If the resulting tissue defect is covered and sutured by a flap of tissue from the immediate vicinity of the wound after the incision of the tailbone fistula, this surgical technique is called "plastic". The tissue flap mobilized to cover the defect usually consists of skin and subcutaneous fatty tissue. Since the incision for mobilization of the tissue flap lies outside the midline (gluteal fold), the various plastic procedures are also referred to as "asymmetrical". The wound also comes almost completely to the side of the gluteal fold, which is why the English literature speaks of "off-midline procedures".
In 1946, surgeon David H. Patey and pathologist R.W. Scarff questioned for the first time in a renowned English journal the assumption that pilonidal disease is congenital. Through investigations, they came to the conclusion that pilonidal cyst and tailbone fistula are mainly due to the penetration of hair into the skin of the gluteal fold. The dreaded wound healing disorders and the recurrence of fistulas were therefore not due to insufficient radical cutting of the fistula system, but to the surgical wound itself in the depth of the gluteal fold.
In the 1950s, based on Patey and Scarff's investigations, initial attempts were made to leave the extensive, radical soft tissue resections and instead to cause an anatomical flattening of the gluteal fold and not to place the surgical wound in the depth of the fold. One of the surgical techniques that meets these requirements is the so-called "Z-plasty". In an initial Z-plasty study involving 30 patients, Monro and McDermott reported in the 1960s that no patient developed a new fistula.
Despite further positive reports, Z-plasty was hardly used to cover defects and to raise the gluteal fold. It was not until 1988 that another study was published on the experience with Z-plasty, which led to wound healing disorders in over 67% of patients operated on using the procedure. The dying of skin in the corners of the Z-plasty and the recurrence of fistulas at the crossing points of the surgical wound with the bottom fold was described as problematic, which sealed the "end" for the Z-plasty.
Even if Z-plasty has no or only a subordinate role in the surgical treatment of fistulas of the tailbone, it is historically of great importance, as it paved the way for more modern plastic surgical procedures. In the 1950s and 60s, Z-plasty was the first attempt to counter wound healing disorders and renewed fistula formation with an anatomical flattening of the butt fold and not with more radicality.
Literature sources:
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Petersen S, Koch R et al (2002) Primary closure techniques in chronic pilonidal sinus: a survey of the results of different surgical approaches. Dis Colon Rectum 45:1458–1467
McCallum IJ, King PM et al (2008) Healing by primary closure versus open healing after surgery for pilonidal sinus: systematic review and metaanalysis. BMJ 336:868–871
Kooistra HP (1942) Pilonidal sinuses. Am J Surg 55:3–17
Patey DH (1969) A reappraisal of the acquired theory of sacrococcygeal pilonidal sinus and an assessment of its influence on surgical practice. Br J Surg 56:463–466
Patey DH, Scarff RW (1946) Pathology of postanal pilonidal sinus; its bearing on treatment. Lancet 2:484–486
Monro RS (1967) A consideration of some factors in the causation of pilonidal sinus and its treatmentby Z-plasty. Am J Proctol 18:215–225
Monro RS, McDermott FT (1965) The elimination of causal factors in pilonidal sinus treated by Z-plasty. Br J Surg 52:177–181
Tschudi J, Ris HB (1988) Morbidity of Z-plasty in the treatment of pilonidal sinus. Chirurg 59:486– 490
Karydakis GE (1992) Easy and successful treatment of pilonidal sinus after explanation of its causative process. Aust N Z J Surg 62:385–389
