The literature on surgical treatment of hidradenitis suppurativa is huge and the review of this disease goes back to the 1950s [16–19]. Recently, many articles have been published regarding this point and some recent key references exist regarding surgical treatment of hidradenitis suppurativa [20, 21]. Primary closure, healing by secondary intention and skin grafting are considered to be the most widely used procedures. Furthermore, several surgical techniques depending on secondary intention for minor or extensive disease are also described in the literature .
In fact, 18,75 % recurrence rate can be considered high after extensive surgery procedures. On the other hand, this recurrence rate was strongly associated with the extent (Hurley grade) of disease. Herein, in very advanced cases with Hurley grade III, it can be very hard to radically remove all HS tissue even if very extensive surgery is applied and at least minor recurrence is expected and accepted. Sartorius score cannot, but Hurley classification with clinical margin evaluation can possibly give valuable information for proper treatment options.
Excision and split skin grafting is a basic tool in the surgical treatment and the result of this procedure is often satisfactory [22–24]. Massive regional hidradenitis suppurativa can be successfully managed with wide surgical excision, VAC therapy, and skin grafting for better outcomes . Furthermore, Negative-pressure dressings have been used as bolster for skin grafts in order to reconstruct such defects after wide surgical excision [26, 27].
However, the use of flaps to prevent less favorable functional results was introduced at an early stage. A review of the Limberg flap for axillary hidradenitis was presented quite recently . Local fasciocutaneous V-Y advancement flaps was reported for large defects following wide surgical excision of long-standing hidradenitis suppurativa of the axilla . Other option is the double opposing V-Y perforator-based flaps which have been described for reconstruction of axillary defects following excision of hidradenitis suppurativa to recreate the axillary contour after wide surgical excision of the hair-bearing skin of the axilla . More options exist like the use of a versatile transpositional flap for axillary hidradenitis suppurativa . Some flaps may be indicated in particular cases such as the use of thoracodorsal artery perforator flap (TDAP) in axillary hidradentitis suppurativa [32, 33]. Herein, lateral thoracic fasciocutaneous island flap was also used for treatment of recurrent hidradenitis axillaris suppurativa and other axillary skin defects .
The pedicled gracilis myocutaneous flap has been introduced as a surgical treatment of hidradenitis suppurativa of the groin and perineum . It was even proposed that the medial thigh lift to be considered for immediate defect closure after radical excision of localised inguinal hidradenitis suppurativa provided that no perifocal signs of infection are present after debridement . Furthermore, modified abdominoplasty was also reported as a functional reconstruction for recurrent hidradenitis suppurativa of the lower abdomen and groin . The anterolateral thigh (ALT) flap has been reported for reconstruction of groin and vulval hidradenitis suppurativa . Furthermore, the anterior Obturator Artery Perforator (aOAP) flap seems to be a save option for the reconstruction of perineal defects after wide surgical excision of hidradenitis suppurativa , although it was not introduced specifically for this disease.
It should be noted that the use of colostomy is not an absolute indication for treating such defects in the perianal or perineal region. We believe that flaps in these areas are more susceptible to infections. Colostomy can be performed but should be preserved for selected patients with massive extensive defects. Some patients do not agree with colostomy and, thus the consent of this procedure does not apply in many cases. However, this does not interfere with the selected treatment plan.
For buttocks, more options have been stated in the literature such as the fasciocutaneous flaps in gluteal hidradenitis suppurativa . Other options were also documented such as the extended split superior gluteus maximus musculocutaneous flap. This flap is easy to harvest and leaves aesthetically satisfactory results .
There is no doubt that this approach of treatment is mainly dependent on the size and the site of the defect. Despite the method of reconstruction, the hospitalization period can be reduced and, thus reducing the cost of treatment. This goal can be elusive and therefore radical excision and more advanced reconstruction techniques are performed in order to close defects in a permanent way. We found that wide surgical excision as well the direct closure technique showed better outcome and limited the cost of treatment and the hospitalization period as well as the recurrence rate.
It is of great importance to determine the timing of wide surgical excision and the selected method of reconstruction. During the acute phase, surgical drainage, irrigation with the administration of antibiotics should only be the mainstay of the treatment. Our approach has not been conducted in this phase. It was important to obtain a non-infectious wound to perform this approach and not to expect septic complications. Then, planning of reconstruction should be initiated to achieve the best outcome and consequently decreasing the risk of recurrence and complications after surgery.