Reconstruction of Axillary Defects With Propeller Parascapular Flap After Resection in Patients With Advanced Hidradenitis Suppurativa

First described by Velpeau in 1839, HS is a chronic disease characterized by inflammation and infection of the apocrine sweat glands or hair follicles, as well as recurrent abscess and nodule formation.¹ HS can occur anywhere on the body where apocrine sweat glands are present, although the infection generally occurs on the skin in the axillary, inguinal, perineal, and inframammary regions.² If painful and purulent lesions become recurrent, they can cause chronic sinus tracts, fistulas, scarring, and fibrosis.³ Thus, HS can seriously affect patient quality of life and cause considerable mental and physical difficulties.

Although abscess drainage and local excision provide short-term relief, these techniques do not deliver long-term benefits and can lead to complications such as recurrence and chronic inflammation.³ To prevent these complications, wide excision of the affected skin tissue and apocrine glandular region is considered the standard of care for advanced HS.^4-6 Published studies of advanced HS surgery mention secondary healing or repair with STSG after extensive excision.^7,8 However, considerable complications such as a long healing process, secondary contractions, and joint contractures may be associated with these treatment methods.^7,8

Skin and subcutaneous tissues adjacent to the defect can be harvested and prepared as a fasciocutaneous flap by transposition or advancement without separating tissues from the vessels from which they originate. The addition of muscle to these tissues results in a musculocutaneous flap. The local flap is adjacent to the defect; a part of the skin is left intact on one side to ensure the blood supply to the flap is unaffected.

The propeller flap is an island fasciocutaneous flap that is based on a single dissected perforator. Propeller flaps have a wide rotation arc range of up to 180°. The parascapular propeller flap is prepared by complete harvesting with only a principal pedicle (Figure 1). Thus, there is no attachment to prevent wide rotation of the flap. The flap can then be placed in the defect.⁹ The literature indicates that local and regional flaps such as the fasciocutaneous V-Y flap, Limberg flap, latissimus dorsi musculocutaneous flap, thoracodorsal artery perforator flap, and parascapular flap have been used in the management of HS.^10,11 However, to the knowledge of the authors of the current study, the literature on the use of parascapular flaps for this indication consists solely of limited case reports, and no studies involving large numbers of patients have been published.

The authors of the current study hypothesized that the propeller parascapular flap can be reliably used in unilateral or bilateral axillary defects after excision in patients with advanced axillary HS.

Eleven patients (10 males, 1 female) with unilateral or bilateral advanced HS who underwent propeller parascapular flap surgery between July 2016 and December 2018 were included in this retrospective, single-center study. This study was approved by Necmettin Erbakan University, Meram Faculty of Medicine, Konya, Turkey. Both written and verbal informed consents were obtained from the patients. All patients with HS were categorized according to the Hurley classification (Table 1).^12,13 Only patients with stage III disease were included in the study. Four patients presented with unilateral HS on the right side, 3 presented with unilateral HS on the left side, and 4 patients presented with bilateral HS.

To minimize disruption to their lives, patients with bilateral HS underwent propeller parascapular flap surgery 2 months after the first surgery on the contralateral side. Patients with Hurley stage I or II HS—as well as those whose symptoms regressed with medical treatment, who were lost to follow-up, or who refused flap surgery—were excluded from the study.

Follow-up data and demographic information on smoking, chronic disease, and obesity were analyzed (Table 2). Patients who actively smoked were asked to stop 3 weeks preoperatively. Patients were evaluated in terms of 2 main postoperative complications: postoperative recurrence and flap viability. In addition, other complications such as bleeding, infection, dehiscence, contracture, or hypertrophic scarring were noted.

Surgical technique

Patients underwent surgery under general anesthesia in the lateral decubitus position, and the ipsilateral arm was released. Incision lines were marked using the scapula as a guide, and the pedicle was identified with the help of Doppler USG. Flap harvesting was started on the inferior side. The harvesting was then continued deep to the triangular space, and the flap was harvested above the deep muscle fascia. The triangular fascia was included in the flap when the fascia was reached. The muscles were split, and then the descending branch of the circumflex scapular artery was explored and released. The pedicle was dissected to the extent possible to prevent torsion (Figure 1). The flap was transposed to the defect as a propeller flap. Perfusion of the flap was checked using Doppler USG following placement of initial sutures, and the flap was inset into the defect area. A Hemovac drain (Zimmer Biomet) was placed. Typically, these drains were removed on postoperative day 2 or when drain contents were less than 25 mL per day.

