Author's: Martins, Ana¹; Teixeira, Nelson¹ 

Affiliations: 1 – Plastic and Reconstructive Department of Hospital Egas Moniz – Unidade Local de Saúde Lisboa Ocidental (ULSLO);  

Authors declare that the contents of this article are their own original unpublished findings.

Corresponding Author: Email: anaisabelmartins@campus.ul.pt; Adress: Rua da Junqueira, 126, 1349-019 Lisboa, Portugal; Telephone: +351912309394; ORCID: 0009-0001-0445-0442

ABSTRACT 

Hidradenitis suppurativa (HS) is a chronic inflammatory disease of the apocrine gland-rich areas of the hair follicles, commonly affecting the axilla, groin and perineum.

The need for surgical reconstruction of the axilla are not seen frequently, however after radical excision of axillary fistulous tracts in HS, reconstruction of the subsequent axillary defects should be accurately planned. Though these defects can heal secondarily, be closed primarily with direct closure or skin grafts, this is less desirable as it may cause contractures and limitation in the range of movement. Alternatively, reconstruction can be done with musculocutaneous or fasciocutaneous flaps (like parascapular, lateral intercostal artery perforator, thoracodorsal artery perforator and posterior arm flap).

With this report we aim to present a review on the knowledge regarding the etiology and the developments on medical-surgical approach of HS, in particular cases of the axillary region. Here we present our series of 4 patients (2 male, 2 female) aged between 19 and 37 years who presented with HS grade II-III Hurley in the axillary region in which two presented bilateral lesions. After extended excision surgery, each patient underwent reconstruction with posterior arm flap, either island or skin bridge, which we evaluated retrospectively.

Despite various conservative therapeutic options, the radical surgical approach is considered the most effective in advanced stages of HS. Here we show that the posterior arm flap is a better option comparing to the randomized geometric flaps, like the Limberg, as this option in the literature is described as leading to local fibrosis which, in the event of an eventual recurrence, makes revision surgeries too difficult. From our perspective, posterior arm flaps should be considered as the primary option during the planning stages of axillary reconstruction.

Keyword's: Hidradenitis suppurativa, Hurley Classification, Adalimumab, Axillary Reconstruction, Fasciocutaneous Flap, Posterior Arm Flap

INTRODUCTION

Hidradenitis suppurativa, also known as acne inversa, is a chronic, inflammatory, recurrent, debilitating skin disease of the terminal hair follicle. Usually presents after puberty with painful, deep-seated, inflamed lesions in the apocrine gland-bearing areas of the body, most commonly the axillary, inguinal, and anogenital regions. The onset of HS is typically in the second to fourth decades and it affects about 1% of young European adults, with a female to male ratio of approximately 3:1 [1]. It is a multifactorial disease in which genetic and environmental factors play a key role. A family history of HS has been demonstrated in 40% of patients although the exact mechanism of inheritance remains unclear [2]. Also African‐ Americans develop HS at a rate that is 2.5 times greater than that of Caucasians [3].

The first severity classification of HS was proposed by Hurley in 1989, categorizing patients into three stages based mainly on the presence of sinus tracts and scarring. The stages are: I, the most common, includes abscess formation, single or multiple, without sinus tracts and cicatrization; II consisting in recurrent abscesses with tract formation and cicatrization, single or multiple, widely separated; and III which includes diffuse or near-diffuse involvement or multiple interconnected tracts and abscesses across the entire area [4]. A more complex and detailed scoring, better suited to accurately assess disease severity and grade of inflammation, was proposed in 2003 - the Sartorius Scoring system [5]. However, this score may be timeconsuming in routine clinical practice. Nowadays, the Hurley staging and the Sartorius scoring, together with HS Physician Global Assessment systems are the most used assessment tools.

In advanced stages, recurrences are frequent especially in cases undergoing only medical therapy or limited excision. Medical therapy can be used as monotherapy in the case of biological drugs or as adjuvant role to surgery. However, the surgical approach with extended resection is the only treatment with curative potential. It is also reported that early wide surgical excision is important and effective in preventing complications, avoiding recurrence, and improving the patient’s quality of life [6]. Parks et. al recommend that wide excision should be performed by removing all subcutaneous tissue down to the deep underlying fascia from all hair bearing skin or at least excision of a minimum of 5 mm of subcutaneous fat, to ensure that the apocrine glands have been removed [7]. Reconstruction after wide excision is important in terms of wound healing time and cosmetic results. The reconstruction method does not influence disease recurrence and should be chosen according to the size and location of the excised area.

