Secondary Intention Healing vs. Flap Closure for HS Excision: What Your Surgeon Should Tell You

Written by Dr. rer. nat. Dennis Alexander Kwiatkowski

When wide excision is being planned for hidradenitis suppurativa (HS), patients typically focus on the size of the excision and the duration of recovery. The closure method — how the resulting defect is managed — gets relatively little attention. This is the wrong emphasis. The closure decision shapes the next several months of life more than almost any other single factor in the surgery, and the differences between the options are substantial enough that they should be an explicit conversation, not a default chosen by surgeon habit.

This article compares the four main closure methods used after HS wide excision: primary closure, split-thickness skin graft, local or distant flap reconstruction, and secondary intention healing. It covers what each involves, what the recovery actually looks like, what the published recurrence and complication rates are, and the situations where each makes most sense.

Educational content only. Closure method is an individualized surgical decision that depends on defect size, location, tissue availability, your medical situation, and surgical expertise. This article describes general patterns rather than personal recommendations.

Key takeaways

• The four standard options after wide HS excision are primary closure, split-thickness skin graft (STSG), local or distant flap reconstruction, and secondary intention healing. Each has distinct trade-offs.
• In the current meta-analysis evidence (Cucu et al., 2024, 121 studies), recurrence rates differ substantially: flaps ~12%, skin grafts ~18%, primary closure ~25%, secondary intention ~28%. These differences partly reflect surgical selection rather than inherent superiority.
• Flap reconstruction has the lowest recurrence but the highest immediate complication risk and requires specialist surgical expertise.
• Secondary intention healing has the slowest recovery and highest published recurrence rate but the lowest immediate complication rate and works in situations where the other methods are impractical.
• The “right” choice depends on defect size, anatomical site, tissue availability, surgical expertise available, your individual risk profile, and your priorities around recovery duration versus aesthetic outcome.

Why this decision deserves explicit discussion

The closure method shapes:

• How long recovery takes — weeks versus months
• How much wound care burden you carry — daily complex dressings versus simple care
• The complication risk profile — immediate complications (flap necrosis, graft failure, dehiscence) versus delayed complications (prolonged non-healing, hypergranulation)
• The final aesthetic and functional outcome — flat soft scars versus extensive scarring
• The recurrence risk at the operated site — meaningful differences across closure methods
• The need for additional procedures — some closure methods involve donor sites or staged reconstructions

Many surgeons have a default approach — often secondary intention healing in dermatology-led practice, often flap or graft closure in plastic surgery practice — and apply it across most cases. This is not necessarily wrong, but it means the alternative may not be discussed unless you raise it.

The four options in detail

Primary closure

The wound edges are brought together and sutured directly, similar to closing a surgical wound after a minor procedure.

When it’s used: Small excisions where the local tissue is mobile enough to allow approximation without excessive tension. This is the most straightforward closure technique and the option that produces the shortest healing time when it works.

Recovery: Sutures removed (or absorbing) over 1 to 3 weeks. Wound essentially closed at the time of surgery. Healing follows the standard timeline of primary wound healing — full strength of the scar progressively returns over months.

Recurrence: In the 2024 Cucu meta-analysis, approximately 25% (95% CI 20–30%). This is the highest of the closure methods in current pooled data, partly because primary closure tends to be used for smaller excisions that often have narrower margins (since wider margins would produce defects too large for primary closure).

Complications: Wound dehiscence is the main concern, particularly in mobile or friction-prone areas. The 2025 Journal of Investigative Dermatology data put primary closure complication rates around 44%, the highest among closure methods.

Best for: Small, well-localized excisions in areas with mobile surrounding tissue and limited mechanical stress on the wound during healing.

Worst for: Large defects, mobile anatomical sites (axillae with active arm movement, groin with active hip movement), or patients with poor wound healing factors.

Split-thickness skin graft (STSG)

A thin layer of skin — epidermis and a partial dermis — is harvested from a donor site (typically the thigh) and applied to the granulating wound bed of the excision site. The graft has no immediate blood supply and must vascularize from the underlying tissue over the first one to two weeks.

When it’s used: Larger defects where direct closure or flap reconstruction is impractical, but where the wound bed is suitable for grafting and a faster final outcome than secondary intention is desired.

Recovery: Initial healing of both the graft site and the donor site takes 1 to 2 weeks. The graft site requires careful immobilization for the first week to allow vascularization. The donor site heals as a partial-thickness wound — typically 2 to 3 weeks of dressing care. Substantial activity restriction for the first 2 to 4 weeks. Continued scar maturation over months.

Recurrence: Approximately 18% (95% CI 14–22%) in the 2024 meta-analysis.

Complications: Graft loss (partial or complete failure of the graft to take), infection at either site, donor site morbidity (pain, slow healing, visible scarring), contracture of the grafted area limiting function.

Best for: Large defects where complete coverage is desired and where flap reconstruction is not appropriate or available. Common choice for very large axillary or groin defects.

Worst for: Mobile joint areas (where contracture limits function), heavily exudating wound beds, and patients particularly concerned about donor site morbidity.

