The Combined Use of Integra and RECELL in a Case of Severe Hidradenitis Suppurativa

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Rais, Patrick A. Palines, Hiba Saifuddin, Jonathon C. Boraski This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-6384118/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract Hidradenitis suppurativa (HS) is a debilitating disease when extensive, results in significant medical and psychologic morbidity. Refractory HS is often treated via staged surgical intervention involving excision and subsequent reconstruction. In a patient with severe HS, the use of cultured epithelial autograft (RECELL), in conjunction with the dermal substitute Integra, can serve as a viable surgical option for treatment in this patient demographic. Figures Figure 1 Figure 2 Figure 3 Introduction Hidradenitis suppurativa (HS) is a chronic, inflammatory skin condition that primarily affects areas rich in apocrine glands, such as the axillary, inguinal, and perianal regions. It is characterized by recurrent abscesses, sinus tracts, painful nodules, and progressive scarring, making it a source of significant morbidity for patients. The pathogenesis of HS remains incompletely understood, but factors such as follicular occlusion, inflammation, and bacterial infection are believed to play key roles. The disease often leads to psychological distress and a reduction in the overall quality of life due to its recurrent and painful nature ( 1 , 2 ). Treatment options for HS vary based on disease severity, with a range of therapeutic strategies aimed at controlling symptoms and improving quality of life. For early-stage disease, topical antibiotics, oral antibiotics, and lifestyle modifications may be effective. However, in moderate to severe cases, patients may require more aggressive therapies, including biologics, immunosuppressive agents, and surgical interventions ( 3 ). Surgical options for reconstruction following resection include primary closure, healing by secondary intention, local and regional flaps, and split-thickness skin grafting. As an adjunct, dermal substitutes such as Integra (Integra LifeSciences; Princeton, NJ) and MatriDerm (MatriDerm USA; Augusta, GA) are increasingly being employed to improve outcomes in reconstructive surgery for HS ( 4 ). Dermal substitutes provide a bioactive mix of collagens, elastins, and support for revascularization in advance of split-thickness skin grafting ( 5 ). Dermal substitutes have been shown to optimize wound beds by promoting a more uniform and robust granulation tissue layer, thereby improving skin graft take and overall wound contour. In a case study by Dhanoon et al., MatriDerm, a collagen-elastin dermal replacement scaffold, was used successfully in conjunction with meshed split-thickness skin grafts to reconstruct HS-affected areas. This combination showed promising results in improving wound healing and reducing recurrence. This is impactful to patient outcomes, as the traditional management of HS being medical treatment and surgical excision, often leads to variable outcomes ( 6 ). Another case series by Gonzaga et al. demonstrated the successful use of Integra in treating HS in four patients. These cases involved excision of the diseased areas followed by Integra placement to facilitate wound healing. Follow-up split-thickness skin grafting was performed after sufficient granulation tissue had formed, and all patients showed no recurrence of HS post-treatment ( 5 ). The introduction of cultured epithelial autograft techniques, such as RECELL (Avita Medical, Inc, Valencia, CA, USA), has provided a novel approach to wound healing in HS. RECELL is commonly utilized in burn and trauma by creating a suspension of autologous keratinocytes, fibroblasts, and melanocytes which is then applied to the wound bed to significantly accelerate healing and reduce scarring ( 7 ). RECELL is commonly used to treat large surface area burns due to its use of a much smaller donor site relative to a proportional size of split-thickness skin grafts. The reduction in donor site need is important, as patients with full-body burns often face limitations of available donor sites ( 8 ). When used in conjunction with skin grafting, RECELL has been shown to augment graft take and reepithelization of meshed interstices. The application of RECELL in the treatment of HS has not been previously explored. In this case report, we present a unique case of a 35-year-old male with extensive gluteal and perianal HS who was treated using a combination of Integra, RECELL, and split-thickness skin grafting, providing a potential new avenue for the management of severe HS. Case A 35-year-old Black male with a past medical history of human immunodeficiency virus (HIV) well-controlled on antiretroviral therapy and extensive Hurler stage 4 hidradenitis suppurativa of the bilateral axillae, buttocks, and perianal region presented with acute, extensive abscess formation. Due to involvement of the perianal region, the patient underwent a diverting colostomy to reduce contamination of the anticipated surgical sites. Following maturation of his colostomy, the patient was taken to the operating room for the excision of his left gluteal HS. Under general anesthesia, the patient was placed