The surgeon’s perspective: a retrospective study of wide local excisions taken to healthy subcutaneous fat in the management of advanced hidradenitis suppurativa

BackgroundHidradenitis suppurativa (HS) is a chronic debilitating folliculopilosebaceous disease that affects the skin most commonly in the axilla, groin, inframammary, genital and buttock areas. Surgical intervention may be an appropriate option in selected cases, but there is a risk of recurrence. The purpose of this study was to assess the results of wide local excision (WLE) to healthy subcutaneous fat with secondary intention healing in patients with HS who were under concurrent surgical and dermatologic care.MethodsWe conducted a retrospective review of 192 consecutive HS consultations to a general surgical service, identifying patients treated with WLE. Cases involving minor procedures (deroofing, incision and drainage) were excluded. Data on patient demographics, surgical site, method of closure, complications and recurrence were extracted from patient charts. We also conducted a literature review of surgical procedures in the management of HS.ResultsA total of 66 patients underwent 133 WLE to healthy subcutaneous fat. All patients were under concurrent medical care directed by a dermatologist. No medical therapies, including biological treatments, were interrupted or withheld for surgery. One hundred procedures were closed primarily with rotation or advancement flaps and 33 by secondary intention healing. Local recurrence occurred in 18% of primary closures and 18% of secondary intention closures (p = 0.98, χ² test, no difference between groups). One patient with secondary intention healing returned to the emergency department for bleeding; 34% of patients with primary closure experienced some dehiscence (23% major, 11% minor separation). Two patients with axillary disease had restrictions in their ability to raise their arm that required physiotherapy. Median follow-up was 14.5 (range 1–55) months.ConclusionResection to healthy subcutaneous fat during WLE provides disease control comparable to that with deeper resections, simplifying care.     

The role of negative pressure wound therapy in the management of hidradenitis suppurativa: a case report and literature review

Hidradenitis suppurativa (HS), also known as acne inversa, is a chronic, recurrent inflammatory disease affecting skin that bears apocrine glands. It is characterised by the presence of tender subcutaneous nodules that may rupture, resulting in deep dermal abscesses, fibrosis with dermal contractures and induration of the skin. The management of HS is a challenge for physicians as the pathogenesis is not clearly defined and prevents the use and development of directed therapies. Treatment options are oral agents (antibiotics, immunomodulators) and surgical excision. Historically, surgical management has been complicated by difficult closure and high recurrent rates. In the last 10 years, negative pressure wound therapy (NPWT) has proven to be a great adjunct for wound management as it provides the adequate conditions for wound healing, promotes granulation and helps to control infection. Here, we report a case of severe perineal HS treated with radical excision and NPWT as an adjunct. The patient only had a recurrence 3 years after primary treatment and was surgically treated for cosmetic reasons without any complications. Finally, we present a review of the relevant literature.     

Adipo-fascio-cutaneous flaps in the treatment of pilonidal sinus: experience with 50 cases

OBJECTIVE: To retrospectively analyse the results of pilonidal sinus managed using wide excision with primary eccentric closure with various adipo-fascio-cutaneous flaps. METHODS: Data from 50 consecutive patients who had elective surgery for chronic pilonidal sinus with wide excision of all the sinuses and primary eccentric closure with various adipo-fascio-cutaneous flaps (40 lateral advancements, 4 Z-plasties, four rotations, 1 rhomboid and 1 V-Y advancement) were retrospectively analysed. Special emphasis was placed on partial obliteration of the natal cleft, duration of wound healing, postoperative morbidity and hospital stay, loss of work days, cosmetic outcome and recurrence. RESULTS: In all patients, partial obliteration of the natal cleft was achieved by eccentric primary wound closure, with good cosmesis. Superficial necrosis of the flaps occurred in five patients (3 Z-plasties, 2 rotation flaps). None had collection, haematoma, infection or recurrence. CONCLUSION: Complete eccentric excision and partial obliteration of the natal cleft using various adipo-fascio-cutaneous flaps ensured reliable wound healing with fewer dressings and morbidity, shortened hospital stay and early resumption of work, good cosmesis and prevention of early and late recurrence. The lateral advancement flap is a viable option in the treatment of chronic pilonidal sinus.     

Thoracodorsal artery perforator (TAP) type I V-Y advancement flap in axillary hidradenitis suppurativa.

Hidradenitis suppurativa is a chronic debilitating disease. Surgical removal of all apocrine glands in the affected region is the definitive treatment. The resulting wound may either be left to heal secondarily or closed primarily. Secondary healing in the axilla may cause contractures and stiffening of the shoulder. Primary healing requires direct closure, split-skin grafting or local flap application. Direct closure is associated with a high incidence of recurrence compared to skin grafting or flaps. Local flap cover is the ideal method of wound closure after excision of the glands. We have used a thoracodorsal artery perforator (TAP) V-Y advancement flap (type I) to achieve closure as a single-stage procedure successfully in four cases. It is a single stage procedure capable of closing large axillary defects whilst preserving the axillary contour.     

Surgical management of a giant plexiform neurofibroma of the lower extremity

The authors review their experience with the management of a giant 49-kg (108 lb) neurofibroma of the lower extremity in a 37-year-old male with NF1. The patient presented with right thigh pain, paresthesias, increasing edema, and accelerated growth of the mass. The patient was taken to the operating room, where approximately 39 kg (86 lb) of tumor and 10 L (22 lb) of interstitial fluid was removed. The postoperative course was complicated by cellulitis, delayed wound closure, and recurrent lymphedema. Complications were managed with antibiotics, ultrasound-guided drainage, surgical revision of closure, compressive dressings, passive drainage, and vacuum-assisted wound closure. Giant neurofibromas similar to this tumor require complex intraoperative and postoperative management strategies. Surgical closure is best managed with local flaps, and postoperative lymphedema is best managed with passive drainage and compressive dressings.     

