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The surgeon’s perspective: a retrospective study of wide local excisions taken to healthy subcutaneous fat in the management of advanced hidradenitis suppurativa

Background: Hidradenitis suppurativa (HS) is a chronic debilitating folliculopiloseba­ ceous disease that affects the skin most commonly in the axilla, groin, inframammary, genital and buttock areas. Surgical intervention may be an appropriate option in selected cases, but there is a risk of recurrence. The purpose of this study was to assess the results of wide local excision (WLE) to healthy subcutaneous fat with secondary intention healing in patients with HS who were under concurrent surgical and dermatologic care.

Résultats : En tout, 66 patients ont subi 133 interventions d'ELL jusqu'aux tissus adipeux souscutanés sains. Tous les patients prenaient concomitamment un traite ment médicamenteux sous la supervision d'un dermatologue. Aucun des traitements médicamenteux, y compris les agents biologiques, n'a été suspendu ou interrompu pour la chirurgie. Cent interventions ont été refermées principalement par lambeaux de rotation ou d'avancement et 33 par cicatrisation secondaire. Les récurrences H idradenitis suppurativa (HS) is a chronic disease affecting the folliculopilosebaceous unit. 1 The dis ease was roughly divided into 3 surgical stages by Hurley, but newer staging systems have been described and apply to the evaluation of medical therapies. [2][3][4] In its severe forms the disease is a painful, malodorous, socially isolating condition that profoundly affects patients' lives. It typically begins in adolescence or early adulthood. The condition can be exacerbated by obesity and smoking but is not caused by either. 3,5 It is characterized by recurrent inflammatory nodules in characteristic areas, but repeated episodes can create heaped scars and chronic sinuses or tunnels under the skin surface.
As an inflammatory disease HS is managed collabora tively with medical and surgical approaches. 6 Modern evidencebased guidelines address medical care, and sur gery can play an important role in both localized and more severe disease. 7 The choice of surgical intervention will depend on presentation. The most common procedure is incision and drainage, performed in the acute setting, such as in emergency departments. Other common procedures include deroofing, steroid injections and limited local exci sions, which are typically done as office procedures. Wide local excision (WLE) is another technique in which exci sion extends beyond the margins of the gross disease and into the subcutaneous layer. It is often done for extensive axillary or groin involvement and can be closed by flaps, grafts or secondary intention healing. However, previous reports have suggested high recurrence rates, between 27% and 100% depending on the procedures per formed. [8][9][10][11][12] In recent years, a growing number of reports of surgical interventions for patients with HS have shown more promising results. 13 Even in the setting of local recurrence postoperatively, the disease is usually more manageable and less extensive than preoperatively.
The purpose of this study was to assess the results of WLE with secondary intention healing to healthy subcuta neous fat in patients with HS who were under concurrent surgical and dermatologic care. We focused on WLE spe cifically to healthy adipose tissue rather than fascia, similar to fullthickness laser ablations, which have been found to produce good results. [14][15][16] This technique is based on the understanding that HS has a pilosebaceous origin rather than an apocrine gland source. A shallower excision simpli fies the procedure and can eliminate the need for complex reconstruction in many cases. This technique also expands the opportunities for secondary intention healing as a clos ure option.

Methods
A retrospective chart review of 192 consecutive HS con sultations to a general surgical service at St. Michael's Hospital in Toronto, Canada, was undertaken to identify patients treated with WLE. Patients who underwent minor procedures (deroofing, incision and drainage) were excluded. Data on patient demographics, surgical site, method of closure, complications and recurrence rate were extracted from patient charts.
This study was approved by the Unity Health Toronto Research Ethics Board of St. Michael's Hospital, Univer sity of Toronto.
We also conducted a literature review of surgical approaches to the management of HS. We included only traditional surgical techniques (laser surgery and any other techniques using energybased devices were excluded). We searched PubMed and EMBASE between 2000 and the end of June 2018 using the following terms: "hidradenitis suppurativa,'' ''acne inversa'' and ''surgery." The literature search was limited to articles published in English.

Results
Sixtysix patients underwent 134 WLE. The median age of the patients was 37 years (range 18-61 yr). The sites of surgery were the axilla (44 procedures), the inguinal region (40 procedures), the breast and inframammary region (13 procedures), the genitals (vulva, mons, scro tum, 18 procedures), the posterior neck (2 procedures) and the buttocks, perianal and natal cleft areas (17 proced ures). All WLE were extended to healthy subcutaneous fat. In all cases we removed gross disease including drain ing sinuses, obvious nodules and heaped scarring. While performing procedures we were attentive to any tracks or tunnels emanating from the more obvious disease. Our goal was to resect to healthy tissue radially as well as to healthy subcutaneous tissue in terms of depth.