Postoperative care

After surgery, prophylactic antibiotic treatment (intravenous cefazoline 1000 mg twice daily) was initiated. After discharge, a 7-day treatment regimen with oral amoxicillin clavulanate (1000 mg twice daily) was given. No patients were prescribed antithrombotic therapy. Patients were restricted to adduction and abduction less than or equal to 90° for 5 to 6 days postoperatively.

A total of 15 propeller parascapular flaps were performed in 11 patients who underwent axillary defect reconstruction after wide resection to manage advanced HS. The mean patient age was 34 years (range, 19–54 years). Seven patients had previously undergone an average of 8.1 surgical procedures at other centers; these patients had predominantly undergone primary closure or local flap coverage.

In the current study, the average flap area was 160 cm² (range, 112–297 cm²). Axial length, width, and depth of flaps ranged in size from 14 cm to 27 cm, 7 cm to 12 cm, and 1 cm to 2.2 cm, respectively. All donor sites were primarily closed. Dehiscence occurred in only 1 of 15 flaps (6.7%) (Figure 2). Final wound healing was achieved by wound dressing and re-suturing. None of the patients experienced infection, partial necrosis, total flap loss, or recurrence. The average hospital length of stay was 4 days (range, 3–6 days), and the mean follow-up period was 18 months (range, 12–38 months).

At final follow-up, no patient exhibited contracture restricting movement of the shoulder joint. One patient had anemia of chronic disease, 1 had diabetes and hypertension, and 6 actively smoked. Five patients had a body mass index over 30 (mean, 27.2 kg/m²). In case 6, internal medicine physicians diagnosed anemia of chronic disease related to HS. Patient 7, who had diabetes and hypertension, was referred to the department of cardiology and internal medicine for preoperative evaluation. The patient’s HbA_1c level was 8.2%, and blood pressure was normal owing to a regimen of oral enalapril 20 mg and lercanidipine 10 mg. The patient had been taking oral antidiabetics (metformin 1000 mg twice daily and linagliptin 5 mg once daily). The oral antidiabetics were stopped preoperatively, and short-acting insulin (Humulin R [Eli Lilly and Company]) was used to maintain blood sugar levels at 70 mg/dL to 200 mg/dL. Oral antidiabetics were reintroduced when the patient resumed oral feeding after surgery.

Case 6

A 54-year-old male presented with a 7-year history of bilateral HS. The patient had previously undergone 2 operations at a different center. Because of a preoperative hemoglobin level of 10.1 g/dL, the patient was referred to the internal medicine clinic. Anemia of chronic disease was diagnosed. After wide excisions, reconstruction was performed with parascapular flaps measuring 20 cm × 7 cm and 18 cm × 8 cm (Figure 3). No early or late complications were observed.

At 12-month follow-up, the patient’s Hb level was 12.6 g/dL. The patient’s anemia of chronic disease was successfully treated in the postoperative follow-up period.

Case 8

A 28-year-old male had previously undergone several dermatologic treatments over 9 years because of recurrent purulent lesions in the left axillary region. According to medical history, the patient had undergone 41 local resection and primary closure procedures at another medical center, and had no comorbidities. Following wide resection at the authors’ center, parascapular flap surgery was performed in the left axillary region; a flap measuring 27 cm × 11 cm was created. The hospital length of stay was 4 days, and the follow-up period was 18 months. No early or late complications were observed (Figure 4).

