Figure - available from: European Journal of Plastic Surgery
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Intraoperative image of severe left axillary hidradenitis suppurativa with incision planning to include all hair-bearing area (a). Defect size of 17 cm × 9 cm (153 cm²) post-wide excision, exposing the vital structures including axillary vessels and intercostal branch nerve (b). Reconstruction of left axilla with left pedicle partial latissimus dorsi myocutaneous flap (c). Surgical scar 3 years after surgery (d). Patients have no restriction in both upper limbs post operation (e)
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Background
Hidradenitis suppurativa (HS) is a chronic debilitating inflammatory disease of the apocrine gland-bearing body areas, characterized by painful recurrent abscess, sinus tract formation, and scarring. The treatment for HS consists of medical and surgical treatments in a multidisciplinary approach. Wide excision and reconstruction over the...
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Citations
... The reconstructive approach after resection of HS should, therefore, account for an optimal soft-tissue support. Although wound conditioning with subsequent coverage using STSG remains a historically established approach for large defects, there are many indisputable drawbacks when used in the axillary region: unsafe graft take, poor scarring with reduced range of movement, prolonged recovery time, and multiple revision surgeries needed [18,20,21]. Due to these shortcomings, surgical reconstruction of the axilla using flap coverage has gained increased popularity [22]. ...
... Similar results were reported by Chen and Friedman [11], where 3 of 11 patients needed regrafting; only 8 of 24 defect sites showed skin graft take over 90%, and isolated abscess formations were documented almost in all patients adjacent to the grafted areas. A prolonged operation time for axillary defect coverage using a pedicled flap compared to STSG coverage was reported in a study be Lee et al. [20] as well. Consequently, no need for regrafting or VAC dressing changes in the flap group resulted in the statistically significant decrease in the in-patient stay, number of out-patient claims, time to complete wound healing, as well as return to work. ...
... Our data showed lowest scarring formation for group A. Scarring and contracture formation, in addition to pain, have been reported as the most frequent complications after defect coverage using STSG or secondary intention [18,20]. Notably, patients with burns affecting the axillary area suffer from devastating movement restrictions due to scar contractures [34]. ...
Background: Radical excision of debilitating hidradenitis suppurativa lesions is the only curative approach in the advanced stages of the disease. Different concepts for axillary reconstruction do exist, but data on their clinical outcome are scarce.
Methods: This is a retrospective cohort study of two reconstructive methods (posterior arm flap vs. vacuum-assisted closure [VAC] + split-thickness skin graft [STSG]) for axillary defects in patients with severe axillary hidradenitis suppurativa treated at the University Hospital Zurich between 2005 and 2020.
Results: A total of 35 patients (mean age 36 ± 10 years, mean BMI 29 ± 5 kg/m 2 , Hurley stage II-III) with 67 operated axillae were stratified according to their type of reconstruction. Median operation time in the flap group was 144 min (IQR 114-207) (cumulative 181 min [IQR 124-300]) and 50 min (IQR 40-81) in the VAC + STSG group (cumulative 151 min [IQR 94-194], p < 0.01; p = 0.20 [cumu-lative time]). The cumulative length of stay was 6 ± 3 days in the flap group and 14 ± 7 days in the VAC + STSG group (p < 0.01). Time to complete wound healing was 27 days (IQR 20-49) in the flap group and 62 days (IQR 41-75) in the VAC + STSG group (p < 0.01). Vancouver Scar Scale score was 6 (IQR 4-9) in the flap group and 11 (IQR 9-12) in the VAC + STSG group (p < 0.01). Protective sensory recovery was most satisfactory in the flap group (p < 0.01). Forty-four percent of patients of the VAC + STSG group demonstrated functional impairment of arm abduction. Time to return to work was less in group A with 42 days (IQR 27-57) needed as compared to group B with 48 days (IQR 34-55) needed (p = 0.32). The average cost saving was 25% higher for the flap group than for the VAC + STSG group.
Conclusion: Despite an increased operation time, axillary reconstruction by the posterior arm flap yields a reduced length of stay, less time to complete wound healing along with restoration of a protective sensibility, and less axillary scarring avoiding functional deficits-eventually allowing earlier return to work.
Hidradenitis suppurativa (HS) is a chronic, debilitating disease affecting between 1 and 4% of the global population. The exact etiology of HS remains unclear. More recent evidence suggests the continuous cycle of inflammation in HS is initiated by follicular plugging, or occlusion from hyperkeratosis and hyperplasia of the infundibular epithelium. Diagnosis of HS is clinical, relying heavily on a thorough history and physical exam. Lifestyle changes and medical management are the first-line treatments for a new diagnosis of HS. Surgical procedures are oftentimes reserved for those unresponsive to topical and system medical management, or have severe stage III, persistent disease. Wide excision of all neighboring affected areas is associated with some of the lowest recorded rates of recurrence. Defects following wide excision can be reconstructed with skin grafts depending on the location and depth of the defect. Fasciocutaneous and musculocutaneous flaps continue to gain popularity in recent years for their ability to cover large defects with superior aesthetic outcomes and overall improvement in quality of life.
