Secondary intention healing in skin surgery: our own experience and expanded indications in hidradenitis suppurativa, rhinophyma and non-melanoma skin cancers

A review of surgical and reconstructive techniques for hidradenitis suppurativa

Hidradenitis suppurativa (HS) is an inflammatory follicular dermatological condition that typically affects the intertriginous and anogenital regions of the apocrine gland-bearing skin. The management of this chronic and recurring disease necessitates a combination of lifestyle changes, medication, and surgical approaches to achieve the best possible outcomes. While medical treatments are recommended for this multimodal disease, surgical therapy, which is the gold standard of treatment for HS, has proven to be the most effective treatment because it provides long-lasting local disease control, reduces the recurrence of lesions, and ensures complete healing of lesions. In the last decade, there has been exponential growth in research into various surgical techniques and reconstructive care, enabling patients to have more surgical options. There is a wide range of surgical management procedures available, such as incision and drainage, deroofing, excisional surgery, carbon dioxide laser therapy, and skin tissue-sparing excision with electrosurgical peeling. Among these surgical procedures, wide surgical excision is the best option since it can eradicate all the affected lesions. Meanwhile, the preferred approach to reconstruction at various anatomical locations remains debatable. Here, we review a variety of surgical treatments and reconstructive techniques for HS, particularly various flap techniques for the axillary, gluteal, and inframammary regions.

Effects of the modified excision combined with bidirectional photodynamic therapy on refractory hidradenitis suppurativa: a retrospective study

To describe the clinical features of refractory hidradenitis suppurativa (HS) patients (Hurley stageII and stage III) and evaluate the efficacy of combined treatment of the modified excision with bidirectional photodynamic therapy (PDT). A retrospective, multicenter study was conducted in 35 refractory HS patients. They were treated with the modified excision combined with bidirectional PDT. The outcomes, patients' satisfaction, adverse effects, and the Dermatology Life Quality Index (DLQI) were observed. There were more males than females (6:1). The axilla was the most frequently affected region (37.5%). All patients had experienced treatment failures before and had good response to our combined therapy (clearance rate > 75%). The average time required for complete wound healing was 11 days. After 1 year of follow-up, no significant recurrence was observed. The DLQI decreased significantly after the combined treatment. The comprehensive evaluation of scar and the deformation showed good cosmetic results after treatment. Reversible adverse events such as small patchy blackness, necrosis, or ulcer in the tip of the flap occurred in six patients (17.1%). Of the 35 patients, 30 were very satisfied with the treatment. This case series finds that the modified excision combined with bidirectional PDT may hold promise for radical treatment of Hurley stage II and stage III.

Improvement in Quality of Life and Pain in Patients With Hidradenitis Suppurativa After Wide Local Excision: A Prospective Study

BACKGROUND

Hidradenitis suppurativa (HS) is a chronic inflammatory skin disease that affects patients' quality of life (QoL).

OBJECTIVE

To investigate changes in QoL in patients with HS after wide local excision (WLE) and to examine the level of pain, rate of postoperative complications, recurrences, and the time to complete wound closure.

METHODS

Fifty-five patients were enrolled in this prospective study. All patients underwent WLE of HS, followed by secondary wound healing. Dermatologic Life Quality Questionnaire, pain, and wound size were measured 1 day, 3 weeks, 3 months, and 6 months after surgery.

RESULTS

Dermatologic Life Quality Questionnaire and pain scores (mean ± SD) improved significantly (both p < .001) from 14.5 ± 7.3 and 3.7 ± 2.8 at baseline to 5.8 ± 6.9 and 0.8 ± 1.7, 6 months postoperatively, respectively. Wounds were closed completely by secondary intention after 4.4 ± 2.8 months. Sixteen patients (29.1%) experienced postoperative complications, local recurrences in the treated sites were observed in 11 patients (20%), and new lesions in untreated sites were observed in 5 cases (9.1%).

CONCLUSION

Wide local excision significantly improves patients' QoL and pain, and, given its low rate of recurrence and complications, should be considered as a first-line therapy, especially in patients with higher Hurley stages.