The present case series is a reminder that although axillary defects are unusual, they emerge after radical excision of axillary fistulous tracts in HS, and reconstruction should be accurately planned and executed as the axilla contains a variety of relevant neurovascular structures that should be protected and requires enough mobility to allow shoulder joint function. In our case series we show that the posterior arm flap is a useful and reliable option, either island and skin bridge, for covering axillary defects.

CASE PRESENTATION

We present our series of 4 patients (2 male, 2 female) aged between 19 and 37 years who were referred to a Plastic and Reconstructive Surgery appointment with HS grade II-III Hurley in the axillary region (figure 1). In two patients, the lesions were bilateral. Only one of the patients was non-smoker.

Fig 1. Our serie of 4 patients (2 male, 2 female) aged between 19 and 37 years who had presented with HS grade II-III Hurley in the axillary region. In two patients - (B) and (D) - the lesions were bilateral.

All the procedures were performed under general anaesthesia. Patients were placed in supine position with their involved upper extremity abducted by 90 grades and a pillow placed under the scapula. Methylene blue dye was injected in the affected area into each fistula with a blunt tip-cannula until the dye overflowed from the fistula tract, which help the delimitation of the zone of excision.

The excision tissue included all macroscopically affected skin, subcutaneous tissues dyed with methylene blue, and the deformed fibrotic tissue. We perform a wide excision down to the deep underlying fascia, preserving the underlying neurovascular structures. The dimensions of the defect are measured and flaps were designed in an elliptical shape, proportionate to the size of the defect, with the long axis of each located in the midline on the posterior aspect of the arm and extending between the olecranon and the posterior axillary line (figure 2). The farthest length of the flap reach the junction of distal 1/3rd of the arm. The width of the flap was determined via pinch test, trying not to exceed the width of 7-8cm which will allow primary closure of the donor area. 

Fig 2. After extended excision surgery patients underwent reconstruction with posterior arm flap either island or skin bridge. In this case we choose to carry an island flap.

We use an intraoperative handheld Doppler device which helped in marking the perforator artery. In all cases, this artery was located 1 to 2 cm medial to the long head of the triceps muscle and 3 to 4 cm distal to the axillary crease. The elevation of the flap was initiated distally, and as the dissection proceeded proximally, the triceps muscle fascia were included in the flap. After the pedicle was observed entering the flap through the undersurface, the branch supplying the medial head of the triceps could need to be ligated in order to gain extra pedicle length.

The posterior arm flap is designed either islanded or skin bridge, deciding intraoperatively according to the best fit of the flap. In our serie of cases, usually in the relatively large defect cases (wider than 10cm in width) we designed the flap with small skin bridges.

After the adaptation of the flaps, closure was performed in 2 layers. However, the donor site closure was performed in 3 layers (fascia, subcutaneous tissue, and skin). No splintage was utilised in any case, at any point of management. Patients were discharged usually between the fourth and fifth postoperative day. Follow-up of patients ranged from 12 to 36 months.

As long as patients collaborate and have support in home, in the bilateral cases we routinely performed both sides simultaneously, following a two-team approach. We choose a single-staged procedure since the time taken for surgery was reduced with a two-team approach and the need for second general anaesthesia is avoided. This also reduces the period of absence from work and is cost-effective for the hospital.

We offer a relatively early surgical intervention irrespective of previous medical treatment. Two patients were under biologic medication with Adalimumab and this same ones needed surgical revisions for partial dehiscence. In one case the revision consisted in flap readvancement and in the second case in flap readvancement and grafting of wound dehiscence areas.

Fig 3. Postoperative result after 1 year (A) and 3 years (B). The patients have no functional limitation or donor site morbidity at long term follow up. This flap ensures a good tissue match and leaves a well concealed scar on the arm.

In the postoperative period, around 8 to 34 months of post-surgery, patients show no functional donor site morbidity and an acceptable scar on the posterior arm which is well hidden – “brachioplasty like incision” (figure 3). The flap insetting ensures a great aesthetic result, without recurrence of the pathology. This flap is actually not bulky and doesn’t obstruct shoulder movements – the full range of movement was achieved in all of the cases.

