Author

(year of publication)

Methode of surgery.

Level of evide-nce

Study design

Patients (N)

Inclusion criteria

Follow-up

Outcome measures

Results

Lost to follow-up

Comments

Aksakal 2008

C

prospective study

12

A total of 30 lesions were treated; 6 of 30

were localized in the axilla and 24 in the inguinal

region.

Patients with HS with hurley grade I (n=9) or II (n=3). Only previously untreated patients were included.

Without comorbidities that would affect the wound healing.

2 months

Not mentioned in paper

In 10 of 12 (83%) patients, and in 26 of 30 (86%) lesions, cure was observed in a mean of 16 days (range 15 to 21 days).

In this group, the lesions healed leaving a slightly depressed scar. Our method achieved success in 20 (100%) lesions of all patients with Grade I and in 6 of 10 (60%) lesions in Grade II patients. Four lesions in 2 patients with Grade II became infected and required a short course of antibiotic therapy. Therefore, these four lesions were considered as failure in treatment.

0

Only early disease Hurley grade I or II.

Alharbi 2012

.

C

Retrospective study

32

50 operative procedures

in 5 anatomical sites, 23 axilla,

17 inguinal and 8 Perianal/ perineal area, 1

gluteal region and 1 trunk region

patients with

chronic inflammatory moderate to severe hidradenitis

suppurativa (Hurley grade II and III) treated in our hospital

from 2003 to 2009

Mean follow-up time is 24 months

Not mentioned in paper

Twenty eight Patients (87,5 %) showed no complications after surgery. The average time of hospital stay period was 5 days.

After follow up 26 Patients (81,25 %) showed no recurrence. Recurrence rate was observed in 6 patients

(18,75 %) and was seen in patients with

Hurley grade III, 5 out of these 6 patients were smokers (83,33 %).

unknown

Balik 2009

C

Retrospective review

15

Total number of 21 operations:

In 11 patientes (73.33%) the wounds were left open for secondary healing.

2 patients (13.3%) underwent primary wound closure by rotation flaps.

Delayed skingrafts were applied tot the remaining 2 patients (13.3%).

Patients diagnosed with stage III extensive HS located in the perineal/perianal, inguinal, and gluteal areas,

who were treated in the University of Istanbul, Istanbul

Faculty of Medicine, Department of General Surgery

between January 1990 and July 2003

mean follow-up period of 5 years

Not mentioned in paper

The mean time for complete wound healing of the patients treated by total excision and healing with secondary intention was 12.2 (range, 9.5–22) weeks. The complete healing period for the patients in the total excision and rotation flap group was 2 weeks.

In the delayed skin grafting group, complete wound healing took a total of 8 weeks.

unknown

Bohn 2001

C

crossectional/prospective?

138

Altogether 367 affected sites were excised; most cases required skin grafting.

unknown

Postoperative

follow-up was eight years (range 0–

21).

Not mentioned in paper

There were no serious surgical complications. In 38 patients (33%) the disease recurred to some degree. When a recurrence occurred a new lesion developed usually some cm’s away from the previous excision (in 30 patients; 78%), but sometimes at the edge of the scar (in 8 patients; 22%). No patient relapsed in the skingrafted sites. 14 patients (10% of all cases) required reoperation. Forty (34%) patients developed

temperate lesions at areas other than the

operation sites but they did not require further

surgery. Six patients had a subsequent operation to improve the aesthetic result. Ninety-six of the patients (83%) answered that they would recommend the procedure to other patients under similar circumstances.

(22) Two patients

Had died, five could not be traced, and 15

failed to reply the questionnaire.

Buimer 2008

C

prospective and randomized study

200

76 patients underwent surgical excision with primary closure (PC), and 124 PCs over a gentamicin-collagen sponge (GC).

In accordance with the patient’s views, we selected for

treatment the symptomatic lesions, i.e., those with discharge, inflammation, infiltration, or suspected

abscesses.

3 months

After one week and 3 months the wounds were described and characterized:

dehiscence, dehiscence and infection, seroma and/or infection. Furthermore, the local

recurrence rate was scored after 3 months.