Novel Management of Rhinophyma by Patterned Ablative 2940nm Erbium:YAG Laser

Introduction

Rhinophyma is a cosmetic disorder that causes emotional distress if the symptoms are extensive or obvious enough. Treatment options range from topical antibiotics or isotretinoin, surgical resection, cryosurgery, electrocautery, dermabrasion and more recently laser therapy. With the limitations of surgical techniques, lasers gained popularity for treating rhinophyma. However, laser ablation is invasive and can lead to side effects and prolonged downtime. Fractional photothermolysis (FP) was introduced to overcome the limitations posed by conventional ablative lasers. To the best of our knowledge, there are no previous studies to evaluate the use of Er:YAG in an ablative mode with a fractional handpiece for the treatment of rhinophyma.

Aim of the Work

The goal of this study was to evaluate the efficacy and safety of fractional ablative 2940 nm Er:YAG laser for the treatment of mild to moderate rhinophyma.

Patients and Methods

Sixteen patients having mild to moderate rhinophyma were treated with fractional ablative 2940 nm Er:YAG laser. All patients received 4 laser treatments and were followed up over the following 3 months. An additional follow-up appointment 6 months after the last session was arranged to detect any signs of recurrence.

Outcome Measures

Patient questionnaire was used to evaluate patient subjective satisfaction. Objective evaluation was performed by a blind assessment of clinical photographs that were taken before and 3 months after the final treatment by two independent blinded evaluators.

Results

Patient questionnaire taken 3 months after last treatment revealed that 8 patients (50%) were “very satisfied”, 4 patients (25%) were satisfied, and 4 patients (25%) were somewhat satisfied. None of the patients assessed their results as not satisfying.

Conclusion

In conclusion, the use of patterned ablative Er:YAG laser with a PS01 handpiece and parameters used in this study comprise an effective tool for treatment of mild to moderate rhinophyma with rapid postoperative recovery compared with conventional surgical procedures and other ablative lasers.

What Is the Impact of Depletion of Immunoregulatory Genes on Wound Healing? A Systematic Review of Preclinical Evidence

Cytokines and growth factors are known to play an important role in the skin wound closure process; however, in knockout organisms, the levels of these molecules can undergo changes that result in the delay or acceleration of this process. Therefore, we systematically reviewed evidence from preclinical studies about the main immunoregulatory molecules involved in skin repair through the analysis of the main mechanisms involved in the depletion of immunoregulatory genes, and we carried out a critical analysis of the methodological quality of these studies. We searched biomedical databases, and only original studies were analyzed according to the PRISMA guidelines. The included studies were limited to those which used knockout animals and excision or incision wound models without intervention. A total of 27 studies were selected; data for animal models, gene depletion, wound characteristics, and immunoregulatory molecules were evaluated and compared whenever possible. Methodological quality assessments were examined using the ARRIVE and SYRCLE's bias of risk tool. In our review, the extracellular molecules act more negatively in the wound healing process when silenced and the metabolic pathway most affected involved in these processes was TGF-β/Smad, and emphasis was given to the importance of the participation of macrophages in TGF-β signaling. Besides that, proinflammatory molecules were more evaluated than anti-inflammatory ones, and the main molecules evaluated were, respectively, TGF-β1, followed by VEGF, IL-6, TNF-α, and IL-1β. Overall, most gene depletions delayed wound healing, negatively influenced the concentrations of proinflammatory cytokines, and consequently promoted a decrease of inflammatory cell infiltration, angiogenesis, and collagen deposition, compromising the formation of granulation tissue. The studies presented heterogeneous data and exhibited methodological limitations; therefore, mechanistic and highly controlled studies are required to improve the quality of the evidence.

Medical and Surgical Management of Hidradenitis Suppurativa: A Review of International Treatment Guidelines and Implementation in General Dermatology Practice

BACKGROUND

Hidradenitis suppurativa (HS) is a chronic painful skin disease that severely impairs patients' quality of life. While high-quality trials of HS therapies remain limited, medical knowledge of best treatment practices is rapidly evolving, leading to the recent publication of multiple international treatment guidelines for HS.

