Hypothesis: Pilonidal sinus is a common chronic disorder affecting the sacrococcygeal area in young patients. Controversy  still exists about the best surgical technique for treatment of pilonidal sinus disease. The aim of this study is to seek for the preferred option for management of   pilonidal  sinus  disease regarding  recurrence  rate   and   post- operative scar. Design: case series. Setting: This study was conducted in the General Surgery Department, Faculty of Medicine, Zagazig University, from November 2006 to June 2008. Patients: Thirty two patients (20 men and 12 women; 11/5and 9/7) with a median age of 25 and 23 years (range 19-33 years). They are divided in two groups; each contains 16 patients. Intervention: The patients were treated by eccentric elliptical excision of the diseased tissues down to the sacral fascia and closure of the defect with either island flap in 16 patients group A or primary closure in 16 patients group B, after placing a closed suction drain at the base of the wound, then suturing the flaps with loose Vicryl® 210 sutures.The follow-up period ranged from 14 to 32 months (mean, 24 months). Main outcome measure: Length of hospital stay and return to normal activities, early wound complications, and recurrence. Results: The mean hospital stay was 16.6 hours in group A (island flap) versus 22 .2 hours in group B (primary closure). Wounds healing time was 13 days in group A versus 35 days in group B. Superficial wound infection occured in one patients in group A versus three in group B. Superficial gangrene of wound edges occured in one patient and partial wound breakdown in one patient in group A. Two patients in group B had recurrence. The patients returned  to work after 12.3 days in group A and 18.8 days in group B. Conclusion:  An island flap is an easy and acceptable method with superior cosmetic scar effect  and patients' satisfaction in comparison with the primary  excision  and closure  for management of extensive pilonidal disease