CO₂ laser tunnel closure for HS.

A sinus tract is not inflammatory tissue. It is an epithelialized channel — a tunnel under the skin with a surface layer of cells that behaves like the skin itself. Antibiotics do not close it. Biologics do not close it. Once it is there, the only way to remove it is to remove it.

Left in place, tracts perpetuate the disease. They drain intermittently, they expand, they recruit adjacent follicles, and over time they connect into the diffuse networks characteristic of Hurley III. The question for a patient with established tracts is not whether to have a procedure but which one.

Our preference is the smallest operation that removes the disease. For most patients with mapped, accessible tracts that is tract-by-tract CO₂ laser closure. For a minority with diffuse confluent disease, it is wide excision — and we will tell you when that is the right answer.

The operation begins before the operating room. Clinical exam is the foundation — palpation along the skin to feel the tracts, gentle probing through patent openings to trace their course. For straightforward disease this is enough.

Ultrasound is added when tracts run beneath visually intact skin and the architecture is not obvious by exam alone. It is quick, non-irradiating, and changes the operative plan meaningfully in selected cases.

MRI is reserved for extensive disease, for suspected involvement near the sphincter complex, or for anatomy that does not behave the way clinical exam suggests. We do not order it routinely; when we do, it is because the information will change what we do.

After CO₂ closure the wounds are left open, intentionally. They heal from the base upward and from the edges inward by forming granulation tissue — new tissue that fills the defect and eventually re-epithelializes. This is called healing by secondary intention.

Patients used to closed surgical wounds find this counterintuitive. We close it back up. Why don't we close this? The answer is that in HS, closing a wound under tension over diseased tissue is the most reliable way to produce recurrence. Open wounds in this disease heal cleanly, drain freely, and do not trap inflammation under a closed surface. It is the standard of care for procedural HS wounds and it is one of the reasons recovery is more forgiving than patients expect.

Daily care is straightforward: gentle cleansing, an absorbent dressing changed once or twice a day, packing for deeper defects in the early weeks. We teach you and a family member at the post-op visit and we check in remotely between in-person follow-ups.

At six months, the operative wounds are fully closed in most cases. Drainage from the treated tracts is substantially reduced or absent. Day-to-day function — sitting, walking, exercise — is restored.

At twelve months, scar maturation is complete. Functional outcomes (mobility, sitting tolerance, intimacy) are restored for most patients. Recurrence within treated tracts is uncommon. Recurrence in adjacent untreated regions is common — it is the reason medical co-management and follicle-directed therapy continue, and why our outcomes are best when the whole disease is being managed in parallel, not just the tracts we removed.

We do not publish patient photographs without explicit informed consent, and we do not promise outcomes from anyone else's case. The right way to assess whether this operation is right for you is a consultation with photographs of your own disease.

CO₂ closure addresses structural disease. Follicle therapy addresses the inflammation that produces new structural disease. Medical therapy controls the underlying disease process that makes both necessary. The three work together — they are not alternatives.

Read about follicle-directed therapy →Read the full treatment model →