SUMMARY

This review compares international HS treatment guidelines, describes evidence for effectiveness of common and emerging HS therapies, and provides guidance for integrating evidence-based HS care into practice. Although over 50 medical and procedural treatments are mentioned across international HS guidelines, only adalimumab and infliximab have grade B/weak recommendation or higher across all major guidelines. This review describes the appropriate patient selection and effectiveness of the most commonly used medical and procedural treatments for HS. It also includes recommendations for counseling, dosing, and duration of medical therapies as well as procedure videos for the practicing dermatologist.

The surgeon’s perspective: a retrospective study of wide local excisions taken to healthy subcutaneous fat in the management of advanced hidradenitis suppurativa

Background

Hidradenitis suppurativa (HS) is a chronic debilitating folliculopilosebaceous disease that affects the skin most commonly in the axilla, groin, inframammary, genital and buttock areas. Surgical intervention may be an appropriate option in selected cases, but there is a risk of recurrence. The purpose of this study was to assess the results of wide local excision (WLE) to healthy subcutaneous fat with secondary intention healing in patients with HS who were under concurrent surgical and dermatologic care.

Methods

We conducted a retrospective review of 192 consecutive HS consultations to a general surgical service, identifying patients treated with WLE. Cases involving minor procedures (deroofing, incision and drainage) were excluded. Data on patient demographics, surgical site, method of closure, complications and recurrence were extracted from patient charts. We also conducted a literature review of surgical procedures in the management of HS.

Results

A total of 66 patients underwent 133 WLE to healthy subcutaneous fat. All patients were under concurrent medical care directed by a dermatologist. No medical therapies, including biological treatments, were interrupted or withheld for surgery. One hundred procedures were closed primarily with rotation or advancement flaps and 33 by secondary intention healing. Local recurrence occurred in 18% of primary closures and 18% of secondary intention closures (p = 0.98, χ2 test, no difference between groups). One patient with secondary intention healing returned to the emergency department for bleeding; 34% of patients with primary closure experienced some dehiscence (23% major, 11% minor separation). Two patients with axillary disease had restrictions in their ability to raise their arm that required physiotherapy. Median follow-up was 14.5 (range 1–55) months.

Conclusion

Resection to healthy subcutaneous fat during WLE provides disease control comparable to that with deeper resections, simplifying care.

Surgical Treatment Strategy for Severe Rhinophyma With Bilateral Pedicled Nasolabial Flaps

BACKGROUND

Rhinophyma is a rare disease characterized by chronic inflammation and hypertrophy of sebaceous glands, blood vessels, and fibrous tissue, associated with end-stage severe acne rosacea. There are multiple approaches to treatment and repair, including dermal shaving, secondary intention healing, free skin graft, and skin flaps. However, these methods have various disadvantages, such as prolonged healing, obvious scarring, and skin texture mismatch. Therefore, the authors adopted surgical excision with bilateral pedicled nasolabial flaps, which have better color, texture, thickness, and symmetry.

METHODS

The authors present a case of severe nasal tip rhinophyma successfully treated by excision and repair with bilateral pedicled nasolabial flaps. This procedure combines deep excision of the focal lesion and coverage with bilateral nasolabial flaps.

RESULTS

The bilateral pedicled nasolabial flaps were used for severe rhinophyma in a patient. After the operation, the flaps survived uneventfully in this study. Both functional and aesthetic results were satisfactory at 3 months.

CONCLUSION

The authors offer an effective method for surgical treatment of rhinophyma. Excision of hypertrophic nasal tissue is an acknowledged effective treatment for patients with severe rhinophyma. After excision, reconstruction with nasolabial flaps results in satisfactory outcomes both functionally and aesthetically. Therefore, this approach should be considered an appropriate alternative in cases of severe rhinophyma.