One week postoperatively there were significantly fewer complications in the GC group. Overall, 59% of the patients treated with gentamicin had no complications after 1 week, compared to 47% in the group without antibiotics (p<.03). Three months postoperatively, there was no statistical difference in observed complications (p = .14). The mean duration of wound healing was 21 days in the GC group of patients, compared to 24 days in PC group (p = .078). In the GC group, 65% of the patients were recovered within 2 months, compared with 33% in the PC group.

Treatment with gentamicin had no influence on the local recurrence rate after 3 months; this was comparable in both groups, 42% versus 40% (p = .8).

unknown

The imbalance in randomization was due to early cessation of the study.

Burney 2017

C

retrospective review

122

245 operations, patients underwent from 1 to 10 procedures, 61 patients (50%) underwent two or more procedures; and 26 (21%) underwent three or more.

unknown

5.6 years (median follow-up)

Specific data abstracted included patient age, weight, admission, length of stay, wound size, type of wound care, number of post-op visits, time to heal, and recurrence.

Wound sizes at operation ranged from quite small to over 1500 cm2. A total of 197 wounds healed by secondary intention: 83 of these (median size 159 cm2) were left completely open at the time of surgery; 117 (median size 100 cm2) were partially closed. A total of 30 wounds (median size 38 cm2) were closed primarily; 15 (median size 196 cm2) were closed by skin graft. Patients undergoing 139 procedures were admitted to the hospital for the initial wound care. Their median combined total wound size was 160 cm2; length of stay was 5.5 days; and median time to heal was 60 days. In total, 106 procedures were ambulatory; median wound size was 30 cm2; and median time to heal was 40 days. Recurrent or new disease was common, with some patients requiring multiple procedures over many years to maintain control of symptoms. Although wound healing can take up to several months, patients quickly learned how to care for themselves and were usually pain-free after the first two or three weeks.

unknown

This report is spanning a period of 35 years.

Most of the data analyses were done by type of operation and location of disease, rather than by patient, since most patients had more than one site of disease and underwent either more than one operation or operations at

more than one site over a period of years.

Chen 2011

C

retrospective review

11

with 24 regional disease sites

treated

unknown

?unknown

Not mentioned in paper

The total percentage estimated surface area of graft take was

approximately 75%, excluding 1 patient with total graft failure due

to patient compliance issues. Of the 24 areas grafted, only 5 required small areas of regrafting (4 of the regrafts were in a single patient) again with the exception of one patient, and in each case the second graft had 100% take.

Control of locoregional disease does not preclude isolated

abscess formation in sites adjacent to or distant from the grafted areas. However, these recurrences are usually not incapacitating and

are treated with antibiotics, local incision, and drainage.

unknown

Chen 2014

C

retrospective chart review

a total of 60 cases in 27 patients

Equal numbers of cases were performed without

internal vacuum-assisted closure (30 cases in 15

patients) and with internal vacuum-assisted closure (30 cases in 12 patients).

only cases performed by the same surgeon

and senior author (D.P.O.) at the Brigham and Women’s Hospital, which included patients

treated both with and without internal vacuum assisted closure.

a mean follow-up time of 2.3 months

(range, 0.4 to 9.8 months)

Collected data included: demographic data

on sex, age, surgical site, and clinical risk factors (i.e., smoking status, hypertension, diabetes mellitus, steroid use, and immunosuppression). We also collected outcome data on days hospitalized after surgery, time to healing, time of total followup,

and any postoperative complications.

Patients managed with internal vacuum-assisted closure (IVAC) had wounds on average four times larger in area than patients managed without IVAC: Patients with IVAC had significantly larger

average defect sizes: 123 cm2 in the IVAC group (n = 30) versus 32 cm2 in the no–IVAC group (n = 30) (p = 8.80E-06). In both groups, all wounds were eventually closed primarily. The average time from the date of surgery to the date of epithelization without recurrence was not significantly different

between the IVAC (2.2 months) and no–IVAC groups (2.7 months; p = 0.39). At an average follow-up time of 2.3 months, all patients with IVAC had no recurrence of their local disease.

unknown

Egemen 2013

C

review of cases

11 patients with 13 local islanded perforator flaps

unknown

mean follow-up was 11.5 months range, 4 to 24 months

The data for age, sex, anatomic location, flap size, flap type,

complications, and duration of follow-up were recorded

(Table 1).

