Keywords
Hidradenitis suppurativa - Radical excision - Axilla reconstruction - Posterior arm
flap
Introduction
Recurrent infection of the axilla with hidradenitis suppurativa (HS) is a debilitating
disease. Antibiotics alone are not effective in the treatment of recurrent and advanced
disease.[1]
Radical excision of all the involved tissues up to the fascia is mandatory to eliminate
the disease definitively.[2] The resultant defect should be reconstructed with well-vascularized tissue. Simultaneous
reconstruction of bilateral axillary defect can be done with the posterior arm flap,
which has a robust blood supply. The added advantage is that this technique can be
executed without a change in the patient's position.
This study presents our experience of radical excision of HS of bilateral axilla and
reconstruction with posterior arm flap.
Patients and Methods
Patients with HS in the axillary region who underwent reconstruction with posterior
arm flap between August 2017 and December 2020 were included in the study. Patient
variables including age, gender, body mass index (BMI), duration of complaints, sites
involved, and details of previous treatment were recorded. Surgical variables included
the size of a defect, length of hospital stay, and complications. On follow-up, recurrence
and patient satisfaction were recorded.
Surgical Technique
General anesthesia was used in all patients. Patients were positioned in a supine
posture with both arms abducted and rested on hand tables. The involved tissue was
excised radically, with all the unhealthy subcutaneous fat and fibrotic tissue and
the sinuses, including the fascia. Most often, the dissection extended till the axillary
vein was exposed.
With the arm lifted at 90° from the table and supported by an assistant, an ellipsoid-shaped
posterior arm flap was designed with its long axis connecting the olecranon and the
posterior axillary fold. A constant perforator was detected with the help of a handheld
Doppler (8MHz) at 1 to 2 cm medial to the postaxillary border and 3 to4 cm distal
to the axillary crease on the arm. Size of the flap may vary depending on the size
of the defect, with the farthest length reaching the junction of proximal 2/3rd and
distal 1/3rd of the arm, while the width depends on skin pinch and ability to close
the donor primarily.
Elevation of the flap is straightforward, from distal to proximal, in the subfascial
plane up to the marked perforator. The skin and the subcutaneous tissue were incised
down through the brachial fascia, including the fascia into the flap. The plane is
in between the triceps brachii muscle and the fascia. The pedicle can be seen on the
undersurface of the flap, running within the fascia. At this point, either an islanded
flap or a flap with a skin bridge would be easily transposed on the defect. Perforator
dissection is not mandatory for the flap to reach the defect in the axilla. The donor
site was closed primarily after keeping a suction drain.
Results
A total of 15 posterior arm flaps were done on eight patients in the study period
([Table 1]). HS was seen in bilateral axillae in all our patients, presenting at different
stages. Five patients had bilaterally stage III disease. Three patients had a lower
stage on one side. Females were affected more commonly than males (3:1). The affected
individuals belonged to the age group of 17 to 34, the mean age being 27.6. Obesity
with BMI > 25 was found in 5 patients. None of the patients were smokers. The duration
of symptoms varied from 1.5 years to 17 years. Patients typically had been to multiple
centers undergoing different medical treatments. Seven patients had undergone incision
and drainage numerous times. Three patients had completed a course of multidrug anti-Kochs
treatment started empirically. Extra-axillary involvement was noted in 5 patients.
Table 1
Patient details
|
S.no.
|
Age
|
Gender
|
BMI
|
History (years)
|
Previous treatment history
|
Bilateral HS
Hurley staging
|
Extra-axillary involvement
|
Defect size right (cm)
|
Defect size left (cm)
|
Flaps
|
LOHS
|
Complications
|
Follow-up (in months)
|
Recurrence
|
|
1
|
31
|
F
|
27.3
|
1.5
|
Cap acetretin
Multiple
antibiotics
Cyclosporin 75 mg BD × 3 months
|
III (R)
II (L)
|
|
9 × 6
|
9 × 7
|
Bilateral PAF
|
2
|
Nil
|
42
|
On right side
|
|
2
|
17
|
F
|
30.4
|
2
|
Incision and drainage
AKT × 6 months
Multiple
Antibiotics
|
III (R)
II (L)
|
Perineum
|
14 × 8
|
13 × 8
|
Bilateral PAF
|
8
|
Surgical site infection
|
39
|
Nil
|
|
3
|
33
|
F
|
24.7
|
17
|
Incision and drainage
Multiple
Antibiotics
Laser for hair removal × 5 sessions
|
III (bilateral)
|
Left groin
|
10 × 6
|
12 × 7
|
Bilateral PAF
|
6
|
Nil
|
33
|
Nil
|
|
4
|
22
|
F
|
19.1
|
6
|
Incision and drainage
Multiple Antibiotics