Hidradenitis suppurativa: Current and emerging treatments

The treatment of hidradenitis suppurativa (HS) has remained challenging because of the many knowledge gaps regarding etiology. However, recent studies into the pathogenesis of HS have enabled the investigation of newer therapies. The second article in this continuing medical education series reviews the evidence for established therapies for HS, including anti-inflammatories, antibiotics, and surgery. New and emerging therapies that specifically target cytokines involved in HS pathogenesis will be covered. The potential therapeutic roles of anticytokine therapies, including both the expanded application of existing molecules as well as the specific development of novel therapies for HS are discussed. With increased attention on HS and with numerous clinical trials currently underway, we hope that the variety of treatment options for HS will be expanded.

Application of secondary intention for the restoration of the apical triangle after Mohs micrographic surgery

BACKGROUND

Restoring the apical triangle (AT) to maintain the symmetry of the face after Mohs micrographic surgery can be challenging. We have applied secondary intention (SI) after partial closure in cases with large defects.

OBJECTIVE

To compare the cosmetic results between immediate closure (IC) and SI.

METHODS & MATERIALS

We retrospectively reviewed 24 patients (IC group: n = 15, SI group: n = 9). To evaluate the symmetry, the comparative ratio (CR; area of the AT of the involved side/area of the normal contralateral side) was calculated.

RESULTS

The defects were significantly larger in the SI group than in the IC group (588.89 ± 346.53 mm² vs. 252.87 ± 196.52 mm², p < .01). While there was no statistically significant difference in average CR, the standard deviation was higher in the SI group (0.95 ± 0.08 vs. 0.93 ± 0.31, p = .3359), indicating the difficulty in predicting the results of SI healing. The average visual analog scale score evaluated by two dermatologists was higher in the IC group, albeit without a significant difference (8.23 ± 0.96 vs. 7.78 ± 1.52, p = .5267).

CONCLUSION

SI after partial closure can be an option for large defects in the AT area.

North American clinical management guidelines for hidradenitis suppurativa: A publication from the United States and Canadian Hidradenitis Suppurativa Foundations: Part I: Diagnosis, evaluation, and the use of complementary and procedural management

Hidradenitis suppurativa is a chronic inflammatory disorder affecting hair follicles, with profoundly negative impact on patient quality of life. Evidence informing ideal evaluation and management of patients with hidradenitis suppurativa is still sparse in many areas, but it has grown substantially in the last decade. Part I of this evidence-based guideline is presented to support health care practitioners as they select optimal management strategies, including diagnostic testing, comorbidity screening, and both complementary and procedural treatment options. Recommendations and evidence grading based on the evidence available at the time of the review are provided.

Procedural management of rhinophyma: A comprehensive review

BACKGROUND

Rhinophyma is a cosmetically deforming disease characterized by nodular overgrowth of the lower 2/3 of the nose and is considered the end stage of acne rosacea.

AIMS

Review the spectrum of procedural techniques for treatment of rhinophyma with a focus on the advantages and disadvantages of each modality.

METHODS

A comprehensive literature search was conducted using the search terms "rhinophyma," "treatment," and "surgery" in PubMed. Case reports, case series, and small retrospective trials using procedural techniques for management of rhinophyma were included for review. Animal studies, non-English articles, and reports of medical treatment of rhinophyma were excluded.

RESULTS

There are currently no prospective, randomized controlled studies evaluating procedural management of rhinophyma. The most commonly employed treatments include scalpel excision, resection with heated knives, dermabrasion, electrosurgery and lasers, specifically carbon dioxide (CO₂ ) and erbium:yttrium-aluminum-garnet (Er:YAG). The main complication associated with complete excision of rhinophymatous tissue is excessive scarring. To correct for this adverse effect, partial or tangential excision with preservation of underlying adnexal structures is now the accepted technique, irrespective of the chosen modality.

CONCLUSION

There is no accepted gold standard for management of rhinophyma, and each modality succeeds in maintaining hemostasis, reducing scarring and achieving satisfactory cosmesis to different degrees. There is a conflicting data on the theoretical risk of recurrence with partial excision due to incomplete removal of tissue. Further studies evaluating this risk and alternate methods of prevention are required.