in the prone position, and a wide excision was performed to removing all diseased tissue. The wound, measuring 36 x 24 cm (864 sq cm), extended from the anus to greater trochanter. Following debridement, the wound was covered with Integra to promote granulation tissue formation and facilitate skin grafting. The procedure was completed without complications. Two weeks later, the patient returned to the operating room for split-thickness skin grafting. A Zimmer dermatome was used to harvest graft at a thickness of 14 thousands of an inch; this was subsequently meshed 1:1.5. A small piece of skin graft 4x4 cm in size and .008 inches in thickness was harvested and prepared for epithelial autograft suspension utilizing a RECELL Go kit. The skin grafts were then secured using a combination of running and interrupted 3 − 0 chromic sutures. The RECELL suspension was then sprayed over both the recipient and donor sites. Both the skin graft and the donor sites were dressed according to RECELL recommendations. Postoperatively, the patient was placed in a Long-Term Acute Care (LTAC) unit to assist with wound care. He was positioned prone or in lateral decubitus to avoid shearing of the fresh grafts. Given persistent purulence from the contralateral buttock HS, the patient was continued on piperacillin-tazobactam postoperatively; this was in conjunction with recommendations per Infectious Disease. The dressings were removed 1-week post-operation following the subsequent excision on the right buttock. The patient followed wound care protocols consisting of dressing changes 3 times per week of his extremity wounds and daily dressing changes of his buttock wounds in addition being instructed on showering with gauze over the buttock wounds. Two weeks later, the patient was subsequently taken for excision of his right buttock HS. The patient underwent grafting and RECELL application in an identical manner to the left side. The patient tolerated the procedure well without complications. The patient’s recipient sites showed adequate healing within 1 month and was mostly healed at 3 months. Final follow-up 3 months post-operation demonstrated complete healing of all sites without evidence of recurrence. The patient reported being pain free, satisfaction with his result, and later underwent successful colostomy reversal. Discussion Hidradenitis suppurativa (HS) poses as a challenge for physicians and patients due to its chronic and recurrent nature. Surgical intervention is often required for severe cases of HS to remove diseased tissue completely, but the extent of tissue excision and difficulty in achieving wound closure are problems faced when performing excisional surgery for extensive HS. In recent years, the combination of dermal regeneration templates, such as Integra, and autologous skin cell suspensions, such as RECELL, have become seemingly promising options for the management of complex HS. Integra, a bilayer dermal regeneration template, offers an alternative to traditional skin grafts. It provides a scaffold for adequate dermal regeneration. This scaffold supports ultimately improves the quality of the granulation tissue formation. The use of Integra has good results in the treatment of HS, especially for wounds that involve great tissue loss. Gonzaga et al. reported that Integra facilitated successful coverage and healing of large HS excision sites, with patients experiencing minimal contracture and hypertrophic scarring compared to traditional grafting techniques ( 9 ). Furthermore, Integra has been found to reduce donor-site morbidity and improve patient satisfaction ( 10 ). Integra benefits in less painful dressing changes and minimal blood loss as opposed to traditional wet-to-dry dressings while waiting for the wound bed to granulate. RECELL, on the other hand, promotes wound healing via a processing and spray-on of autologous cell suspensions to the wound bed. This approach accelerates epithelialization and improves the quality of the regenerated epidermis. RECELL has been used in various wound types, mainly burns and also traumatic injuries, but its application in HS is limited. According to Wood et al., RECELL-treated wounds showed faster re-epithelialization with improved pigmentation and overall cosmetic appearance compared to traditional skin grafting techniques ( 7 ). It is important to note the use of RECELL is commonly used for burn or thermal injuries as well as necrotizing soft-tissue infections. However, when combined with Integra, RECELL may offer synergistic benefits by enhancing both dermal and epidermal regeneration, creating a more robust and aesthetically pleasing reconstruction in the treatment of HS ( 11 , 12 ). A significant advantage of this combination approach is the reduction in donor-site morbidity. Traditional split-thickness skin grafts require rather large donor areas, which creates additional pain and scarring to the patient. By using a combination of Integra and RECELL, this reduces the need for excessive skin-grafting in a patient already debilitated by their significant in situ wounds. Dhanoon et al. demonstrated that this approach allowed for effective coverage of large wounds while reducing the need for multiple grafts, ultimately improving patient recovery time and outcomes ( 5 ). In our patient, this approach was undertaken to expedite healing given the patient’s extensive disease. Furthermore, the additional skin needed for formation of the cultured epithelial autograft suspension was minimal and easily harvested concurrently with the rest of the grafts. In addition, repigmentation is another large benefit with the use of RECELL, especially in a dark-skinned individual such as our patient. RECELL’s benefit with retaining native skin color has even been studied in patients with vitiligo, an autoimmune condition where there the immune system mounts an attack on melanocytes, resulting in the loss of skin color in affected areas. In a case report by Cerveli et al., their patient with vitiligo of the hands treated with RECELL resulted in successful restoration of native skin pigment of their hands. The Vitiligo Area Scoring Index (VASI), which scores pigmentation in ratings of poor, fair, good, and excellent, was used to assess the patient’s results. The patient’s hands post-treatment scored excellent on VASI, and the authors demonstrate the color of the repigmented area was comparably similar to adjacent native areas ( 13 ). This is important, as skin color, in a cosmetic sense, is often desired to be evenly retained by patients, especially in darker-skinned individuals to reduce or eliminate the color mismatch. The affected gluteal region, one could argue, is especially pertinent in female patients, as this is a cosmetically geared societal norm in which most women would like to retain their native pigmentation ( 14 ). However, despite these advantages, the use of Integra and RECELL has limitations. The cost of these advanced wound care products can offset its usage, especially in cases where large surface areas require coverage. The cost of Integra is $ 3150.00 for 100 cm 2 , and the list price of RECELL is $ 7500.00 per device ( 12 , 15 ). However, these costs can theoretically be offset by increased rate of healing and decreasing patient stay. In a study by Carter, et al., the use of RECELL was associated with a shorter hospital length of stay (LOS) by 3.3 days. The decrease in LOS amounted to a cost saving of $ 36,949.00 per patient ( 16 ). The overall benefit here is more rapid healing of both graft and donor sites. Conclusion The combination of Integra and RECELL showcases a significant and promising advancement in the surgical management of severe HS. These techniques and materials not only provide functional and aesthetic improvements to conventional methods but also reduce donor-site morbidity and have faster recovery times. However, challenges such as cost, materials, and severity of disease must be addressed to fully realize the potential of these innovative therapies. Further studies and clinical trials over longer term periods of study are warranted to refine the use of these products and expand their application in HS treatment. Declarations Authorship Contribution: All authors, Mohammed S. Rais, Patrick A. Palines, Hiba Saifuddin, and Jonathon C. Boraski, declare they have made substantial contributions to the conception of the study, acquiring pertinent information, and drafting the manuscript. All have consented final approval of this manuscript to be submitted. Abbreviations: Hidradenitis suppurativa (HS) Data Availability: Not applicable Patient Consent: Written informed consent was obtained directly from the patient. Consent for Publication: Written informed consent was obtained directly from the patient Clinical Trial Number: Not applicable Competing Interest: Not applicable Conflict of Interest Statement: The authors have no conflicts of interest to disclose. Funding: All authors declare no external funding was received for the work of this manuscript. References Alikhan A, Sayed C, Alavi A, Alhusayen R, Brassard A, Burkhart C, Crowell K, Eisen DB, Gottlieb AB, Hamzavi I, Hazen PG, Jaleel T, Kimball AB, Kirby J, Lowes MA, Micheletti R, Miller A, Naik HB, Orgill D, Poulin Y. North American clinical management guidelines for hidradenitis suppurativa: A publication from the United States and Canadian Hidradenitis Suppurativa Foundations: Part II: Topical, intralesional, and systemic medical management. J Am Acad Dermatol. 2019;81(1):91–101. Epub 2019 Mar 11. PMID: 30872149; PMCID: PMC9131892. von der Werth JM, Jemec GB. Morbidity in patients with hidradenitis suppurativa. Br J Dermatol. 2001;144(4):809 – 13. 10.1046/j.1365-2133.2001.04137.x . PMID: 11298541. Gulliver W, Zouboulis CC, Prens E, Jemec GB, Tzellos T. Evidence-based approach to the treatment of hidradenitis suppurativa/acne inversa, based on the European guidelines for hidradenitis suppurativa. Rev Endocr Metab Disord. 2016;17(3):343–51. 10.1007/s11154-016-9328-5 . PMID: 26831295; PMCID: PMC5156664. Kohorst JJ, Baum CL, Otley CC, Roenigk RK, Schenck LA, Pemberton JH, Dozois EJ, Tran NV, Senchenkov A, Davis MD. Surgical Management of Hidradenitis Suppurativa: Outcomes of 590 Consecutive Patients. Dermatol Surg. 2016;42(9):1030-40. 