Surgical Methods of Management for Hidradenitis Suppurativa: A Narrative Review

Sally Ng, MBBS, FRACS (Plas)

Plastic and Reconstructive Surgeon, Austin Health, 145 Studley Rd, Heidelberg, Victoria 3084, Australia; E-mail: sally.ng@austin.org.au

INTRODUCTION

Hidradenitis Suppurativa (HS), also known as acne inversa, is a chronic inflammatory condition that affects millions worldwide.^1,2 HS is characterised by the development of painful nodules, abscesses and sinus tracts which can become infected and purulent.

Excruciating pain, reduction in range of motion (ROM) and issues with mental health and self-esteem are reported as significant, and detrimental to patient quality-of-life (QoL).³ The severity of HS is most often measured using the Hurley staging system, ranging from I-III. Stage I is characterised by the presence of abscesses without any sinus tracts or scarring. Stage II involves multiple abscesses or sinus tracts existing in a single area. In stage III, sinus tracts and scarring are interconnected, and multiple abscesses occur in the region.¹ Figure 1 describes the different stages of the Hurley staging system.

Figure 1. Photos of HS Lesions

(a) Hurley stage I HS with one or possibly two solitary nodules. (b) Hurley stage II HS with multiple abscesses. (c) Hurley stage III HS with diffuse and connected abscesses, sinus tracts and cicatrization.

For mild HS, management is typically conservative in nature, involving topical antiseptic wash or topical antibiotics such as 0.1% clindamycin.⁴ Other options for mild to moderate HS are the use of long course oral antibiotics, or in severe cases, treatment with biological agents such as tumour necrosis factor (TNF) inhibitors adalimumab or infliximab.⁵

Surgery is indicated when HS is not medically responsive and is considered the only definitive treatment for recurrent abscesses and sinus tracts associated with stage II-III HS.⁶ Currently there are a wide range of approaches available, however, there is no consensus on the timing and type of surgery that should be performed. As such, this review aims to critically evaluate the surgical methods of treating HS and their outcomes, as reported in the literature.

METHODS

The Ovid Medline and PubMed databases were used to search for relevant literature. Manuscripts with type I-V⁷ evidence were included. The search phrases used for both databases were as follows:

– (Acne inversa OR hidradenitis suppurativa) AND (surgery OR surgical) AND (management OR treatment) with the following filters applied: Last 10-years, Full text available in English.

Inclusion Criteria

1. The full text was available in English.
2. The literature was published in the last 10 years (2012- current).
3. The article was relevant to the surgical treatment of hidradenitis suppurativa with a surgical treatment defined as “the use of instrumentation or manual methods to make an incision or remove body tissues in the treatment of a pathological process”.
4. The primary outcome of “recurrence of HS after surgery” was reported.

Secondary outcomes assessed in included articles were: surgical complications, restriction in ROM post-surgery and QoL changes post-surgery.

Exclusion Criteria

– The article did not report whether recurrence occurred post-surgery.
– The recurrence rate was not linked to a defined surgery method.
– The article was a review.

RESULTS

The search yielded 326 results, 33 duplicates were removed, and 293 articles underwent title and abstract screening. The title and the abstract were assessed using the inclusion and exclusion criteria and 145 articles were sought for a full text review. Two articles could not be retrieved in English and thus only 143 articles were analysed in the full text review. During the full text review articles were read in full and assessed against the exclusion and inclusion criteria. At the end of this process 48 articles were included in the review. Figure 2 summarises the search.

Figure 2. PRISMA Flow Diagram of the Screening Process Used in this Review

Incision and Drainage/Deroofing

Procedures Incision and drainage (I&D) is typically used in more acute disease lesions either when only abscesses or nodules exist, such as Hurley Stage I disease. After thorough washout of the cavity, the wound is packed with dressings and allowed to heal secondarily.

Deroofing is a procedure in which a superficial portion of a nodule or sinus tract is excised, leaving the floor of the tract or nodule to allow for more rapid re-epithelisation with the wound left to heal by secondary intention. A skin tissue sparing excision and electrosurgical peeling (STEEP) technique is a type of deroofing whereby a HS lesion is removed in a layer-by-layer fashion until the floor of the tracts is left. Table 1 outlines the articles that performed I&D and deroofing procedures included in this review.