|
III (bilateral)
|
Perineum (developed on follow-up)
|
10 × 7
|
9 × 6
|
Bilateral PAF
|
7
|
Nil
|
30
|
Nil
|
|
5
|
25
|
M
|
29.2
|
2
|
Incision and drainage Multiple
Antibiotics
|
III (bilateral)
|
Perineum
|
8 × 5
|
18 × 14
|
right PAF
Left SSG
|
8
|
Nil
|
28
|
Nil
|
|
6
|
34
|
M
|
24.6
|
3
|
Incision and drainage Multiple
Antibiotics
|
II (R)
III (L)
|
|
8 × 5
|
8 × 5
|
Bilateral PAF
|
1
|
Nil
|
24
|
Nil
|
|
7
|
27
|
F
|
26.8
|
6
|
Incision and drainage
Multiple
Antibiotics
AKT × 8 months
|
III (bilateral)
|
|
10 × 6
|
14 × 7
|
Bilateral PAF
|
1
|
Nil
|
23
|
Nil
|
|
8
|
32
|
F
|
29.7
|
10
|
Incision and drainage
AKT × 2 years
Multiple antibiotics
|
III (bilateral)
|
Genital and perineal
|
9 × 5
|
8 × 6
|
Bilateral PAF
|
8
|
Nil
|
12
|
Nil
|
AKT, Anti-Kochs treatment; BMI, body mass index (weight in kg/height in m2); HS, hidradenitis suppurativa; L, Left; LOHS, length of hospital Stay; PAF, posterior
arm flap; R, right; SSG, split skin graft.
Bilateral radical excision of the disease was done simultaneously in all eight patients
with the help of a two-team approach. Reconstruction of the axilla was done with a
posterior arm flap bilaterally, except one side in a single patient where the split-thickness
skin graft was performed. There were no significant complications seen in any patient,
with only one patient having a minor surgical site infection that healed in a few
days with dressings. Length of hospital stays varied from 1 to 8 days. Follow-up of
patients ranged from 12 to 42 months. A single patient had a recurrence on one side.
The rest were satisfied with the procedure, with complete relief of symptoms and no
significant flap or donor morbidity ([Figs. 1] and [2]).
Fig. 1 Patient 3: 33-year-old female with 17-year history of bilateral disease. (a and b) = preoperative with flap marking (right and left). (c) = intraoperative defect (left side). (d) = elevated and transposed flap with pedicle visualized (left side). (e and f) = postoperative.
Fig. 2 Patient 2: 17-year-old female with 2-year history of bilateral disease. (a and b) = preoperative. (c) = postoperative.
Discussion
Following wide excision in advanced HS of the axilla, reconstruction is planned routinely
with regional flaps or split skin graft. Flaps have a definite advantage over skin
grafts, avoiding complications like poor graft take, poor color match, and possible
secondary contracture, limiting the range of motion. The flaps described include local
transposition flaps such as Limberg flap[3] or the V-Y advancement flap,[4] thoracodorsal artery perforator flap,[5] lateral thoracic flap,[6] and posterior arm flap.[7]
[8]
[9]
In our experience, a posterior arm flap is a preferred choice, considering its simplicity
and reliability. It is based on an unnamed constant artery arising from the brachial
artery or the profunda brachii artery through the triceps muscle aponeurosis at the
termination of the tendon of teres major. Initially, it was described as a free flap
by Masquelet et al.[10] Later, pedicled posterior arm flap was used in axillary reconstruction after excision
in severe HS[7]
[8] and axillary burn contractures.[11] It is used with a skin bridge at the base or an islanded flap in axilla reconstruction.
The constant robust vascularity explains the low incidence of complications in these
patients, corroborated in all studies.[12]
[13]
[14] It is a consistently reliable flap with no instances of flap ischemia or partial
or complete flap failure. Donor-site morbidity was only in the form of a linear scar
in the back of the arm, which was accepted readily in our patients because of the
brachioplasty effect seen simultaneously on both arms.[15] The color and contour match is acceptable, with no secondary procedures needed in
most patients.
In bilateral cases, Sirvan et al preferred to operate the less affected side after
there was complete healing on another side.[8] Similarly, Thomson et al also preferred a second procedure for the contralateral
side.[9] We routinely followed a two-team approach with simultaneous bilateral axillary wide
excision and posterior arm flap cover in our patients. We preferred a single-staged
procedure with the help of a two-team approach, since the time taken for surgery was
reduced, with the need for second general anesthesia avoided. It is also cost-effective
for the patients. We routinely offer early surgical intervention irrespective of previous
medical treatment in chronic/recurrent HS.
Conclusion
Radical excision of HS of the axilla must be considered early on presentation, since
this is definitive treatment. Simultaneous reconstruction of the bilateral axilla
with posterior arm flap is a simple and reliable technique, with an excellent patient-reported
outcome.
