I. Introduction

You might be considering surgery or perhaps surgery was recommended to you by a healthcare provider. Surgery, when combined with medical management, can be a helpful option for patients with HS. There are many different types of surgery, all of which – when combined with medical management and lifestyle changes – can lead to an improved quality of life. This chapter focuses on surgical excisions (which were briefly described in Chapter 21).

II. How the Procedure Works

A surgical excision is a procedure where HS tunnels and affected areas are removed down to the level of subcutaneous tissue, or “fat.” This surgery can be done in an outpatient office under local anesthesia (or numbing medicine), although bigger surgeries are performed in the operat in groom with the patient asleep under general anesthesia. There are many different physicians that perform this type of surgery, including some dermatologists, dermatologist surgeons, general surgeons, plastic surgeons, and gynecologists. If you are trying to find a health care provider who can do this, an important question to ask when you call to schedule an appointment is: “Does this clinic do surgery for HS?” Surgery requires patience and trust in your physician.

Once surgery for HS is performed, and the diseased tissue is removed, there is typically a wound, much like a hole, in the skin. The post-surgery wound can be big or small, depending on how much of the HS-affected areas are removed. Some people prefer to have a large excision done at one time, and others decide to have a series of smaller excisions done over a longer period of time. It is a personal decision to discuss with your surgeon. The wounds can be dealt with in different ways and one approach is not necessarily better than the other.

III. Wound Closure

One way to close a wound after a surgical excision is by letting it heal by what is called “secondary intention healing,” or basically just letting it healon its own from the inside out, without using stitches. This can be done with wound dressing with either moist gauze, petrolatum jelly (e.g., Vaseline®), bacitracin, or specialized wound care products. Wound care and dressings are further discussed in Chapter 15. The body is amazing, and patients with HS often discover that they heal very well after surgery. What was once a large wound can shrink down over the course of a few months to a scar that is only a fraction of the size of the original wound.

Some wounds can be closed at the time of surgery. This involves the placement of stitches (also known as “sutures”) to hold the skin and tissue together, and sometimes there is a drain placed that you go home with to keep fluid from building up under the skin during the healing process. The stitches are typically removed at a later time in the office, although sometimes dissolvable stitches are used underneath the skin that go away by themselves.

A third way to close the wound is to do something called a flap. A flap involves taking tissue from next to the wound, or any other area of the body, to close the hole. Not everyone needs a flap and there are many other options.

Many patients considering surgery ask if they will need skin grafts, and this is a fourth way to close the surgical wound. Skin grafts are a great way to cover a wound quickly once the wound has healed enough. The surgery is typically done in an operating room and under general anesthesia, which means you will go to sleep for the surgery. Skin is taken from an area such as the back or the thigh, and placed over a wound. This is typically done weeks after the original surgery.

For a skin graft to work, it does not matter whether the wound has been treated with daily wound care or with a wound vac. The wound just needs to have a good base of what we call healthy granulation tissue (i.e., the bright red tissue) and has healed enough based on the surgeon’s evaluation. The skin graft is placed over the wound and attached using sutures or staples. Either a spongy bolster dressing (a type of dressing that is sewn on top of a skin graft) or a wound vac is then placed for approximately five days, and then the dressing is removed during your post-op clinic visit to see if the skin is sticking to the wound as intended.

Most of the time, skin grafts work really well, and the wound is officially closed at the five day mark. But there is always the chance that the skin graftmay not survive on the wound, leaving you with a wound that needs to close. In that case, you will also have another wound on your thigh or back from where the skin was taken and that can be very painful, both physically and emotionally. If the skin graft does work well, typically there will be a patterned look to the skin once it has healed, meaning it will not look like your smooth typical skin. This occurs because small holes are made in the piece of skin that is taken from another part of your body for the skin graft. This allows surgeons to use a smaller piece of skin to cover a bigger wound. Talk to your surgeon about whether this is the right option for you.

IV. Benefits of Surgical Excisions

Surgical excision of affected HS skin is one of the easiest ways to get back to your regular life quickly—while the wounds are healing, many people are able to work, take care of family members like children, cook, drive, and even exercise. Another option on how to manage the wound after excision is to place a wound vac on the wound. A wound vac is a specialized sponge attached to a suction canister that pulls fluid out of the wound and helps the wound close. The benefit of the wound vac is that the dressing only needs to be changed every three or so days. The downside, however, is that you are attached to a little portable machine, so there can be some painful “pulling” or “tugging” sensations, and it requires a special nurse to change the wound vac. It is important to remember that every surgeon has a sense of what works best with how they do their surgeries, and to have discussions about post-surgical care.

Talk to your healthcare provider about whether you are a good candidate for surgical excision of your HS. Your healthcare provider will help determine which technique is most appropriate for you—sometimes, it involves excisions, combined with other techniques like deroofing (see Chapter 21) in certain areas. The most important thing to remember is that it is important to first establish the goal of surgery before picking the type of surgery.

Surgery to treat HS can have different goals. One goal might be to remove as much of the diseased skin as possible. Another goal might be to remove the areas causing the most pain or drainage, especially in people who have severe HS and many affected areas. Think about what your treatment goals are and work together with your healthcare provider to figure out if surgery is right for you.