In our serie, island flaps are easier to adapt, can be transferred based on the pivot point (perforating artery) up to 180º and closed without tension. Pedicled flaps, which are used for the greater axillary defects, allow for less mobilization, so the more distal area may be closed with greater tension and are more prone to suffer from dehiscence. In our serie, dehiscence happened only in the pedicle flaps of patients undergoing the anti-TNF medication (Adalimumab) (figure 4).

Fig 4. Postoperative result after around 8 to 34 months. The last two patients (C) and (D), who were under biologic medication with Adalimumab, needed surgical revisions for partial dehiscence. After total cicatrization, no patient had recurrence of the disease in this localization.

DISCUSSION

Reconstruction of the axillary region included several techniques but there is a lack of general consensus on the best method. Although the method of surgical repair did not seem to affect the local recurrence rate in most literature [8], some studies reported recurrence rates as 54-70% after primary repair, 0-33% after skin graft application, and 0-6.6% after reconstruction with flaps [9]. This could be explained given that the defects that allow primary closure and skin grafting are generally smaller defects, whose excision will probably not have been as radical as necessary, increasing the likelihood of recurrence.

Actually, secondary healing is less desirable as it requires a long and demanding period of time for closure, may cause contractures and subsequent limitation in the arm's range of movement leading to stiffening of the shoulders. Primary closure is only possible in limited excision and not in wide local excision, which is defined as >1 cm beyond hair bearing skin and has the best cure rate [10]. Also direct closure is not ideal as it results in complications such as contractures and excessive scarring. Skin grafts could be done as single-time or staged procedure, which was considered superior (like artificial dermal matrix with graft or topical negative pressure dressing with graft). However, unesthetic results associated with excessive scarring and contractures usually occur.

Local flaps including transposition flaps such as Limberg flaps, rotation flaps, or V-Y advancement flaps can also be used in the reconstruction of axilla, and provide both sufficient coverage and good color matches. However, their limited mobilization capacity makes these flaps unsuitable for the reconstruction of larger defects. Furthermore, they cause areas of local fibrosis, which in the event of an eventual recurrence, make revision surgeries too difficult.

As local skin is not the most advisable, various regional and distant flaps have been described trying to overcome these shortcomings. Musculocutaneous flaps (like pectoralis major and latissimus dorsi flaps) or fasciocutaneous flaps (like parascapular, lateral intercostal artery perforator, thoracodorsal artery perforator and posterior arm flap) have been outlined. Pectoralis major and latissimus dorsi flaps can interfere with function of the upper extremity due to its bulk (as they prevent optimal adduction) and they also cause higher morbidity of the donor area (associated with the donor muscle function deficit).

Soldin et al. concluded that different flaps can be used depending on the size of the excised defect, recommending a fasciocutaneous randomized flaps for small to medium defects and pedicled fasciocutaneous axial flaps (like the parascapular flap and posterior arm flap) for larger defects [11].

Depending on the two cutaneous branches of the circumflex scapular artery, the scapular flap, which is designed horizontally, and the parascapular flap, which is designed obliquely, have been described. However, these flaps can manage mainly posterior fold contracture and have a limitation in mainly anterior fold contractures (which can be overcome with skeletonizing the pedicle, passing the flap through the triangular space, and transferring it anteriorly [12]). Actually, the major factor against this flap is the common widening of the dorsal donor site scars, which because of the location are already quite visible.

The lateral intercostal artery perforator flap (LICAP) is devoid of the problem of bulkiness, has good reach with width that allow donor site primary closure. Still, the donor site scar that results is quite visible as it extends from the lateral mammary fold to approximately 5 cm posterior to the posterior axillary line.

The thoracodorsal artery perforator (TDAP) flap was demonstrated in several studies to reduce recovery time and have fewer postoperative complications. Also, it has shown the ability to maintain the diamond shape of the axilla with minimal donor site morbidity. However, it leaves a more visible donor site scar. 