Surgical Excision

Surgical excision, either wide or radical, was the most reported surgical treatment. It was typically offered for Hurley Stage II or III disease. The wound was either allowed to heal by secondary intention (SIH), primarily closed, or reconstructed with a skin graft or flap. Wide excision typically detailed excision down to healthy tissue whereas radical excision typically referred to excision down to muscle fascia. Table 2 summarises the studies that used primary closure or healing by secondary intention following excision of HS.

Skin Grafting/Flap

Reconstruction Split thickness skin grafts (STSG) were used as a single stage reconstruction or two stage reconstruction with an adjunct such as negative pressure wound therapy (NPWT) or dermal matrices used as bridging treatments prior to definitive skin grafting.²⁴ Table 3 summaries the articles that examined skin grafts as a wound closure method post-surgery.

Multiple tissue flaps have been described to reconstruct various defects. The flaps used were all variations of perforator flaps with different characteristics such as donor site and advancement method. In perforator flap reconstruction, perforator vessels are left intact as the flap is moved to its new location creating a “pedicle” that connects the donor site with reconstruction site that the flap has been moved to. This type of reconstruction is beneficial in HS cases as it allows for areas with wide defects to be reconstructed. Table 4 summarises the articles reporting flap use as part of the surgical management of HS.

Novel Techniques

Three novel techniques were identified in the literature search. These techniques involved removing diseased tissue using CO₂ lasers using a layer-by-layer approach like the STEEP procedure. Table 5 summaries the articles using novel techniques.

DISCUSSION

There was no standardised treatment protocol for HS. Less invasive methods such as incision and drainage were offered for early HS (Hurley stage I) and were sometimes paired with the use of hydrogen peroxide or cryo insufflation with liquid nitrogen. These methods aimed to optimise healing by removing the bacterial load in the area. These treatments were effective in reducing pain and discomfort associated with HS lesions. However, they were also associated with a moderate rate of recurrence (19-30%). It should be noted that there was a small number of articles that reported I&D procedures and as such the recurrence rates are most likely not indicative of all I&D patients.

Deroofing procedures reported recurrence rates of 0 to 30% with the most common complication being post-surgical hyper-granulation.^9,10 Recurrence in these procedures is thought to be related to unexcised diseased follicles that were either deep to the margins of the deroofing or from sinuses that were not completely deroofed⁹ or from previously normal follicles that have progressed to become diseased after the procedure. The success of deroofing procedures is heavily determined by the ability of the surgeon to identify and deroof all lesions in the area or patient factors such as the severity of HS or complexity of sinus networks. Deroofing appears to be a viable option for patients not suited to or not willing to undergo larger procedures, however, there have not been any large cohort studies examining efficacy, nor have there been any trials comparing it to other surgical methods.

Surgical Excision

Management after excision was varied. Primary closure and healing by second intention were associated with shorter operating time and required less follow-up monitoring, but were associated with high rates of recurrence, with rates between 18% and 75% in larger cohort studies (n>30). The reported complication rates varied significantly between the articles that examined methods using excision and repair with primary closure or healing by second intention. However, the most frequently reported complications were wound infections and post-operative pain.^{12,16,18–22,24} Some proposed reasons for this were that secondary intention healing and primary closure were typically suited to smaller wounds. Limited excision is likely to leave some diseased follicles behind and thus leave a seed for recurrence. However, this has not been proven.

Most of the patients who underwent secondary intention healing or primary closure had HS of Hurley stage I-II and this may be because primary closure (PC) and SIH may not be possible for wide and deep wounds. More severe Hurley stage II or Hurley stage III HS typically encompass wider areas and have tracts extending deeper into the dermis or adipose tissue of the area and the large wounds left from complete excision of diseased tissue would be difficult to close using PC and may lead to significant restrictions in ROM. Wide excision with SIH or primary closure is most suited to less severe HS or smaller disease areas in regions that are easier to access or where ROM impairment is not as big of a factor.