Flap dimensions ranged from 11 cm ± 6 cm to

15 cm ± 13 cm. Patients with bilateral disease underwent surgery in separate sessions. Among 13 flaps, 1 was interpolation type, 4 were rotation types, and 8 were advancement

types. Donor areas of the 12 flaps were closed primarily. The donor area of the largest flap (15 cm ± 13 cm) in the series was partially skin grafted.

There were no total flap losses in the postoperative period.

One patient who had undergone reconstruction with TAP flap had amarginal necrosis due to venous congestion at the distal

part of the flap. Two patients developed

wound infections. During follow up there were no recurrences of HS

lesions. None of the patients requested a revision of the donor

or recipient area.

unknown

Humphries 2016

C

retrospective case review

17

These patients underwent 23 separate surgical encounters, five with excision of

multiple areas.

All patients

aged 18-85 years who underwent surgical treatment of HS with subsequent wound healing by secondary intent

with topical antimicrobial therapy by five plastic surgeons

over a 14-year period (January 1, 2000 to January 1, 2014).

The mean follow-up was 1.02 years with a median of 6 months ranging from 1.2 months to 5.25 years.

length of HS diagnosis, previous surgical and medical interventions for HS, symptoms at the time of surgical intervention, anatomic sites affected by HS and subsequently surgically

treated at our institution, size of wound after surgical

excision, method of wound healing, length of wound healing

time, and postoperative or wound-healing

complications.

Seventeen excisional procedures were conducted on the upper half of the body

(axillary, breast) and 11 on the lower half (inguinal, perineum, perianus, and abdomen). Two patients developed HS recurrence adjacent to the surgical site (one requiring reexcision and

the other treated with topical therapy), whereas two developed HS flares at distant nonsurgical sites managed medically. The mean follow-up was 1.02 years with a median of 6 months ranging from 1.2 months to 5.25 years. Complete wound healing ranged from 8 weeks to 16 months, with limited range of motion (ROM) in two patients.

unknown

Patients with missing data remained included in

the study, but missing data from these patients were

excluded from calculated averages.

Maeda 2015

C

retrospective review

18

unknown

mean follow-up was 61.3 months (range, 17-113 months)

Severity (Hurley classification system), skin-graft thickness, the need for an additional normal skin graft,

histological findings and recurrence rate were investigated.

Five cases were classified into severity group I, 12 cases into severity group II and one case into severity group III. The range of skin-graft thicknesses was 0.013-0.020 inches. An additional donor site

was unnecessary in 10 cases (three cases in group I (60%) and seven cases in group II (58.3%)). Histological

examination indicated that a buried epidermal cyst could cause chronic gluteal hidradenitis

suppurativa recurrence. None of the patients experienced severe skin contracture limiting lower-limb motion, or underwent an operation for releasing contracture. No recurrence was noted in any case at the surgical site during follow-up.

unknown

Mutaf 2014

C

Case report analysis

16

unknown

A mean follow-up for 36 months (6 months-5 years)

Not mentioned in paper

In all patients, a successful tension-free and durable closure of the defect was obtained without any difficulty. Except for 2 patients who had tip necrosis, all patients healed uneventfully.

There was no patient with infection and wound dehiscence. The mean follow-up time revealed no recurrence and an aesthetically acceptable scar formation in all patients. In the long-term, there was no recurrence and no patient required additional surgery.

unknown

Van Rappard 2012

C

retrospective single-centre study

57

In total 92 local incisions with primary closure were performed.

Consecutive HS-patients treated between 2005 and 2010 in the

Department of Dermatology with local surgery and primary wound closure

If the excisions were subsequently managed by primary closure,

patients’ data were included in the study.

The follow-up period ranged from 3 months to a maximum

of 84 months (average 14 months).

The immediate post-operative results

were extracted from the medical records.

For the long-term follow- up, all patients were contacted to fill out a questionnaire. The questionnaire included general questions on disease duration, smoking habits and previous treatments. Pain during the procedure was recorded using a pain score ranging from 0 to 10. The clinical course was evaluated on post surgical pain, occurrence of complications, time required for resuming

daily activities, time required for total wound healing and recurrence rate, an overall judgment

of cosmetic results of the postoperative sites and if they would recommend similar procedures to other patients with comparable conditions.

