Background: The management of severe hidradenitis suppurativa with destruction of the perianal region can be challenging; local tissue may not be available for closure. Methods: Patients were managed by proctectomy and reconstruction with musculocutaneous flaps based on the rectus abdominis muscle (RAM). Results: Three patients were managed using this approach achieving closure without recurrence. Conclusion: RAM-based flaps provide a good reconstructive option in the management of patients with severe therapy-refractory hidradenitis suppurativa in the gluteal region, combined with severe perianal destruction. Level of Evidence: Level V, therapeutic study.