Thoracodorsal Artery Perforator Flap Versus Split-Thickness Skin Graft Reconstruction for Advanced Axillary Hidradenitis Suppurativa: Long-Term Outcomes.

Background: Axillary hidradenitis suppurativa (HS) often requires wide surgical excision and reconstruction. Thoracodorsal artery perforator (TDAP) flaps and split-thickness skin grafts (STSGs) are common options, but comparative long-term data are insufficient. Methods: In this single-center retrospective study, patients aged ≥ 17 years with Hurley stage II-III axillary HS underwent wide excision followed by TDAP flap or STSG reconstruction. Demographic variables, surgical characteristics, complications, recurrence, shoulder mobility, and dermatology-specific quality-of-life outcomes assessed using the Dermatology Life Quality Index (DLQI) were analyzed. Results: In total, 35 reconstructions were reviewed: TDAP (n = 15, 42.9%) and STSG (n = 20, 57.1%). Follow-up was longer for TDAP (28.53 ± 16.38 vs. 19.65 ± 28.06 months; p = 0.014). Mean defect size was 105.47 ± 26.29 cm2 (TDAP) vs. 164.65 ± 77.99 cm2 (STSG; p = 0.116). Both groups showed significant improvement in DLQI from preoperative to postoperative assessments (TDAP: +20.87; Graft: +18.50; both p < 0.0001), with no significant postoperative difference (p = 0.9608). Smokers had higher preoperative DLQI scores than non-smokers (+5.72; p = 0.0051), but postoperative outcomes were similar (p = 0.5908). Conclusions: Both reconstructions after wide axillary excision provided durable coverage, low complication rates, and significant improvement in quality of life. Incorporating patient-reported and functional outcomes into reconstructive planning may optimize surgical decision-making for axillary HS.