Axillary Hidradenitis Reconstruction Using a Dermal Regeneration Template

Hidradenitis suppurativa is a debilitating condition characterized by chronic inflammation of apocrine glands, most commonly in the axillary, perineal, and anorectal regions, resulting in symptoms ranging from recurrent nodules and abscesses to sinus tracts and hypertrophic scarring and contractures.^1,2 Hidradenitis most commonly occurs in adulthood, and children in whom hidradenitis is diagnosed are more likely than adults to have hormonal abnormalities, obesity, and a family history of hidradenitis.² The Hurley staging system is commonly used to describe hidradenitis, with mild cases (stages I and II) being treated with nonsurgical modalities such as topical antibiotics, oral antibiotics, biologics, laser therapy, and botulinum toxin.^2–5 For severe cases (stage III), wide excision and reconstruction remain the mainstays of treatment to minimize recurrence.^6,7

Because of the relatively low incidence of hidradenitis in the pediatric population, literature on treating this population is sparse. For this study, the authors sought to evaluate their experience treating axillary hidradenitis at a tertiary pediatric hospital using a dermal regeneration template (DRT) (Dermal Regeneration Template; Integra LifeSciences) and split-thickness skin grafting, with the hypothesis that this method of reconstruction results in acceptable functional outcomes with a low recurrence rate.

Patient selection
After institutional review board approval was obtained, all patients undergoing axillary hidradenitis reconstruction by a single surgeon were retrospectively reviewed from 2015 through 2018. All patients were included if the DRT was used for the reconstruction. Exclusion criteria included reconstruction using any other method, absence of plastic surgery involvement in reconstruction, or hidradenitis location other than the axilla. Demographic data and medical comorbidities, including body mass index, history of diabetes, and immunosuppression, comprised the inclusion criteria. Treatment data were recorded, including several negative pressure wound therapy (NPWT) changes, time to skin grafting, age at treatment, pain medication consumption, and axillary range of motion. Surgical complications including infection, DRT loss, graft loss, and hidradenitis recurrence were also recorded.

Surgical technique
After a patient had been deemed appropriate for treatment of their hidradenitis, complete axillary excision was performed to encompass all hair follicles of the axilla (Figure 1). Excision was carried through the dermis to the subcutaneous tissue, and all affected dermis was excised entirely. The DRT was then trimmed to the shape of the excised area and stapled into place (Figure 2). The DRT was used because of its well-known ability to reduce scar contracture of a wound bed, theoretically reducing the risk of axillary contracture compared with skin grafting alone.⁸ The NPWT device was applied over the DRT and set to −125 mm Hg of continuous suction. The patient’s arm was placed in an airplane splint that had been customized preoperatively by an occupational therapist (Figure 3). This splint remained in place at all times to prevent shear forces and disruption of the reconstruction. The patient was then admitted to the hospital for observation and pain control. Weekly or biweekly NPWT changes were done under light sedation, depending on the family’s ability to transport the patient to the clinic. When complete take of the DRT was deemed to have occurred, the patient was returned to the operating room based on clinical evaluation of tissue ingrowth to the entirety of the matrix and the ability to easily peel off the superficial silicone layer for split-thickness skin grafting. The NPWT was again applied over the skin graft, and the patient maintained use of the airplane splint until the NPWT device was removed at follow-up, at which time skin graft take was determined (Figure 4). Gentle use of the arm as tolerated was allowed, and standard wound care for skin grafting—specifically, a daily dressing of a petrolatum-based fine mesh gauze and antibiotic ointment for several weeks, followed by daily moisturizing lotion application—was continued until complete healing was confirmed.

Five patients undergoing 7 axillary hidradenitis reconstruction procedures were eligible for inclusion after applying the exclusion and inclusion criteria (Table). At the time of the operation, the average patient age was 18.2 years (range, 14.8–20.9 years). All patients were female. The average body mass index was 33.0 kg/m² (range, 27.0–37.2 kg/m²). No patient had any medical comorbidities that would affect wound healing or skin graft take. Four patients had undergone an average of 1.4 incision and drainage procedures (range, 1–3 procedures) prior to reconstruction. After DRT placement, the average length of hospital stay was 1.6 days (range, 1–3 days) for pain control. Patients underwent an average of 4.9 NPWT changes (range, 3–8 changes) prior to final skin grafting for each reconstruction, with an average of 27.7 days (range, 23–36 days) between DRT placement and skin grafting. Total morphine equivalents (MEqs) consumed during admission were 61.2 MEq for excision and DRT placement (range, 13.9–254 MEq) and 35.9 MEq for skin grafting (range, 19–79 MEq). No patients had any recorded complications, including infection, DRT loss, or full or partial skin graft loss. For all patients, axillary range of motion was explicitly noted to be full at the final follow-up visit. No recurrence of hidradenitis was noted in any of the surgically managed axillae. Time to final follow-up averaged 273.4 days from final skin grafting (range, 38–546 days).

Managing the resultant defect after wide surgical excision of axillary hidradenitis can be challenging, particularly in the pediatric population. Many different techniques have been described for axillary reconstruction, including NPWT, skin grafting, local flaps, extended latissimus dorsi flaps, and thoracodorsal artery perforator flaps.^9–12 The use of bilayer DRT for axillary reconstruction has been reported with good results.^13,14 These studies are limited, with Ribeiro and Guerra¹³ describing a single case report and Gonzaga et al¹⁴ reporting a cohort of 4 patients with a 25% skin substitute loss rate and 50% reoperation rate. In the pediatric cohort reported in the current study, there were no unplanned operations and there was no DRT loss or recurrence of hidradenitis. Cost concerns have been raised in the literature. However, in the authors’ experience, the reduced risk of axillary contracture from using DRT and the elimination of additional donor sites is worth consideration until higher-level studies are performed.¹⁵

This study is not without limitations. This study is a limited case series of a single surgeon’s experience at 1 academic center, which may not be applicable throughout the United States. A single surgeon may reduce variation in surgical technique but induce bias in other ways that cannot be quantified. Additional prospective, large-scale, multi-surgeon studies are warranted for further analysis

Management of axillary hidradenitis with complete excision and reconstruction using a DRT with skin grafting appears to be safe and effective in the pediatric population. Patients in the current cohort tolerated the procedure well and had no complications, including loss of DRT or skin graft, infection, loss of axillary range of motion, or recurrence of hidradenitis. Surgeons should consider using this method of reconstruction for axillary hidradenitis, although more extensive studies are needed to confirm its safety and efficacy.

Authors: Casey Kraft, MD¹; and Gregory Pearson, MD^1,2

Affiliations: ¹Ohio State University Wexner Medical Center, Columbus, OH; ²Nationwide Children’s Hospital, Columbus, OH

Correspondence: Gregory Pearson, MD, Nationwide Children’s Hospital, 700 Children’s Dr, Columbus, OH 43205; gregory.pearson@nationwidechildrens.org

Disclosure: The authors disclose no financial or other conflicts of interest.