Hidradenitis Suppurativa Surgery: Wide Excision Treatment

Hidradenitis Suppurativa Surgery: A Path to Relief

When non-surgical treatments for hidradenitis suppurativa are no longer effective, surgery offers a way to manage this chronic skin condition. This guide explains the options, focusing on wide excision for severe cases. We cover candidacy, the step-by-step surgical process, and the week-by-week recovery. We will also explore advanced reconstruction techniques and the significant, positive impact that surgery can have on your psychological wellbeing and overall quality of life.

Mr. Roshan Vijayan, FRCS (Plast), is committed to a patient-partnership approach, ensuring you feel heard and supported. His extensive experience in both the NHS and private practice in London and Hertfordshire underpins his specialist care. To explore your treatment options and discuss a bespoke solution, we invite you to Book Now a one-on-one consultation.

Table of Contents

• What Is Hidradenitis Suppurativa (HS) Surgery?
• Why Is Wide Excision Surgery for HS Needed?
• Are You a Candidate for HS Surgery in the UK?
• Non-Surgical and Minor HS Treatment Options
• The Hidradenitis Suppurativa Surgery: Wide Excision Process
• What Is the Recovery Time for HS Excision Surgery?
• Psychological Wellbeing After HS Surgery
• Advanced Reconstruction After Wide Excision Surgery
• Your HS Surgery Consultation in London & Hertfordshire

What Is Hidradenitis Suppurativa (HS) Surgery?

Hidradenitis Suppurativa (HS) surgery is a group of procedures designed to treat the physical manifestations of this chronic inflammatory skin condition. HS, also known as acne inversa, causes painful, deep-seated nodules, abscesses, and tunnels (sinus tracts) in areas where skin rubs together, such as the armpits (axillae), groin, buttocks, and under the breasts. It is not an infection and is not caused by poor hygiene; it is understood to be a disorder of the hair follicle that leads to a profound inflammatory response.

Historically, the condition was thought to be a disease of the apocrine sweat glands, leading to terms like ‘apocrine gland removal’. However, current understanding points towards follicular occlusion as the primary event. This blockage triggers inflammation, rupture, and the subsequent formation of painful lesions that can leak pus and lead to significant scarring over time.

Dermatologists and GPs often classify the severity of HS using the Hurley staging system:

• Hurley Stage I: Single or multiple abscesses without sinus tracts or scarring.
• Hurley Stage II: Recurrent abscesses with sinus tracts and scarring, with lesions separated by healthy skin.
• Hurley Stage III: Widespread involvement across an entire area, with multiple interconnected sinus tracts and abscesses and little to no healthy skin remaining.

Surgery is typically reserved for patients with Hurley Stage II and III disease, where medical treatments alone are insufficient to control the symptoms. The goal of surgery is not just to drain a single abscess, but to remove the entire network of diseased tissue, including the sinus tracts and scarred skin, to prevent recurrence in that specific area. This approach targets the structures where the inflammation originates, offering long-term relief where other treatments may have failed.

Why Is Wide Excision Surgery for HS Needed?

For individuals living with moderate to severe HS, the condition can become a relentless cycle of pain, drainage, and inflammation. Medical treatments such as antibiotics, hormonal therapies, and biologics are often the first line of defence, but they may not be effective for everyone, particularly those with extensive scarring and established sinus tracts. When this chronic skin condition surgery becomes necessary, wide excision is considered the gold standard for achieving long-term control in a specific anatomical area.

The primary reason wide excision is needed is that it addresses the root of the local problem. Unlike a simple incision and drainage, which only provides temporary relief by releasing pressure from an abscess, wide excision removes the entire affected skin and subcutaneous tissue. This includes the scarred tissue and the interconnected tunnels beneath the surface that harbour chronic inflammation and are the source of recurrent flare-ups. By removing this entire pathological unit, the cycle is broken.

Benefits and Recurrence Rates

The principal benefit of wide excision is providing lasting relief from the debilitating symptoms of HS. Patients often experience a dramatic reduction in pain, odour, and drainage, which significantly improves their quality of life. However, it is crucial to understand that surgery is not a cure for Hidradenitis Suppurativa. HS is a systemic inflammatory condition, and you may still develop new lesions in other, untreated areas of the body. The goal of surgery is to achieve durable remission in the treated area.