HS is a recurrent chronic disease caused by bacterial infection of the occlusion of the apocrine glands. Superinfection, chronicization, recurrence, and a lack of response to medical treatment lead to disease progression and soft tissue destruction. Optimization of treatment requires a thorough understanding of the underlying pathology and the prevention of recurrence. Thus, the main goal of surgical treatment should be total excision of the affected tissue.³ Insufficient excision almost always results in recurrence and complications in patients with HS. Studies have shown that inadequate excision is a major cause of recurrence.^2,14 Thus, sufficient excision and subsequent reconstruction should be performed.^4-11 Primary closure and secondary healing using STSG and reconstruction with fasciocutaneous flaps have been performed to treat HS, and results have been reported.⁸

Reported recurrence rates range broadly, from 0% to 70%.⁸ A recurrence rate of 13% after wide excision was reported in a meta-analysis by Mehdizadeh et al.¹⁶ However, the data in that meta-analysis study¹⁶ are not specific to axillary HS. Recovery, infection, and recurrence rates may differ depending on the anatomic region affected. For this reason, the anatomic region should be taken into consideration when determining treatment plans.

Ovadja et al⁸ performed a retrospective multicenter study evaluating 107 surgical procedures for axillary HS in 54 patients. Patients treated with primary closure, secondary healing, STSG, or fasciocutaneous flaps were compared. Recurrence rates were significantly lower in patients who underwent fasciocutaneous flaps (P =.03).⁸ Based on their findings,⁸ all defects in the current study were reconstructed with flaps following wide resection. The parascapular flap was preferred because of the primary closure of the donor area, its use as a propeller flap, and its reliable pedicle.

The Hurley classification from 1989 was used in the current study because it is the most commonly used categorization of HS in the literature.^11,12 All patients in this study were classified as having Hurley stage III HS.

Local flaps such as the Limberg flap and the V-Y advancement flap can be used for reconstruction of axillary defects and may even form effective tissue coverage. The limited mobilization capacity of these flaps, the inability to use them in large defects, and the maintenance of pedicle flap length ratio are major challenges to their use, however. In addition to local flaps, thoracodorsal artery perforator flaps, pectoral flaps, and scapular and parascapular perforator flaps can be used for the reconstruction of axillary defects.¹⁷

The circumflex scapular artery is a branch of the subscapular artery which originates from the axillary artery. The blood supply of the parascapular flap is carried by a descending branch of the circumflex scapular artery. The length of the pedicle of this flap ranges from 3 cm to 7 cm, providing a wide rotation arc. Thus, it can be used as a propeller pedicled or free flap.

The number of case reports in the literature regarding the use of parascapular flaps in HS is limited,^10,11 and no large studies supporting the use of this type of flap in HS have been conducted. Nevertheless, the parascapular flap has the following advantages: its vascular anatomy does not present much variability, it is suitable for large defects, the primary donor area can be closed, it can be used as a pedicled or free flap, and it can be harvested at sizes as large as 30 cm × 15 cm.^18,19 The parascapular flap is defined for use in lower and upper extremity defects,^20-22 though Mayou et al²³ reported that it also can be used as an island flap in reconstruction of the shoulder, axilla, breast, chest, and neck.

Elboraey et al³ reported a series of 6 patients who underwent the parascapular flap procedure for HS. They found the propeller flap technique can be effective for immediate or delayed closure. Although the delayed technique was used and the axial length of the longest flap was 18 cm, 1 wound dehiscence and 1 distal flap necrosis were reported. The mean follow-up period was 10 months.

In the current study, 15 propeller parascapular flaps were performed in 11 patients, and no partial or complete flap loss was observed in any patient. Furthermore, delayed reconstruction was not required, and the axial length of the longest flap was 27 cm. No recurrence was observed after an average 18-month follow-up.

This study had several limitations, including its retrospective design and the limited number of patients. Because 7 of the patients in this study had a previous history of surgery, no other treatment groups were planned; thus, this study lacked a control group. Additionally, because parascapular flaps are used in patients requiring wide resection, only patients with Hurley stage III HS were included in the study.

The advantages of the propeller parascapular flap—low recurrence rate, low flap failure, and low donor area morbidity, in addition to sufficient flap size to ensure a wide rotation arc—make it a reliable and practical option for the surgical management of advanced HS.

It is hoped that the propeller parascapular flap will be the subject of future controlled prospective studies that will shed further light on this procedure, especially in the treatment of patients with recurrent advanced HS.