INTRODUCTION
Hidradenitis suppurativa (HS) is a chronic, inflammatory, recurrent, and
debilitating cutaneous follicular disease that usually presents after puberty
with deep, inflamed, painful lesions in areas of the body with apocrine glands,
most commonly axillary, inguinal, and anogenital regions, which can lead to
serious physical and emotional consequences.
The prevalence of HS is unknown, but estimates range from 0.00033% to 4.10%. It
occurs more frequently in young adults and is twice as common in women as
men1,2. The perineal area is the second most commonly
affected, treated with wide excisions, requiring challenging reconstructions.
Surgical resection of affected tissues offers greater hope for definitive
treatment of HS, so having a flap option to reconstruct large perineal defects
after HS resections is important2.
Some techniques have already been published for reconstructing defects in the
perineal and gluteal region in treating HS, such as primary closure, grafts,
or
perforator flaps of the superior and inferior gluteal artery. However, they have
not been widely studied in extensive defects that compromise the anterior and
posterior perineum2,3.
The V-Y medial thigh fasciocutaneous flap is a flap based on perforating arteries
of the femoral artery, is technically reproducible and provides sufficient
volume with good coverage of skin and subcutaneous cellular tissue for extensive
defects of the perineum in the treatment of HS.
OBJECTIVE
To present a case report that shows the use of the medial fasciocutaneous thigh
flap in bilateral V-Y advancement as an option for reconstructing extensive
areas of the perineal region to treat hidradenitis suppurativa.
A female patient, 43 years old, was referred to the plastic surgery service after
a diagnosis of hidradenitis suppurativa in the anterior and posterior perineum
without prior treatment (Figure 1). It was
planned resection of the affected tissue and reconstruction with a bilateral
V-Y
medial thigh fasciocutaneous flap in two surgical stages.
Figure 1 - Hidradenitis suppurativa lesion of the bilateral total perineal
region.
Figure 1 - Hidradenitis suppurativa lesion of the bilateral total perineal
region.
With the patient in the lithotomy position, under general anesthesia, lesions in
the perineal region and bilateral labia majora were resected, with a margin of
1.5 cm laterally and medially, up to the subcutaneous plane, with resection of
the entire lesion (Figure 2), collection of
samples for anatomopathological study, cultures using negative pressure therapy
at 125mmHg continuous. The anatomopathological report concluded a diagnosis of
bilateral hidradenitis suppurativa, and culture results indicated infection with
multisensitive Staphylococcus aureus and
Corynebacterium striatum, with antibiotic therapy being
indicated.
Figure 2 - Appearance of the perineal defect after 3 days of negative
pressure therapy.
Figure 2 - Appearance of the perineal defect after 3 days of negative
pressure therapy.
After 48 hours, the defect was reconstructed with 25x30cm flaps on the right
thigh and 25x22cm on the left thigh, based on perforating arteries of the
femoral artery. The dissection was performed in the fasciocutaneous plane up
to
the fascial plane with detachment of the proximal and distal third of the flap
and advancement in V-Y, with fixation points and placement of portovac drains
with distal exteriorization and closure in layers (Figure 3).
Figure 3 - Perineal reconstruction completed with medial thigh
fasciocutaneous flap in bilateral V-Y advancement.
Figure 3 - Perineal reconstruction completed with medial thigh
fasciocutaneous flap in bilateral V-Y advancement.
The procedure was carried out uneventfully; the flaps had good skin and
subcutaneous cellular tissue coverage, and no medications were prescribed to
reduce the number of bowel movements or an ostomy. Twenty-four hours after
surgery, antithrombotic prophylaxis was prescribed and maintained for 7 days.
On
the second postoperative day, she was allowed to sit and walk with short steps
and was discharged on the sixth day. The drains were removed on the eighth day.
Two months after surgery, three areas of dehiscence were observed and treated
conservatively. One and a half years after surgery, the flap remains in good
condition, with no evidence of disease recurrence or vulvar irritation, with
an
acceptable aesthetic result (Figures 4 to
6).
Figure 4 - Medial fasciocutaneous thigh flap in bilateral V-Y one year 6
months postoperatively.
Figure 4 - Medial fasciocutaneous thigh flap in bilateral V-Y one year 6
months postoperatively.
Figure 5 - Medial fasciocutaneous thigh flap in bilateral V-Y one year 6
months postoperatively. Previous view.
Figure 5 - Medial fasciocutaneous thigh flap in bilateral V-Y one year 6
months postoperatively. Previous view.
Figure 6 - Medial fasciocutaneous thigh flap in bilateral V-Y one year 6
months postoperatively. Back view.
Figure 6 - Medial fasciocutaneous thigh flap in bilateral V-Y one year 6
months postoperatively. Back view.
DISCUSSION
Hidradenitis suppurativa (HS) is a chronic, inflammatory, recurrent,
debilitating, and cutaneous disease characterized by painful, deep and inflamed
lesions, mainly in the regions containing apocrine glands and hair follicles,
characterized by a perifollicular leukocyte infiltrate. The prevalence of HS
varies from 1% to 4% in Europe and the United States in the general population.