When considering the success rate of surgical treatment, wide excision has the lowest reported recurrence rates compared to less aggressive procedures. Studies show that recurrence in the surgically treated area after a wide excision is significantly lower, often cited in the range of 10-30%. This contrasts sharply with simple incision and drainage, where recurrence is nearly 100%. The success of the procedure depends heavily on the surgeon’s ability to remove all the affected tissue and the patient’s ongoing management of the condition post-operatively.

Are You a Candidate for HS Surgery in the UK?

Deciding to proceed with surgery for Hidradenitis Suppurativa is a significant step, made in collaboration with your specialist. It is typically considered when conservative measures have failed to provide adequate relief and the condition is severely impacting your daily life. A good candidate for HS surgery generally meets several of the following criteria:

• A Confirmed Diagnosis: You have a definitive diagnosis of Hidradenitis Suppurativa, usually from a dermatologist.
• Disease Severity: You have moderate to severe disease, typically classified as Hurley Stage II or III, with persistent, painful nodules, abscesses, and established sinus tracts.
• Failure of Medical Management: You have tried and not responded adequately to medical treatments, which may include long-term courses of oral antibiotics, retinoids, or biologic therapies.
• Significant Impact on Quality of Life: The condition causes you chronic pain, restricts your movement, affects your work or social life, and has a considerable negative impact on your mental and emotional wellbeing.
• Specific, Localised Disease: Your HS is concentrated in one or more well-defined areas (like both armpits or the groin), making it amenable to complete surgical removal.
• Medically Fit for Surgery: You are in good general health and able to undergo anaesthesia and the subsequent wound healing process. Conditions like uncontrolled diabetes or smoking can significantly impair healing and must be addressed before surgery.

As a Consultant Plastic Surgeon with extensive experience in the specialist skin surgery required for complex conditions like HS, Mr. Vijayan will conduct a thorough assessment during your consultation. This includes a physical examination, a detailed review of your medical history and previous treatments, and an open discussion about your goals to determine if wide excision is the most appropriate course of action for you.

Non-Surgical and Minor HS Treatment Options

Surgical options for hidradenitis suppurativa range from minor procedures for single lesions to extensive excision for widespread disease, chosen based on the severity and location of your condition. Before considering a major operation like wide excision, you and your clinical team will likely have explored or discussed less invasive approaches.

• Incision and Drainage (I&D): This is a minor procedure to relieve the intense pain of a single, acutely inflamed abscess. A small cut is made to allow pus to drain. Whilst it provides immediate relief, it does not address the underlying disease process and recurrence is almost certain.
• Deroofing (or Unroofing): In this procedure, the "roof" of skin over a sinus tract or abscess is surgically removed, exposing the tunnel from the inside. The base is then allowed to heal naturally. It is more effective than I&D for recurrent lesions but may not be suitable for extensive, interconnected tracts.
• Wide Excision: The most definitive surgical treatment. This involves removing the entire area of affected skin and underlying tissue, including all sinus tracts and scars. The resulting wound is then closed with advanced reconstructive techniques. This is the focus of this article and is for more severe (Hurley II/III) disease.
• Laser Surgery (CO2 Laser): A carbon dioxide laser can be used to vaporise the affected tissue. This can be effective for some patients, particularly in reducing the number of inflammatory lesions. It can be used for both excision and vaporisation of superficial tissue, but healing can be prolonged.

The Hidradenitis Suppurativa Surgery: Wide Excision Process

Undergoing a HS wide excision is a structured process focused on safety, comfort, and achieving the best possible long-term outcome. As a patient, understanding the journey from consultation to the operating theatre can help alleviate anxiety and prepare you for the recovery ahead. The procedure is almost always performed under general anaesthesia, meaning you will be asleep throughout.

The Consultation and Planning Phase

Your journey begins with an in-depth consultation. Mr. Vijayan will assess the extent of your HS, discuss your symptoms, and determine the precise area requiring excision. He will explain the procedure in detail, including the likely size of the area to be removed and the plan for wound closure, which may involve skin grafts or flap surgery. This is your opportunity to ask questions and establish clear, realistic expectations.

