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Year : 2020  |  Volume : 28  |  Issue : 1  |  Page : 38-43

Reconstruction of axillary hidradenitis suppurativa defects with thoracodorsal artery perforator flaps: Our clinical experience

Department of Plastic, Aesthetic and Reconstructive Surgery, Saglik Bilimleri University, Ankara Numune Training and Research Hospital, Ankara, Turkey

Date of Web Publication31-Dec-2019

Correspondence Address:
Dr. Atakan Bas
Department of Plastic, Aesthetic and Reconstructive Surgery, Saglik Bilimleri University, Ankara Numune Training and Research Hospital, Talatpasa Boulevard No: 5 Altindag, Ankara
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/tjps.tjps_2_19

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Background: Axillary hidradenitis suppurativa (HS) is a chronic, debilitating condition. Sinus tracts, abscess foci, and relapsing chronic inflammation are the hallmarks of the disease, which affects about 1% of the population. Various treatment options have been used to counter the underlying inflammation, but their efficacy profile yields an unsatisfactory result. Aims and Objectives: Subpar treatment results guided us to a different treatment approach, putting surgical modalities as the hallmark of our approach. Surgical debridement of affected tissues often results in a defect, requiring a safe,effective reconstructive method. Results: Thoracodorsal artery perforator (TDAP) flap is a versatile flap which can be applied to reconstruct thoracic and axillary defects, whereas a free fasciocutaneous flap can be used as a reliable method to cover extensive defects located elsewhere in the body. In axillary HS, TDAP flap is a reliable method for reconstruction, providing adequate soft-tissue coverage, three-dimensional regular contours, and less adverse effects in the long term compared to skin grafts. Conclusion: In our article, we shared our experience with the usage of TDAP flap. Our results indicate that TDAP should be considered as a primary option in reconstruction of axillary HS defects.

Keywords: Axillary hidradenitis suppurativa, perforator-based reconstruction, thoracodorsal artery perforator flap

How to cite this article:
Ergani HM, Bas A, Yasar B, Unlu RE. Reconstruction of axillary hidradenitis suppurativa defects with thoracodorsal artery perforator flaps: Our clinical experience. Turk J Plast Surg 2020;28:38-43

How to cite this URL:
Ergani HM, Bas A, Yasar B, Unlu RE. Reconstruction of axillary hidradenitis suppurativa defects with thoracodorsal artery perforator flaps: Our clinical experience. Turk J Plast Surg [serial online] 2020 [cited 2021 Oct 26];28:38-43. Available from: http://www.turkjplastsurg.org/text.asp?2020/28/1/38/274437

  Introduction Top

Hidradenitis suppurativa (HS) is pathologically defined as a disease initiating with hyperkeratosis of hair follicles and involving an inflammatory process stemming from obstructed apocrine glands associated with the follicles. The diagnosis is made by the modified Dessau definition, which combines diagnostic lesions, topographic features, and the history of the disease.[1] Clinically, HS is described as a chronic inflammatory process with relapsing and remitting course in the skin folds. HS is associated with painful nodules, abscess foci, sinus tracts, scarring, and pseudocomedones. HS prevalence is highly variable,[2],[3] and the risk factors such as age, gender, obesity, smoking, and genetic characteristics affect the prognosis of the disease.[4],[5] Due to limited effectiveness of defined treatment options and chronic course, HS has negative effects on the quality of life and psychological state of the patients.[6],[7],[8]

Although no standardized approach is described for HS treatment, various treatment modalities have been suggested. Antibiotics, retinoids, corticosteroids, laser treatments, and radiation therapies are proposed as conservative treatment modalities, yet high recurrence rates are encountered.[9],[10] Surgical debridement of the affected tissue is the only convincing method providing a permanent solution. Primary closure, application of split-thickness skin grafts (STSGs), local flaps, and musculocutaneous flaps have been described for defect reconstruction following complete excision of the lesions.[11],[12],[13] Secondary healing is not preferred due to high recurrence rate and increased morbidity rates and longer hospital stay. Functional limitations resulting from secondary graft contraction in patients reconstructed with skin grafts suggest the use of flaps in HS surgical treatment.

Axillary region is frequently involved in HS patients. For smaller lesions, the defects following the excision of surgically affected tissues can be closed primarily. If primary closure is unlikely, local advancement transposition and rotation flaps are the mainstays for treatment.