Treatments for hidradenitis suppurativa

Hidradenitis suppurativa (HS) is not easily treated. Although not uncommon, HS is often misdiagnosed outside specialized clinics and inappropriately treated as a simple boil or abscess. In recent years, guidelines have been developed on the basis of expert opinion and the available literature. A multifaceted approach is necessary as HS lesions include both inflammation (amenable to medical treatment) as well as fibrosis (amenable to surgery only). The recommended antiinflammatory therapies encompass both antimicrobials and regular anti-inflammatory drugs. We have, therefore, reviewed treatments with the following agents: clindamycin, tetracycline, rifampicin, ertapenem, dapsone, triamcinolone, infliximab, adalimumab, and anakinra. The development of new medical treatments, however, is an ongoing effort, and important new data have been presented since the publication of the guideline. The current approach to the management of fibrotic lesions is surgery. It is important, as manifest fibrosis is generally not susceptible to medical treatment. Here minor excision, carbon dioxide-laser, and major surgery are discussed, and current evidence supporting their use is provided. A comprehensive three-pronged approach with adjuvant therapy, medical therapy, and surgery is recommended. The importance of adjuvant therapy, that is, pain management, wound care, and attention, is stressed. Adjuvant therapy not only plays a major role in patients' perception of a successful treatment but also is of practical importance to their coping and self-management. HS presents a significant unmet need, and this review provides a mechanistic update on the current real-world therapeutic option for the management of this distressing disease.

Sequential Change of Wound Calculated by Image Analysis Using a Color Patch Method during a Secondary Intention Healing

BACKGROUND

Photographs of skin wounds have the most important information during the secondary intention healing (SIH). However, there is no standard method for handling those images and analyzing them efficiently and conveniently.

OBJECTIVE

To investigate the sequential changes of SIH depending on the body sites using a color patch method.

METHODS

We performed retrospective reviews of 30 patients (11 facial and 19 non-facial areas) who underwent SIH for the restoration of skin defects and captured sequential photographs with a color patch which is specially designed for automatically calculating defect and scar sizes.

RESULTS

Using a novel image analysis method with a color patch, skin defects were calculated more accurately (range of error rate: -3.39% ~ + 3.05%). All patients had smaller scar size than the original defect size after SIH treatment (rates of decrease: 18.8% ~ 86.1%), and facial area showed significantly higher decrease rate compared with the non-facial area such as scalp and extremities (67.05 ± 12.48 vs. 53.29 ± 18.11, P < 0.05). From the result of estimating the date corresponding to the half of the final decrement, all of the facial area showed improvements within two weeks (8.45 ± 3.91), and non-facial area needed 14.33 ± 9.78 days.

CONCLUSION

From the results of sequential changes of skin defects, SIH can be recommended as an alternative treatment method for restoration with more careful dressing for initial two weeks.

Surgical Procedures in Hidradenitis Suppurativa

Hidradenitis suppurativa is difficult to treat owing to its complex pathomechanism; beside the extensive inflammation with abscesses and inflammatory nodules, there is also an architectural loss with sinus tract formation and in severe cases with extensive scarring. Therefore, surgery is mandatory in moderate and severe HS.

Evidence-based approach to the treatment of hidradenitis suppurativa/acne inversa, based on the European guidelines for hidradenitis suppurativa

