Hidradenitis suppurativa (HS) is a chronic inflammatory disease that significantly impairs quality of life, particularly in patients with severe, recurrent disease. When medical management fails, surgical intervention becomes the cornerstone of definitive treatment. This chapter presents a case of severe axillary HS managed with wide local excision and flap-based reconstruction, illustrating the critical role of operative care in restoring function and reducing recurrence. Surgical techniques include deroofing, skin grafting, negative pressure wound therapy, and flap reconstruction. The decision to pursue surgical management is guided by the Hurley staging system. Optimal outcomes depend on multidisciplinary collaboration—including referral to a plastic surgeon experienced with hidradenitis suppurativa care. Surgery offers a functional cure from this debilitating condition and should be considered early in patients with refractory or extensive disease.