The Day of Your Surgery

On the day of the procedure, you will be admitted to the hospital. Mr. Vijayan will see you beforehand to confirm the surgical plan and make markings on your skin. These markings outline the boundaries of the excision, ensuring a margin of healthy tissue is removed around the affected area to minimise the risk of recurrence. In the operating theatre, once you are under anaesthesia, the surgical site will be cleaned and prepared.

The Surgical Procedure

The term 'wide excision' accurately describes the technique. Mr. Vijayan, a board-certified Consultant Plastic Surgeon, FRCS (Plast), will carefully excise the entire marked area of skin and subcutaneous fat, removing all visible abscesses, sinus tracts, and scarred tissue. The removal goes down to the fascia, the layer of tissue that covers the muscle, to ensure all elements of the disease in that area are cleared. For axillary surgery HS (in the armpit), this requires careful navigation around important nerves and blood vessels. Once the diseased tissue is removed, the second, crucial stage begins: reconstruction of the defect, which is detailed in a later section.

What Is the Recovery Time for HS Excision Surgery?

The recovery from HS excision surgery is a gradual process that requires patience and diligent adherence to post-operative care instructions. The timeline can vary significantly depending on the size and location of the excised area and the method used for wound closure. A large wound left to heal by secondary intention will take longer than one closed with a skin graft or flap, but your surgical team will guide you through the specific expectations for your case.

The First 48 Hours

You will wake up with a bulky dressing over the surgical site. Pain and discomfort are expected and will be managed with prescribed pain relief. Your movement will likely be restricted to protect the area, especially if the surgery was in the groin or armpit. Depending on the scale of the operation, you may stay in hospital for one or two nights for observation and pain management.

Week 1

The initial focus is on wound care and managing discomfort. You will have a follow-up appointment with a nurse to have your dressings changed. It is vital to keep the area clean and dry as instructed. You should avoid any strenuous activity, heavy lifting, or stretching that could put tension on the wound. Most people will need to take this week off from work, particularly if their job is physical.

Weeks 2-4

During this period, healing progresses. If you had stitches, they might be removed. If you had a skin graft, it will be checked to ensure it has "taken" successfully. You may still have dressings, but they will become less bulky. Discomfort should be decreasing, and you can gradually increase your range of motion as advised. Depending on your job, you may be able to return to sedentary work towards the end of this period. Driving is usually not permitted until you are comfortable, free from significant pain, and no longer taking strong pain medication.

1 to 3 Months and Beyond

This phase is about maturation of the scar and returning to all normal activities. The wound should be fully healed, but the new skin and scar tissue will be delicate. It’s important to continue protecting the area from friction and sun exposure. Massaging the scar with moisturising ointment can help it to soften and flatten over time. Full return to vigorous exercise or sport is usually possible after about 6-8 weeks, but always on the advice of your surgical team. The final appearance of the scar will continue to improve for up to 12-18 months.

Psychological Wellbeing After HS Surgery

The impact of Hidradenitis Suppurativa extends far beyond the physical symptoms. Living with chronic pain, unpredictable flare-ups, malodour, and drainage can take a significant toll on mental and emotional health. Many individuals with HS experience feelings of embarrassment, shame, and social isolation. The condition can affect self-esteem, intimacy, and the simple freedom to wear certain types of clothing or participate in activities like swimming. This psychological burden is a core part of the patient experience and a key reason why effective treatment is so important.

For many, surgery offers a profound sense of psychological relief that is just as meaningful as the physical recovery. The primary benefit is the cessation of the chronic inflammatory cycle in the treated area. Waking up without the constant, draining pain can be a transformative experience. The end of persistent drainage and odour can restore a sense of personal freedom and confidence that may have been lost for years.

Reclaiming your life is a common theme among patients who have undergone successful wide excision. It can mean the ability to lift your arms without pain, to wear a sleeveless top in summer, or to sit comfortably for long periods. It can mean rebuilding intimacy in relationships without fear of pain or embarrassment. Whilst the surgical scars are a permanent reminder of the journey, they are often seen as a symbol of healing and control rather than a mark of disease. By removing the source of the physical distress, surgery can liberate patients from the constant anxiety of the next flare-up, allowing them to focus on living their lives more fully.

