Free tissue transfer for necrotizing fasciitis reconstruction: A case series

Effectiveness of negative pressure wound therapy in complex surgical treatment of necrotizing fasciitis of the upper limb

BACKGROUND

Necrotizing fasciitis (NF) of the upper extremities is a severe surgical pathology, and the incidence of this disease has been steadily increasing in recent decades. Surgical treatment is accompanied by the formation of extensive wounds, which can be treated with significant difficulties. In recent years, negative pressure wound therapy (NPWT) has proven to be highly effective. It is also promising for the treatment of NF.

AIM

To explore the effectiveness of NPWT in the treatment of NF of the upper extremities.

METHODS

The results of the treatment of 36 patients with NF of the upper extremities in two groups (NPWT group and control group; 2022-2023) were retrospectively analyzed. In the NPWT group, the NPWT method (120 mmHg; constant mode) was used after surgical treatment. The number of vacuum-assisted dressings in patients ranged from 1 to 3, depending on the dynamics of the wound process. The duration of fixation of one bandage was up to 2-3 d. In the control group, conventional methods of local wound treatment were used. The following indicators were analyzed: The treatment delay, the prevalence of inflammation, the microbial landscape, the number of debridements, the duration of wound preparation for surgical closure, and the nature of skin plastic surgery.

RESULTS

Most patients experienced a significant treatment delay [4 d, interquartile range (IQR): 2-7 d], which led to the spread of the pathological process to the forearm and shoulder. The most common pathogens were Staphylococcus aureus (14; 38.9%) and Streptococcus pyogenes (22; 61.1%). The average number of debridements per patient was 5 (IQR: 3-7), with no difference between groups. The average time to prepare wounds for surgical closure was 11 ± 4 d in the NPWT group and 29 ± 10 d (P = 0.00001) in the control group. In the NPWT group, the wounds were more often closed with local tissues (15; 83.3%), and in the control group, split-thickness skin grafts were more often used (4; 50%).

CONCLUSION

The predominant isolation of Staphylococcus aureus and/or Streptococcus pyogenes from the lesions allowed us to classify these patients as NF type II. Multiple debridement procedures have become a feature of this disease treatment. The use of NPWT has significantly reduced the time required to prepare wounds for surgical closure. Early closure of wounds allows for more frequent use of local tissue repair, which ensures better results. NPWT is a highly effective way to prepare wounds for early surgical closure in patients with upper extremity NF.

Eight Tales of Cervical Necrotizing Fasciitis and Free Tissue Transfer

OBJECTIVES

Aggressive surgical debridement is required in cervical necrotizing fasciitis, and in severe defects, subsequent free tissue transfer might be necessary. However, there is concern that the inflammatory environment of the infection site may threaten free flap viability, particularly with concerns for thrombosis of feeding vessels and compromised tissue integration. Cases in the head and neck area are rare, so there are limited data regarding outcomes of free tissue transfer in these patients.

METHODS

A retrospective chart review assessed patients with cervical necrotizing fasciitis treated at an academic tertiary hospital between 2015 and 2021. Twenty-five patients were identified, and eight required free tissue transfer after adequate surgical debridement. Treatment, hospital course, and demographic data were collected on these eight patients.

RESULTS

All flaps had full survival at follow up (median follow up 3 months, range 1-39 months) without concerns for vascular compromise.

CONCLUSION

These data suggest that in patients with large soft tissue defects due to cervical necrotizing fasciitis, free tissue transfer may be a safe treatment modality.