10.1097/DSS.0000000000000806 . PMID: 27340739. Gonzaga TA, Endorf FW, Mohr WJ, Ahrenholz DH. Novel Surgical Approach for Axillary Hidradenitis Suppurativa Using a Bilayer Dermal Regeneration Template: A Retrospective Case Study. J Burn Care Res. 2013;34:51–7. Dhannoon A, Hurley CM, Carr S, Hussey A. Acellular dermal substitute use in the reconstruction of axillary hidradenitis suppurativa. JPRAS Open. 2022;31:129–33. Wood FM, Giles N, Stevenson A, Rea S, Fear M. Characterisation of the cellular response in autologous skin cell suspension (ReCell) treated wounds. Burns. 2012;38(1):44–51. 10.1016/j.burns.2011.09.003 . Holmes Iv JH, Molnar JA, Carter JE, Hwang J, Cairns BA, King BT, Smith DJ, Cruse CW, Foster KN, Peck MD, Sood R, Feldman MJ, Jordan MH, Mozingo DW, Greenhalgh DG, Palmieri TL, Griswold JA, Dissanaike S, Hickerson WL. A Comparative Study of the ReCell® Device and Autologous Spit-Thickness Meshed Skin Graft in the Treatment of Acute Burn Injuries. J Burn Care Res. 2018;39(5):694–702. 10.1093/jbcr/iry029 . PMID: 29800234; PMCID: PMC6097595. Gonzaga TJ, Ead J, Belcher CM, Edhegard KD. Use of Integra dermal regeneration template for excision and coverage of hidradenitis suppurativa lesions: A case series. J Plast Reconstr Aesthetic Surg. 2018;71(2):249–54. 10.1016/j.bjps.2017.10.023 . Tarassoli SP, Clarke J, Grobbelaar AO. Dermal regeneration templates for the reconstruction of complex defects: A systematic review. J Plast Reconstr Aesthetic Surg. 2018;71(6):894–904. 10.1016/j.bjps.2018.01.019 . Holmes Iv JH, Molnar JA, Carter JE, Hwang J, Cairns BA, King BT, Smith DJ, Cruse CW, Foster KN, Peck MD, Sood R, Feldman MJ, Jordan MH, Mozingo DW, Greenhalgh DG, Palmieri TL, Griswold JA, Dissanaike S, Hickerson WL. A Comparative Study of the ReCell® Device and Autologous Spit-Thickness Meshed Skin Graft in the Treatment of Acute Burn Injuries. J Burn Care Res. 2018;39(5):694–702. 10.1093/jbcr/iry029 . PMID: 29800234; PMCID: PMC6097595. Marquez JL, BA*; Nuckles BMD, Tausinga TBS, Foley, Brittany MD*; Sudbury, Dallin MOT†; Sueoka, Stephanie CHT†; Zang, Chong MS‡; Lewis, Priya MD*; Goodwin, Isak MD*. Analysis of the Radial Forearm Phalloplasty Donor Site: Do Dermal Matrices Improve Donor Site Morbidity?, Plastic. & Reconstructive Surgery-Global Open 12(9):p e6114, September 2024. | 10.1097/GOX.0000000000006114 Cervelli V, Spallone D, Lucarini L, Palla L, Brinci L, De Angelis B. Treatment of stable vitiligo hands by ReCell system: a preliminary report. Eur Rev Med Pharmacol Sci. 2010;14(8):691–4. PMID: 20707289. Rowland HM, Burriss RP. Human colour in mate choice and competition. Philos Trans R Soc Lond B Biol Sci. 2017;372(1724):20160350. 10.1098/rstb.2016.0350 . PMID: 28533465; PMCID: PMC5444069. Kowal S, Kruger E, Bilir P, Holmes JH, Hickerson W, Foster K, Nystrom S, Sparks J, Iyer N, Bush K, Quick A. Cost-Effectiveness of the Use of Autologous Cell Harvesting Device Compared to Standard of Care for Treatment of Severe Burns in the United States. Adv Ther. 2019;36(7):1715–29. 10.1007/s12325-019-00961-2 . Epub 2019 May 7. PMID: 31065995; PMCID: PMC6647544. Carter JE, Carson JS, Hickerson WL, Rae L, Saquib SF, Wibbenmeyer LA, Becker RV, Walsh TP, Sparks JA. Adv Ther. 2022;39(11):5191–202. 10.1007/s12325-022-02306-y . Epub 2022 Sep 14. PMID: 36103088; PMCID: PMC9472178. Length of Stay and Costs with Autologous Skin Cell Suspension Versus Split-Thickness Skin Grafts: Burn Care Data from US Centers. Additional Declarations No competing interests reported. Cite Share Download PDF Status: Posted Version 1 posted You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. Our growing team is made up of researchers and industry professionals working together to solve the most critical problems facing scientific publishing. Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-6384118","acceptedTermsAndConditions":true,"allowDirectSubmit":true,"archivedVersions":[],"articleType":"Case Report","associatedPublications":[],"authors":[{"id":491420860,"identity":"b7ceb07a-0577-42c1-8608-db9c3f59692f","order_by":0,"name":"Mohammed S. Rais","email":"","orcid":"","institution":"Louisiana State University Health Sciences Center","correspondingAuthor":false,"prefix":"","firstName":"Mohammed","middleName":"S.","lastName":"Rais","suffix":""},{"id":491420861,"identity":"f23e456e-41a7-4f35-8cf2-8c68093f04f7","order_by":1,"name":"Patrick A. Palines","email":"","orcid":"","institution":"Louisiana State University Health Sciences Center","correspondingAuthor":false,"prefix":"","firstName":"Patrick","middleName":"A.","lastName":"Palines","suffix":""},{"id":491420862,"identity":"382400d0-f16b-4b74-b9a9-c5d66d0099e9","order_by":2,"name":"Hiba Saifuddin","email":"","orcid":"","institution":"Louisiana State University Health Sciences Center","correspondingAuthor":false,"prefix":"","firstName":"Hiba","middleName":"","lastName":"Saifuddin","suffix":""},{"id":491420863,"identity":"fba70035-af9b-491c-8bf5-16f8aba06e8d","order_by":3,"name":"Jonathon C. Boraski","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAAw0lEQVRIiWNgGAWjYBACxhlgykaGgYEHItBApJY0HuK1MEiAycMkaGGe3Xzsw48/53nkZ+Qe/vCDwUZ2wwFCDptzLHlmb9ttHoMbeWmSPQxpxoS1zMgxZuBtAGqRyDFjBrowkSgtjH/+nAM6LMf4MwPDf+K0MPOwHeBhuJFjIM3AcIAILUC/MMu2JfMYnHljJtljkGw8k5AWw9nNhxnf/LGTk2/PMf7wo8JOto+glgYUrgEB5SAgT4SaUTAKRsEoGOkAACcvQJjq5CaJAAAAAElFTkSuQmCC","orcid":"","institution":"Louisiana State University Health Sciences Center","correspondingAuthor":true,"prefix":"","firstName":"Jonathon","middleName":"C.","lastName":"Boraski","suffix":""}],"badges":[],"createdAt":"2025-04-05 23:38:13","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-6384118/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-6384118/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":87800253,"identity":"b71a2011-f2f9-437b-9729-6be95c8ab705","added_by":"auto","created_at":"2025-07-29 07:48:41","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":565083,"visible":true,"origin":"","legend":"\u003cp\u003eInitial hidradenitis suppurativa of the gluteal region presentation prior to any surgical intervention by Plastic and Reconstructive Surgery team.