Hidradenitis suppurativa/acne inversa (HS) is a chronic inflammatory skin disease characterized by painful, recurrent nodules and abscesses that rupture and lead to sinus tracts and scarring. To date, an evidence-based therapeutic approach has not been the standard of care and this is likely due to the lack of evidence based treatment guidelines. The purpose of this study was to promote a holistic evidence-based approach which implemented Level of Evidence and Strength of Recommendation for the treatment of HS. Based upon the European Dermatology Forumguidelines for the management of HS, evidence-based approach was explored for the treatment of HS. The diagnosis of HS should be made by a dermatologist or other healthcare professional with expert knowledge in HS. All patients should be offered adjuvant therapy as needed (pain management, weight loss, tobacco cessation, treatment of super infections, and application of appropriate dressings). The treating physician should be familiar with disease severity scores, especially Hurley staging, physician global assessment and others. The routine use of patient'reported outcomesincluding DLQI, itch and pain assessment (Visual Analogue Scale) is strongly recommended. The need for surgical intervention should be assessed in all patients depending upon type and extent of scarring, and an evidence-based surgical approach should be implemented. Evidence-based medical treatment of mild disease consists of topical Clindamycin 1 % solution/gel b.i.d. for 12 weeks or Tetracycline 500 p.o. b.i.d. for 4 months (LOE IIb, SOR B), for more widespread disease. If patient fails to exhibit response to treatment or for a PGA of moderate-to-severe disease, Clindamycin 300 p.o. b.i.d. with Rifampicin 600 p.o. o.d. for 10 weeks (LOE III, SOR C) should be considered. If patient is not improved, then Adalimumab 160 mg at week 0, 80 mg at week 2; then 40 mg subcutaneously weekly should be administered (LOE Ib, SOR A). If improvement occurs then therapy should be maintained as long as HS lesions are present. If the patient fails to exhibit response, then consideration of second or third line therapy is required. A growing body of evidence is being published to guide the treatment of HS. HS therapy should be based upon the evaluation of the inflammatory components as well as the scarring and should be directed by evidence-based guidelines. Treatment should include surgery as well as medical treatment. Future studies should include benefit risk ratio analysis and long term assessment of efficacy and safety, in order to facilitate long term evidence based treatment and rational pharmacotherapy.

Wide excision and healing by secondary intent for the surgical treatment of hidradenitis suppurativa: A single-center experience

BACKGROUND

This study reviewed a single center's 14-year experience with surgical treatment of chronic, severe hidradenitis suppurativa (HS) through wide excision technique and healing by secondary intention.

METHODS

All patients who underwent wide excision of HS between 2000 and 2014 and allowed to heal by secondary intention were included. Wound care consisted of topical antimicrobials and hydrotherapy. Physical therapy was initiated for joint contracture prevention. Patients were followed until complete wound closure.

RESULTS

Seventeen patients underwent 23 separate surgical encounters, five with excision of multiple areas. Seventeen excisional procedures were conducted on the upper half of the body (axillary, breast) and 11 on the lower half (inguinal, perineum, perianus, and abdomen). Two patients developed HS recurrence adjacent to the surgical site (one requiring reexcision and the other treated with topical therapy), whereas two developed HS flares at distant nonsurgical sites managed medically. The mean follow-up was 1.02 years with a median of 6 months ranging from 1.2 months to 5.25 years. Complete wound healing ranged from 8 weeks to 16 months, with limited range of motion (ROM) in two patients.

CONCLUSIONS

Attempts at removing all tissue affected by HS through wide surgical excision are the mainstay intervention for achieving complete local cure, particularly in the most severe cases of the disease. Our experience with wide excision of disease and healing by secondary intent demonstrated clinically satisfactory functional and excellent aesthetic results in multiple anatomic areas and even for large defects. This healing modality requires strict adherence to the wound healing protocol, which is often tolerated only by patients who have endured symptoms of severe HS for an extended length of time.

European S1 guideline for the treatment of hidradenitis suppurativa/acne inversa

Hidradenitis suppurativa/acne inversa (HS) is a chronic, inflammatory, recurrent, debilitating skin disease of the hair follicle that usually presents after puberty with painful, deep-seated, inflamed lesions in the apocrine gland-bearing areas of the body, most commonly the axillae, inguinal and anogenital regions. A mean disease incidence of 6.0 per 100,000 person-years and an average prevalence of 1% has been reported in Europe. HS has the highest impact on patients' quality of life among all assessed dermatological diseases. HS is associated with a variety of concomitant and secondary diseases, such as obesity, metabolic syndrome, inflammatory bowel disease, e.g. Crohn's disease, spondyloarthropathy, follicular occlusion syndrome and other hyperergic diseases. The central pathogenic event in HS is believed to be the occlusion of the upper part of the hair follicle leading to a perifollicular lympho-histiocytic inflammation. A highly significant association between the prevalence of HS and current smoking (Odds ratio 12.55) and overweight (Odds ratio 1.1 for each body mass index unit) has been documented. The European S1 HS guideline suggests that the disease should be treated based on its individual subjective impact and objective severity. Locally recurring lesions can be treated by classical surgery or LASER techniques, whereas medical treatment either as monotherapy or in combination with radical surgery is more appropriate for widely spread lesions. Medical therapy may include antibiotics (clindamycin plus rifampicine, tetracyclines), acitretin and biologics (adalimumab, infliximab). A Hurley severity grade-relevant treatment of HS is recommended by the expert group following a treatment algorithm. Adjuvant measurements, such as pain management, treatment of superinfections, weight loss and tobacco abstinence have to be considered.

