Reconstruction of the Axillary Region after Excision of Hidradenitis Suppurativa: A Systematic Review

Abstract

Introduction Hidradenitis suppurativa (HS) is a chronic, debilitating, recurrent, auto-inflammatory disease of the pilosebaceous units of the skin. The axillary region is the most affected anatomical site and its reconstructive options include skin grafts, local random plasties, regional axial flaps, and regional perforator flaps. The main aim of this systematic review is to identify the best surgical technique for axillary reconstruction in the context of HS, in terms of efficacy and safety.

Methods We adhered to Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) throughout the whole review protocol build-up. The literature search was performed using MEDLINE, Embase, and Cochrane library databases, updated to March 2021. Quality was assessed for each study, through the National Institutes of Health Quality Assessment Tool.

Results A total of 23 studies were included in the final analysis. We reviewed a total of 394 axillary reconstructions in 313 patients affected by HS Hurley Stage II or III. Skin grafts were associated with the highest overall complication rate (37%), and highest rate of reconstruction failure (22%). Between thoraco-dorsal artery perforator flap, posterior arm flap, and parascapular flap, the latter showed fewer total complications, recurrences, and failures.

Conclusion Regional axial flaps should be considered as the best surgical approach in the management of advanced HS. The parascapular flap emerges as the most effective and safest option for axillary reconstruction. Local random flaps might be considered only for selected minor excisions, due to the higher risk of recurrence. The use of skin grafts for axillary reconstruction is discouraged.

Keywords

hidradenitis suppurativa - axillary hidradenitis - axillary reconstruction - parascapular flap

• References

• 1 Slade DE, Powell BW, Mortimer PS. Hidradenitis suppurativa: pathogenesis and management. Br J Plast Surg 2003; 56 (05) 451-461
• 2 Alikhan A, Lynch PJ, Eisen DB. Hidradenitis suppurativa: a comprehensive review. J Am Acad Dermatol 2009; 60 (04) 539-561 , quiz 562–563
• 3 Narla S, Lyons AB, Hamzavi IH. The most recent advances in understanding and managing hidradenitis suppurativa. F1000 Res 2020; 9: F1000 F1000 Faculty Rev-1049
• 4 Garg A, Kirby JS, Lavian J, Lin G, Strunk A. Sex- and age-adjusted population analysis of prevalence estimates for hidradenitis suppurativa in the United States. JAMA Dermatol 2017; 153 (08) 760-764
• 5 Ortiz CL, Castillo VL, Pilarte FS, Barraguer EL. Experience using the thoracodorsal artery perforator flap in axillary hidradenitis suppurativa cases. Aesthetic Plast Surg 2010; 34 (06) 785-792
• 6 Danby FW, Hazen PG, Boer J. New and traditional surgical approaches to hidradenitis suppurativa. J Am Acad Dermatol 2015; 73 (5, Suppl 1): S62-S65
• 7 Taylor EM, Hamaguchi R, Kramer KM, Kimball AB, Orgill DP. Plastic surgical management of hidradenitis suppurativa. Plast Reconstr Surg 2021; 147 (03) 479-491
• 8 Page MJ, McKenzie JE, Bossuyt PM. et al. The PRISMA 2020 statement: an updated guideline for reporting systematic reviews. BMJ 2021; 372 (71) n71
• 9 Study Quality Assessment Tools | NHLBI, NIH. https://www.nhlbi.nih.gov/health-topics/study-quality-assessment-tools Accessed April 21, 2022
• 10 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 (01) 68-77
• 11 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 (06) 688-693
• 12 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 (08) e2387
• 13 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 (06) 694-701
• 14 Elliot D, Kangesu L, Bainbridge C, Venkataramakrishnan V. Reconstruction of the axilla with a posterior arm fasciocutaneous flap. Br J Plast Surg 1992; 45 (02) 101-104
• 15 Morgan WP, Harding KG, Hughes LE. A comparison of skin grafting and healing by granulation, following axillary excision for hidradenitis suppurativa. Ann R Coll Surg Engl 1983; 65 (04) 235-236
• 16 Soldin MG, Tulley P, Kaplan H, Hudson DA, Grobbelaar AO. Chronic axillary hidradenitis–the efficacy of wide excision and flap coverage. Br J Plast Surg 2000; 53 (05) 434-436
• 17 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 (08) 676-678
• 18 Geh JLC, Niranjan NS. Perforator-based fasciocutaneous island flaps for the reconstruction of axillary defects following excision of hidradenitis suppurativa. Br J Plast Surg 2002; 55 (02) 124-128
• 19 Altmann S, Fansa H, Schneider W. Axillary hidradenitis suppurativa: a further option for surgical treatment. J Cutan Med Surg 2004; 8 (01) 6-10
• 20 Varkarakis G, Daniels J, Coker K, Oswald T, Akdemir O, Lineaweaver WC. Treatment of axillary hidradenitis with transposition flaps: a 6-year experience. Ann Plast Surg 2010; 64 (05) 592-594
• 21 Busnardo FF, Coltro PS, Olivan MV, Busnardo APV, Ferreira MC. The thoracodorsal artery perforator flap in the treatment of axillary hidradenitis suppurativa: effect on preservation of arm abduction. Plast Reconstr Surg 2011; 128 (04) 949-953
• 22 Jandali S, Mirzabeigi MN, Fosnot J, Low DW. Thoracodorsal artery perforator flaps and muscle-sparing latissimus dorsi myocutaneous flaps for the treatment of axillary hidradenitis. Ann Plast Surg 2012; 69 (04) 371-375
• 23 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 (01) 51-57
• 24 Hallock GG. Island thoracodorsal artery perforator-based V-Y advancement flap after radical excision of axillary hidradenitis. Ann Plast Surg 2013; 71 (04) 390-393
• 25 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 (05) 538-541
• 26 Wormald JCR, 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 (08) 1118-1124
• 27 Schmidt M, Dunst-Huemer KM, Lazzeri D, Schoeffl H, Huemer GM. The versatility of the islanded posterior arm flap for regional reconstruction around the axilla. J Plast Reconstr Aesthet Surg 2015; 68 (07) 953-959
• 28 Ching DL, Mughal M, Papas A, Soldin M. Axillary reconstruction for hidradenitis suppurativa with an inner-arm transposition flap creating a brachioplasty effect. Arch Plast Surg 2017; 44 (03) 228-233
• 29 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 (01) 29-34
• 30 Sirvan SS, Demir IA, Irmak F. et al. Posterior arm perforator flap for axillary reconstruction after hidradenitis suppurativa excision. Plast Surg (Oakv) 2019; 27 (03) 204-210
• 31 Alharbi Z, Kauczok J, Pallua N. A review of wide surgical excision of hidradenitis suppurativa. BMC Dermatol 2012; 12: 9
• 32 Karvar M, Panayi AC, Alavi A, Baziar Z, Orgill DP. Trends in the management of hidradenitis suppurativa in the Middle East region: a systematic review. Int J Dermatol 2021; 60 (11) e440-e448
• 33 Kohorst JJ, Baum CL, Otley CC. et al. Patient satisfaction and quality of life following surgery for hidradenitis suppurativa. Dermatol Surg 2017; 43 (01) 125-133
• 34 Farrell AM, Randall VA, Vafaee T, Dawber RP. Finasteride as a therapy for hidradenitis suppurativa. Br J Dermatol 1999; 141 (06) 1138-1139
• 35 Guha G, Agarwal AK, Gupta S. et al. Posterior arm flap in management of axillary contracture. Burns 2013; 39 (05) 972-977