\u003c/p\u003e","description":"","filename":"floatimage1.png","url":"https://assets-eu.researchsquare.com/files/rs-6384118/v1/806a630359f59852180251de.png"},{"id":87802453,"identity":"51873cfa-c621-4853-a15f-1d1089a211bf","added_by":"auto","created_at":"2025-07-29 08:04:42","extension":"jpeg","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":1031211,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003e2A and 2B:\u003c/strong\u003e Status-post excision 4 days after L gluteal excision (2A) and 6 days after R gluteal excision (2B) of total bilateral HS.\u003c/p\u003e","description":"","filename":"floatimage2.jpeg","url":"https://assets-eu.researchsquare.com/files/rs-6384118/v1/0a11841334f0f64d27aade22.jpeg"},{"id":87801882,"identity":"ddf31a99-4e3b-437e-9d0f-748b471b7598","added_by":"auto","created_at":"2025-07-29 07:56:42","extension":"png","order_by":3,"title":"Figure 3","display":"","copyAsset":false,"role":"figure","size":2141061,"visible":true,"origin":"","legend":"\u003cp\u003e4 months after Integra, skin grafting, and RECELL application. Grafts are well-integrated with reepithelialization of meshed interstices. Of note is significant re-pigmentation of the left buttock (performed first). No evidence of infection or recurrent disease.\u003c/p\u003e","description":"","filename":"floatimage3.png","url":"https://assets-eu.researchsquare.com/files/rs-6384118/v1/222beb5bf21041b85a20e639.png"},{"id":101305296,"identity":"a37a8bf5-1892-44ed-a0f9-d6f38f2062ed","added_by":"auto","created_at":"2026-01-28 10:05:24","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":4092053,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-6384118/v1/8ff50878-f849-4ca4-93e7-5789e507b3b1.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"The Combined Use of Integra and RECELL in a Case of Severe Hidradenitis Suppurativa","fulltext":[{"header":"Introduction","content":"\u003cp\u003eHidradenitis suppurativa (HS) is a chronic, inflammatory skin condition that primarily affects areas rich in apocrine glands, such as the axillary, inguinal, and perianal regions. It is characterized by recurrent abscesses, sinus tracts, painful nodules, and progressive scarring, making it a source of significant morbidity for patients. The pathogenesis of HS remains incompletely understood, but factors such as follicular occlusion, inflammation, and bacterial infection are believed to play key roles. The disease often leads to psychological distress and a reduction in the overall quality of life due to its recurrent and painful nature (\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e, \u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e).\u003c/p\u003e\u003cp\u003eTreatment options for HS vary based on disease severity, with a range of therapeutic strategies aimed at controlling symptoms and improving quality of life. For early-stage disease, topical antibiotics, oral antibiotics, and lifestyle modifications may be effective. However, in moderate to severe cases, patients may require more aggressive therapies, including biologics, immunosuppressive agents, and surgical interventions (\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e). Surgical options for reconstruction following resection include primary closure, healing by secondary intention, local and regional flaps, and split-thickness skin grafting. As an adjunct, dermal substitutes such as Integra (Integra LifeSciences; Princeton, NJ) and MatriDerm (MatriDerm USA; Augusta, GA) are increasingly being employed to improve outcomes in reconstructive surgery for HS (\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e).\u003c/p\u003e\u003cp\u003eDermal substitutes provide a bioactive mix of collagens, elastins, and support for revascularization in advance of split-thickness skin grafting (\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e). Dermal substitutes have been shown to optimize wound beds by promoting a more uniform and robust granulation tissue layer, thereby improving skin graft take and overall wound contour. In a case study by Dhanoon et al., MatriDerm, a collagen-elastin dermal replacement scaffold, was used successfully in conjunction with meshed split-thickness skin grafts to reconstruct HS-affected areas. This combination showed promising results in improving wound healing and reducing recurrence. This is impactful to patient outcomes, as the traditional management of HS being medical treatment and surgical excision, often leads to variable outcomes (\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e). Another case series by Gonzaga et al. demonstrated the successful use of Integra in treating HS in four patients. These cases involved excision of the diseased areas followed by Integra placement to facilitate wound healing. Follow-up split-thickness skin grafting was performed after sufficient granulation tissue had formed, and all patients showed no recurrence of HS post-treatment (\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e).