Axillary region has a wide spectrum of flaps for defect reconstruction; pedicled flaps such as latissimus dorsi musculocutaneous flap, lateral thoracic perforator flap, and thoracodorsal artery perforator flap (TDAP) have significant value. Furthermore, free flaps can be used in addition to the classically defined advancement and rotation flaps. TDAP is a local flap that can be used in axillary zone defects.[14],[15]

In our study, we aimed to prevent the local recurrences caused by other treatments applied in axillary HS patients in the chronic period, together with the esthetic and functional reconstruction of the region. For this purpose, we suggest some clues about the surgical technique, boosting the success of the reconstruction through TDAP, which we believe is superior to other options in terms of esthetic and function. Here, we present the long-term follow-up data and patient satisfaction in the postoperative period for the patients treated with TDAP in our clinic.

  Materials and Methods Top

Nine patients (four males and five females) were admitted to our clinic with axillary HS between 2016 and 2017, who had multiple HS foci refractory to medical treatment and defects that are not suitable for primary closure. These patients were evaluated in terms of flap size, length of hospital stay, and complications. Patients included in the study were assessed with a Skindex-16 satisfaction questionnaire following the treatment, 3 months postoperatively. Skindex-16 is the latest Turkish-adapted health-related quality of life questionnaire available and hence our preference. The mean follow-up period of the patients was 12 months with a minimum of 8 months and a maximum of 2 years.[16]

Thoracodorsal artery perforator flap

TDAP flap is a fasciocutaneous flap that is frequently fed by the first branch of the 2 or 3 perforators stemming from the descending branch of thoracodorsal artery (TDA). These perforating branches usually originate 2–3 cm from the lateral margin of the latissimus dorsi muscle, 8 cm inferior to the posterior axillary fold. The third perforator branch, if present, is often located 1–2 cm inferior with a smaller caliber. Among these perforators which arise from the descending branch of the TDA, numerous muscular branches feed the latissimus muscle fascicles, while the fasciocutaneous branches supply the skin and subcutaneous tissues.[17],[18]

Surgical technique

Preoperative preparation

We start by visualizing the regions where hair follicles and apocrine glands are most common. Abscesses, sinus tracts, and fistula orifices, which patients actively complain about and are associated with high recurrence, are identified. Subsequently, the TDAP flap, which is to be adapted to the defect, is designed according to the size of the projected defect. In TDAP flap design, inclusion of the recognized perforating branches with a reliable diameter is of utmost importance for postoperative flap survival. The region where the Thoracodorsal Artery Perforators are frequently found at 8–10 cm inferior to the axillary fossa, approximately 2 cm to the anterior border of the latissimus dorsi muscle. The TDAP can be designed horizontally or longitudinally, according to the shape of the defect to be formed. However, the highest success is achieved by the “pinch test,” determining the axis with minimum skin tension. Perforating branches of the artery should be localized preoperatively with Doppler ultrasonography (USG). If visualization is insufficient with USG, computed tomography (CT)/magnetic resonance (MR) angiography can be used to identify intercostal perforators and thoracodorsal perforating branches, especially in obese patients.[19]

TDAP has a vascular pedicle about 7–12 cm long, and the diameter of the perforator is approximately 1 mm. The venous drainage of the flap is often provided by the concomitant veins traversing with the artery. Occasionally, the calibration of the veins accompanying perforating branches is low, and patients with venous drainage to the superficial veins are present. We advise for close monitoring of venous insufficiency in patients with small caliber veins. To avoid the loss of sensory function of the flap, the lateral branches of the intercostal nerves, which may be seen during dissection in the immediate vicinity of the perforating arteries, should be preserved. It has been shown that a TDAP flap fed through perforators can be used for the reconstruction of even 15 cm × 25 cm large defects.

Peroperative planning, flap preparation, and defect reconstruction

Following anesthesia induction, the patient is positioned in lateral decubitus position. The involved axilla is examined with the arm abducted. After all involved areas or the areas having the potential for involvement are marked, the skin and subcutaneous tissue are completely excised with a safety margin. Once the incision is completed, the flap is planned to be 20% larger than the projected defect, taking the locations of the TDA perforating branches that are marked with Doppler USG into account. Flap elevation is initiated with the incision at the anterior margin. About 8–14 cm after originating from the subscapular artery, the TDA penetrates the latissimus dorsi muscles and gives perforating branches to the muscle and skin. Whereas the TDA extends parallel to the anterior margin of the latissimus muscle, the horizontal branches obliquely follow to the dorsomedial course. Exquisite work to identify perforator branches and following their traces during dissection is of great importance. After identifying the perforator branches and their course, the dissection is continued until the TDA and the horizontal branches are separated. This dissection is sufficient for the reconstruction of most defects, and vascular rotation during the flap transposition does not cause any adverse effect on flap blood flow. When the dissection of the perforator branches is completed, incisions are made on other borders to provide flap elevation. The obtained flap is tunneled for the reconstruction of the defect. During the transposition, extra attention is required to preserve the pedicle. Avoiding vascular over-rotation and tension along the suture lines provides a viable flap. Flap donor sites up to 10 cm can be closed primarily. Progressive tension sutures are placed to prevent seroma development during primary closure of the donor sites. Drains were placed at the base of the flap and the donor site, and regular 24-h follow-ups were performed. When the drainage got below 25 cc/day, the drains were removed. During the hospitalization period, the patients were followed with their shoulder joint abducted at 90°. Patients were referred to the physical therapy and rehabilitation clinic following suture removal to ensure full range of shoulder motion after the operation.