Necrotizing Fasciitis of the Upper Extremity - A Review

Necrotizing fasciitis is a soft tissue infection that habitually originates from the fascial sheaths, expands at a volant pace, leads to extensive necrosis of the subcutaneous tissues, and eventually ends up in a life-threatening condition with notably elevated amputation and mortality rates. Factors that induce interruption of skin integrity, such as trauma or intravenous drug use, are the most common inciting events. Specific clinical signs heralding its presence are usually absent in the early stages, often resulting in misdiagnosis. Early recognition, prompt and aggressive surgical debridement, antibiotic use, and supportive care constitute the fundamental principles to lean on for a better prognosis. Necrotizing fasciitis of the upper extremity is relatively rare and consequently holds a limited place in the literature. Only a few studies assess it as a separate entity, with most of them being case reports or small case series. We, therefore, performed a review of the current literature, to assemble the dispersed results of different studies and clarify the various aspects of upper limb necrotizing fasciitis. In this systematic review, we present the epidemiological data, the causative events, the most frequent underlying diseases, the risk factors, the amputation and mortality rates, the pathogenic microorganisms, the clinical characteristics, the diagnostic tools, the medical and surgical management concerning necrotizing fasciitis of the upper limb. Finally, the results indicating its differentiation compared to necrotizing fasciitis of other anatomic sites are remarkably highlighted.

Necrotizing fasciitis of the face: current concepts in cause, diagnosis and management

PURPOSE OF REVIEW

Necrotizing fasciitis of the face is uncommon but potentially life threatening. With adequate multidisciplinary treatment, mortality and has significantly improved. This article highlights current concepts and supporting literature in the management of facial necrotizing fasciitis.

RECENT FINDINGS

Management of necrotizing fasciitis involving the face requires a multisciplinary team approach, including early medical and surgical intervention. With early haemodynamic support, broad spectrum antibiotics and aggressive surgical debridement, mortality has reduced significantly. Soft-tissue reconstruction can be effectively utilized once the infection has been adequately treated. Although some adjunctive treatment such as vacuum assisted closure dressing has shown to be of benefit, other treatments such as hyperbaric oxygen remains controversial.

SUMMARY

Necrotizing fasciitis is an aggressive soft tissue involving that rapidly spreads along fascial planes. Necrotizing fasciitis involving the face is rare owing to its rich blood supply but is also difficult to manage due to the complex regional anatomy. Common sources are odontogenic, sinugenic, peritonsillar or salivary gland infections and often polymicrobial. The principles of treatment include early and aggressive haemodynamic support, broad spectrum antibiotics and aggressive surgical debridement. Often times repeat debridements following close monitoring is required. Reconstructive options are viable only after the infection has been adequately treated. Although mortality has significantly improved, mediastinal involvement, multiple comorbidities and delayed treatment confers a worse prognosis.

Soft Tissue Reconstruction for Upper Extremity Necrotizing Soft Tissue Infections

INTRODUCTION

One of the main aspects of management for necrotizing soft tissue infection (NSTI) is surgical excision and debridement, which can result in large soft tissue defects. This study examined the reconstructive options and outcomes of patients with upper extremity NSTIs.

METHODS

A retrospective chart review was performed on patients from a single institution who were diagnosed with an upper extremity NSTI between 2014 and 2019. Patient characteristics, infectious etiology, surgical debridements, reconstructive procedures, and secondary procedures were analyzed.

RESULTS

There were 99 patients included in the study. The median size of the wound from the initial surgical debridement was 100 cm2 (interquartile range, 300 cm2). The mean number of debridements was 3.4. Seven patients underwent amputations, and 12 patients died. Most wounds were reconstructed via delayed primary closure (15 patients), skin grafting (16 patients), or a combination of the two (30 patients). Three patients underwent reverse radial forearm flaps, 1 patient underwent a groin flap, 3 patients underwent pedicled latissimus muscle flaps, and 2 patients underwent local flexor carpi ulnaris muscle flaps. Seven patients did not undergo any surgical reconstruction, and their wounds were managed with local wound care. Eight patients had complete or partial failure of their initial soft reconstruction requiring an additional operation, and 5 patients had secondary operations for neuromas and/or contractures.

CONCLUSIONS

Overall, patients with upper extremity NSTIs survive and undergo successful reconstruction of their wounds. Few patients required additional procedures for reconstructive failure or sequela of their wounds.

