Case 18 (2023): Surgical management of hidradenitis suppurativa
Ema Šutáková med. stud., Dominika Miklišová med. stud., Mirka Verbat med. stud., Julia Bartková
Abstract
A 59 year old female presented with chronic hidradenitis suppurativa in both axillae, lower quadrants of breasts, inframammary folds and both groins. She had a medical history of essential hypertension treated by angiotensin II receptor antagonists, hypothyroidism on thyroid hormone replacement therapy and type II diabetes treated by oral antidiabetic drugs. She underwent a hysterectomy in 2007. H
BeforeAfterA 59 year old female presented with chronic hidradenitis suppurativa in both axillae, lower quadrants of breasts, inframammary folds and both groins. She had a medical history of essential hypertension treated by angiotensin II receptor antagonists, hypothyroidism on thyroid hormone replacement therapy and type II diabetes treated by oral antidiabetic drugs. She underwent a hysterectomy in 2007. Hidradenitis suppurativa first occured in 2020. Considering risk factors, the patient denies smoking, but presents obesity as a significant risk factor with body mass index 33,6. She had negative family history of hidradenitis suppurativa. Female gender is another risk factor to be considered as this disease occurs more frequently in female with a female:male ratio 3:1. The overall prevalence of hidradenitis suppurativa was found to range between 0.7% and 1.2% in the European-US population. (1,2)
Multiple interconnected sinus tracts and fibrotic scarring in left axilla and upper lateral quadrant of left breast.
2
Marking the areas of planned excision.
3
Excision of the affected areas under general anesthesia in both axillae and upper lateral quadrant of right breast. Before the preparation of the operating field started, a skin swab had been performed and sent for microbiological examination with further negative result. After that preparation of the surgical field started with disinfection by povidone-iodine topical disinfectant and draping the surgical field to maintain sterility. We then proceeded with the excision of the areas. Electrocoagulation was used for hemostasis.
4
Excision of the affected areas on the right side.
5
In the first intention the defects in the axillae were partially closed by deep dermal suture and simple interrupted epidermal suture. The rest of the wound bed was temporarily covered by sterile polyethylene mesh with polyurethane foam dressing to prepare the wound surface for further dermoepidermal graft autotransplantation. Skin stapler was used for fixation of the dressing. The defects of the upper lateral quadrants of the breasts were closed by deep dermal suture and simple interrupted epidermal suture. The patient had systemic antibiotic profylaxis to decrease the risk of infection of the wound. In the second intention, about 10 days after the procedure, the wound was covered by autologous dermoepidermal skin graft meshed 1:1,5. The donor site of the autotransplant was the left inner thigh. The graft was fixed by skin stapler.
6
Dressing placement on the right side.
7The patient was seen 4 months post-op in the outpatient clinic for a follow-up, the wound was without any signs of infection, skin graft was vital, contracture was not present. The patient denied any signs of discomfort or pain in the areas or limitations in range of motion. Second follow-up was made by phone-call 18 months post-op, the patient presents no contracture of the skin grafts and is very satisfied with the esthetic result. She has no recurrence of hidradenitis suppurativa in the axillae. There is a persistent difference in color of the graft and the surrounding skin, but the patient does not see it as an issue.
The patient continues the treatment of hidradenitis suppurativa by adalimumab and she has regular follow-up visits with a dermatologist.
How to cite this article
Ema Šutáková med. stud., Dominika Miklišová med. stud., Mirka Verbat med. stud., Julia Bartková. Case 18 (2023): Surgical management of hidradenitis suppurativa. Journal of Plastic, Breast & Reconstructive Surgery. 2023.
Open access. © 2023 The Author(s). Published by the Journal of Plastic, Breast & Reconstructive Surgery. Copyright to this case is shared between the author(s) and the journal; authors may reuse their own case for education, presentations and social media.