Local or distant flap reconstruction

A piece of skin and underlying tissue, with its blood supply preserved, is moved from an adjacent area (local flap) or from a more distant donor site (distant or free flap) to cover the defect.

When it’s used: Defects where intact full-thickness tissue with intact blood supply is needed — for cosmetic outcome, for functional reasons, or because the wound bed is not suitable for grafting. Often the choice for axillary defects in plastic-surgery-led HS surgery.

Recovery: Initial hospitalization usually 1 to 5 days. Careful positioning and activity restriction for 2 to 4 weeks to protect the flap. Final healing typically 4 to 8 weeks. Significant initial postoperative restrictions but a relatively short total recovery compared to secondary intention.

Recurrence: Approximately 12% (95% CI 9–15%) — the lowest of the closure methods. This advantage partly reflects the wider margins that flap reconstruction allows (since the surgeon has confidence in their ability to close the defect) and partly reflects the inherent advantages of healthy full-thickness tissue covering the area.

Complications: Flap necrosis (partial or complete loss of the flap due to vascular compromise), dehiscence at the flap junction, donor site complications, infection. Reoperation rates are higher than for other closure methods if the flap is compromised.

Best for: Defects where the lowest recurrence rate is the priority, where surgical expertise is available, and where the patient can comply with the postoperative restrictions to protect the flap.

Worst for: Patients with poor general health, smokers who continue smoking, patients with limited surgical expertise available locally, and situations where the larger immediate operation is undesirable.

Secondary intention healing

The wound is left open and allowed to heal by granulation from below and epithelialization from the edges — the same process described in detail in the companion article on wound healing in the first 90 days.

When it’s used: Large defects in moist or friction-prone areas where the other closure methods are impractical or carry high complication risk. Common choice for extensive perineal, gluteal, or large groin defects in dermatology-led HS surgery. Often chosen when surgical expertise for flap reconstruction is not readily available.

Recovery: Daily or alternate-day dressing changes initially. Wound takes 8 to 16+ weeks on average to fully close, with significant variation. Substantial wound care burden over the entire healing period. Often substantial mobility limitations during the worst weeks, depending on site.

Recurrence: Approximately 28% (95% CI 23–33%) — the highest of the closure methods. This number is partly inflated by the fact that secondary intention is often chosen for the largest, most extensive disease where recurrence would be more likely under any method.

Complications: Lowest immediate operative complication rate (no flap to fail, no graft to lose, no closure to dehisce). Main concerns are slow healing, hypergranulation requiring intervention, indolent low-grade infection prolonging healing, and the cumulative quality-of-life impact of months of wound care.

Best for: Large defects where complete primary closure is impractical, situations where flap expertise is unavailable, patients who prioritize avoiding immediate complications over recovery duration, and complex anatomical sites (perineal disease is a common example).

Worst for: Patients with poor home wound care support, very mobile or active patients who struggle with extended activity restriction, and situations where the prolonged healing burden is unacceptable.

How the numbers should and shouldn’t be interpreted

The recurrence percentages above are useful but should be read with several caveats.

The patient populations are not directly comparable. Surgeons select closure methods partly based on disease severity, defect characteristics, and patient factors. Secondary intention is often chosen for the most extensive, most difficult cases; flap reconstruction is often chosen for cases where the local tissue is in better condition. The recurrence differences partly reflect these selection differences rather than the inherent superiority of one technique.

Heterogeneity in published studies is substantial. Different studies define recurrence differently (within 0.5 cm of the scar versus elsewhere in the region), use different follow-up durations, and include patients with different disease severities. The pooled numbers above represent broad averages across very heterogeneous data.

Individual factors matter more than population averages. For any specific patient at a specific anatomical site with a specific defect size, the realistic recurrence estimate depends on disease severity, margin adequacy, postoperative medical management, and modifiable factors like smoking and weight. The closure method is one factor among several.

The complication rates and recurrence rates need to be weighed together. A closure method with low recurrence but high immediate complication risk may produce worse overall outcomes than one with moderate recurrence but low complication risk, if complications are common enough to drive secondary surgery or prolonged morbidity.

How the decision is actually made

In practice, the closure decision usually emerges from the intersection of several factors:

Defect size and location. Small defects → primary closure or local flap. Medium defects with mobile surrounding tissue → flap. Large defects in difficult sites → secondary intention or staged reconstruction. Defects crossing functional anatomical units (such as the axillary apex affecting arm movement) → flap with functional considerations.

Tissue quality. Healthy, mobile, well-vascularized surrounding tissue allows flap or primary closure options. Scarred, chronically inflamed, or fibrotic surrounding tissue often pushes toward secondary intention or grafting.

Surgical expertise available. Flap reconstruction requires specific surgical skill and is not universally available. A dermatologist-led HS service may not offer flap reconstruction, while a plastic surgery service may default to it.

Patient factors. Smoking, diabetes, immunosuppression, and obesity all affect wound healing and may push toward more conservative closure choices. Younger active patients may prioritize faster recovery (favouring flap or primary closure) while patients with mobility-limited lifestyles may tolerate the longer secondary-intention recovery better.