Factors Associated with Mortality Following Burns Complicated by Necrotizing Skin and Soft Tissue Infections: A Systematic Review and Meta-analysis of Individual Participant Data

We reviewed studies with individual participant data of patients who sustained burn injury and subsequently developed necrotizing skin and soft tissue infections (NSTI). Characteristics and managements were compared between patients who lived and patients who died to determine factors associated with mortality. Six databases (PubMed, EMBASE, Cochrane Library, Web of Science, Scopus and CINAHL) were searched. PRISMA-IPD guidelines were followed throughout the review. Eligible patients sustained a burn injury, treated in any setting, and diagnosed with a NSTI following burn injury. Comparisons were made between burned patients who lived "non-mortality" and burned patients who died "mortality" following NSTI using non-parametric univariate analyses. Fifty-eight studies with 78 patients were published from 1970 through 2019. Non-mortality resulted in 58 patients and mortality resulted in 20 patients. Patients with mortality had significantly greater median %TBSA burned (45%[IQR:44-64%] versus 35%[IQR:11-59%],p=0.033), more intubations (79% versus 43%,p=0.013), less debridements (83% versus 98%,p=0.039), less skin excisions (83% versus 98%,p=0.039), more complications (100% versus 50%,p<0.001), management at a burn center (100% versus 71%,p=0.008), underwent less flap surgeries (5% versus 35%,p=0.014), less graft survival (25% versus 86%,p<0.001), and less healed wounds (5% versus 95%,p<0.001), compared to patients with non-mortality, respectively. Non-mortality patients had more debridements, skin excised, systemic antimicrobials, skin graft survival, flaps, improvement following surgery and healed wounds compared to mortality patients. Mortality patients had greater %TBSA burned, intubations, management at a burn center and complications compared to non-mortality patients.

Flap coverage for necrotising soft tissue infections: A systematic review

BACKGROUND

Necrotising soft tissue infections (NSTI) are destructive and often life-threatening infections of the skin and soft tissue, necessitating prompt recognition and aggressive medical and surgical treatment. After debridement, the aim of surgical closure and reconstruction is to minimize disability and optimize appearance. Although skin grafting may fulfil this role, techniques higher on the reconstructive ladder, including local, regional and free flaps, are sometimes undertaken. This systematic review sought to determine the circumstances when this is true, which flaps were most commonly employed, and for which anatomical areas.

METHODS

A systematic review of the literature was conducted utilising electronic databases (Medline, Embase, Cochrane Library). Full text studies of flaps used for the management of NSTI's (including Necrotising Fasciitis and Fournier Gangrene) were included. The web-based program 'Covidence' facilitated storage of references and data management. Data obtained in the search included reference details (journal, date and title), the study design, the purpose of the study, the study findings, number of patients with NSTI included, the anatomical areas of NSTI involved, the types of flaps used, and the complication rate.

RESULTS

After screening 4555 references, 501 full text manuscripts were assessed for eligibility after duplicates and irrelevant studies were excluded. 230 full text manuscripts discussed the use of 888 flap closures in the context of NSTI in 733 patients; the majority of these were case series published in the last 20 years in a large variety of journals. Reconstruction of the perineum following Fournier's gangrene accounted for the majority of the reported flaps (58.6%). Free flaps were used infrequently (8%), whereas loco-regional muscle flaps (18%) and loco-regional fasciocutaneous flaps (71%) were employed more often. The reported rate of partial or complete flap loss was 3.3%.

CONCLUSION

Complex skin and soft tissue defects from NSTIs, not amenable to skin grafting, can be more effectively and durably covered using a spectrum of flaps. This systematic review highlights the important contribution that the plastic surgeon makes as an integral member of multidisciplinary teams managing these patients.

Bilayer wound matrix dermal substitute allows survival of split-thickness skin graft in necrotizing fasciitis defects: A retrospective, uncontrolled case study

BACKGROUND

Necrotizing fasciitis (NF) is a rapid infectious process involving the fascia and subcutaneous tissue. Current standards of care rely on surgical debridement, resulting in large defects, with limited reconstructive options. Wound management has evolved over the last decade, including use of bilayer wound matrices (BWM). The authors sought to assess the use of collagen-GAG bilayer wound matrices on STSG take for NF wounds.

METHODS

A qualitative clinical evaluation (2016-2018) was performed to analyze the efficacy of BWM to aide in STSG take. Primary outcomes were 180-day bilayer matrix success, defined by progressing to split-thickness skin graft (STSG) and STSG take, determined by clinical evaluation. Wounds without a diagnosis of NF or reconstruction with BWM were excluded.

