Surgical Management of HS

  • Dennis Orgill, MD, PhD
    • Brigham and Women’s Hospital
    • Vice Chair, Department of Surgery
    • Medical Director, BWH Wound Care Center
    • Professor, Harvard Medical School

Traditionally HS has been treated with wide excision following prolonged dressing changes to allow for closure. When direct closure was attempted high rates of complications were reported.1 As a result most surgeons do not attempt to operate on HS patients.

When I started in practice, I met a few patients that convinced me to try and operate on them.  Over the years I have learned several principles from them that have helped me advise patients regarding surgery that I will describe.

1.  A wide excision of HS can be definitive, once healed most patients are quite happy with their results.

Hidradenitis Suppurativa surgery

2. Although surgery is not always curative, it can make many patients substantially better.

Hidradenitis Suppurativa surgery

3. Working closely with a Dermatologist that specializes in HS treatment is very helpful.  I allow the Dermatologist to manage medications, diet and other medical issues.

Hidradenitis Suppurativa surgery

5. HS can be painful, I personally try to do minimal manipulation to diseased areas in the office.  I do most excisions in the operating room under general anesthesia.  For complex cases that need dressing changes, I also try to do the dressing changes in the operating room when possible.  I try to get the wound closed as soon as possible. ship.

Hidradenitis Suppurativa surgery

6. HS surgery should be staged.  I usually will start with the axillae, then the groins and finally the buttock areas.  Breasts and abdomens can be treated with breast reduction or panniculectomies which are very nice operations for the appropriate patient.

Hidradenitis Suppurativa surgery

7. Most cases can be excised and closed without skin grafts and flaps. We will sometimes do this in two stages with 2 or 3 days between excision and closure. We use NPWT systems (VAC) between the two treatments.

Hidradenitis Suppurativa surgery

8. When adjacent lesions come up, these can be treated medically or often with small excisions.

“All images, Figures 1-7, were constructed by Andreana Panayi, University of Cambridge.”

Hidradenitis Suppurativa surgery

Resources
  • Chen YE, Gerstle T, Verma K, Treiser MD, Kimball AB, Orgill DP. Management of hidradenitis suppurativa wounds with an internal vacuum-assisted closure device. Plastic and reconstructive surgery. 2014 Mar 1;133(3):370e-7e