Postoperative pain, requiring pain medication, was present after 61% of the surgical interventions. The average duration for

patients for resuming daily activities was 1.5 weeks. The average

time required for total wound healing was 3.2 weeks. The overall rate of postoperative complications was 29%,

mostly minor complications like suture dehiscence, postoperative

bleeding and postoperative infection. In none of the cases, hospitalization was required.

Successful treatment, without any recurrence, was accomplished in 66% of the cases (Figs 1, 2). The average follow-up duration without

recurrence was 27 months. Recurrence within the operated

fields occurred in 23% of the cases, after an average duration of

10 months. In 11% of the cases, de novo suppurating lesions

appeared near the initial sites of surgery, after an average duration

of 5 months.

unknown

Romanowski 2017

C

Retrospective Review

98

unknown

The mean

number of follow-up clinic visits was 4.2 ± 3.7 visits within 1 year of surgery.

Outcomes included graft loss (estimated from percentage of total wound) and

regrafting requirements. Graft loss was recorded at

the first postoperative dressing removal. Length of stay (LOS) and number of follow-up visits within 1 year of surgery were also noted.

All 142 grafts were split-thickness skin grafts. The most common time between procedures was 4 days (mean time 4.59 days). The mean area grafted was 416 ± 500 cm2 (90–3400 cm2). There were 74 axillary-only debridements with 2 primary closures and 72 grafting procedures.

The Length of stay (LOS) varied with the location of the disease and performance of grafting during the admission, with the mean LOS being 6.3 ± 5.6 days. Patients with buttock and multiple-site procedures had the longest LOS at 9.3 ± 8.3 and 9.5 ± 7.0 days, respectively.

Slightly more than half of the patients had 100% graft take (75, 51%). No patients who had less than 30% graft loss underwent a regrafting procedure. Of the 18 patients who had >30% graft loss, only nine (9%) patients required regrafting. At 30 days after the initial procedure, 94.7%

of all wounds were fully grafted and closed.

unknown

Schmidt 2015

C

prospective

35 posterior arm flaps were used in 24 patients

Defects were predominately due to HS (n=31).

Between 2008 and 2013, all patients receiving a posterior arm flap for regional reconstruction around the axilla were entered in a prospectively maintained database.

unknown

Patient data, surgical details, complications and the need for revisional procedures were recorded.

Average flap dimension measured 8x12 cm. However, flaps as big as 12x16 cm were elevated still allowing for primary closure in all of our patients. Major wound complications such as total or partial flap necrosis were not

encountered in our series. In one patient initial venous flap congestion was observed, which eventually led to flap tip necrosis. In two further patients an additional VY-advancement flap was needed for closure of the pronounced defect. Minor complications included partial superficial wound dehiscence (n=4) and superficial wound infection (n=1), all of which were successfully

managed with a conservative wound regimen.

unknown

20 patients with HS, with a total of 31 defects due to HS.

Other 4 due to burn contracture, thoracic wall defect, metastatic disease or sarcoma.

No results of disease activity/recurrence of HS.

Soldin 2000

C

retrospective analysis

59 (94 axillae)

The three types of excision performed were:

1. Limited local excision. Only the obviously diseased

tissue is excised. Usually this is within the area of the hair bearing skin.

2. Hair bearing skin excision - the area of axillary

tissue containing terminal hair is excised. The

excision was down to axillary fascia.

3. Wide local excision - all axillary hair bearing tissue

and an additional 2 cm margin of surrounding

skin was emoved. The excision was also down to axillary fascia.

all patients

who presented for surgical treatment of chronic axillary

hidradenitis. The study was undertaken in two centres: Groote Schuur Hospital, Cape Town and Mount Vernon Hospital, Middlesex.

The follow-up ranged from 4 to 122 months (mean

16 months).

Particularly, we surveyed the outcome regarding extent of excision and method of closure.

26 axillae had limited local excision. 39 axillae were treated by excision of all hair bearing skin. There was a significant reduction in recurrent disease when excision of all the hair bearing skin was performed (P = 0.04, Fischer's exact test). 29 axillae had wide local excision. There was no significant difference in disease recurrence between excision of all the hair bearing skin and wide local excision (P = 0.18, Fischer's exact test).

Of the wounds closed primarily (35), there were complications in 7 (these were minor wound breakdowns that healed with conservative care). All these complications

occurred in patients that had had excision of all the hair bearing tissue.