It generally manifests after puberty in the second and third decades of life,
with a female predominance. Long-term lesions can be complicated by squamous
cell carcinoma1-3.
Hurley staging is recommended in the clinical setting as it is simple and helps
determine therapeutic needs. Hurley stage I is characterized by the presence
of
single or multiple abscesses, however, without fistula or scars; stage II is
due
to the presence of single or multiple recurrent abscesses, separated by the
formation of fistulas and scars; and stage III is characterized by the presence
of multiple interconnected fistulas and abscesses involving at least one
complete anatomical area. For stage III, the preferred treatment is wide
surgical resections of the skin, apocrine glands, and hair follicles because
they are more likely to be cured, with a lower recurrence rate of HS2-4. For this reason, having flap options to reconstruct
defects after large HS resections in the perineal region is essential.
Perineal wounds that close primarily are associated with a high recurrence rate
of HS3. Despite being a resolving option, healing by secondary intention, even
in large excisions, subjects patients to long periods of painful dressing
changes, with pronounced scar contraction and an unpleasant final
appearance2,3. Closure with a partial skin
graft is also described, but in the perineal region, the risk of loss due to
bacterial contamination is high3-5.
Some flaps based on the descending and medial branches of the inferior gluteal
and deep femoral arteries have been published in the reconstruction of HS wounds
of the perineum partially, but none of them have been described for
reconstructing large wounds that compromise the total perineum4,6.
With pedicled gluteal flaps based on superior and inferior gluteal artery
perforators, studied in the reconstruction of perineal defects due to HS,
despite being considered large flaps, a skin dissection of 10 to 12 cm was
necessary to reach more distant areas, making flaps more difficult to create,
in
contrast to the fasciocutaneous tissue of the thigh. Furthermore, due to the
proximity to the perianal region, in some cases antidiarrheal medications or
colostomy were indicated to inhibit fecal contamination of the reconstructed
areas with a minimum hospitalization time of 6 days4,5,7.
Gluteal flaps generally require a prone position postoperatively, which is more
uncomfortable for the patient. Other flaps, such as the fasciocutaneous lotus
petal and gluteal fold flaps, have been described for perineal wounds caused
by
HS, but they have been indicated for defects in the medial and posterior zone
of
the perineum, and in the case of the total perineum, they have not been
described so far5,6,8.
The V-Y medial thigh fasciocutaneous flap is a flap based on femoral artery
perforators; it has been widely studied in perineal defects caused by cancer
and
not for HS, despite multiple advantages such as covering defects in the anterior
and posterior perineum without requiring pedicle dissection, making it a flap
that is easier and more practical to make9,10. This flap
does not sacrifice muscle, avoiding donor site morbidity, and the vascular
supply is reliable.
The medial fasciocutaneous flap of the thigh in V-Y advancement is a reproducible
technique, offers sufficient coverage of skin and subcutaneous cellular tissue,
being a good option for reconstructing defects after wide resections of skin,
apocrine glands, and hair follicles in the treatment of severe perineal HS, with
acceptable aesthetic and functional results.
REFERENCES
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10.1308/003588413x13629960047155
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10.1097/GOX.0000000000004752
4. Unal C, Yirmibesoglu OA, Ozdemir J, Hasdemir M. Superior and
inferior gluteal artery perforator flaps in reconstruction of gluteal and
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after resection of severe gluteal hidradenitis suppurativa with fasciocutaneous
flaps. J Plast Reconstr Aesthet Surg. 2009;62(6):800-5. DOI:
10.1016/j.bjps.2007.09.063
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Vulvar reconstruction using the “lotus petal” fascio-cutaneous flap. Gynecol
Oncol. 2013;131(3):726-9. DOI: 10.1016/j.ygyno.2013.08.030
7. Saunte DML, Jemec GBE. Hidradenitis Suppurativa: Advances in
Diagnosis and Treatment. JAMA. 2017;318(20):2019-32. DOI:
10.1001/jama.2017.16691
8. Sugio Y, Tomita K, Hosokawa K. Reconstruction after Excision of
Hidradenitis Suppurativa: Are Skin Grafts Better than Flaps? Plast Reconstr Surg
Glob Open. 2016;4(11):e1128. DOI: 10.1097/GOX.0000000000001128
9. Wong DS. Reconstruction of the perineum. Ann Plast Surg.
2014;73(Suppl 1):S74-81. DOI: 10.1097/SAP.0000000000000237
10. Saito A, Sawaizumi M, Matsumoto S, Takizawa K. Stepladder V-Y
advancement medial thigh flap for the reconstruction of vulvoperineal region.
J
Plast Reconstr Aesthet Surg. 2009;62(7):e196-9. DOI:
10.1016/j.bjps.2009.01.090
1. Universidade de São Paulo, São Paulo, SP,
Brazil
2. Faculdade de Medicina da Universidade de São
Paulo, São Paulo, SP, Brazil
Corresponding author: Alexander Fabricio
Vicente-Rivas Rua Alves Guimarães, 1554, Pinheiros, São Paulo, SP,
Brazil, Zip Code: 05410-000, E-mail: afvr90@live.com
Article received: June 26, 2022.
Article accepted: August 20, 2023.
Conflicts of interest: none.
