Abstract Background Off-midline closure after excision and primary closure in the treatment of sacrococcygeal pilonidal disease has been suggested to improve surgical outcomes and reduce median recurrence rate. The aim of this study was to investigate several features known to be related to recurrence, allowing adequate comparison of recurrence between D-shaped asymmetric and symmetric excision in the treatment of sacrococcygeal pilonidal disease. Methods An analysis of a prospectively maintained database of 569 surgical excisions performed for sacrococcygeal pilonidal disease between 1988 and 2007 was performed. Results The recurrence rate was lower in the asymmetric (n = 423) than in the symmetric (n = 101) group (9% vs 22.0%, P = .0001). After a median follow-up period of 11 years, 5-year 10-year, and 20-year disease-free survival rates were higher in the asymmetric group (94%, 92%, and 89% vs 84%, 79%, and 71%, respectively, P = .005). Conclusions D-shaped asymmetric excision is an effective treatment of sacrococcygeal pilonidal sinus. Better long-term recurrence rates are achieved compared with symmetric excision, when stratified for several features known to be related to recurrence.