Surgical excision and reconstruction of defects in severe hidradenitis suppurativa: indications, grafts, flaps and outcomes

Abstract

Hidradenitis suppurativa is a chronic inflammatory disease of hair follicles characterized by painful nodules, recurrent abscesses, draining tunnels, and scarring in intertriginous regions. In severe disease, persistent tunnels and fibrosis may require surgical excision followed by reconstruction, creating an interface between general surgery, dermatology, and plastic surgery. This narrative review examines indications for surgery, excision extent, criteria for selecting secondary intention healing, primary closure, skin grafts, and flaps, as well as complications and recurrence. International guidelines and clinical studies available through October 2026 were critically appraised with emphasis on evidence relevant to reconstructive decision-making. Surgery is supported for persistent tunnels, symptomatic scars, and extensive lesions, provided that anatomical planning and inflammatory disease management are integrated. A 2025 meta-analysis reported pooled recurrence estimates of 25% after primary closure, 18% after grafting, and 12% after flap reconstruction; however, these comparisons are limited by confounding due to case selection and methodological heterogeneity. The randomized SHARPS trial identified improved clinical response with adalimumab combined with excision and secondary intention healing, without a detectable increase in postoperative wound complications in the studied setting. Reconstruction should therefore be individualized according to defect location, wound-bed quality, tissue perfusion, functional requirements, patient preferences, and the need for long-term disease control. Current evidence does not establish a universally superior closure method.