There were 16 axillae closed with split thickness skin graft. Complications included incomplete graft take in 6 (1 requiring regrafting), and 5 axillary wound contractures.

43 axillae were closed using a flap. The flap was lost in two patients (both cutaneous). Two patients complained of unsatisfactory scars. (one needing revision), and minor wound breakdown occurred in 9 patients that healed with conservative care (regular dressings).

unknown

Tanaka 2001

C

Case review

19

23 sites of HS:

Nine sites were limited and 14

sites were severe.

patients with

chronic inflammatory skin lesions treated surgically in our hospital from 1977 through 1999, with a follow-up of at least 20 months

The postoperative follow-up period ranged from

20 to 60 months

Not mentioned in paper

The lesions were divided into two groups: The

limited group (9 sites) was comprised of mild lesions, which appear

isolated and have limited abscesses without sinus tract formations. The severe group (14 sites) was compromised of severe lesions, which included diffuse, multiple abscesses with severe sinus tract formation and fibrosis. After resecting the lesion, the defect was covered with a split-thickness skin graft (4 sites were

limited, 9 sites severe), a musculocutaneous flap (5 sites severe), primary closure (4 sites limited), and a local skin flap (one site limited). In comparison between both groups, the rate of recurrence in the severe group was significantly higher (p = 0.0480. In the severe group there was no significant difference in the follow-up period between the cases covered with split skin graft (mean, 36.0 months) and those covered with a musculocutaneous flap

(mean, 39.6 months).

unknown

Unal 2011

C

prospective study

12

11 SGAP and 6 IGAP flaps

Only patients with gluteal and perineal/perineal region involvement were included in this study.

The mean postoperative follow-up period was 20 months (range 8–36 months).

Data of each patient included age, sex, disease localization, duration of symptoms, comorbidities, size of defect after excision, perforator flap chosen,

complications, and postoperative follow-up.

Size of skin defect after excision of lesions ranged from 7x9 cm to 23x40 cm (mean 13x19 cm). A total of 11 SGAP flaps were performed, Only three of the SGAP flaps were advancement type and eight of them were propeller flaps.

Six IGAP flaps were used in four patients. Four of these flaps were advancement flaps and

two were propeller flaps. There was one suture detachment in one patient that needed secondary revision. One SGAP flap failed because

of hematoma formation and venous congestion. The defect was grafted with a split thickness skin graft. The mean hospitalization time for patients was 6 days (range 3–10 days). There was no recurrence of HS lesions in any of the patients during the course of follow-up period.

unknown

Wormald 2014

C

prospective study

27

Those

patients with Hurley’s stage III (27) with extensive disease or

recurrent disease were divided into two groups defined by

their treatment: TDAP reconstruction and SSG reconstruction.

There was no randomisation and the decision on type of reconstruction was based on patient’s preference

following a full informed consent.

all consecutive patients

undergoing surgical treatment for axillary HS at the

Department of Plastic and Reconstructive Surgery of the

Norfolk and Norwich University Hospital in Norwich, UK

from September 2008 to September 2012.

patients with Hurley’s stage III with extensive disease or

recurrent disease

Follow-up evaluation was

conducted at 3, 6 and 12 months after surgery.

Operative variables that were measured include: operating time,

hospital stay, complications, recurrence of disease, total number of surgical procedures, follow-up and return to preoperative activity.

The dermatology life quality index (DQLI) questionnaire and a visual analogue scale for pain and discomfort were completed by patients before surgery and at 12 months

post-operatively to determine effect of the surgical treatment

on quality of life

The mean hospital stay was 4.7 days for TDAP flap and 6.7 days for SSG. There was a significant difference in the mean recovery time, defined as a full return to pre-operative activity, between the two groups mean recovery time was about 5 weeks for TDAP group and 14 weeks for SSG group (p=0.03). The SSG group had an average of 5.2 follow-up clinic appointments

for dressing and wound review compared to the TDAP flap group who had significantly fewer appointments with an

average of 1.6 follow-up (p≤0.005).

The TDAP group had significantly fewer complications than the SSG group (p≤0.005).

DLQI and VAS results showed improvement in patients’ quality of life across both groups. The TDAP group showed significantly better

improvements in quality of life compared to those who underwent SSG, with a mean reduction in DQLI of 23.1 points compared to 19.3 points (p=0.02).

unknown