What does tissue fixity mean in a dehisced wound after wide excision for hidradenitis suppurativa?

Tissue Fixity in Dehisced Wounds After Wide Excision for Hidradenitis Suppurativa

Tissue fixity refers to the degree to which the wound edges and surrounding tissues are immobile, adherent to underlying structures, and resistant to movement—a critical factor that determines whether primary closure is feasible or whether the wound must heal by secondary intention or require skin grafting.

Understanding Tissue Fixity in the Context of HS Surgery

Tissue fixity is assessed by examining whether the wound edges can be approximated without tension and whether the surrounding skin has sufficient mobility to allow closure. 1

Key Components of Tissue Fixity Assessment

• Mobility of wound edges: The ability to bring wound edges together without creating excessive tension that would compromise blood supply or cause ischemic necrosis 1
• Adherence to deeper structures: Scar tissue and chronic inflammation in HS create fibrosis that fixes skin to underlying fascia, limiting tissue mobility 2, 3
• Extent of surrounding induration: Chronic inflammation leads to extensive fibrosis and scarring that reduces tissue elasticity and increases fixity 4, 2

Clinical Implications for Wound Management

When Tissue Fixity Prevents Primary Closure

If tissue fixity is high (immobile, adherent tissues), attempting primary closure creates unacceptable tension and significantly increases dehiscence risk, making secondary intention healing or delayed reconstruction the preferred approach. 1

• Primary closure under tension has higher recurrence rates than secondary intention healing in HS wounds 1
• Reconstruction methods such as primary closure, grafts, and flaps may be associated with higher recurrence rates than secondary intention healing when tissue fixity limits mobility 1

Reconstruction Options Based on Tissue Fixity

For wounds with high tissue fixity after wide excision, secondary intention healing is often preferred despite prolonged recovery times of 10 weeks (range 7-17 weeks), as it avoids the complications of closure under tension. 5

• Split-thickness skin grafting can be performed after initial healing reduces inflammation and improves the wound bed, with mean healing time of 6 weeks (range 3-9 weeks) 5
• Delayed closure following days to weeks of secondary intention healing allows tissue fixity to decrease as inflammation resolves, though this requires prolonged recoveries and can be complicated by infection, joint contractures, and scarring 1

Specific Assessment Technique

Evaluating Tissue Fixity at the Time of Dehiscence

• Attempt gentle approximation of wound edges to assess whether they can be brought together without blanching of tissue (indicating excessive tension) 1
• Palpate surrounding tissues to determine the extent of induration and fibrosis that limits mobility 2
• Assess the depth of fixation by determining whether subcutaneous tissues are adherent to deeper fascial planes 1

Management Algorithm for Dehisced HS Wounds

Step 1: Assess Tissue Fixity and Wound Characteristics

• If wound edges are mobile and can be approximated without tension → Consider delayed primary closure with continuous subcuticular sutures 6
• If tissue fixity is high with immobile, indurated edges → Plan for secondary intention healing or delayed skin grafting 1, 5

Step 2: Wound Bed Preparation

• Allow secondary intention healing for days to weeks to reduce inflammation and improve tissue quality before attempting reconstruction 1
• Consider negative-pressure wound therapy to shorten the duration between excision and delayed closure or grafting 1

Step 3: Definitive Management

• For secondary intention: Use absorptive, atraumatic dressings with mean healing time of 10 weeks 1, 5
• For delayed skin grafting: Perform split-thickness grafting once granulation tissue forms and inflammation resolves, with mean healing time of 6 weeks 5
• Avoid immediate primary closure in the setting of high tissue fixity, as this is associated with higher recurrence rates 1

Critical Pitfalls to Avoid

• Never attempt primary closure when tissue fixity prevents tension-free approximation, as this dramatically increases dehiscence risk and recurrence rates 1
• Do not underestimate healing time: Secondary intention healing in HS wounds requires 7-17 weeks, and patients must be counseled about this prolonged recovery 5
• Avoid skin grafting on inflamed, indurated tissue beds: Wait for inflammation to resolve and tissue fixity to decrease before attempting grafting 1, 5
• Recognize that location matters: Perianal, vulvar, and inferior breast locations have higher recurrence rates regardless of reconstruction method due to inherent tissue characteristics and movement 1

Pain Management During Healing

• Topical analgesics such as lidocaine, oral acetaminophen, and oral nonsteroidal anti-inflammatory drugs are preferred for acute pain 1
• Consider tramadol as an alternative to conventional opioids for chronic pain during the prolonged healing period 1
• A multidisciplinary approach with pain specialists may be necessary for complex cases with extensive wounds 1