Keep reading
Related cases
Case 20 2026: Staged Excision and Delayed Primary Closure of a large Nodular Basal Cell Carcinoma of the Anterior Scalp
Mikkel Halborg Sørensen, Nanja Gotland Sundstrup, Christian Lyngsaa Lang
Keywords: Basal cell carcinoma, scalp reconstruction, staged excision, primary closure, scalp biomechanics. Authors: Mikkel Halborg Sørensen, MD; Nanja Gotland Sundstrup, MD; Christian Lyngsaa Lang, MD. Institution: Department of Plastic Surgery and Burns, Rigshospitalet, Copenhagen University Hos-pital, Denmark Abstract A 48-year-old woman was referred with a non-radically excised nodular basal cell carcinoma of the anterior scalp complicated by wound infection and dehiscence. Re-excision with 3 mm margins to the galea was performed under local anesthesia. Given local inflammation and uncertain margin status, delayed reconstruction was planned pending histopathological confirmation. After clear margins were verified, controlled subgaleal undermining allowed tension-reduced primary closure. This staged strategy ensured oncologic safety while preserving hair-bearing scalp and avoiding unnecessary flap reconstruction. Patient medical history A 48-year-old woman was referred after incomplete excision of a nodular basal cell carcinoma (nBCC) of the anterior scalp performed in private plastic surgery practice. Histology demonstrated tumor involvement of the lateral margins, while the deep margin was free of tumor. Postoperatively, wound rupture and infection developed. Microbiology showed sparse growth of Staphylococcus aureus, and antibiotic therapy was initiated. The patient was otherwise non-smoking and healthy, with well-treated asthma, as her only relevant comorbidity. Before and After Patient examination Clinical examination revealed a 22 × 19 mm anterior scalp defect with limited perifocal erythema and minimal purulent discharge. No regional lymphadenopathy was palpable. Pre-operative considerations Initial histopathology demonstrated nodular basal cell carcinoma with focal lateral margin involvement and a clear deep margin, without perineural invasion or other high-risk features. In accordance with current recommendations for low-risk BCC, re-excision with 3 mm c
Case 22 2026: Superior Gluteal vessel: A rarely used recipient for free flap reconstruction of lumbosacral defects: a case report.
Tushar Dutta, Arun PS, Swati Sattavan
Keywords: Superior gluteal vessel, free flap reconstruction, lumbosacral defects Authors: 1. Tushar Dutta, Consultant Plastic Surgeon; 2. Arun PS, Consultant Surgical Oncologist; 3. Swati Sattavan, Consultant Surgical Oncologist; Institute: State Cancer Institute, Guwahati, Assam, India Abstract Lumbosacral defects that are too large for local flap reconstruction should be considered for microvascular free tissue transfer. However, lack of suitable recipient vessels in the area makes the task technically difficult. Options such as thoracodorsal and inferior gluteal vessels extended with vein grafts and AV loops have been described. Each option has its own drawbacks. Despite having a short course at its origin, the superior gluteal vessel is a viable alternative. We describe here a case where the vessel was dissected out with adequate length and used as a recipient for free flap reconstruction. Patient medical history The patient was a 41-year-old lady with no known comorbidities. She presented to us with a large lumbosacral mass that had been growing for one year. Before visiting our center, she had been operated twice at other institutions and had recurrences after each occasion. During the last three months the mass had started to grow rapidly and caused ulceration. There was no pain or fever. There was no neurological involvement of lower limbs. Patient had an ECOG status 1. Before and After Patient examination A 17x 22 cm mass was noted encompassing the left part of lumbosacral region and crossing the midline to the opposite side. The superior limit of the lesion was at the L3 vertebra and inferior extent was near the coccyx. Skin ulceration was noted at the center of the mass. On palpation, the mass was warm to touch, hard in consistency and immobile. Skin was fixed and fixity was also noted to the underlying muscle. No tenderness was elicited. Surrounding possible donor sites for flap harvest showed no scars. Pre-operative considerations Preoperative biopsy co
Case 23 2026: “Minimally Invasive Finger Amputation Using a Volar ‘Toilet seat’ Flap for Invasive Squamous Cell Carcinoma”
Claes Hannibal Killerich, Nikolaj Warming
Keywords: Squamous cell carcinoma; finger amputation; volar flap; local reconstruction; traction neurectomy; hand surgery. Authors: Claes Hannibal Killerich, Nikolaj Warming Abstract A 93-year-old woman presented with a chronic non-healing dorsal finger wound initially diagnosed as actinic keratosis. Repeat biopsy revealed invasive squamous cell carcinoma with joint and bone involvement. Due to the extent of invasion, distal amputation of the third finger was required. Reconstruction was performed using a volar “toilet seat” flap under digital nerve block to minimize surgical burden. The procedure achieved clear margins, preserved stump length, and avoided donor-site morbidity. This case highlights the importance of early re-biopsy of non-healing lesions and adapting surgical strategy to patient age, function, and comorbidity. Patient medical history A 93-year-old woman presented with a wound on the dorsal aspect of the proximal phalanx of the left third finger. A primary biopsy revealed actinic keratosis, and the lesion was treated several times with curettage and electrodesiccation by a private dermatologist. Despite repeated treatments under professional supervision, the wound failed to heal.Due to the persistent non-healing nature of the lesion, a repeat biopsy was performed, confirming the diagnosis of squamous cell carcinoma (SCC). The patient was referred to the Department of Plastic Surgery, Aalborg University Hospital, where a primary excision was performed with a 7 mm surgical margin. Histopathological examination demonstrated invasive tumor growth involving both joint and bone. The defect was subsequently reconstructed using a full-thickness skin graft. Before and After Patient examination The left third finger showed a healed full-thickness skin graft on the dorsal aspect of the proximal phalanx, covering the proximal interphalangeal (PIP) joint. There was no visible residual tumor, and no palpable lymphadenopathy in the left cubital fossa or axillary re