The posterior arm flap was initially described by Masquelet in 1985 as a free flap [13] and after by Elliot in 1992 as a pedicled fasciocutaneous transposition flap [14]. This flap is a direct axial fasciocutaneous flap from the posterior surface of the arm, supplied by a posterior cutaneous unnamed branch (constant in 71% of patients) arising from the artery supplying the medial head of triceps, and this muscular branch comes from either the brachial artery or profunda brachial artery [15]. This cutaneous branch enters the posterior aspect of arm at the angle between the long head of the triceps and latissimus dorsi, beneath a fibrous band joining these two muscles. It is drained by the accompanying venae comitantes. It is a sensate flap which is innervated by the first medial sensory branch of the radial nerve and the posterior brachial cutaneous nerve, which makes it suitable for reconstruction of defects in zones requiring sensory innervation.

The posterior arm perforator flap is a reliable option and offers several advantages for axillary reconstruction – it’s a sensate flap, ensures good tissue match, has no functional donor site morbidity and leaves an acceptable scar on the arm with improvement to the contour (actually it is a “brachioplasty like incision”). In our serie of cases, as described in literature, the donor site could be closed immediately with widths up to 7cm.

In our serie, the flaps that needed revision for partial dehiscence was the pedicle ones but only in patients undergoing Adalimumab. Adalimumab, sold under the brand name Humira, is a humanized monoclonal anti-TNF-alpha IgG1 antibody, administered by subcutaneous injection. The mechanism of action is based on both the neutralization of TNF-alpha bioactivity and the induction of apoptosis of TNF-expressing mononuclear cells, dampening inflammatory pathways [16]. This is the only biologic agent registered for management of moderate-to-severe HS, approved by the European Medicines Agency (EMA) and the Food and Drugs Administration (FDA), and shows clinical response in up to 60% of patients [17].

In our serie it was not possible to conclude on the rate of complications associated with flap adaptation. However, our results showed that patients undergoing Adalimumab have higher probability of a revision surgery (for dehiscence). We believe these are patients with a more aggressive disease and with higher basal inflammatory load that could explain this complication.

To point out, recent studies demonstrate that this human monoclonal antibody anti-TNF is an effective and safe adjunctive therapy to surgery during the perioperative and post operative periods [18]. Some studies even show that the effect of biologics was greater in patients who also underwent surgery, that the timing of biologics relative to surgery did not impact efficacy and that patients who received HS surgery with biologic therapy were most likely to achieve the 75% reduction in active nodule count [19]. In contrast, other studies showed that time to wound closure by secondary intention healing, after wide-excision surgery is significantly prolonged not only by higher Hurley stage but also for treatment with biologics [20].

Actually, studies considered Adalimumab treatment efficacious in conjunction with wide-excision surgery (followed by secondary intention healing) for moderate to severe HS, indicating no need to interrupt Adalimumab treatment prior to surgery. Based on the more recent evidence for this knowledge, our patients continue to receive Adalimumab in the pre and post operative period. However, only wide-excision surgery followed by secondary intention healing was assessed in this studies and not other options of closure or secondary reconstruction (like locoregional flaps) and further studies are needed to confirm these results, especially the role of Adalimumab in post surgical wound healing of flaps.

CONCLUSION

Hidradenitis suppurativa is a chronic debilitating skin disease, leading to a substantial impact on quality of life and sexual health. Despite various conservative therapeutic options, the radical surgical approach is considered most effective in advanced stages of HS. The resulting axillary defects could heal by secondary intention, direct closure, skin grafts, musculocutaneous or fasciocutaneous flaps. However, it is reasonable to conclude that most studies agree that flap reconstruction is superior to the other options.

The posterior arm flap is a better option comparing to geometric flaps, like the Limberg, because this one causes areas of local fibrosis that, in the event of an eventual recurrence, makes revision surgeries too difficult. The posterior arm flap ensures a great aesthetic result with a well-hidden donor site scar and allows a full range of movements. From our perspective, it should be considered among the primary options during the planning stages of axillary reconstruction.

Our results showed that patients undergoing Adalimumab could have higher probability of needing a revision surgery (for dehiscence), although more studies are needed to state this assertively and considering that our small sample is a limitation to take this conclusion. We postulate that these patients have more aggressive disease with higher basal inflammatory load that could explain this complication. Although, recent studies demonstrate that this human monoclonal antibody anti-TNF is an effective and safe adjunctive therapy to surgery, and should be maintained during the perioperative period.

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