Pilonidal disease is a common acquired condition characterized by occluded hair within small midline pits superior to the intergluteal cleft. Varying presentations are possible which include an acute abscess, simple pilonidal cyst or complicated, recurrent sinus. Pre-operative preparations should include resolution of an acute abscess and appropriate preparation in positioning in addition to antibiotics. Many surgical options exist for the treatment of pilonidal disease including, incision and curettage, marsupialization, excision and primary closure, cleft closure, Z-plasty, V-Y advancement flap, rhomboid flap, and gluteus maximus myocutaneous flap. Time to healing remains variable from 3 to 4 weeks on average. Recurrence rates following surgical therapy may be as high as 40 % with simple drainage of the abscess to as low as 1 % with advancement flap procedures. This chapter presents a myriad of common surgical approaches to the treatment of pilonidal disease, complete with descriptive illustrative figures.