Comparison of three methods in surgical treatment of pilonidal disease

Background : The present study was designed to compare three methods that are still used for the surgical treatment of pilonidal disease: marsupialization, primary midline closure and skin flaps. Methods : One hundred and one out of a total of 203 pilonidal disease patients underwent excision and marsupialization, while 82 patients had excision and primary closure and the remaining 20 were treated with excision and skin flaps. The minimum and maximum follow‐up periods for the aforementioned surgical methods were 4 and 5 years, respectively. All patients were reviewed for in‐hospital stay, return to work, wound infection and recurrence rates. Student’s t‐test and Fisher’s exact test were used for statistical analysis. Results : Average hospital stays for marsupialization, primary closure and skin flaps were 2.84 ± 0.13, 2.62 ± 0.12 and 5.95 ± 0.52 days, respectively. Hospital stay for the skin flaps method was longer than that for the other two methods. The average time to return to work after marsupialization was 5.42 ± 0.08 weeks; but the time needed to return to work after undergoing the primary closure or the skin flaps methods was much shorter: 2.15 ± 0.05 and 2.90 ± 0.20 weeks, respectively (P < 0.001). There was no difference in wound infection rate (P = 1.000) or recurrence rates. Conclusion : The fact that there were no differences in terms of wound infection or recurrence rates between the three groups, and the relatively shorter period for returning to work, emphasize the usefulness of the excision and repair techniques in the surgical treatment of pilonidal disease.     

Hidradenitis suppurativa

Hidradenitis suppurativa is a chronic, debilitating disease of apocrine gland-bearing skin. Its management must be individualized according to the site and extent of the disease. Initial conservative measures with antibiotics, local wound care, and limited incision and drainage can alleviate the acute symptoms, but more radical surgery will likely eventually be necessary in order to control and prevent recurrent disease. Options include unroofing and marsupialization, local excision, or more extensive operative excision with primary or secondary closure, skin grafting, or flap coverage of defects. Wide excision will offer the most definitive therapy, with the trade-off being a higher morbidity. Split-thickness skin grafts in the anal canal may contract and result in anal stenosis and should be avoided. Perianal disease is often best managed with local excision alone, with primary closure for small defects, and either unroofing or healing by secondary intention for larger wounds.     

Chronic axillary hidradenitis--the efficacy of wide excision and flap coverage.

A number of different modalities of surgical treatment for axillary hidradenitis suppurativa have been suggested. This study compares three different methods of surgical excision. Fifty-nine patients (94 axillae) were treated over a 14-year period. There were 42 females and 17 males with an average age of 32 years (range 16-65 years). Twenty-six axillae had excision of only the diseased skin and recurrent disease occurred in seven. However, in 39 axillae that were treated by excision of all the hair bearing skin, only three developed recurrent disease, which is a significant reduction in the incidence of recurrent disease (P = 0.04, Fischer's exact test). Twenty-nine axillae were treated by wide local excision (2 cm beyond the hair bearing skin) and no recurrence occurred. However, there was no statistical difference (P = 0.18, Fischer's exact test) in disease recurrence between excision of all the hair bearing skin and wide local excision. This study suggests that excision of all the hair bearing skin is the preferred method of surgical treatment. Flap coverage was an effective method to achieve wound closure after adequate excision and can be achieved by random fasciocutaneous flaps for small or medium sized defects and parascapular flaps for large defects.     

A comparison of flap reconstruction vs the laying open technique or excision and direct suture for pilonidal sinus disease: A meta‐analysis of randomised studies

Many treatments have been described for pilonidal disease, but recurrence cannot be completely eliminated. The aim of this study was to perform a meta‐analysis of randomised, controlled trials comparing flap repair vs the laying open technique and/or excision and direct closure techniques in the treatment of chronic pilonidal sinus disease. The primary outcome measure was the recurrence rate. Secondary outcomes were complete wound‐healing time, duration of the incapacity to work, quality of life and patient satisfaction, postoperative pain, wound infection, bleeding or haematoma, skin wound complications, and duration of hospital stay. Seventeen studies were included. The meta‐analysis demonstrated a lower risk of recurrence, a shorter duration of incapacity to work, a lower risk of wound infections, a lower risk of skin wound complications, and a shorter duration of hospitalisation in favour of flap vs direct closure. A shorter time to complete wound healing and a shorter duration of incapacity to work for flap vs the laying open technique were observed. Superiority of flap repair vs direct closure in pilonidal sinus treatment was demonstrated in this meta‐analysis. These results suggest avoiding primary direct closure in clinical practice. Compared with the laying open technique, flaps result in faster healing and a shorter time to return to activities.     

Reconstruction of extensive pilonidal sinus defects with the use of S-GAP flaps

Pilonidal sinus is a chronic intermittent inflammatory condition that is predominantly located in the sacrococcygeal region. For the closure of uncomplicated small pilonidal sinuses, conventional therapeutic techniques including total excision of the sinus and leaving the defect open for secondary healing have been reported with varying success rates. However, the treatment of recurrent and extensive disease remains as a difficult condition. The ideal treatment should be associated with short hospital stay, minimal complication rates, and no disease recurrence. Secondary wound healing after large excision results in a chronic wound that requires cleansing and dressing changes for a long time. The condition also negatively affects the patient's social life. With the progression of reconstructive techniques, the lowest recurrence rates for the treatment of extensive disease have been reported after local flap usage. The purpose of the current article is to report the efficacy of superior gluteal artery perforator flap in the reconstruction of extensive sacrococcygeal pilonidal sinus defects. This perforator flap is a refinement of the classic gluteal musculocutaneous flaps, which have been popularly used for the closure of sacral pressure sores over many years.