  Results Top

Our study included nine patients (four males and five females), and the average age was 36.4 (range between 17 and 49 years). We intended to treat all of our patients with an ipsilateral TDAP flap. Median hospital stay is 7 days. The largest TDAP flap dimension was 12 cm × 9 cm, and the surface area ranged from 70 to 108 cm2. We had a female patient with mild hypertension and a male patient with diabetes mellitus, regulated by oral antidiabetics. Raw results can be found, as presented in [Table 1]. Overall, we enjoyed good success postoperatively, but we also had some complications and handled them appropriately. Venous pooling in patients number 2 and number 9 and postoperative seroma in patient number 5 were early complications that were noticed. While changing the position was sufficient for the first patient with venous pooling, medical leech therapy was applied additionally to the another patient. Venous pooling was observed to be regressed, and the flap survival was complete as a result of these interventions. Hypertrophic scar development tendency in the flap donor site was recognized in case number 1 from the 1st postoperative month. Hypertrophic scar development was prevented by topical agents. Minimal skin irritation was present in long-term follow-up. The outcomes of the patients according to Skindex-16 questionnaire were found to be lower than those of chronic skin diseases. The outpatient clinic follow-up also showed high operation satisfaction. Although no additional treatment was used in the 1-year follow-up, relapse recurrence was not observed.
Table 1: Patients and flap-related data

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  Case Reports Top

Case 1

The patient applied to our outpatient clinic as sinus tracts, abscess foci, and painful nodules developed due to bilateral axillary HS ongoing for 5 years. The patient stated no change in the progression of the disease despite the usage of various antibiotics, nonsteroidal anti-inflammatory drugs, and steroids recommended by other health centers. The operation plan was explained in detail to the patient following her application. The TDAP flap was initially planned for the right axillary region where the symptoms were more prominent, and following the 3-month healing period, another TDAP flap was planned for the left axillary region. In the first operation, the elevated TDAP flap was adapted to the defect after the excision of all affected tissues. The patient was followed up in ward for 7 days during the postoperative period. The patient was discharged without any complication.

The patient applied for the operation of the left axillary region 3 months later. Preoperatively hand Doppler-marked perforating branch was noticed not to be the TDAP but a branch of the anterior intercostal artery during the flap elevation. Because the anterior intercostal artery-based flap was unable to cover the defect and the perforator branch was not suitable for reconstruction, the planned flap was placed back to the donor site and the defect was reconstructed with a STSG harvested from the anterolateral side of the ipsilateral thigh.

Case 2

In our patient's first visit, he had symptoms consistent with right axillary hidradenitis, ongoing for 3 years. The skin and the subcutaneous tissue of the axillary region were excised, and the TDAP flap was planned for the reconstruction of the resulting defect. Excision of subcutaneous fat tissue was also made to provide a better axillary contour, and the flap was provided to have a smooth appearance. The range of motion of the joint was observed to be complete in the postoperative period. Preoperative and early postoperative photographs are shown in [Figure 1], [Figure 2], [Figure 3].
Figure 1: Preoperative lesions of axillary hidradenitis suppurativa

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Figure 2: Early postoperative result

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Figure 3: Postoperative 8th day, with interrupted suture removal

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  Discussion Top

Long-term cure rates do not reach satisfactory levels in HS treatment despite trial of various nonoperative treatment options.[9],[10] In untreated HS cases, patients' quality of life is known to be low, and physical and psychological problems are experienced.[6],[7],[8] In patients unable to achieve symptomatic improvement with nonoperative medical treatments, the only possible way to improve quality of life is excision of surgically affected tissues without any delay. Extensive removal of surgically affected tissues is known to be the only treatment method that can cure HS. However, large-scale tissue defects frequently occur after wide excisions. Due to the large-size defects, secondary follow-up is practically impossible, and reconstructive surgery with graft or flap is required.

