Management of Surgical Dehiscence with Suspected Infection After Wide Excision for Hidradenitis Suppurativa
Yes, negative pressure wound therapy (NPWT) is strongly indicated for surgical dehiscence with suspected infection following wide excision for hidradenitis suppurativa, and should be initiated immediately upon recognition of the dehiscence.
Immediate NPWT Application
Apply NPWT as the first-line treatment for dehisced wounds after hidradenitis suppurativa excision, as it significantly reduces wound complications, accelerates healing, and decreases re-dehiscence rates compared to standard gauze dressings 1, 2.
The North American guidelines specifically recommend negative-pressure therapy for selected large open wounds for a short period (1-4 weeks) followed by delayed reconstruction 1.
Set continuous negative pressure at 50-80 mmHg and change dressings every 48-72 hours based on output volume and wound condition 2.
NPWT with instillation and dwell time (NPWTi-d) can be particularly effective, as demonstrated in a case series where it achieved 70-90% graft uptake after an average of 3.5 days of therapy 3.
Critical Time-Sensitive Window
You have a 7-10 day window from dehiscence recognition to achieve fascial closure before tissue fixity develops, after which primary closure becomes impossible 2.
Delaying NPWT application allows progression to higher-grade dehiscence with worse outcomes 2.
Early definitive closure within 4-7 days is the gold standard for preventing complications including fistulae and massive incisional hernias 2.
Antibiotic Management for Suspected Infection
Initiate broad-spectrum antibiotics immediately with empiric coverage using piperacillin/tazobactam 4.5g IV every 6 hours or similar broad-spectrum agent 2.
Collect wound samples for microbiological analysis and adjust antibiotics based on culture results 2.
One study demonstrated that gentamicin-collagen sponge enclosure after primary excision reduced complications from 52% to 35% at 1 week postoperatively, though this applies to primary closure rather than dehiscence management 4.
Wound Care Principles
Follow individualized best-practice wound care principles as recommended by North American guidelines, with dressing choice based on drainage amount, location, periwound skin condition, cost, and patient preference 1.
Consider antiseptic washes, though they carry low risk of contact dermatitis 1.
Local wound care for surgical wounds in hidradenitis suppurativa follows standard best-practice principles 1.
Reconstruction Planning After NPWT
After NPWT stabilizes the wound bed (typically 1-4 weeks), plan for delayed reconstruction 1.
Split-thickness skin grafts are associated with lower recurrence rates (adjusted OR 0.31) compared to other closure methods in hidradenitis suppurativa surgery 5.
Secondary intention healing, flaps, grafts, and skin substitutes are all acceptable options depending on wound characteristics 1.
TOPS database data shows improved outcomes with NPWT, split-thickness skin grafts, and muscle flaps compared to primary closure techniques 6.
Common Pitfalls to Avoid
Do not delay NPWT application once dehiscence is recognized—immediate initiation is critical 2.
Do not allow the 7-10 day window to pass without attempting closure, as this eliminates the possibility of primary fascial closure 2.
Do not apply NPWT foam directly to exposed tissue without a protective non-adherent interface layer, as this can cause tissue injury 2.
Do not use simple primary closure for complex hidradenitis suppurativa wounds, as complication rates reach 80% with this approach 6.
Monitoring During Treatment
Wound dehiscence itself is associated with increased risk of disease recurrence (adjusted OR 2.55), making aggressive management essential 5.
Track NPWT output volume daily and monitor for signs of infection progression, fistula formation, or advancement to higher-grade dehiscence 2.
Overall complication rates after hidradenitis suppurativa surgery are high (59.6-80% depending on closure method), making vigilant monitoring mandatory 6.
Continuing Medical Therapy
- Continue systemic medical therapy for hidradenitis suppurativa in the perioperative period, as experience suggests this is likely beneficial and poses minimal risk of increased postoperative complications 1.