Hidradenitis suppurativa (HS), a chronic skin condition characterized by painful abscesses and scarring, often proves resistant to conventional treatments. In advanced cases, such as those classified as Hurley stage II or III, surgical intervention becomes necessary due to the severity of inflammation, scarring, and tissue damage. Wide surgical excision, which involves removing the affected tissue along with a margin of healthy skin, is commonly performed when systemic therapies fail. However, selecting the optimal wound closure method after surgery remains a significant challenge for clinicians.
A recent systematic review and meta-analysis sought to assess the effectiveness of various wound closure techniques for HS surgery, evaluating recurrence rates, patient outcomes, and complication risks. The options explored in the study included primary closure, split-thickness skin grafts, local or distant flaps, and secondary intention healing.
Findings on Recurrence Rates and Patient Outcomes
Researchers found that secondary closure methods, particularly local/distant flaps and split-thickness skin grafts, resulted in significantly lower recurrence rates compared to primary closure. Local/distant flaps reduced recurrence by 55%, while split-thickness grafts led to a 45% reduction. In contrast, primary closure, while simpler and quicker, was associated with higher recurrence, likely due to its limited ability to manage the extensive tissue damage and inflammation characteristic of HS.
Secondary intention healing, although not as effective at reducing recurrence compared to other methods, has the advantage of avoiding donor site morbidity and preserving range of motion. However, it requires a lengthy healing process and intensive wound care, particularly for larger defects.
Surgical Techniques and Complications
Each wound closure method carries its own set of risks. The study found that primary closure and secondary intention healing had lower rates of wound dehiscence compared to flap procedures. However, no significant differences in infection or bleeding rates were observed between the different methods. Data on movement impairments was limited, making it difficult to draw definitive conclusions.
Flap procedures, though effective at integrating with surrounding tissue, present challenges due to their complexity and a higher risk of complications such as tissue necrosis and hemorrhage. Split-thickness skin grafts offer good coverage but come with the drawback of potential donor site morbidity. Secondary intention healing, while avoiding these issues, demands prolonged healing time and meticulous care.
Study Methodology and Limitations
The systematic review adhered to PRISMA guidelines and analyzed studies published between 1965 and 2024. Researchers conducted a thorough search across multiple databases, excluding case reports and non-surgical studies. The quality of the studies was assessed using the Newcastle-Ottawa Scale, with most studies categorized as either fair or good. Data were synthesized through multi-intervention network meta-analysis and direct comparisons to evaluate recurrence rates and complications.
Despite the thorough analysis, the study noted several limitations. Most of the included studies were retrospective, which could introduce bias. The variability in patient populations and follow-up periods further contributed to heterogeneity, and the lack of standardized definitions for recurrence hindered direct comparisons across studies.
Recommendations for Improved Outcomes
To enhance surgical outcomes, researchers recommended preoperative use of anti-inflammatory therapies, such as biologics or corticosteroids, to help differentiate between inflamed and healthy tissue. This could improve surgical precision and reduce the risk of recurrence.
Conclusion
For patients undergoing wide excision surgery for HS, the study suggests that secondary closure techniques, especially local/distant flaps, should be considered the gold standard for minimizing recurrence. While primary closure remains a practical option, it is less effective in managing extensive defects and is associated with higher recurrence rates. Flaps and grafts provide durable solutions but require careful patient selection and surgical expertise. Future research, including multicenter, randomized trials, is needed to refine these findings and establish evidence-based guidelines for wound closure in HS management.
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