\u003c/p\u003e\u003cp\u003eThe introduction of cultured epithelial autograft techniques, such as RECELL (Avita Medical, Inc, Valencia, CA, USA), has provided a novel approach to wound healing in HS. RECELL is commonly utilized in burn and trauma by creating a suspension of autologous keratinocytes, fibroblasts, and melanocytes which is then applied to the wound bed to significantly accelerate healing and reduce scarring (\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e). RECELL is commonly used to treat large surface area burns due to its use of a much smaller donor site relative to a proportional size of split-thickness skin grafts. The reduction in donor site need is important, as patients with full-body burns often face limitations of available donor sites (\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e). When used in conjunction with skin grafting, RECELL has been shown to augment graft take and reepithelization of meshed interstices. The application of RECELL in the treatment of HS has not been previously explored.\u003c/p\u003e\u003cp\u003eIn this case report, we present a unique case of a 35-year-old male with extensive gluteal and perianal HS who was treated using a combination of Integra, RECELL, and split-thickness skin grafting, providing a potential new avenue for the management of severe HS.\u003c/p\u003e"},{"header":"Case","content":"\u003cp\u003eA 35-year-old Black male with a past medical history of human immunodeficiency virus (HIV) well-controlled on antiretroviral therapy and extensive Hurler stage 4 hidradenitis suppurativa of the bilateral axillae, buttocks, and perianal region presented with acute, extensive abscess formation. Due to involvement of the perianal region, the patient underwent a diverting colostomy to reduce contamination of the anticipated surgical sites.\u003c/p\u003e\u003c/p\u003e\u003cp\u003eFollowing maturation of his colostomy, the patient was taken to the operating room for the excision of his left gluteal HS. Under general anesthesia, the patient was placed in the prone position, and a wide excision was performed to removing all diseased tissue. The wound, measuring 36 x 24 cm (864 sq cm), extended from the anus to greater trochanter. Following debridement, the wound was covered with Integra to promote granulation tissue formation and facilitate skin grafting. The procedure was completed without complications.\u003c/p\u003e\u003cp\u003eTwo weeks later, the patient returned to the operating room for split-thickness skin grafting. A Zimmer dermatome was used to harvest graft at a thickness of 14 thousands of an inch; this was subsequently meshed 1:1.5. A small piece of skin graft 4x4 cm in size and .008 inches in thickness was harvested and prepared for epithelial autograft suspension utilizing a RECELL Go kit. The skin grafts were then secured using a combination of running and interrupted 3\u0026thinsp;\u0026minus;\u0026thinsp;0 chromic sutures. The RECELL suspension was then sprayed over both the recipient and donor sites. Both the skin graft and the donor sites were dressed according to RECELL recommendations.\u003c/p\u003e\u003cp\u003ePostoperatively, the patient was placed in a Long-Term Acute Care (LTAC) unit to assist with wound care. He was positioned prone or in lateral decubitus to avoid shearing of the fresh grafts. Given persistent purulence from the contralateral buttock HS, the patient was continued on piperacillin-tazobactam postoperatively; this was in conjunction with recommendations per Infectious Disease. The dressings were removed 1-week post-operation following the subsequent excision on the right buttock. The patient followed wound care protocols consisting of dressing changes 3 times per week of his extremity wounds and daily dressing changes of his buttock wounds in addition being instructed on showering with gauze over the buttock wounds.\u003c/p\u003e\u003cp\u003eTwo weeks later, the patient was subsequently taken for excision of his right buttock HS. The patient underwent grafting and RECELL application in an identical manner to the left side. The patient tolerated the procedure well without complications.\u003c/p\u003e\u003cp\u003eThe patient\u0026rsquo;s recipient sites showed adequate healing within 1 month and was mostly healed at 3 months. Final follow-up 3 months post-operation demonstrated complete healing of all sites without evidence of recurrence. The patient reported being pain free, satisfaction with his result, and later underwent successful colostomy reversal.\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eHidradenitis suppurativa (HS) poses as a challenge for physicians and patients due to its chronic and recurrent nature. Surgical intervention is often required for severe cases of HS to remove diseased tissue completely, but the extent of tissue excision and difficulty in achieving wound closure are problems faced when performing excisional surgery for extensive HS. In recent years, the combination of dermal regeneration templates, such as Integra, and autologous skin cell suspensions, such as RECELL, have become seemingly promising options for the management of complex HS.