Skin Grafts

Skin grafts were a commonly reported method of wound closure after wide or radical excision of HS. There were two main methods of skin grafting, immediate or delayed. In some delayed grafting methods, adjunct treatments such as vacuum dressing assisted NPWT, or dermal matrices, were used to aid granulation tissue formation and vascularisation of said tissue before grafting. The aim of this was to improve ROM and aesthetic outcomes by reducing scar contracture. These adjuncts were commonly used in axillary cases of HS where ROM impairment significantly impairs QoL.^24,26,36

Most articles examined reported no recurrence of HS post excision and skin graft, however Ovadja et al²¹ and Mendes et al¹⁹ reported recurrence rates of 63% and 50% with samples sizes of 11 and 2 respectively. Similarly, to deroofing procedures, it is postured that local recurrence stems from incomplete removal of diseased follicles or from progression of healthy follicles to a diseased state. The most common complication was wound dehiscence, but the rates were highly varied between papers. Overall, skin grafting, especially when used after surgical excision was reported to be an effective treatment for HS with low recurrence and good outcomes functionally (low ROM restriction) and aesthetically, while being appropriate for HS of large areas. Thus, suggesting that these methods could be applied to HS of high severity in most areas of the body. It is noted however that delayed skin grafting with adjuvants requires a high-level of patient adherence, as these methods involve regular wound dressing management or temporary movement restricting braces such as 90-degree abduction shoulder braces to optimise the NWPT or extracellular matrix (ECM) adjuncts. As such, optimal treatment results require discussion on these points to be held before treatment is commenced.

Flap Reconstruction

The aim of using flaps was to allow for large areas of radical excision to excise as much diseased tissue as possible, while having a method of reconstruction that would be able to close the site and allow for good functional outcomes. Flaps help achieve this goal as having their own blood supply, flaps can be used to cover large areas while also being unlikely to exhibit any contraction and thus are unlikely to impair ROM in the long-term.⁵⁷

The use of flaps does pose some challenges. Procedures involving flaps take significantly longer than other options such as skin grafting and are often more complicated with considerations for the flap donor site, flap blood supply, flap advancement and long-term flap monitoring, needing to be made. Within this study, flaps were typically reported to be used for cases of axillary HS or gluteal/groin HS where the lesion area was large. The flaps used were local or perforator flaps with no free flaps being reported. Recurrence rates were generally low with the majority of articles reporting rates between 0% and 7%, however, a small number of articles reported higher recurrence rates of 18%-53% with moderate patient sample sizes (n=25 to n=100). Complication rates varied with reports ranging from no complications to 42% complication rates post-surgery. Of the reported complications, wound dehiscence and minor flap necrosis were the most reported and highlight the complexities of constructing flaps with adequate blood supply and underlining the need for long-term surveillance of the flap. Positive functional outcomes were widely reported especially in axillary cases of HS. Shoulder ROM was reported to range between 160° of abduction and full ROM post-surgery and the reporting of contracture was rare, occurring along scar lines along the flap’s border in some cases but did not significantly hinder ROM. Overall flap reconstruction was effective at preserving ROM and covering areas of wide excision like those found in the treatment of severe HS. Of note however, is the increase in complexity in surgery and treatment follow-up when using flaps.

Novel Techniques

The novel techniques identified revolved around laser ablation or removal of diseased tissue. Hazen et al⁵⁵ and Mikkelsen et al⁵⁶ examined the use of CO₂ laser to ablate diseased tissue while Abdel Azim et al⁵⁴ examined CO₂ laser ablation and Nd:YAG laser treatments. Nd:YAG lasers work by emitting a wavelength or radiation that is highly absorbed by hair follicles and thus theoretically destroys or partially cauterises the follicle. Recurrence rate varied, ranging from 0 to 45% with CO₂ laser treatment, while Nd:YAG monotherapy was reported to have a 80% recurrence rate. A positive characteristic of laser ablation is that the ablation of tissue also provides a haemostatic effect like electrocautery which could be beneficial during treatment of wide areas or areas with a higher bleeding risk.

LIMITATIONS

There were several factors that prevented quantitative comparison between articles reporting different surgical treatment methods. Reporting of outcomes was incredibly varied. There was no standard follow-up time, no standard set of reported outcomes and recurrence rate was often variable even when comparing articles examining similar procedures. Ununiform reporting was further compounded by the heterogenous nature of HS with differing disease morphology and patient co-morbidities making each case slightly different and not directly comparable to other patients. The inclusion of all articles with evidence levels of type I-V meant that novel and small sample size procedures could be assessed and discussed but also meant that quantitative comparisons would not be reliable. Comparisons between QoL improvement could not be made as this was not widely reported and a common scale for assessing this was not adopted between studies.