Patient preference. When the surgical options genuinely present a real choice, patient priorities matter. Some patients accept higher complication risk for shorter total recovery; others accept slower healing for lower immediate complication risk. This is a legitimate area for shared decision-making.

What “the surgeon should tell you” actually means

The minimum honest informed-consent conversation about closure should include:

1. Which closure methods are options for this defect (not all options are technically feasible for all defects).
2. Which closure method the surgeon is planning to use and specifically why. “Because that’s what I do” is not a sufficient answer for a major surgical decision.
3. What the realistic recovery timeline is for the planned closure — concrete numbers in weeks for major milestones.
4. What the realistic recurrence rate is for this approach at this site, in this surgeon’s hands — ideally, the surgeon’s own outcomes or close approximations from comparable practice.
5. What the most likely complications are and what would happen if they occur — particularly the reoperation pathway for flap or graft failure.
6. Whether other closure options were considered and why they were rejected.
7. What the alternative would look like if the primary plan turns out to be impractical during surgery.

If this conversation feels rushed, incomplete, or evasive, that is reasonable grounds to seek a second opinion before agreeing to surgery. Wide excision is a major operation; the closure decision is not a footnote.

When seeking a second opinion makes sense

Second opinions are particularly worth considering when:

• The proposed surgery is large and the closure plan is secondary intention without clear discussion of alternatives
• The surgeon does not regularly perform HS surgery (rather than HS being an occasional case in a general practice)
• The defect site is functionally important (axilla affecting arm movement, perineum affecting urination or sexual function, gluteal region affecting sitting)
• You have specific concerns about cosmetic outcome and the surgeon has not addressed these
• You have factors that complicate the decision (significant obesity, diabetes, immunosuppression, prior failed HS surgery)

In Germany, a second opinion (Zweitmeinung) is typically straightforward to arrange — your treating dermatologist can refer to another HS specialist, or you can self-refer to a recognized HS centre. Several university hospital HS clinics offer second-opinion consultations for surgical planning. GKV covers second opinions in most situations.

In Germany specifically

A few additional practical points:

• Multidisciplinary HS clinics at several German university hospitals coordinate dermatology, plastic surgery, and general surgery for surgical planning. For complex closure decisions, this is the appropriate setting.
• DRG billing structures different closure methods differently. This is not your problem directly, but it can affect what the hospital is willing to offer routinely.
• Anschlussheilbehandlung (AHB) following major surgery may be available, particularly for patients with significant secondary-intention wounds and limited home support.
• Coverage of advanced wound care products (foam dressings, negative pressure wound therapy, specialized materials) is generally available through Verordnung von Verbandsmitteln under GKV when prescribed appropriately.

Frequently asked questions

Can I request a specific closure method?

You can express preferences, and a good surgeon will discuss them. Whether a specific method is technically appropriate for your defect is a surgical judgment that you cannot override, but the conversation about preferences is legitimate. If the surgeon refuses to discuss alternatives, that is a signal worth taking seriously.

Why does my surgeon default to secondary intention when the meta-analysis shows it has the highest recurrence rate?

Several legitimate reasons: the meta-analysis figures partly reflect selection of the most difficult cases for secondary intention; the immediate complication rate is lower than for flap or graft; secondary intention requires less specialized surgical expertise; and for some anatomical sites (extensive perineal disease) it is the most practical option regardless of recurrence considerations. That said, “we always do secondary intention” without acknowledging the trade-offs is not the same as “secondary intention is the best option for your specific situation.”

Is flap reconstruction always better if it’s available?

No. Flap reconstruction has the lowest recurrence rate but the highest immediate complication risk. For patients with risk factors that predict flap complications (continued smoking, poorly controlled diabetes, significant obesity), the calculus may favour an approach with lower immediate complication risk even at the cost of higher recurrence.

How long do I have to decide on closure method?

For non-urgent surgery, you typically have weeks. Use that time to ask questions, seek a second opinion if appropriate, and make sure the closure plan addresses your specific situation. Rushing the decision to fit a surgery date is rarely appropriate for elective HS surgery.

What happens if the closure plan doesn’t work intraoperatively?

Surgeons usually have a contingency plan. A flap that turns out to be unfeasible may be converted to a graft; a primary closure that turns out to have too much tension may be converted to secondary intention. The intraoperative judgment is the surgeon’s; what matters is that the plan and the contingency were discussed with you in advance.

Will I have a major scar regardless of closure method?

Yes. The scar from wide excision is substantial regardless of closure technique. Flap closures and skin grafts tend to produce more aesthetically integrated scars over time; secondary intention often produces wider, more obvious scars that mature for many months. None of the options produce “normal skin” outcomes. For most patients, even the most visible scar is a cosmetic improvement over years of unmanaged disease in the area.

Disclaimer. This article is for general education and does not constitute personal medical advice. The closure method for HS wide excision is an individualized surgical decision that should be made together with a surgeon experienced in HS surgery, ideally within a multidisciplinary HS team.