\u003c/p\u003e\u003cp\u003eIntegra, a bilayer dermal regeneration template, offers an alternative to traditional skin grafts. It provides a scaffold for adequate dermal regeneration. This scaffold supports ultimately improves the quality of the granulation tissue formation. The use of Integra has good results in the treatment of HS, especially for wounds that involve great tissue loss. Gonzaga et al. reported that Integra facilitated successful coverage and healing of large HS excision sites, with patients experiencing minimal contracture and hypertrophic scarring compared to traditional grafting techniques (\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e). Furthermore, Integra has been found to reduce donor-site morbidity and improve patient satisfaction (\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e). Integra benefits in less painful dressing changes and minimal blood loss as opposed to traditional wet-to-dry dressings while waiting for the wound bed to granulate.\u003c/p\u003e\u003cp\u003eRECELL, on the other hand, promotes wound healing via a processing and spray-on of autologous cell suspensions to the wound bed. This approach accelerates epithelialization and improves the quality of the regenerated epidermis. RECELL has been used in various wound types, mainly burns and also traumatic injuries, but its application in HS is limited. According to Wood et al., RECELL-treated wounds showed faster re-epithelialization with improved pigmentation and overall cosmetic appearance compared to traditional skin grafting techniques (\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e). It is important to note the use of RECELL is commonly used for burn or thermal injuries as well as necrotizing soft-tissue infections. However, when combined with Integra, RECELL may offer synergistic benefits by enhancing both dermal and epidermal regeneration, creating a more robust and aesthetically pleasing reconstruction in the treatment of HS (\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e, \u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e).\u003c/p\u003e\u003cp\u003eA significant advantage of this combination approach is the reduction in donor-site morbidity. Traditional split-thickness skin grafts require rather large donor areas, which creates additional pain and scarring to the patient. By using a combination of Integra and RECELL, this reduces the need for excessive skin-grafting in a patient already debilitated by their significant in situ wounds. Dhanoon et al. demonstrated that this approach allowed for effective coverage of large wounds while reducing the need for multiple grafts, ultimately improving patient recovery time and outcomes (\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e). In our patient, this approach was undertaken to expedite healing given the patient\u0026rsquo;s extensive disease. Furthermore, the additional skin needed for formation of the cultured epithelial autograft suspension was minimal and easily harvested concurrently with the rest of the grafts.\u003c/p\u003e\u003cp\u003eIn addition, repigmentation is another large benefit with the use of RECELL, especially in a dark-skinned individual such as our patient. RECELL\u0026rsquo;s benefit with retaining native skin color has even been studied in patients with vitiligo, an autoimmune condition where there the immune system mounts an attack on melanocytes, resulting in the loss of skin color in affected areas. In a case report by Cerveli et al., their patient with vitiligo of the hands treated with RECELL resulted in successful restoration of native skin pigment of their hands. The Vitiligo Area Scoring Index (VASI), which scores pigmentation in ratings of poor, fair, good, and excellent, was used to assess the patient\u0026rsquo;s results. The patient\u0026rsquo;s hands post-treatment scored excellent on VASI, and the authors demonstrate the color of the repigmented area was comparably similar to adjacent native areas (\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e). This is important, as skin color, in a cosmetic sense, is often desired to be evenly retained by patients, especially in darker-skinned individuals to reduce or eliminate the color mismatch. The affected gluteal region, one could argue, is especially pertinent in female patients, as this is a cosmetically geared societal norm in which most women would like to retain their native pigmentation (\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e).\u003c/p\u003e\u003cp\u003eHowever, despite these advantages, the use of Integra and RECELL has limitations. The cost of these advanced wound care products can offset its usage, especially in cases where large surface areas require coverage. The cost of Integra is \u003cspan\u003e$\u003c/span\u003e3150.00 for 100 cm\u003csup\u003e2\u003c/sup\u003e, and the list price of RECELL is \u003cspan\u003e$\u003c/span\u003e7500.00 per device (\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e, \u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e). However, these costs can theoretically be offset by increased rate of healing and decreasing patient stay. In a study by Carter, et al., the use of RECELL was associated with a shorter hospital length of stay (LOS) by 3.3 days. The decrease in LOS amounted to a cost saving of \u003cspan\u003e$\u003c/span\u003e36,949.00 per patient (\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e). The overall benefit here is more rapid healing of both graft and donor sites.