CONCLUSION

Surgical management is an effective treatment for HS. It has the potential to be curative even in severe cases of HS. Factors such as surgeon preference, disease severity and patient goals influence what treatment is offered. Despite this, most methods share the same principle of excision of as much diseased tissue as possible. For Hurley Stage I lesions, incision and drainage is the less invasive option that is effective in managing symptoms such as pain. For Hurley Stage II-III lesions, wide excision with reconstruction seems to be a curative option that preserves function of the affected area. However, there are currently no randomised control trials comparing different methods and this is likely due to the heterogenicity of disease morphology and lack of defined treatment algorithm.

CONFLICTS OF INTEREST

The authors declare that they have no conflicts of interest.

1. Ovadja ZN, Schuit MM, van der Horst CMAM, Lapid O. Interand intrarater reliability of Hurley staging for hidradenitis suppurativa. Br J Dermatol. 2019; 181(2): 344-349 doi: 10.1111/bjd.17588

2. Jfri A, Nassim D, O’Brien E, Gulliver W, Nikolakis G, Zouboulis CC. Prevalence of hidradenitis suppurativa: A systematic review and meta-regression analysis. JAMA Dermatol. 2021; 157(8): 924- 931. doi: 10.1001/jamadermatol.2021.1677

3. Matusiak Ł. Profound consequences of hidradenitis suppurativa: A review. Br J Dermatol. 2020; 183(6): e171-e177. doi: 10.1111/bjd.16603

4. Alavi A, Kirsner RS. Local wound care and topical management of hidradenitis suppurativa. J Am Acad Dermatol. 2015; 73(5 Suppl 1): S55-S61 doi: 10.1016/j.jaad.2015.07.048

5. van Rappard DC, Mekkes JR, Tzellos T. Randomized controlled trials for the treatment of hidradenitis suppurativa. Dermatol Clin. 2016; 34(1): 69-80 doi: 10.1016/j.det.2015.08.012

6. Saunte DML, Jemec GBE. Hidradenitis suppurativa: Advances in diagnosis and treatment. JAMA. 2017; 318(20): 2019-2032 doi: 10.1001/jama.2017.16691

7. Burns PB, Rohrich RJ, Chung KC. The levels of evidence and their role in evidence-based medicine. Plast Reconstr Surg. 2011; 128(1): 305-310 doi: 10.1097/PRS.0b013e318219c171

8. Haoxiang X, Chengrang L, Baoxi W, Xinfeng W. Modified abscess drainage in treatment of eight cases with hidradenitis suppurativa in China. Dermatol Surg. 2013; 39(5): 779-783 doi: 10.1111/dsu.12110

9. Janse IC, Hellinga J, Blok JL, et al. Skin-tissue-sparing excision with electrosurgical peeling: A case series in hidradenitis suppurativa. Acta Derm Venereol. 2016; 96(3): 390-391. doi: 10.2340/00015555-2258

10. Lin CH, Chang KP, Huang SH. Deroofing: An effective method for treating chronic diffuse hidradenitis suppurativa. Dermatol Surg. 2016; 42(2): 273-275. doi: 10.1097/DSS.0000000000000609

11. Molina-Leyva A, Salvador-Rodriguez L, Martinez-Lopez A, Cuenca-Barrales C. Effectiveness, safety and tolerability of drainage and punch-trocar-assisted cryoinsufflation (cryopunch) in the treatment of inflammatory acute fluid collections in hidradenitis suppurativa patients. J Eur Acad Dermatol Venereol. 2019; 33(5): e221-e223. doi: 10.1111/jdv.15406

12. Ravi S, Miles JA, Steele C, Christiansen MK, Sayed CJ. Patient impressions and outcomes after clinic-based hidradenitis suppurativa surgery. JAMA Dermatol. 2022; 158(2): 132-141. doi: 10.1001/jamadermatol.2021.4741

13. Chen YE, Gerstle T, Verma K, Treiser MD, Kimball AB, Orgill DP. Management of hidradenitis suppurativa wounds with an internal vacuum-assisted closure device. Plast Reconstr Surg. 2014; 133(3): 370e-377e. doi: 10.1097/PRS.0000000000000080