RESULTS

Ten patients with 11 NF wounds were identified. Average BMI was 32 kg/m². Comorbidities included hypertension (70%), diabetes (40%), and peripheral vascular disease (40%). Average wound size was 542cm² (range: 49cm² -1050cm²) and average wound age was 19 days at BWM placement. Matrices were applied to the lower extremity (64%), upper extremity (27%), and perineum (9%). One-hundred percent (n = 11) of wounds were deemed successful by receiving a STSG. Average time to STSG was 44 days (21d -108d). Complications consisted of delayed healing (n = 1, 8%) and partial necrosis (n = 1). No instances of infection or STSG graft loss occurred.

CONCLUSION

Complex defects caused by soft tissue necrotizing infections remain a reconstructive challenge. We highlight the benefit of a BWM as a treatment modality for reconstruction by priming the wound bed for a definitive STSG.

One-stage double free flap arteriovenous loop reconstruction of a massive abdominothoracic defect following necrotizing fasciitis: A case report

We report the case of a 67-year old male with necrotizing fasciitis after injection of the glenohumeral joint. After extensive debridement a massive defect from the left hip joint to the left upper arm, exposing ribs, scapula, axillary vessels and brachial plexus (45 × 40 cm) was present. Reconstruction was performed with a conjoined right myocutaneous tensor fasciae lata/vastus lateralis flap and a left myocutaneous vastus lateralis flap in combination with an arteriovenous loop originating from the axillary vessels using the greater saphenous vein. Revisional surgeries were necessary including ribs resection and flap re-advancements. Due to multiorganic failure invasive ventilation, renal replacement- and extensive transfusion therapy was required. After 241 days the patient was discharged for rehabilitation. At the 12 months follow-up wounds were sufficiently closed without the need for further intervention. This case illustrates that immediate diagnosis followed by an aggressive multidisciplinary treatment approach is crucial for the patient survival.

[Defect coverage after severe soft tissue infections: when and how?]

Severe infections frequently cause large soft tissue defects which require early defect coverage by plastic surgeons. A number of reconstructive treatment options are available, ranging from local flaps to microvascular free flap reconstructions. In this respect it is important that the selection of the optimal reconstructive technique is made based on individual patient characteristics and in a timely manner. Weeks of inpatient treatment with vacuum dressings often delay defect coverage and should be avoided as they burden both the patient and the healthcare system. Therefore, it is in the best interest of patients to receive early treatment by plastic surgeons. This manuscript presents the essential reconstructive treatment approaches based on highly informative case reports of patients from the plastic surgical practice at a university hospital.

Efficacy of Wound Coverage Techniques in Extremity Necrotizing Soft Tissue Infections

Little data exist about management of wounds created by debridement in necrotizing soft tissue infections (NSTIs). Multiple wound coverage techniques exist, including complete primary wound closure, split-thickness skin grafting, secondary intention, and flap creation. We hypothesized that all wound coverage techniques would be associated with high rates of successful wound coverage and low crossover rates to other wound coverage techniques. NSTIs over a three-year period were retrospectively reviewed. Both the initial and secondary wound coverage techniques (if necessary) were recorded. The primary outcome was the ability to achieve complete wound coverage. Overall, 46 patients with NSTIs had long-term data available. Of the patients undergoing split-thickness skin grafting as the initial wound coverage technique, 8/8 (100%) achieved complete wound coverage; and of those undergoing flap creation, 1/1 (100%) achieved complete wound coverage; and of those undergoing complete primary wound closure, 4/4 (100%) achieved complete wound coverage. Of the patients undergoing secondary intention as the initial wound coverage technique, 5/33 (15.2%) achieved complete wound coverage and 28/33 (84.8%) required a secondary wound coverage technique with split-thickness skin grafting. All 46 patients achieved long-term successful wound coverage. Time to wound coverage did not vary with initial wound coverage technique ( P = 0.44). Split-thickness skin grafting, flap creation, complete primary wound closure, and secondary intention are all reasonable choices for initial wound coverage for NSTIs. Although secondary intention had a low success rate as an initial wound coverage technique, all patients ultimately achieved complete wound coverage without a significant increase in time to coverage.

