A review of wide surgical excision of hidradenitis suppurativa

Background Hidradenitis suppurativa (HS) is a chronic inflammatory cutaneous disorder that involves the infundibular terminal follicles in areas rich of apocrine glands. It can be associated with fistulating sinus, scarring and abscesses formation. Hidradenitis suppurativa is a challenging aspect and requires a proper treatment plan which may involve different specialties. We present herein the option of surgical treatment involving wide surgical excision and methods of reconstruction as well as the rate of recurrence. Furthermore, review of the literature regarding surgical treatment of hidradenitis suppurativa is provided. Methods A retrospective analysis reviewed 50 operative procedures for 32 patients in 5 anatomical sites. These anatomical sites have been divided to 23 sites involving the axilla, 17 sites involving the inguinal region and 8 sites involving the perianal/perineal area, 1 site involving the gluteal region and 1 site involving the trunk region. Results Twenty six patients (81, 25 %) showed no recurrence after surgery and the average time of hospital stay period was 5 days. Recurrence was observed only in 6 patients (18, 75 %). Conclusion Elimination of the acute inflammatory process should occur in advance, including the use of antibiotics and minor surgeries such as abscess drainage with proper irrigations. After stabilizing the acute phase, wide surgical excision is recommended. Herein, planning of surgical reconstruction should be initiated to achieve the best outcome and consequently decreasing the risk of recurrence and complications after surgery.


Background
Hidradenitis suppurativa (HS) is a chronic inflammatory cutaneous disorder that involves the infundibular terminal follicles in areas rich of apocrine glands and associated with formation of abscesses and fistulating sinus [1][2][3][4][5]. The pathogenesis of the disease is not fully understood, although it was reported that HS is androgen dependent that can be associated with endocrine abnormalities [6]. Bacterial infection is considered as a secondary event in the pathogenesis. Furthermore, smoking and obesity are both known as risk factors and may increase the severity of the disease [1,6].
Clinical manifestations include painful nodules, abscesses, sinus tracts, and ropelike hypertrophic scars in the apocrine gland-bearing areas [7]. Consequently, the abscesses extend deeper into the subcutaneous tissue and then intercommunicating sinus tracts develop, resulting in irregular hypertrophic scars [8]. Hidradenitis suppurativa was initially classified by using Hurley's Staging System (Table 1) [9].
Likewise, Sartorius et al. have suggested that the Hurley system is not enough to assess the efficacy of the treatment. Therefore, they described the Sartorius Staging System. Points are accumulated in each category to assess the treatment of HS in an accurate way [11]. The Sartorius Staging System [12] accumulates points according to: Anatomic regions involved Number and types of lesions involved (abscesses, nodules, fistulas, scars, points for lesions of all regions involved) The distance between lesions, in particular the longest distance between two relevant lesions (i.e. nodules and fistulas in each region or size if only one lesion present) The presence of normal skin in between lesions It is indeed a challenging aspect and requires a proper treatment plan that may involve different specialties. Hidradenitis suppurativa is commonly misdiagnosed and sometimes even referred to many subspecialties [13]. In general, treatment includes the use of topical or systemic antibiotics, topical antiseptics and intralesional corticosteroids. Furthermore, systemic retinoids, antiandrogen therapy, immunotherapy (TNF alfa inhibitors) and oral immunosuppressive agents have also shown a positive effect on disease progression [10,12]. However, for most cases of advanced hidradenitis suppurativa, radical surgery can be the only curative treatment option [14]. It is also reported that early wide surgical excision is important and effective in order to prevent complications and the recurrence of hidradenitis suppurativa and to improve the quality of life [15].
This article focuses on the surgical treatment of hidradenitis suppurativa with special regard to the methods of reconstruction for resulted defects after wide surgical excision in the axilla, inguinal region, gluteal region, trunk, perineal and perianal area. The rate of recurrence will be also reviewed. Furthermore, a review of the literature regarding surgical treatment of hidradenitis suppurativa is provided.

Methods
This retrospective analysis reviewed 32 patients with chronic inflammatory moderate to severe hidradenitis suppurativa (Hurley grade II and III) treated in our hospital from 2003 to 2009 (Table 2). Follow up of all patients has been conducted in our out patient department (OPD) with a mean period of 24 months after surgery. 50 operative procedures were retrospectively reviewed in 5 anatomical sites, 23 sites involving the axilla, 17 sites involving the inguinal region and 8 sites involving the Perianal/perineal area, 1 site involving the gluteal region and 1 site involving the trunk region. The regional ethics committee advised that approval was not necessary for this retrospective analysis. However, all patients have provided written informed consent for the publication of their clinical details and any accompanying clinical images.
The patients had chronic inflammatory hidradenitis suppurativa (Hurley grade II and III). Intravenous antibiotics were prescribed depending on wound tissue swab  Reconstruction of the perianal and the perineal regions included the using of transposition fasciocutaneous flap in 6 sites (75 %) and Gracilis musculocutaneous flap was used in 2 patients (25 %). Reconstruction of the trunk and gluteal region was carried out for only two patients by performing a split thickness skin graft for each site.

Results
Daily dressing has been performed in a sterile concept. Twenty eight Patients (87,5 %) showed no complications after surgery. The average time of hospital stay period was 5 days. Physiotherapy and post-operative rehabilitation were also started.
Reconstruction of the inguinal region included primary closure for mild and moderate lesions. Likewise, split-thickness skin grafting was selected for large defects. Rotation fasciocutaneous flap and transposition fasciocutaneous flap were performed successfully and showed good aesthetic results. For bilateral inguinal lesions and involvement of Mons pubis, an abdominoplasty was performed for one patient and showed good outcome.
For lesions located on the perianal and the perineal regions, several techniques have been carried out including the use of bilateral transposition flap (Figures 5,6,7,8,and 9) or the using of Gracilis musculocutaneous flap for severe lesions. Both techniques required preservation    of the vulva and the anal sphincter. For lesions located in the gluteal and the trunk area, skin grafting was used successfully.

Discussion
The literature on surgical treatment of hidradenitis suppurativa is huge and the review of this disease goes back to the 1950s [16][17][18][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 [21].
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][23][24]. Massive regional hidradenitis suppurativa can be successfully managed with wide surgical excision, VAC therapy, and skin grafting for better outcomes [25]. 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 [28]. Local fasciocutaneous V-Y advancement flaps was reported for large defects following wide surgical excision of long-standing hidradenitis suppurativa of the axilla [29]. 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 hairbearing skin of the axilla [30]. More options exist like the use of a versatile transpositional flap for axillary hidradenitis suppurativa [31]. 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 [34].
The pedicled gracilis myocutaneous flap has been introduced as a surgical treatment of hidradenitis suppurativa of the groin and perineum [35]. 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 [36]. Furthermore, modified abdominoplasty was also reported as a functional reconstruction for recurrent hidradenitis suppurativa of the lower abdomen and groin [37]. The anterolateral thigh (ALT) flap has been reported for reconstruction of groin and vulval hidradenitis suppurativa [38]. 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 [39], 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 [40]. 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 [41].
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.

Conclusion
Treatment of hidradenitis suppurativa has wide modalities. However, surgical option can be the option of treatment especially for those severe cases being treated with conservative modalities. After eliminating the acute inflammatory phase, wide surgical excision is recommended and planning of reconstruction should be initiated to achieve the best outcome and consequently decreasing the risk of recurrence and complications after surgery. Our concept of treatment including reconstructive techniques decreased the time of hospital stay. It is cost effective and prevented skin contractures as well as excessive scarring and showed good functional and aesthetic results.