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Patients undergoing repeat surgery for pilonidal disease are excluded by many authors from their studies because of the highly unfavourable course of disease in these cases. This retrospective analysis was performed to compare long-term results between patients operated by simple excision + lay-open or excision + midline closure (group 1) and patients undergoing Karydakis flap (group 2).Only patients withprevious excision surgery for pilonidal disease were included.Group 1 consisted of 37 patients (25 excision + midline closure, 12 excision + lay-open), group 2 of 39 patients. The mean age, (27.5 vs 25.7 years), duration of disease (48 vs 52 months), number ofprevious operations (2.1 vs 2), and gender (male: 83% vs 85%) were equally distributed between groups. Follow-up data were available in 68 of 76 cases. The recurrence rate was 58% in group 1 and 9% in group 2 (P = 0.0005). The recurrence rate was highest in patients undergoing excision +primary midline closure (67%). All three patents developing recurrence following Karydakis flap had been operated during the first year of the study.In the treatment of recurrent pilonidal sinus. the Karydakis flap is superior to the traditional method.