Management of hidradenitis suppurativa wounds with an internal vacuum-assisted closure device

BACKGROUND

Hidradenitis suppurativa is a chronic, debilitating disease that is difficult to treat. Once medical management fails, wide local excision offers the best chance for cure. However, the resultant wound often proves too large or contaminated for immediate closure.

METHODS

The authors performed a retrospective chart review of hidradenitis cases managed surgically between 2005 and 2010. Data collected included patient characteristics, management method, and outcomes. Approximately half of the patients received internal vacuum-assisted closure therapy using the vacuum-assisted closure system and delayed closure and half of the patients received immediate primary closure at the time of their excision. Delayed closure consisted of closing the majority of the wound in a linear fashion following internal vacuum-assisted closure while accepting healing by means of secondary intention for small wound areas.

RESULTS

Patients managed with internal vacuum-assisted closure had wounds on average four times larger in area than patients managed without internal vacuum-assisted closure. In both groups, all wounds were eventually closed primarily. Healing times averaged 2.2 months with internal vacuum-assisted closure and 2.7 months without. At an average follow-up time of 2.3 months, all patients with internal vacuum-assisted closure had no recurrence of their local disease.

CONCLUSIONS

Severe hidradenitis presents a treatment challenge, as surgical excisions are often complicated by difficult closures and unsatisfactory recurrence rates. This study demonstrates that wide local excision with reasonable outcomes can be achieved using accelerated delayed primary closure. This method uses internal vacuum-assisted closure as a bridge between excision and delayed primary closure, facilitating closure without recurrence in large, heavily contaminated wounds.

CLINICAL QUESTION/LEVEL OF EVIDENCE

Therapeutic, III.

Skin-Tissue-sparing Excision with Electrosurgical Peeling (STEEP): a surgical treatment option for severe hidradenitis suppurativa Hurley stage II/III

BACKGROUND

Surgery is the only curative treatment for removal of the persistent sinus tracts in the skin that are characteristic of severe hidradenitis suppurativa (HS). Complete resection of the affected tissue by wide excision is currently regarded as the preferred surgical technique in these cases. However, relatively large amounts of healthy tissue are removed with this method and suitable skin-tissue-saving techniques aiming at creating less-extensive surgical defects are therefore needed in severe HS.

METHOD

We describe a skin-tissue-saving surgical technique for HS Hurley stage II-III disease: the Skin-Tissue-sparing Excision with Electrosurgical Peeling (STEEP) procedure.

DISCUSSION

In contrast to wide excisions that generally reach into the deep subcutaneous fat, the fat is maximally spared with the STEEP procedure by performing successive tangential excisions of lesional tissue until the epithelialized bottom of the sinus tracts has been reached. From here, secondary intention healing can occur. In addition, fibrotic tissue is completely removed in the same manner as this also serves as a source of recurrence. This tissue-sparing technique results in low recurrence rates, high patient satisfaction with relatively short healing times and favourable cosmetic outcomes without contractures.

Management of severe rhinophyma with sculpting surgical decortication

Rhinophyma, a progressive, disfiguring disease of the nose, is considered the final stage of acne rosacea. In its early stages, rhinophyma can be managed with medical treatment using isotretinoin or oral antibiotics (metronidazole). However, severe cases usually are refractory to medical approaches. Surgical therapies to treat these severe refractory cases have been described. This report describes a simple, safe, efficient, and cost-effective approach to the treatment of severe rhinophyma using a scalpel and the electroscalpel, instruments readily available in every operating room.

LEVEL OF EVIDENCE V

This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .