The only effective way to control chronic hidradenitis suppurativa is timely surgical treatment. The axilla is an easily neglected area that can result in delay of the ...
Aesth. Plast. Surg. 20:443446, 1996
Aes_theuc © 1996 Springer-Verlag New York Inc.
A New Approach in Axillary Hidradenitis Treatment: The Scapular Island Flap Jos6 Amarante, M.D., Jorge Reis, M.D., Ant6nio Santa Comba, M.D., and Edgardo Malheiro, M.D. Oporto, Portugal
Abstract. The scapular island flap technique has been used in the treatment of seven cases of axillary hidradenitis suppurativa. This flap, providing a smooth skin surface with good elastic properties, easily covers the axilla and permits the cutaneous reconstruction of the involved axillary tissue excision with satisfying aesthetic, functional results and a rapid local cicatrization. The donor site was closed by primary suture.
Key words: Axillary hidradenitis--Scapular flap--Parascapular flap
Inflammatory disease of the apocrine glands presents most frequently as a deep recurrent abscess in the axilla. This condition results in scarred deep sinus tracts, fluctuant draining abscess with a constant malodorous discharge from axilla, accompanied by excruciating pain and limited abduction of the shoulder. Early lesions can be successfully treated by conservative measures, namely, application of heat, antibiotics, or incision and drainage. In chronic forms, the only effective means to eradicate the disease is the excision of all the involved tissue. To reconstruct the excisional axillar area, we have used eight scapular island flaps successfully.
Operative Technique The patient is positioned in the lateral position with the arm free to allow better access to the axilla, to facilitate
a wide excision, and to avoid the necessity of turning the patient for flap elevation and axillar transfer. The involved skin and subcutaneous tissue hidradenitis are excised followed by the design of scapular island flap that will cover the excisional area. This flap is based on the circumflex scapular artery that passes through the triangular space formed by the teres minor, teres major, and the long head of the triceps muscle. This triangular space is easily palpated with the index finger in the axilla while the thumb runs along the posterior border of the deltoid muscle. After marking the pedicle position, the surgeon designs the skin island vertically or horizontally with the lateral corner positioned over the already marked triangular space. This skin island is determined by the amount of tissue required for the reconstruction of axillary defect after surgical excision. Elevation of the flaps begins medially in an avascular plane just above the superficial fascia of the supraspinatus and teres major muscles. As the elevation reaches the lateral edge of the scapula, the cutaneous branch of the circumflex scapular vessels, which come out through the triangular space, can be seen entering the undersurface of the flap. Once the triangular space is reached, the vessels can be seen emerging between the teres minor and major muscles. With the deltoid muscle retracted, the vascular pedicle of the flap is easily identified from the lateral aspect. Several branches of the artery and accompanying veins are ligated and divided so that the flap is islanded and inset into the axillary wotmd. Care must be taken to avoid any kinking or angulation of the pedicle. The pedicle can be sutured, and the donor site closed primarily.
Case Reports Correspondence to Jos6 Amarante, M.D., Rua do Lidador, 780, 4100 Porto, Portugal
Our experience with eight flaps in six patients has been quite encouraging (Table 1). Two clinical cases are described in more detail next.
Axillary Hidradenitis
444 Table 1. Patient summaries
Patient age (years)/sex
Localization
Flap
Complications
Follow-up (years)
23/M 46/F 34/F 32/F 30/M 22/F
Left axillae, scrotum Right axillae, inguinal Both axillae, perianal Both axillae Left axillae Right axillae
Parascapular Parascapular Scapular Scapular Parascapular Parascapular
None None None None None None
4 3.5 3 1 0.5 0.5
Fig. 1. (A) Design of the parascapular flap. (B) Elevation of the flap. (C) Flap transposed. (D) Immediate axillar result. (E) The parascapular flap 3 years later.
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Fig. 2. (A) Left axillar hidradenitis. (B) Preoperative view showing the design of the scapular flap. (C) Elevation of the flap. (D) Flap transposed and sutured to bridge the defect. (E) Result 3 years later.
