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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)

Rodriguez, Jorge M., MD*; Rodriguez, Felipe, MD*; Rivera, Daniel, MD; Naranjo, Karol, MD

Plastic and Reconstructive Surgery – Global Open: February 2019 - Volume 7 - Issue 2 - p e2096
doi: 10.1097/GOX.0000000000002096
Case Report
Open
Colombia

Summary: Stage IV hidradenitis suppurativa in the axilla is a chronic disease in which the removal of the affected area and a reconstruction with disease free skin is the definitive treatment; however there is some controversy about the technique to be used in this reconstruction. Studies show superiority in wide resections, and coverage with flaps rather than grafts. The use of pedicle flaps of lateral thoracic artery perforators and thoracodorsal artery perforators has demonstrated superior performance to other techniques in postsurgical follow-up. This article describes the cases of 2 patients with chronic HS in which lesions were resected with disease-free margins and the reconstruction of the defect is carried out with lateral thoracic wall perforator flaps and the subsequent improvement in their life quality after surgery.

From the *Department of Plastic Surgery, San Vicente Fundacion Hospital, Rionegro, Colombia

Department of Plastic Surgery, Nueva Granada Military Hospital, Bogota, Colombia

Department of Plastic Surgery, SOMER Clinic, Rionegro, Colombia.

Published online 5 February 2019.

Received for publication February 17, 2018; accepted November 7, 2018.

Disclosure: The authors have no financial interest to declare in relation to the content of this article. The Article Processing Charge was paid for by the authors.

Jorge M. Rodriguez, MD, San Vicente Fundación Hospital, Llanogrande-Aeropuerto José María Córdova St., km 2.3, Rionegro, Colombia, E-mail: drjorgerodriguez@surgicalgroup.com.co

This is an open-access article distributed under the terms of the Creative Commons Attribution-Non Commercial-No Derivatives License 4.0 (CCBY-NC-ND), where it is permissible to download and share the work provided it is properly cited. The work cannot be changed in any way or used commercially without permission from the journal.

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INTRODUCTION

HS refers to the acute or chronic inflammation of the sweat glands by occlusion, the typical place of appearance is the groin and the axila, with an incidence of 1% reaching up to 4.1% according to some authors.1–6 Other commonly affected areas are the perianal and perineal region.7

Most patients (64.7%) state that the improvement in their quality of life, as measured by the Dermatological Life Quality Index (DLQI), improved significantly when they underwent invasive procedures rather than taking antibiotics, regardless of the location and extent of resection.7

Even though the gold standard for managing advanced stages of the disease is resection of the affected skin, there is debate about which is the proper technique for coverage. Recent studies have compared the use of the thoracodorsal artery perforator flap (TDAP) versus skin grafts for the reconstruction of axillary defects after resection, finding a better postoperative response (shorter recovery time, fewer complications, shorter follow-up, and a better life quality) in those treated with the TDAP flap rather to those treated with skin grafts only.10

The use of a lateral thoracic artery perforator flap has also been described, demonstrating a rapid recovery without the need to immobilize the arm, with a scar that easily hides behind the arm in a neutral position11,12 or, as in one of our cases, the possibility to hide within the brassiere line.

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CASE 1

Case Description

A 38-year-old female patient presents with axillary HS, in whom medical treatments have been exhausted, with a previous history of multiple partial resection of the lesions, resulting in scarring in the axilla with limitation of the range of motion at the shoulder but with frequent relapses of the HS.

The affected area is marked, and a handheld Doppler is used to identify the suitable vessels on the lateral thoracic wall (Fig. 1). On the right side, lateral thoracic artery is identified running close to the mid axillary line and marked; also, thoracodorsal artery perforator is found 2 cm behind the latissimus dorsi border and 10 cm below the axillary fold and marked. The skin paddle is designed so the resulting scar will be hidden by the bra. Then the residual scar tissue and the remaining of the skin affected is completely resected. An exploratory incision is made at the upper border of the flap, using loupe magnification, the most suitable vascular pedicle is selected, on this case the lateral thoracic pedicle is used and dissected proximally and tunneled under the skin until the skin paddle sits on the recipient site without tension, the flap is then sutured, making sure that the pedicle has no kinking or twisting that may alter the blood flow to the flap. Primary closure of the donor area is then performed.

Fig. 1.

Fig. 1.

The procedure was performed in 2 stages, one for each side.

Two months later, the surgery on the contralateral side is performed in the same manner, but on this case the thoracodorsal perforator is found more suitable and is used for the reconstruction by dissecting it through and beneath the latissimus dorsi muscle.

Two-month postoperative follow-up, no scar retraction and full ROM, with no residual affected tissue (Fig. 2).

Fig. 2.

Fig. 2.

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CASE 2

Case Description

A 27-year-old patient with HS, previously managed with multiple antibiotic regimens, without significant improvement.

The patient had a significant negative impact on his life quality with these suppurative lesions, so the DLQI scale was performed before the procedure, reaching the highest score (30), which implies an “extremely large affectation of the patient’s quality of life.”

Multiple lesions can be seen in the with foul odor and leakage in the right axilla (Fig. 3).

Fig. 3.

Fig. 3.

The perforators from thoracodorsal systems are found 8 cm from the axilla and 2 cm from the posterior axillary line. The area of the lesion is completely resected and the TDAP flap is raised by loupe magnification, dissecting its pedicle until it is long enough for the flap to be tunneled to the recipient site without any tension. The donor area is closed by rising the local skin with primary closure. Same procedure is done at the contralateral side.

At 2 months, the benefits of this type of resection and flap reconstruction are clearly appreciated, with upper limbs with normal ROM, no signs of residual disease, and an acceptable aesthetic result. In addition, a DLQI scale is performed with a score of 0, meaning “no effect on the daily life of the patient.”

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DISCUSSION

HS is a chronic and debilitating pathology that affects the quality of life of those who suffer it, being the complete resection of the affected area the most effective way to manage it on its most advanced stages. In the axillary area, partial resection or graft coverage can lead to scar retractions with decreasing ranges of shoulder motion and unpleasant scar formation.

Wide resection and reconstruction with pedicled perforator flaps is validated as an alternative with an excellent functional and aesthetic result for the axillary region for HS management, achieving complete remission as a dermatological pathology in the treated area.

We consider that a proper preoperative marking with vascular Doppler, careful dissection of the selected pedicle with loupe magnification, and a tension-free closure of the flap are paramount for a successful reconstruction.

Fig. 4.

Fig. 4.

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REFERENCES

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2. Collier F, Smith RC, Morton CA. Diagnosis and management of hidradenitis suppurativa. BMJ. 2013;346:f2121.
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8. Revuz JE, Jemec GB. Diagnosing hidradenitis suppurativa. Dermatol Clin. 2016;34:1–5.
9. Esmann S, Jemec GB. Psychosocial impact of hidradenitis suppurativa: a qualitative study. Acta Derm Venereol. 2011;91:328–332.
10. Wormald JC, Balzano A, Clibbon JJ, et al. Surgical treatment of severe hidradenitis suppurativa of the axilla: thoracodorsal artery perforator (TDAP) flap versus split skin graft. J Plast Reconstr Aesthet Surg. 2014;67:1118–1124.
11. Schwabegger AH, Herczeg E, Piza H. The lateral thoracic fasciocutaneous island flap for treatment of recurrent hidradenitis axillaris suppurativa and other axillary skin defects. Br J Plast Surg. 2000;53:676–678.
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Copyright © 2019 The Authors. Published by Wolters Kluwer Health, Inc. on behalf of The American Society of Plastic Surgeons.