A B S T R A C T Background: Pilonidal sinus is a common surgical problem. It has a tendency for recurrence. Recurrent disease is difficult to manage.re-recurrent disease is more difficult to manage, because it is hard to choose the right operation and to provide sufficient tissue to close the defect. This study aims to assess and evaluate the outcomes of keystone perforator island flap and lay open techniques in treatment of pilonidal sinus disease which is recurrent for the second time or more. Methods: This is a single-center comparative clinical study performed at Zagazig University Hospitals from December 2023 to December 2024. The study included 27 patients. Results: 27 patients with re-recurrent pilonidal sinus were classified randomly into two groups. Group 1 underwent treatment with keystone island perforator flap and group 2 underwent closure by lay open technique. There was no statistical significant difference between the 2 groups in age, sex, type of 1st and 2nd operation, mean time for 1st and 2nd recurrence. Operation time, bleeding, pain score and wound dehiscence were more in group 1, while healing time and recurrence rate were more in group 2. Conclusion: Both keystone island perforator flap and lay open techniques can be used in treatment of re-recurrent pilonidal sinus disease. Keystone island flap is better regarding the healing time and recurrence rate.