Advanced Reconstruction After Wide Excision Surgery

Removing a large segment of diseased tissue is only the first half of a successful HS operation. The second, equally critical part is managing the resulting wound, known as a 'defect'. This is where the specialist skills of a Consultant Plastic and Reconstructive Surgeon are paramount. A general surgeon can perform an excision, but a plastic surgeon brings an extensive toolkit of advanced techniques to repair the defect, aiming for the best possible functional and aesthetic outcome.

As a specialist in this field, Mr. Roshan Vijayan, FRCS (Plast), is trained to assess the defect and choose the most appropriate reconstructive method. Within both the NHS and private practice settings, this reconstructive expertise is key to minimising scarring and preserving function, particularly in mobile areas like the armpits and groin. The choice of technique depends on the wound's size, depth, and location.

Common Reconstructive Options:

• Healing by Secondary Intention: For some wounds, particularly in concave areas, the best approach is to allow them to heal naturally from the base up. This involves special dressings and regular care but can result in a good, supple scar without the need for further surgery.
• Split-Thickness Skin Grafts (STSG): For large, shallow defects, a thin layer of healthy skin can be harvested from a donor site (commonly the thigh) and placed over the wound. The graft integrates with the wound bed over several days. This technique allows for the closure of very large areas.
• Local Flap Surgery: This is a more complex reconstructive technique where adjacent healthy tissue, complete with its own blood supply, is moved or rotated to cover the defect. This provides durable, robust coverage with tissue that matches the surrounding skin in colour and texture. It is often the preferred method in areas of high tension or movement, like the axilla, as it provides a more stable and functional long-term result.

The goal of reconstruction is not just to close a hole, but to restore normal form and function. This careful planning and execution are fundamental to achieving a successful outcome that allows you to move freely and comfortably after your recovery.

Your HS Surgery Consultation in London & Hertfordshire

Living with severe Hidradenitis Suppurativa can be challenging, but surgical intervention can offer a significant and lasting improvement in your quality of life. The first step is a comprehensive consultation with a specialist who understands both the disease and the complex reconstructive surgery required to treat it effectively. Mr. Vijayan will listen to your story, assess your condition, and provide a clear and honest opinion on whether Hidradenitis Suppurativa surgery is the right path for you.

To discuss your options with Mr. Vijayan, book a personal consultation at his practice serving patients across London, Hertfordshire, and Stevenage.

Frequently Asked Questions

What is the recurrence rate after wide excision for HS?

Wide excision surgery offers the lowest recurrence rate of all surgical options, generally reported to be under 30% in the treated area. The key to minimising recurrence is the complete removal of all affected tissue, including the deep tunnels. However, HS is a systemic condition, and new areas can develop elsewhere.

Why should I see a plastic surgeon for my HS surgery?

A plastic surgeon specialises in both the removal of diseased tissue and the complex reconstruction required afterwards. This dual expertise is vital for HS, where large excisions in areas like the armpits or groin need advanced techniques like skin grafts or flap surgery to preserve function and optimise the final scar.

What does the recovery timeline look like after HS wide excision?

Initial recovery focuses on wound care and restricted movement, typically lasting 2-4 weeks. Light activities can often resume by this point, with more strenuous exercise avoided for at least 6-8 weeks. Full healing and scar maturation can take several months, depending on the surgical site and reconstruction method used.

How painful is recovery from wide excision surgery?

Post-operative discomfort is expected and will be managed with a tailored pain relief plan. The pain is most significant in the first few days and gradually improves over one to two weeks. For many patients, this temporary surgical pain is preferable to the chronic, unpredictable pain of HS flare-ups.

Will I have a significant scar after my HS operation?

Yes, wide excision surgery to remove a large area of diseased skin will result in a permanent scar. A consultant plastic surgeon employs meticulous techniques to place incisions carefully and manage the wound closure to ensure the scar is as neat and flat as possible as it matures over time.