Abstract
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Background: Hurley stage III hidradenitis suppurativa (HS) is the most severe form of a chronic, relapsing inflammatory disease characterized by diffuse sinus tracts, scarring, and recurrent infection. Medical therapies, including antibiotics, biologics, and hormonal agents reduce flare-ups and the number of lesions but rarely eradicate disease at this stage. Surgical excision is potentially curative but the postoperative wound morbidity, functional impairment, and recurrence have limited its universal adoption. This study evaluates outcomes of wide surgical excision followed by immediate reconstruction using complex fasciocutaneous perforator flaps in patients with Hurley stage III HS.
Methods: A retrospective review was performed of 99 consecutive excisions of Hurley stage III HS treated at a tertiary referral center. All patients underwent radical wide excision of clinically involved tissue to negative margins, followed by immediate reconstruction using regionally appropriate perforator-based fasciocutaneous flaps. Flaps were designed based on thoracodorsal artery perforator (TDAP), intercostal, pudendal, anterolateral thigh (ALT), superficial inferior epigastric artery (SIEA), superior gluteal artery perforator (SGAP), or inferior gluteal artery perforator (IGAP) vessels, depending on disease location. Primary outcomes included disease recurrence, complication rates, and need for reoperation. Secondary outcomes included functional recovery and patient-reported symptom resolution.
Results: The cohort included axillary, inguinal, perineal, gluteal, and truncal disease. Complete disease clearance was achieved in all patients at the time of surgery. At a median follow-up of 6 months, durable remission without local recurrence was observed in the overwhelming majority of patients. Complications were limited to minor wound dehiscence and partial flap edge necrosis, managed conservatively. Patients reported substantial improvement in pain, drainage, mobility, hygiene, and quality of life.
Conclusions: Radical excision with immediate perforator-based fasciocutaneous flap reconstruction provides definitive, durable, and function-preserving treatment for Hurley stage III HS. Unlike non-surgical therapies, which control inflammation without eliminating diseased tissue, this approach is potentially and fundamentally curative. Early referral for surgical management should be strongly considered in advanced HS to prevent prolonged morbidity and repeated ineffective medical treatment.
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