and expertise, disease extent, and individual anatomy.

Common questions

What is the Karydakis flap?

The Karydakis flap is a surgical technique for pilonidal disease where the diseased tissue is excised and the wound is closed using an asymmetric skin flap. The key feature is that the closure line is placed off the midline of the natal cleft, which significantly reduces the risk of wound breakdown and recurrence compared to midline closures.

How does it compare to a cleft lift?

Both the Karydakis flap and the cleft lift share the principle of off-midline closure. The Karydakis technique uses an asymmetric elliptical excision with flap advancement, while the cleft lift involves more extensive reshaping of the natal cleft. For moderate disease, outcomes are comparable. For recurrent or complex disease, some surgeons prefer the cleft lift for its more thorough cleft flattening.

What are the success rates?

Published success rates for the Karydakis flap are generally good, with healing rates typically above 85 to 95 percent and recurrence rates significantly lower than midline closure techniques. The off-midline wound position is the key factor in these outcomes.

What is recovery like?

Recovery involves a closed wound that typically heals within two to three weeks. A drain may be placed for the first few days. Most people return to light activities within one to two weeks and full activities within three to four weeks. The closed wound approach means faster healing than open-wound techniques.

When to seek care Heavy bleeding or feeling faint? Get emergency help now. Emergency: 911

Not sure how urgent it is? Get help today.

Emergency
Heavy bleeding, black tarry stools, feeling faint, severe pain or trouble breathing.

Call 911 or go to the ER.
Today
Fever, pain getting worse, a hot swollen lump, or trouble passing urine.

Call your doctor or go to urgent care.
Soon
Bleeding or bowel changes nobody has checked, or anything lasting 3 weeks.

Book a doctor’s appointment.

Feeling overwhelmed? Call or text 988, any time.

See all the signs

For this topic, get medical advice if you notice:

Increasing redness, swelling, or fever
Wound that stops healing or starts producing pus
Recurrence of symptoms after treatment

Recording how you feel is not the same as being checked. These are the signs that need a doctor’s attention.

Call 911 or go to the emergency room now if you have:

bleeding that will not stop, a lot of blood (the toilet water turns red, or you pass large clots), or any bleeding with feeling faint or dizzy
fainting, a racing heart or trouble breathing
confusion or slurred speech, extreme shivering, no urine in a day, or blotchy skin
sudden severe belly pain, or a swollen, hard belly with vomiting or not passing stool or gas
you cannot pass urine at all, or your bladder feels full and painful and you can’t empty it
redness, swelling or severe pain spreading quickly around your anus, genitals or groin, especially with a fever or feeling very ill
a fever with a painful swelling near your anus if you have diabetes or a weakened immune system (for example, from chemotherapy or transplant medicines)
black, tarry stools

Call your doctor or go to urgent care today (or the ER if you can’t be seen today) if you have:

a temperature of 100.4°F (38°C) or higher, chills, vomiting, or feeling generally unwell
pain that is getting worse over days, or severe pain that stops you sitting or sleeping
a hot, swollen or very tender lump near your anus or at the top of the crease between your buttocks, or foul-smelling discharge
trouble urinating
bleeding that is getting heavier or more frequent, or blood mixed into your stool
feeling much more tired than usual, looking pale, or getting out of breath more easily than you used to
not passing stool for several days, or new belly pain

Make an appointment with your doctor if:

you have never had these symptoms checked by a doctor or nurse — whatever your age
you have had rectal bleeding for more than 3 weeks
your bowel movements have been looser, thinner or more frequent than usual for 3 weeks or more, or you have lost weight without trying
symptoms have not settled after a week or so, or keep coming back
you notice a new lump near your anus, between your buttocks or in your belly, or an itch or discharge that does not clear
you have new leakage or trouble controlling your bowels
you are 45 or over, or have a family history of bowel cancer or inflammatory bowel disease, and any of these symptoms are new for you

If you are unsure, it is always reasonable to ask. If things feel overwhelming, call or text 988 (Suicide & Crisis Lifeline) or chat at 988lifeline.org, any time. If you don’t feel safe, call 911.

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