Other possible surgical treatment options include primary closure for small defects, reconstruction of the defect with STSG, or locally planned transposition/advancement flaps.[11],[12],[13] Only a small number of patients are candidates for primary closure after excision, whereas most cases require a reconstructive procedure. STSG can be preferred in HS treatment as it is a practical method, and the operation duration is relatively short. However, reconstruction with STSG is not associated with good long-term esthetic outcomes. Long-term immobilization may be required to increase graft survival after surgery. In addition, following the reconstruction with STSG, contracture formation in the axillary region and restricted movement in the shoulder region may occur. Considering all these reasons, it can be concluded that reconstruction with STSG is far from being an ideal choice.

Limberg transposition flaps, bilateral V-Y advancement flaps, and lateral thoracic artery flaps were defined as local flaps in axillary HS treatment. Limberg and transposition flaps are randomly patterned flaps. Due to their random pattern, necrosis can be seen at the distal end, especially during the reconstruction of large surface areas. The potential for multiple operations or extended hospital stays significantly lessens their application. The lateral thoracic artery flap originates from the lateral thoracic artery, and the reconstruction of the defect is done by fasciocutaneous island flap, which may also be used as an alternative to TDAP. Inner arm perforator flap is another perforator flap defined to cover the axillary region defects. Despite promising results claimed in its definitive article, there is not another study proving effectiveness and applicability of the flap.

The TDAP flap is successfully placed in various experienced centers. Since the donor site can be closed primarily, it can completely adapt to the defect in three dimensions, instantly providing the soft tissue needed. As the axilla is covered with a viable flap, the range of motion does not become limited, and the possibility of axillary contracture development is low. The outcomes of the patients treated with TDAP flap in our clinic were also found to be consistent with the literature. The reconstruction of HS defects with TDAP in the axillary region stands out as it includes a safe, single-stage surgical procedure with low donor site morbidity and high axillary tissue compatibility and without microsurgical operation requirement.

However, with increasing planned flap size, early complications (e.g., seroma) are more frequently confronted in postoperative follow-up. By placing the progressive tension sutures to the donor site after flap adaptation, wrapping elastic bandage in the postoperative period and performing serial aspiration of any collection if necessary, the seroma development is prevented. These measures also allow drains to be removed earlier, shorten the length of hospital stay, and reduce financial costs. Venous pooling is another complication we often face, especially with bigger TDAP flaps. Pedicled perforator style flaps have a tendency to venous pooling after repositioning the flap for adaptation.[20] Most of the time, clinical follow-up and timely interventions suffice, as flap necrosis happens to be superficial.

During TDAP flap planning, examining the patient in standing position with the arm abducted to 90° is vital. Determination of suitable perforators by preoperative Doppler USG or CT/MR angiography leads to a successful surgery. The localization of TDA perforator can be confused when the patient is in a sitting position during preoperative drawing. It should not be forgotten that the sound provided by the hand Doppler might not represent a perforator branch of the TDA but a perforator branch of the anterior branches of the intercostal artery.

In our clinic, we followed the patients treated due to the axillary HS up for an average of 1 year. During the follow-up period, we did not encounter a late complication postoperatively in the long term. Possible late complications of the TDAP flaps include wound dehiscence, seroma formation, and hypertrophic scar or keloid development. Proper planning of the flap, careful handling of the flap, and reducing tension by tension sutures during the operation may prevent the development of seroma and dehiscence. When the development of hypertrophic scar is detected during close follow-ups of the patients in the postoperative period, prevention is possible with topical steroid treatment. Our patient with hypertrophic scar formation is shown in [Figure 4].
Figure 4: Postoperative hypertrophic scar formation, before Intralesionary steroid application at 6 weeks

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When the satisfaction ratings of patients treated with TDAP in our clinic were evaluated, it was seen that TDAP was superior to other treatment options. We conclude that our results are compatible with similar studies in the literature. TDAP is a good choice for the reconstruction of defects that occur in axillary HS patients because of its inherent reliability, single-stage application, color, texture, and contour compatibility. We believe that TDAP should be one of the first-line surgical options in axillary HS treatment, and more studies should be conducted to optimize its application. In our article, we offered some pearls that might help a dedicated surgeon to minimize complications and relapse rates while enhancing flap success and providing ever-lasting relief to patients.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.