Case I
A 23-year-old man who referred a small nodule that appeared in the left axilla at the age of 18 (Fig. 1). As soon as it increased in size, it was incised and he later spontaneously recovered. Two years later, a spontaneous discharge with a constant malodorous discharge from the axilla was seen. The patient was treated by Skoog's technique consisting of dissection of the offending glands from the deep dermal surface after four skin axillar flaps elevation. Two years later, recovery was seen, and the patient reclaimed a wide axillary excision. The skin and subcutaneous tissue were replaced with an island parascapular flap. Primary suture of the donor
site was easily performed. The skin flap survived completely, all wounds healed without complication, and the patient was able to abduct his arm 180 ° a few weeks later. Case 2 A 34-year-old woman had chronic nodular eruption in both axillas. Three years before, this condition became worse with a constant malodorous discharge from the left axilla (Fig. 2). A bilateral scapular island flap was designed to repair both axillas after the excision of the axillary infected skin
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446
and subcutaneous tissue. The donor area was closed by primary suture. Discussion The only effective way to control chronic hidradenitis suppurativa is timely surgical treatment. The axilla is an easily neglected area that can result in delay of the diagnosis and treatment, and late complication of squamous cell carcinoma has been referred to in chronic inflammatory hidradenitis [1-5]. Excising the involved tissue affords the only effective means of eradicating the chronic focus [6]. On occasion, limited areas of the involvement can be excised and closed directly [7]. For larger defects, Pollock and co-workers [8] reported a technique that must compromise the excision of the pathologic skin to accomplish primary closure. For larger defects, axillar repair by split-skin graft has been suggested [9]. Other techniques using local flaps [6,10] or from adjacent breast flaps [11] have been described. In this limited series, lesions were observed most commonly in women. Three patients have involvement of the groin, perianal, and scrotal areas. The six patients were treated by excision of the hairbearing skin and the infected subcutaneous tissue of the axilla, followed by reconstruction of this excisional area with an arterial scapular flap. This flap, whose dimensions can cover the hair area, may be designed as a scapular [12] or parascapular [13] flap using the horizontal or the vertical branches of the scapular artery, respectively. The scapular and the parascapular flaps used in the postburn scar contracture treatment have many advantages, including a convincing improvement of the shoulder range motion and satisfying aesthetic results [14-17]. The pectoralis major muscle also has been used to reconstruct axillary postburn scar contracture [18], but the excessive bulk of muscle may limit adduction of the arm.
We prefer to use this reliable flap because the 180 ° arc of rotation imposed on the pedicle vessels is well tolerated without necrosis of the flap. It is thin, it does not need to be defatted, it allows a rapid local cicatrization and primary suture donor site, and it can be taken with the patient on his/her side without changing positions.
References 1. Anderson JJ, Dockerty MB: Perianal hidradenitis suppurativa. Dis Colon Rectum 1:23-31, 1958 2. Black SB, Woods JE: Squamous cell carcinoma complicating hidradenitis suppurativa. J Dermatol Surg Oncol 19:25-26, 1982 3. Gordon SW: Squamous cell carcinoma arising in hidradenitis suppurativa. Hast Reconstr Surg 60:800-802, 1977 4. Johnson WH, Miler TA, Frilck SP: Atypical pseudoepitheliomatous hyperplasia and squamous cell carcinoma in chronic cutaneous sinus. Hast Reconstr Surg 66:395, 1980 5. Mendonqa H, Rebelo C, Fernandes A, Lino A, Silva L: Squamous cell carcinoma arising in hidradenitis suppurativa. J Dermatol Surg Oncol 17:830-832, 1991 6. Paletta FX: Hidradenitis suppurativa. Pathologic study and use of skin flaps. Hast Reconstr Surg 31:307-310, 1963 7. Hurley H J, Shelley WB: A simple surgical approach to the management of axillary hyperhidrosis. JAMA 186:109112, 1963 8. Pollock WJ, Virnelli FR, Ryon RF: Axillary hidradenitis suppurativa: a simple and effective surgical technique. Plast Reconstr Surg 49:22-25, 1972 9. Conway H, Stark RB, Climos S, Weeter JC, Garcia FA: Surgical treatment of chronic hidradenitis suppurativa. Surg Gynecol Obstet 95:455-464, 1952 10. Skoog T, Thyresson N: The surgical treatment of axillary hyperhidrosis. Br J Dermatol 78:551-556, 1966 11. Stewart H: Axillary hidradenitis. Br J Hast Reconstr Surg 1:95-98, 1964 12. Gilbert A, Teot L: The free scapular flaps. Plast Reconstr Surg 69:601-604, 1982 13. Nassif TM, Vidal L, Bovet J, Baudet J: The parascapular flap: a new cutaneous microsurgical free flap. Plast Reconstr Surg 69:591-600, 1982 14. Diamond M, Barwick W: Treatment of axillary burn scar contracture using an arterialized scapular island flaps. Hast Reconstr Surg 72:388-391, 1983 15. Yanai A, Nagat S, Hirabayashi S, Nakamura N: Inverted U parascapular flap for the treatment of axillary bum scar contracture. Hast Reconstr Surg 76:126-129, 1985 16. Maruyama Y: Ascending scapular flaps and its use for the treatment of axillary burn scar contracture. Br J Hast Surg 44:97-101, 1991 17. Teot L, Bosse JP: The use of scapular skin island flaps in the treatment of axillary postburn scar contractures. Br J Hast Surg 47:108-111, 1994 18. Freedland E, Lee K, Vandervord JG: Reconstruction of the axilla with a pectoralis major myocutaneous island flap. Br J Plast Surg 35:144-148, 1982
