Background <p>The surgical treatment of acne inversa (hidradenitis suppurativa) requires consistent radical excision of the affected tissue. This frequently results in extensive soft tissue defects in functionally relevant regions, such as the axilla, groin and perineum. The choice of reconstructive strategy has a&#xa0;decisive impact on functional and esthetic outcomes, recurrence rates and consequently on the patients’ quality of life.</p> Objective <p>To present and systematically categorize established plastic reconstructive surgical procedures following radical excision of hidradenitis suppurativa, taking defect-specific and patient-specific factors into account.</p> Material and methods <p>Narrative review based on current guidelines and published literature on the surgical management of hidradenitis suppurativa. Systematic presentation of reconstructive options including secondary wound healing, primary closure and local flaps, split-thickness skin grafting, regional pedicled flaps, and free microvascular flaps.</p> Results <p>Secondary wound healing and split-thickness skin grafting are indicated for small to medium-sized defects or in cases with limited reconstructive options but are associated with scar formation and potential functional impairment. Regional flaps enable tension-free defect coverage with well-vascularized tissue in larger defects and represent the reconstructive standard in appropriately selected cases. Free microvascular flaps are reserved for complex, extensive or multiple previously surgically treated defects as an escalation strategy.</p> Discussion <p>Plastic surgery reconstructive defect coverage is an integral component of the surgical treatment of hidradenitis suppurativa. Stable long-term results require radical disease eradication, structured defect analysis and careful consideration of individual risk factors. Early interdisciplinary planning enables optimal alignment of the resection extent and reconstructive strategy.</p>