A Case of Long-term Follow-up of Severe Hidradenitis Suppurativa of the Buttocks Treated With Free and Pedicled Flap

Summary:

Long-term outcomes of flap surgery for hidradenitis suppurativa (HS) of the buttocks have not been reported. We encountered a case of severe HS in which multiple new lesions appeared during a 27-year follow-up period. This article reports useful information regarding reconstruction using a free flap from the back. The patient was a 62-year-old Japanese man. At the age of 35 years, he developed HS in the bilateral groin and sacral regions. Reconstructive surgery was performed for the left groin using a left pedicled rectus abdominis flap, for the right groin using a left free scapular flap, and for the sacral region using a mesh skin graft. During the follow-up period, new lesions appeared in the axilla, face, buttocks, and lower extremities and were primarily treated with deroofing and skin grafting. Subsequently, no recurrent lesions were observed in the sacrum, left buttock, or axilla, and only mild recurrence was observed in the scapular flap transplanted to the right groin. In such severely affected patients, initially harvesting a flap from a distal area rather than an adjacent area may reduce the burden of any subsequent surgery. In particular, the incidence of HS has been reported to be low in the back, and HS did not occur in this patient. This report describes the challenges of buttock reconstruction for progressive severe HS, the advantages of using a free flap from the back during the initial surgery, and the favorable long-term results achieved.

Hidradenitis suppurativa (HS) is an inflammatory disease of the folliculopilosebaceous unit, which commonly affects the buttocks and axilla. It typically develops in people in their 30s and may persist into older age.^1,2 Smoking, obesity, and mechanical stress all exacerbate the condition. During a 20-year period, 31% of patients improved; 39.4% achieved remission; and 8.7%, particularly those with a family history of HS, experienced disease progression.³ The severity of the disease is classified based on the number of inflammatory nodules, abscesses, fistulas, or drainage channels.⁴ Generally, patients with chronic fistulas are referred to plastic surgery for deroofing, but this becomes more difficult as the fistulas deepen.^1,2 In severe cases, wide excision is often required. Reconstruction methods vary depending on the affected area. Skin grafts are frequently used in the buttocks and groin, and there are few reports on flap reconstruction,⁵ with no reports of free–flap reconstruction. Recurrence is common, with reported rates of 18% after skin grafts and 12% after flap surgery.⁶ However, there have not been any long-term follow-up studies of surgical cases involving disease progression. In this patient, HS subsequently occurred in the buttocks, axilla, face, and lower extremities. The initial buttock reconstruction was performed using free and pedicled flaps. Based on a 27-year long-term follow-up, we report on the difficulties of buttock reconstruction and the advantages of using a flap from the back during the initial surgery.

PATIENT

The patient was a 62-year-old Japanese man with hypertension and allergic rhinitis. He was a nonsmoker and had a family history of diabetes.

At the initial visit at age 35 years, the patient already had numerous fistulas in the left buttock, sacral, perianal, and bilateral groin regions. The fistulas were deep, accompanied by purulent discharge, and the patient occasionally experienced fever. Oral antibiotics had been administered at a local clinic, but their effectiveness had diminished. The patient was diagnosed with HS. Reconstructive surgery was performed for the left groin (using a left rectus abdominis muscle flap), the right groin (using a left scapular flap with anastomosis to the right superficial iliac circumflex vessels), the sacral region (using a mesh skin graft), and the perianal region (using primary suture) (Fig. 1). Subsequently, the patient underwent outpatient follow-up and received treatment with topical ointment, oral antibiotics as needed, and deroofing of small lesions. However, new lesions developed over time. When the lesions worsened, surgery was performed at the patient’s request. At age 36 years, the bilateral axillae were treated with mesh skin grafts. At age 46 years, the left buttock and right thigh were treated with mesh skin grafts, and the left cheek and earlobe were treated with liquid nitrogen. At age 59 years, a culture test detected methicillin-resistant Staphylococcus aureus, but no problems were observed beyond the need for careful selection of antibiotics after skin grafting. The left buttock and posterior right thigh were treated with mesh skin grafts. At age 60 years, human anti-TNFα monoclonal antibody therapy was administered for about 1 year, but treatment was discontinued due to the development of microcytic anemia. Both lower extremities were treated with deroofing (Fig. 1). At age 61 years, the bilateral groin and perineal areas were treated with mesh skin grafts, both the lower extremities were treated with mesh skin grafts, and the perianal area was treated with primary closure. At age 62 years, the right anal area was treated with mesh skin grafts. To date, no recurrence has been observed in the sacral region, left buttock, or axilla. Regarding the areas reconstructed using free or pedicled flaps, recurrence was observed in the central part of the scapular flap in the right groin region, but no recurrence was observed in the left groin region except for the edge of the rectus abdominis flap.

Fig. 1.

Details of the surgery—including the surgical site and procedures such as flap reconstruction, skin grafting, deroofing, and primary closure—and age at the time of surgery.

DISCUSSION

Currently, human anti-TNFα monoclonal antibody therapy is considered a first-line treatment for moderate to severe HS.^1,2 Although side effects occurred, we believe it is clinically significant that the majority of the lesions could be treated with deroofing (Figs. 1, 2). However, the patient did not wish to continue other antibody therapies because some lesions worsened during treatment. No other specific nonsurgical treatments were performed.

Fig. 2.

Twenty-four years after the first surgery. HS was observed on the right lower limb, particularly on the lateral side, and the symptoms improved after several deroofing procedures and treatment with an anti-TNFα monoclonal antibody.

In the initial groin reconstruction, the patient desired a surgical procedure that would minimize contracture. A flap was preferred over a skin graft because it provides elasticity and reduces contracture.

The incidence of HS in the face and back is reported to be 0.19%.⁷ HS occurring at rare sites is more likely to occur at other common sites.⁸ In this patient, HS appeared on the face but not on the back or abdomen (Fig. 3). However, lesions subsequently appeared in both lower extremities at age 59–60 years. Therefore, it is highly likely that recurrence would have occurred if a flap from an area adjacent to the buttock had been used (Figs. 1, 2).

Fig. 3.

Twenty-seven years after the first surgery. No HS was seen on the back.

In HS cases expected to be severe, we believe that harvesting a flap from a distal site may reduce the burden of subsequent operations. The patient refused a free latissimus dorsi flap due to frequent heavy lifting at work; therefore, a left scapular flap was used. In recent years, the thoracodorsal perforator flap has also been considered an option.⁹ Although careful identification and dissection of the perforating arteries are required, this flap has the advantage of allowing adjustment of flap thickness.

The depth of debridement is considered to be the level at which the adipose tissue beneath multiple fistulas becomes soft, although the exact extent has not been clearly defined.¹ Recurrence occurred at both ends of the free right scapula flap and eventually spread to the central part of the flap, suggesting that the debridement in this area may have been insufficient. With large flap reconstruction, no contracture has occurred to date, and there was space to perform partial suturing of the perianal lesions at a later stage (Figs. 1, 4). The strengths and limitations of this report include its use of a free flap from the back for gluteal reconstruction and the favorable long-term outcomes observed.

Fig. 4.

Twenty-six years after the initial surgery, no recurrence was observed in the left pedicled rectus abdominis musculocutaneous flap in the left groin. However, mild recurrence was noted in the central portion of the left free scapular flap in the right groin.

In conclusion, patients with very severe HS are likely to require multiple operations. HS is relatively rare on the back, and in patients with severe disease, buttock reconstruction using a flap from the back may be a useful option for preserving function while avoiding the need for additional surgery.

DISCLOSURE

The authors have no financial interest to declare in relation to the content of this article.