14. Deckers IE, Dahi Y, van der Zee HH, Prens EP. Hidradenitis suppurativa treated with wide excision and second intention healing: A meaningful local cure rate after 253 procedures. J Eur Acad Dermatol Venereol. 2018; 32(3): 459-462 doi: 10.1111/jdv.14770

15. DeFazio MV, Economides JM, King KS, et al. Outcomes after combined radical resection and targeted biologic therapy for the management of recalcitrant hidradenitis suppurativa. Ann Plast Surg. 2016; 77(2): 217-222 doi: 10.1097/SAP.0000000000000584

16. Fertitta L, Hotz C, Wolkenstein P, et al. Efficacy and satisfaction of surgical treatment for hidradenitis suppurativa. J Eur Acad Dermatol Venereol. 2020; 34(4): 839-845 doi: 10.1111/jdv.16135

17. Ezanno AC, Fougerousse AC, Guillem P, Resoverneuil G. The role of negative-pressure wound therapy in the management of axillary hidradenitis suppurativa. Int Wound J. 2022; 19(4): 802-810. doi: 10.1111/iwj.13678

18. Kofler L, Schweinzer K, Heister M, Kohler M, Breuninger H, Hafner HM. Surgical treatment of hidradenitis suppurativa: An analysis of postoperative outcome, cosmetic results and quality of life in 255 patients. J Eur Acad Dermatol Venereol. 2018; 32(9): 1570- 1574. doi: 10.1111/jdv.14892

19. Mendes RRdS, Zatz RF, Modolin MLA, Busnardo FDF, Gemperli R. Radical resection and local coverage of hidradenitis suppurativa-acne inversa: Analysis of results. Rev Col Bras Cir. 2018; 45(3): e1719. doi: 10.1590/0100-6991e-20181719

20. Ngaage LM, Wu Y, Ge S, et al. Factors influencing the local cure rate of hidradenitis suppurativa following wide local excision. Int Wound J. 2020; 17(1): 117-123 doi: 10.1111/iwj.13241

21. Ovadja ZN, Bartelink SAW, Hadi K, van de Kar AL, van der Horst C, Lapid O. A multicenter analysis of wide excision and reconstruction for severe anogenital hidradenitis suppurativa. Ann Plast Surg. 2021; 86(2): 193-200 doi: 10.1097/SAP.0000000000002554

22. Posch C, Monshi B, Quint T, Vujic I, Lilgenau N, Rappersberger K. The role of wide local excision for the treatment of severe hidradenitis suppurativa (Hurley grade III): Retrospective analysis of 74 patients. J Am Acad Dermatol. 2017; 77(1): 123-129.e5. doi: 10.1016/j.jaad.2017.01.055

23. Shavit E, Pawliwec A, Alavi A, George R. The surgeon’s perspective: A retrospective study of wide local excisions taken to healthy subcutaneous fat in the management of advanced hidradenitis suppurativa. Can J Surg. 2020; 63(2): E94-E99. doi: 10.1503/cjs.003119

24. Kraft C, Pearson G. Axillary hidradenitis reconstruction using a dermal regeneration template. Wounds. 2022; 34(2): 43-46. doi: 10.25270/wnds/110121.01

25. Ayala D, Dhanasekara CS, Thomas K, et al. Surgical management of advanced hidradenitis suppurativa via a one-stage procedure: A single-center experience. Am J Surg. 2020; 220(6): 1462- 1466. doi: 10.1016/j.amjsurg.2020.10.004

26. Chaffin AE, Buckley M-C. Extracellular matrix graft for the surgical management of Hurley stage III hidradenitis suppurativa: A pilot case series. J Wound Care. 2020; 29(11): 624-630. doi: 10.12968/jowc.2020.29.11.624

27. Chen ML, Odom B, Santucci RA. Surgical management of genitoperineal hidradenitis suppurativa in men. Urology. 2014; 83(6): 1412-1417. doi: 10.1016/j.urology.2014.01.011

28. El-Helou E, Kansoun A, Abi Fadel E, et al. A novel technique for the treatment of a case of verneuil’s disease of perineum and axillary regions. Surg J (N Y). 2021; 7(3): e163-e167. doi: 10.1055/s0041-1731400

