BACKGROUND Rhomboid excision with Limberg flap (RELF) repair has been shown to be effective in the management of pilonidal disease (PD) in adults. Wide excision allows complete removal of diseased tissue, and the rotational flap allows tensionless coverage as well as helps flatten the natal crease, which is believed to contribute to the recurrence of PD. METHODS This study is a retrospective review of all adolescents who underwent excision of pilonidal disease using RELF at a single institution for a period of 18 months. RESULTS Sixteen adolescents with PD were treated with RELF during this period. All procedures were completed with no intraoperative complications. Mean operative time and hospital stay were 92 +/- 30 minutes and 1.8 +/- 0.29 days, respectively. Mean follow-up was 11 +/- 6.0 months. One patient had recurrence of his disease, and one needed prolonged wound care after wound breakdown. Six others had minor complications including 4 patients (25%) who had superficial wound separation that resolved promptly with dressing change. One patient had a superficial wound infection. One patient had residual pain. CONCLUSIONS Rhomboid excision with Limberg flap is effective in the management of PD in adolescents. The 6% recurrence rate is similar to that reported in the adult literature. Despite the limitations of this study, the low morbidity, hospital stay, and recurrence rate noted with our initial experience are very encouraging.