  References Top

Zouboulis CC, Desai N, Emtestam L, Hunger RE, Ioannides D, Juhász I, et al. European S1 guideline for the treatment of hidradenitis suppurativa/acne inversa. J Eur Acad Dermatol Venereol 2015;29:619-44.  Back to cited text no. 1
Vinding GR, Miller IM, Zarchi K, Ibler KS, Ellervik C, Jemec GB, et al. The prevalence of inverse recurrent suppuration: A population-based study of possible hidradenitis suppurativa. Br J Dermatol 2014;170:884-9.  Back to cited text no. 2
Cosmatos I, Matcho A, Weinstein R, Montgomery MO, Stang P. Analysis of patient claims data to determine the prevalence of hidradenitis suppurativa in the United States. J Am Acad Dermatol 2013;68:412-9.  Back to cited text no. 3
Revuz JE, Canoui-Poitrine F, Wolkenstein P, Viallette C, Gabison G, Pouget F, et al. Prevalence and factors associated with hidradenitis suppurativa: Results from two case-control studies. J Am Acad Dermatol 2008;59:596-601.  Back to cited text no. 4
Canoui-Poitrine F, Revuz JE, Wolkenstein P, Viallette C, Gabison G, Pouget F, et al. Clinical characteristics of a series of 302 French patients with hidradenitis suppurativa, with an analysis of factors associated with disease severity. J Am Acad Dermatol 2009;61:51-7.  Back to cited text no. 5
Onderdijk AJ, van der Zee HH, Esmann S, Lophaven S, Dufour DN, Jemec GB, et al. Depression in patients with hidradenitis suppurativa. J Eur Acad Dermatol Venereol 2013;27:473-8.  Back to cited text no. 6
Shavit E, Dreiher J, Freud T, Halevy S, Vinker S, Cohen AD, et al. Psychiatric comorbidities in 3207 patients with hidradenitis suppurativa. J Eur Acad Dermatol Venereol 2015;29:371-6.  Back to cited text no. 7
Vinding GR, Knudsen KM, Ellervik C, Olesen AB, Jemec GB. Self-reported skin morbidities and health-related quality of life: A population-based nested case-control study. Dermatology 2014;228:261-8.  Back to cited text no. 8
Kromann CB, Deckers IE, Esmann S, Boer J, Prens EP, Jemec GB, et al. Risk factors, clinical course and long-term prognosis in hidradenitis suppurativa: A cross-sectional study. Br J Dermatol 2014;171:819-24.  Back to cited text no. 9
Chuang CJ, Lee CH, Chen TM, Wang HJ, Chen SG. Use of a versatile transpositional flap in the surgical treatment of axillary hidradenitis suppurativa. J Formos Med Assoc 2004;103:644-7.  Back to cited text no. 10
Hudson D, Krige S. Axillary hidradenitis suppurativa – Wide excision and flap coverage is best. Eur J Plast Surg 1993;16:94-7.  Back to cited text no. 11
Geh JL, Niranjan NS. Perforator-based fasciocutaneous Island flaps for the reconstruction of axillary defects following excision of hidradenitis suppurativa. Br J Plast Surg 2002;55:124-8.  Back to cited text no. 12
Angrigiani C, Grilli D, Siebert J. Latissimus dorsi musculocutaneous flap without muscle. Plast Reconstr Surg 1995;96:1608-14.  Back to cited text no. 13
Hamdi M, Van Landuyt K, Monstrey S, Blondeel P. Pedicled perforator flaps in breast reconstruction: A new concept. Br J Plast Surg 2004;57:531-9.  Back to cited text no. 14
Altmann S, Fansa H, Schneider W. Axillary hidradenitis suppurativa: A further option for surgical treatment. J Cutan Med Surg 2004;8:6-10.  Back to cited text no. 15
Aksu AE, Saraçoǧlu ZN, Sabuncu İ, Chren MM, Tozun M. Validity and reliability of the Turkish version of the skindex-16. TURKDERM 2016;50:109-13.  Back to cited text no. 16
Van Landuyt K, Hamdi M. Thoracodorsal artery perforator flap. In: Blondeel PN, Morris SF, Hallock GG, Neligan PC, editors. Perforator Flaps: Anatomy, Technique, and Clinical Applications. St. Louis, MO: QMP Medical Publishing; 2006. p. 441-59.  Back to cited text no. 17
Guerra AB, Metzinger SE, Lund KM, Cooper MM, Allen RJ, Dupin CL, et al. The thoracodorsal artery perforator flap: Clinical experience and anatomic study with emphasis on harvest techniques. Plast Reconstr Surg 2004;114:32-41.  Back to cited text no. 18
Wei FC, Mardini S. Flaps And Reconstructive Surgery. Amsterdam: Elsevier; 2017;648-67.  Back to cited text no. 19
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  [Figure 1], [Figure 2], [Figure 3], [Figure 4]

  [Table 1]


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