\u003c/p\u003e"},{"header":"Conclusion","content":"\u003cp\u003eThe combination of Integra and RECELL showcases a significant and promising advancement in the surgical management of severe HS. These techniques and materials not only provide functional and aesthetic improvements to conventional methods but also reduce donor-site morbidity and have faster recovery times. However, challenges such as cost, materials, and severity of disease must be addressed to fully realize the potential of these innovative therapies. Further studies and clinical trials over longer term periods of study are warranted to refine the use of these products and expand their application in HS treatment.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eAuthorship Contribution:\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAll authors, Mohammed S. Rais, Patrick A. Palines, Hiba Saifuddin, and Jonathon C. Boraski, declare they have made substantial contributions to the conception of the study, acquiring pertinent information, and drafting the manuscript. All have consented final approval of this manuscript to be submitted.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAbbreviations:\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eHidradenitis suppurativa (HS)\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eData Availability:\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;\u0026nbsp;Not applicable\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003ePatient Consent:\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;\u0026nbsp;Written informed consent was obtained directly from the patient.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for Publication:\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;\u0026nbsp;Written informed consent was obtained directly from the patient\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eClinical Trial Number:\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;\u0026nbsp;Not applicable\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting Interest:\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;\u0026nbsp;Not applicable\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConflict of Interest Statement:\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;\u0026nbsp;The authors have no conflicts of interest to disclose.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding:\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAll authors declare no external funding was received for the work of this manuscript.\u0026nbsp;\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eAlikhan A, Sayed C, Alavi A, Alhusayen R, Brassard A, Burkhart C, Crowell K, Eisen DB, Gottlieb AB, Hamzavi I, Hazen PG, Jaleel T, Kimball AB, Kirby J, Lowes MA, Micheletti R, Miller A, Naik HB, Orgill D, Poulin Y. 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PMID: 31065995; PMCID: PMC6647544.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eCarter JE, Carson JS, Hickerson WL, Rae L, Saquib SF, Wibbenmeyer LA, Becker RV, Walsh TP, Sparks JA. Adv Ther. 2022;39(11):5191\u0026ndash;202. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1007/s12325-022-02306-y\u003c/span\u003e\u003cspan address=\"10.1007/s12325-022-02306-y\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e. Epub 2022 Sep 14. PMID: 36103088; PMCID: PMC9472178. Length of Stay and Costs with Autologous Skin Cell Suspension Versus Split-Thickness Skin Grafts: Burn Care Data from US Centers.\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":true,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"","lastPublishedDoi":"10.21203/rs.3.rs-6384118/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-6384118/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003eHidradenitis suppurativa (HS) is a debilitating disease when extensive, results in significant medical and psychologic morbidity. Refractory HS is often treated via staged surgical intervention involving excision and subsequent reconstruction. In a patient with severe HS, the use of cultured epithelial autograft (RECELL), in conjunction with the dermal substitute Integra, can serve as a viable surgical option for treatment in this patient demographic.\u003c/p\u003e","manuscriptTitle":"The Combined Use of Integra and RECELL in a Case of Severe Hidradenitis Suppurativa","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-07-29 07:48:37","doi":"10.21203/rs.3.rs-6384118/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"c9810717-847b-4e56-bfb7-000c4c5d39d2","owner":[],"postedDate":"July 29th, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[],"tags":[],"updatedAt":"2026-01-28T10:04:10+00:00","versionOfRecord":[],"versionCreatedAt":"2025-07-29 07:48:37","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-6384118","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-6384118","identity":"rs-6384118","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}