Most failure and recurrences after excision and grafting occur during the first five months postoperatively. We concluded that this most likely indicated inadequate excision rather than inefficacy of the procedure. For small pilonidal sinus with minor sinus tract and shallow natal cleft, excision with primary closure would seem to be the best procedure. However, for extensive or recurrent sacrococcygeal pilonidal disease, wide excision with primary split thickness skin grafting is superior. We reviewed 58 patients who had undergone excision of extensive or recurrent pilonidal disease, with primary skin grafting. More than 72 per cent of these patients had recurrent disease when first seen at the Cleveland Clinic. The average hospital stay was 9.8 days; the total disability period, time off work, was 28 days; recurrence rate, 1.7 per cent, and failure rate, 3.4 per cent. This procedure is recommended for recurrent or extensive pilonidal disease.