Reconstructive Skin Surgery
Plastic surgery is a fascinating specialty – it addresses clinical problems from head to toe and has been a wellspring of surgical creativity and innovations for centuries. Its fundamental principles – wise planning of reconstruction, creative thinking and delicate operating – represent a rock upon which a plastic surgeon’s mindset is set, a solid foundation upon which all other, additional subspecialist expertise is built on later.
Hidradenitis suppurativa (HS) is a rare, lifelong localised skin disease characterised by recurring abscesses and scarring. Predilection areas are those where the skin rubs together i.e. the groin, buttocks, armpits. These folds and creases are densely populated with the specialised, apocrine glands and associated hair follicles which represent the starting point for boil-like abscesses, red, tender lumps and subcutaneous tunnels.
Chronicity of recurrent inflammations together with unsightly, painful and discharging holes not surprisingly, may have a profound emotional, social and interpersonal effects on an individual.
HS usually starts between puberty and age 40 with a single, painful bump that persists for weeks or months. In some people lump will rupture, ooze pus for few days and then permanently settle and scar. In majority of other patients, unfortunately new lumps will form in a nearby area soon thereafter.
Classical clinical picture is a recurrent mix of red, painful skin lumps, cysts, abscesses and interconnected channels that leak pus. Flare up episode is concluded with scarring and resolution of symptoms for a period of time.
You should seek advice if the lumps are painful, oozy, recur often, affect several locations, do not improve after few weeks and keep coming back.
Although there is no cure for hidradenitis suppurativa, some treatments, especially timely ones, can offer relief by controlling the pain, promoting wound healing, keeping new lumps from forming and preventing complications.
Aim of early medical input is to stop the vicious circle between acute infections, inflammations and consequent scarring, which are all likely to affect the neighbouring skin with the next flare up.
By default, treatment for HS should start with conservative, non-surgical methods.
- Topical and/or oral antibiotics
- Pain killers – usually more potent ones are required in order to achieve effective analgesia i.e. codeine, morphine, fentanyl patches, gabapentin and pregabalin
- Topical and/or oraldrugs derived from vitamin A (retinoids).
- Steroids – usually administered directly into the tender nodule aiming to reduce inflammation. Can be taken orally too
- Immunosuppressants – The drugs infliximab (Remicade) and adalimumab (Humira) show promise in the treatment of HS. These “biologics” are tumor necrosis factor (TNF) inhibitors and are usually injected under the skin in order to suppress the immune system and reduce inflammation
Surgery is never offered as a first modality of treatment. All patients referred to me have failed conservative measures attempted for a while. Lack of lasting remission after “everything else tried for a long time” leaves many people truly exhausted of ‘trials’ and keen on more permanent, surgical solutions. And surgery is indeed, the most radical and risky, but equally, the most effective if indicated sensibly and performed well.
In my practice, the following procedures are most commonly performed:
Incision and drainage of acutely inflamed abscesses- the abscess is being cut open and allowed to drain
Limited excision– ellipse of skin involving active abscesses, sinuses and cysts is removed and if possible, healthy, disease-free skin edges sutured together. If affected area is too large to allow primary skin closure, the wound is left open to heal spontaneously on its own (secondary intention healing). Excisions are relatively simple and predictable interventions, successful in majority of patients, especially if performed early, when disease is limited to the small area
Shaving of the sweat glands– this method preserves the very superficial layer of the overlying skin; sweat and sebaceous glands together with the hair follicles and subcutaneous fat are all aggressively removed
Wide radical excision– usually entire armpit/groin area affected with the disease is surgically removed. Defect is then resurfaced with skin graft or local flap; the latter is my preferred method for many reasons
Urgent concern after your surgery ?
Please ring the hospital where you have been operated on or my secretary and they will get in touch with me