Management of Axillary Defect of Hidradenitis Suppurativa Using Keystone Design Islanded Perforator Flap- A Simple and Durable Option

Abstract

BACKGROUND Hidradenitis suppurativa is a chronic cutaneous disease involving recurrent abscesses, fistulating sinus tracts and scarring. The most common sites involved include the axilla, inguinoperineal region and breasts. The disease causes considerable discomfort to the patient due to recurrent abscess and sinus tract with discharge. Medical management will only give temporary relief in resistant disease and surgical excision followed by suitable cover promises a better outcome and hence better quality of life to the patients with hidradenitis suppurativa. We describe a local fasciocutaneous flap-the keystone design, islanded, perforator-based flap for the reconstruction of axillary defects following wide excision of hidradenitis of axilla. This method provides a durable cover for the axillary region. The aim of this article was to study the effectiveness of keystone flap in reconstruction of axillary defects after excision of hidradenitis suppurativa of the axilla. MATERIALS AND METHODS This case series involves study of 8 patients undergoing keystone flap for axillary defect following wide excision of skin with hidradenitis suppurativa from 2013 to 2015. Patient's demographic data, medical histories, comorbidities, defect characteristics, hospitalisation, complications and follow-up were evaluated and presented as uncontrolled case series. RESULTS Ages of the subjects were ranging from 18 to 55 years with an average of 34.13 years. Six patients had bilateral involvement and remaining two patients had unilateral involvement of the axilla. Fourteen keystone flaps were done for these patients including unilateral and bilateral disease. Surgery was done in two stages for patients with bilateral involvement with a gap of 2 months. The average intraoperative time was 58.5 mins (range 35-75 mins). Suction drain was kept in all the cases for a period of 5 days in all patients. A padded dressing with aeroplane slab was applied in all the patients for 5 days to facilitate wound immobilisation and rest. Wound was inspected on 3 rd postoperative day. All the keystone flaps survived giving a durable cover to the axilla. However, two patients had wound infection, which subsided with dressings and appropriate antibiotics. The average duration of hospital stay of patients was 6.5 days. Sutures were removed after 2 weeks and patients were followed up for 6 months every month. All the flaps survived facilitating full range of shoulder movement. The patients showed good symptomatic relief from pain and pus discharge. Recurrence was not noted in any of these patients within the period of 6 months. CONCLUSION Keystone flap is a relatively simple local flap, which provides suitable cover to the axilla after excision of hidradenitis suppurativa and facilitates normal range of shoulder movement after surgery.

Outcomes and Reliability of Perforator Flaps in the Reconstruction of Hidradenitis Suppurativa Defects: A Systemic Review and Meta-Analysis

“…Among 52 identified, 36 [ 28 , 36 , 37 , 38 , 39 , 40 , 41 , 42 , 43 , 44 , 45 , 46 , 47 , 48 , 49 , 50 , 51 , 52 , 53 , 54 , 55 , 56 , 57 , 58 , 59 , 60 , 61 , 62 , 63 , 64 , 65 , 66 , 67 , 68 , 69 , 70 ] studies were included, as shown in the corresponding flowchart ( Figure 1 ). We included 286 patients with 380 defects and 387 flaps, some defects being reconstructed by two flaps.…”