Reconstruction of bilateral inferomedial gluteal defects after resection of hidradenitis suppurativa with symmetrical keystone flaps designed parallel to relaxed skin-tension lines

Abstract

Rationale: Surgical treatment of hidradenitis suppurativa (HS) is challenging. Wide excision of affected lesions followed by skin graft or flap coverage has been recommended to achieve remission and prevent recurrence. Herein, we present our experience of bilateral inferomedial gluteal defects coverage using symmetrical keystone flaps (KFs) designed parallel to relaxed skin-tension lines (RSTLs).Patient concerns: An 18-year-old man was admitted for chronic inflammatory lesions in both inferomedial gluteal areas.Diagnoses: Physical examination revealed multiple sinuses with broad surrounding scars in both inferomedial gluteal areas, which led to a diagnosis of HS.Interventions: We performed wide excision on all affected lesions. The size of the final defects was 6 Â 10 cm on the right side, and 5 Â 9 cm on the left side. We covered the defects with KFs 9 Â 15 cm (right) and 8 Â 12 cm (left), which were based on the hotspots of the interior gluteal artery and internal pudendal artery perforators, and parallel to RSTLs.Outcomes: The flaps were inset without tension on each side, and the donor sites were closed primarily. All flaps fully survived and there were no postoperative complications. The patient was satisfied with the final outcome after 6 months of follow-up.Lessons: Successful reconstruction of bilateral inferomedial gluteal defects was achieved after resection of HS using symmetrical KFs designed parallel to RSTLs. The KF technique considering RSTLs could be a good reconstructive option for gluteal HS.Abbreviations: FC = fasciocutaneous, HS = hidradenitis suppurativa, KF = keystone flaps, PPF = pedicled perforator flaps, RSTL = relaxed skin-tension line.

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.…”

Keystone Flaps for Coverage of Defects in the Posterior Neck and Lower Occipital Scalp: A Retrospective Clinical Study

“…Through these principles of our KF design, we could reduce postoperative complications and achieve good results, except for one case of marginal maceration. Moreover, as opposed to other flap reconstruction, the direction of final scars was parallel to RSTLs, which could be of help to less noticeable scar formation and no scar contracture in all patients 27 . Meanwhile, a previous study verified the tension-reducing effect of the KF in human bodies 4 .…”

“…Moreover, as opposed to other flap reconstruction, the direction of final scars was parallel to RSTLs, which could be of help to less noticeable scar formation and no scar contracture in all patients. 27 Meanwhile, a previous study verified the tension-reducing effect of the KF in human bodies. 4 They demonstrated significant tension reduction after performing KF reconstruction in the back area, and considered that this tension-reducing effect resulted from the release of the flap during stepwise dissection of the skin and fascia while constructing the island flap.…”

Designing with relaxed skin tension line in perforator-based island flap for sacral sore reconstruction: A STROBE-compliant observational study

“…[ 5 , 12 ] First, we design the long axis of flap parallel to RSTLs, which greatly reduces wound tension and scar formation. [ 15 , 16 ] Second, since defects are rarely circular and the direction of pinch testing results in differently shaped defects. In the range that satisfies the ideal ratio of flaps, [ 17 ] narrower, longer flaps are more efficient and economical for primary closures.…”