29. Ge S, Orbay H, Silverman RP, Rasko YM. Negative pressure wound therapy with instillation and dwell time in the surgical management of severe hidradenitis suppurativa. Cureus. 2018; 10(9): e3319. doi: 10.7759/cureus.3319

30. Gonzaga TA, Endorf FW, Mohr WJ, Ahrenholz DH. Novel surgical approach for axillary hidradenitis suppurativa using a bilayer dermal regeneration template: A retrospective case study. J Burn Care Res. 2013; 34(1): 51-57 doi: 10.1097/BCR.0b013e31826a7be7

31. Hsiao SC, Chang CH, Huang SH. Recycled split-thickness skin grafting: A novel treatment for axillary hidradenitis suppurativa. Dermatol Surg. 2021; 47(8): 1142-1143 doi: 10.1097/DSS.0000000000002935

32. Lim SYD, Cheong EC, Oon HH. Management of severe hidradenitis suppurativa with biologic therapy and wide excision. Arch Plast Surg. 2019; 46(03): 272-276. doi: 10.5999/aps.2018.00339

33. Maeda T, Kimura C, Murao N, Takahashi K. Promising longterm outcomes of the reused skin-graft technique for chronic gluteal hidradenitis suppurativa. J Plast Reconstr Aesthet Surg. 2015; 68(9): 1268-1275. doi: 10.1016/j.bjps.2015.05.025

34. Steele AW, Miller NF, Wallace SJ, et al. Hidradenitis suppurativa: A comparison of institutional experience and the tracking operations and outcomes for plastic surgeons registry. Plast Reconstr Surg. 2022; 149(5): 1216-1224. doi: 10.1097/PRS.0000000000009024

35. Wormald JC, Balzano A, Clibbon JJ, Figus A. Surgical treatment of severe hidradenitis suppurativa of the axilla: Thoracodorsal artery perforator (TDAP) flap versus split skin graft. J Plast Reconstr Aesthet Surg. 2014; 67(8): 1118-1124. doi: 10.1016/j.bjps.2014.04.032

36. Yamashita Y, Hashimoto I, Matsuo S, Abe Y, Ishida S, Nakanishi H. Two-stage surgery for hidradenitis suppurativa: Staged artificial dermis and skin grafting. Dermatol Surg. 2014; 40(2): 110-115. doi: 10.1111/dsu.12400

37. Alharbi M, Perignon D, Assaf N, Qassemyar Q, Elsamad Y, Sinna R. Application of the inner arm perforator flap in the management of axillary hidradenitis suppurativa. Ann Chir Plast Esthet. 2014; 59(1): 29-34. doi: 10.1016/j.anplas.2013.10.005

38. Elboraey MA, Alali AB, Alkandari QA. Immediate and delayed reconstruction after excision of axillary hidradenitis suppurativa using a propeller flap. Plast Reconstr Surg Glob Open. 2019; 7(8): e2387. doi: 10.1097/GOX.0000000000002387

39. Elgohary H, Nawar AM, Zidan A, Shoulah AA, Younes MT, Hamed AM. Outcome of pedicled thoracodorsal artery perforator flap in the surgical treatment of stage II and III hidradenitis suppurativa of Axilla. Ann Plast Surg. 2018; 81(6): 688-693 doi: 10.1097/SAP.0000000000001658

40. Fu S, Fan J, Liu L, et al. Aesthetic mental and cervical reconstruction after severe acne inversa by using a bilateral pedicled expanded forehead flap. J Craniofac Surg. 2012; 23(6): e615-e617 doi: 10.1097/SCS.0b013e31826cf6b2

41. Hallock GG. Island thoracodorsal artery perforator-based V-Y advancement flap after radical excision of axillary hidradenitis. Ann Plast Surg. 2013; 71(4): 390-393 doi: 10.1097/SAP.0b013e31824b3e42

42. Hoang D, Chen V, Saber S, Patel K, Carey J. Bilateral pedicled superficial inferior epigastric artery flap in the treatment of hidradenitis suppurativa. Plast Reconstr Surg Glob Open. 2016; 4(8): e833 doi: 10.1097/GOX.0000000000000847