Conclusion :
La résection jusqu'aux tissus adipeux souscutanés sains durant l'ELL permet de maîtriser la maladie aussi bien que les résections plus profondes, mais sim plifie les soins. as disease appearing within 0.5 cm of the resection site; this definition was based on a previous study. 13 There was local recurrence in 18% of cases (18 of 100) with primary clos ures and in 18% of cases (6 of 33) in which the wound healed by secondary intention (p = 0.98, χ 2 test, no statis tically significant difference between groups). One patient with secondary intention healing returned to the emer gency department for bleeding, which was controlled with silver nitrate; 34% of patients with primary closure experi enced some dehiscence (23% experienced major dehis cence requiring nursing and home care, 11% experienced minor separation). Two patients with axillary disease who underwent primary closure experienced restrictions in their ability to raise their arm that required physiotherapy.
All patients had ongoing dermatology followup. Ninetyfour percent of patients were taking medication at the time of surgery; we did not discontinue any therapies for the surgery. Fiftyone percent of patients were on oral antibiotics (usually clindamycin/rifampin or doxycycline), 29% were on biologic therapy (antitumour necrosis factor α) combined with oral antibiotics, 8% were on bio logic therapy combined with intravenous antibiotics (ertapenem) and 6% were on biologic therapy alone. Patients were treated to what we felt was maximal medical benefit, and surgery focused on persistent areas of disease, drainage and flaring.
The median duration of followup was 14.5 months (range 1-55 mo). All patients were followed concurrently by dermatologic and surgical services. No patients were lost to followup.
Our initial literature search produced 255 articles. When we narrowed the search with the term "wide local excision," we found 30 publications, 8 of which were review articles. Table 1 provides a summary of the 22 arti cles that remained after we excluded the review articles, including data on patient demographics, type of surgical procedure, location of surgery and recurrence rate.

discussion
Hidradenitis suppurativa is a chronic, debilitating disease that leads to clinically scarred areas in affected anatomic regions, such as the axilla and genitals, leading to tremen dous disability, low selfesteem and substantially reduced body image. 17 The tunnels and ropelike scars in HS may also be a place for growing biofilms as a potential trigger for the recurrence of inflammation in these areas. Almost 70% of chronic lesions were shown to present with bio films, based on recent studies. 18 Surgical intervention is important for removal of these tunnels and scars. Con cerns have been raised previously about the high recur rence rate. [19][20][21] Much of the surgical literature from 1997 to 2017 recommends extending excisions for HS to the muscular fascia, removing apocrine gland projections into the subcutaneous layer; these studies have reported recur rence rates of 3% to 54%. [19][20][21][22] In 2018, Walter and col leagues reported a postoperative recurrence rate as high as 54.2%. 22 In contrast, Deckers and colleagues reported a 38% recurrence rate when WLE was used. 13 Recurrence was defined in their study as a new inflammatory nodule within 0.5 cm of the lesion. 13,23 Our recurrence rate was 18% for primary closures and 18% for secondary intention closures, and the study included only patients for whom excision was performed to healthy subcutaneous adipose tissue. No patient underwent resection to muscular fascia. The rationale for this approach is the newer understanding of HS as a piloseba ceous unit disease rather than a disease of the sweat glands, meaning that resection does not need to go to fascia but rather simply to healthy tissue. This simplifies the surgery and makes closures less complicated. When compared with the results of earlier studies, our results were not superior, but rather were equivalent to more aggressive approaches. Our results are promising, suggesting equivalent or better local control than most series, despite the purposeful effort to limit the depth of tissue removed. Interestingly, only 2 (3%) of our patients with axillary disease experienced restrictions in their ability to raise their arm that required physiotherapy.
As mentioned earlier, all of our patients were under medical care. Many were receiving combinations of med ical care to achieve as much medical control over their inflammation as possible. Surgery (WLE) was reserved for areas of persistent drainage and flaring that had not responded to medical treatment.
The decision whether to close wounds with flaps or with secondary intention healing was made case by case, with patients' input and preferences taken into consider ation. Patients were shown photos of previous cases that involved secondary intention closure so that they would know what to expect. Their preference was to use second ary intention closure for larger defects. In our study, 43% of axillary wounds, 13% of inguinal wounds, 23% of geni tal wounds and 41% of buttock (including perianal, natal cleft) wounds were closed by secondary intention healing. The choice not to use skin grafts is not evidencebased but it reflects our experience. There are a few advantages of secondary intention closure over skin grafting, including the following: the use of a donor site is avoided, no im mobilization is required (difficult areas are the axilla and the inguinal regions), the patient is able to move and use the extremity for maximum range of motion as the wound heals, and it is an easier surgical approach.
This series leaves us preferring secondary intention over primary intention closure for many cases. Secondary inten tion closure seems advantageous for wider areas of exci sion. It enables us to avoid skin grafting and complex flaps with disease control that is equivalent to that of more involved surgical approaches. Secondary intention closure provided for good range of motion with good cosmesis after healing, simplified the surgical procedure and is sup ported by other studies in the literature. 13,[24][25][26] The disad vantage of secondary intention healing is the dressing care required until the wound is closed. This was well tolerated in our patients, who are generally used to dressing care for their active disease. The patients who underwent primary closure experienced dehiscence of more than 30% (minor and major dehiscence) even though they were being main tained on their preoperative medical treatments. All patients in this series were followed by a dermatolo gist and had their medical therapy continued in the peri operative and postoperative periods. Seventyseven percent of patients were on biologic therapies, and these were not discontinued or withheld perioperatively. In this series we were not able to show a difference in outcome for the patients on biologics; however, we emphasize the necessity of continuation of such treatment throughout the manage ment of patients with HS.

Limitations
Our study has some limitations, including patient selec tion and retrospective design, and therefore the risk of bias. Also, our study is limited by its relatively small sample size.

conclusion
Wide local excision to healthy subcutaneous adipose tissue provides good control of HS. The 18% local recurrence rate reported here is at the better end of the rates reported in other series in the literature. Wide local excision with secondary intention closure is a useful and practical sur gical approach, which is facilitated by not resecting to fas cia. It can simplify the surgical procedure while providing equivalent local control and extremity function. Primary closure in HS is associated with a significant dehiscence rate of which surgeons and patients should be aware. Larger studies with a better design and longer followup are required to determine the optimal surgical approach and optimal medical control.