43. Marchesi A, Marcelli S, Zingaretti N, Parodi PC, Vaienti L. Pedicled thoracodorsal artery perforator and muscle-sparing latissimus dorsi flaps in the axillary reconstruction after hidradenitis suppurativa excision: Functional and aesthetic issues. Ann Plast Surg. 2018; 81(6): 694-701. doi: 10.1097/SAP.0000000000001664

44. Marchesi A, Amendola F, Garieri P, Steinberger Z, Vaienti L. Wide local excisions and pedicled perforator flaps in hidradenitis suppurativa: A study of quality of life. Ann Plast Surg. 2021; 86(2): 201-205 doi: 10.1097/SAP.0000000000002482

45. Mutaf M, Gunal E, Berberoglu O, Gokce A. Surgical treatment of extensive sacrococcygeal hidradenitis suppurativa with triangular closure technique. Ann Plast Surg. 2014; 73(5): 583-587 doi: 10.1097/SAP.0b013e3182840831

46. Nail-Barthelemy R, Stroumza N, Qassemyar Q, Delage M, Nassif A, Atlan M. Evaluation of the mobility of the shoulder and quality of life after perforator flaps for recalcitrant axillary hidradenitis. Ann Chir Plast Esthet. 2019; 64(1): 68-77. doi: 10.1016/j.anplas.2018.01.003

47. Nesmith RB, Merkel KL, Mast BA. Radical surgical resection combined with lymphadenectomy-directed antimicrobial therapy yielding cure of severe axillary hidradenitis. Ann Plast Surg. 2013; 70(5): 538-541 doi: 10.1097/SAP.0b013e31828ea7cb

48. Oliveira M, Sayed C. Surgical treatment of intermammary hidradenitis suppurativa with a 3-point advancement flap (Mercedes Closure). Dermatol Surg. 2020; 46(11): 1457-1460 doi: 10.1097/DSS.0000000000002102

49. EndNote™. !!! INVALID CITATION !!!. Web site. https://community.endnote.com/t/invalid-citation/259536. Accessed November 11, 2022.

50. Rodriguez JM, Rodriguez F, Rivera D, Naranjo K. Treatment of hidradenitis suppurativa with extensive resection of the lesion and coverage with perforator flaps of the lateral thoracic wall (Lateral Thoracic Artery, Thoracodorsal Artery Perforators). Plast Reconstr Surg Glob Open. 2019; 7(2): e2096. doi: 10.1097/GOX.0000000000002096

51. Teo W-L, Ong Y-S, Tan B-K. Radical surgical excision and use of lateral thoracic flap for intractable axillary hidradenitis suppurativa. Arch Plast Surg. 2012; 39(06): 663-66. doi: 10.5999/aps.2012.39.6.663

52. Thomson DR, Saltrese S, Mehdi S. Modified posterior arm flap for axillary hidradenitis suppurativa. Ann Plast Surg. 2022; 88(1): 84-87. doi: 10.1097/SAP.0000000000002819

53. Virág TH, Kadar IA, Matei IR, Georgescu AV. Surgical management of hidradenitis suppurativa with keystone perforator island flap. Injury. 2020; 51: S41-S47. doi: 10.1016/j.injury.2020.03.025

54. Abdel Azim AA, Salem RT, Abdelghani R. Combined fractional carbon dioxide laser and long-pulsed neodymium: Yttrium-aluminium-garnet (1064 nm) laser in treatment of hidradenitis suppurativa; a prospective randomized intra-individual controlled study. Int J Dermatol. 2018; 57(9): 1135-1144. doi: 10.1111/ijd.14075

55. Hazen PG, Daoud S. Scrotal hidradenitis suppurativa with secondary lymphedema and lymphangiomata: Successful management with carbon dioxide laser excision and marsupialization. Dermatol Surg. 2015; 41(3): 431-432. doi: 10.1097/DSS.0000000000000302

56. Mikkelsen PR, Dufour DN, Zarchi K, Jemec GB. Recurrence rate and patient satisfaction of CO2 laser evaporation of lesions in patients with hidradenitis suppurativa: A retrospective study. Dermatol Surg. 2015; 41(2): 255-260 doi: 10.1097/DSS.0000000000000264

57. Le Cocq H, Stanley PRW. Closing the gap: Skin grafts and flaps. Surgery (Oxford). 2011; 29(10): 502-506 doi: 10.1016/j.mpsur.2011.06.021