Post-traumatic occipital psoriatic plaque complicated by extensive necrotizing fasciitis of the head and neck: a case report and literature review

Necrotizing fasciitis (NF) is a severe infection involving the superficial fascial layers, subcutaneous cellular tissue, and possibly skin. It usually has a fulminant evolution, rapidly leading to death in the absence of early diagnosis and aggressive surgical treatment. We herein report a rare case of NF secondary to a traumatized occipital psoriatic plaque in an alcoholic 47-year-old woman and compare this case with the published literature. The NF extended to the entire scalp, right face, and posterior and lateral cervical region. Despite the initially guarded prognosis, the patient’s survival emphasizes the importance of aggressive surgical treatment with wide excision of all necrotic structures without any aesthetic compromise.

Physiology, not modern operative approach, predicts mortality in extremity necrotizing soft tissue infections at a high-volume center

BACKGROUND

Multiple factors are associated with mortality in necrotizing soft tissue infection, such as organ dysfunction and underlying medical comorbidities, but are not often modifiable. Operative interventions are an attractive modifiable variable in modern management of extremity necrotizing soft tissue infection, but the influence of amputation and advanced wound management techniques on mortality is unknown.

METHODS

A single-institution review was performed of extremity necrotizing soft tissue infection . Admission demographics, organ dysfunction, and operative interventions were investigated. The primary outcome was mortality. Advanced wound management techniques were considered flap creation or use of a dermal matrix substitute for coverage of neurovascular structures, tendon, or bone.

RESULTS

Overall, 124 patients with extremity necrotizing soft tissue infection were included, with 112 of 124 (90.3%) patients living and 12 of 124 (9.7%) patients dying. Patients who lived had a lower Sequential Organ Failure Assessment score (1.00 [interquartile range, 5] vs 10.50 [interquartile range, 11], P < .001), but no difference in use of amputation (11.6% vs 25.0%, P = .19) or advanced wound management techniques (12.5% vs 0%, P = 0.36), respectively. Indications for amputation in the 16 patients who underwent amputation included nonsalvageable limb in 13 of 16 (81.3%), medical comorbidity in 2 of 16 (12.5%), and a nonsalvageable limb and medical comorbidity in 1 of 16 (6.3%) patients. In multivariate analysis, only the Sequential Organ Failure Assessment score remained associated with mortality (odds ratio 1.315, 95% confidence interval 1.146-1.509, P < .001) CONCLUSION: Use of amputation or advanced wound management techniques was not associated with mortality in patients with extremity necrotizing soft tissue infection. At centers able to provide the critical care support, aggressive use of limb salvage may not affect mortality.

Factors predicting health-related quality of life following necrotizing fasciitis

BACKGROUND

Necrotizing fasciitis (NF) is a debilitating soft tissue infection that results in disfiguring scars and often amputations. While mortality rates have improved, long-term outcomes in survivors of NF are poorly understood.

OBJECTIVES

The objective of this study is to analyze the impact of NF on survivors' health-related quality of life (HRQoL) influenced by age, sex, comorbidities, %TBSA, and confidence with appearance.

METHODS

We surveyed 56 adult patients with NF treated at either of two regional referral centers in Manitoba, Canada, between January 1, 2004, and December 31, 2014. Necrotizing soft tissue infections involving the fascial planes were identified during surgical debridement. HRQoL was measured by the Medical Outcomes Short Form-36. Derriford Appearance Scale-24, age, sex, comorbidities, and %TBSA were recorded, and group comparisons and stepwise regression models were developed for the mental and physical component scores separately.

RESULTS

Mean Mental Component Score (MCS) was 44.5 ± 14.3 and mean Physical Component Score (PCS) was 36.5 ± 11.5; both means were lower than the Canadian population norm of 50. Although stepwise linear regression analyses with block entry indicated influence from age, sex, and comorbid conditions for the MCS and PCS, the only factors that were statistically significant in the final models were confidence with appearance for the MCS and %TBSA for the PCS.

CONCLUSIONS

NF has long-term impact on mental and physical health-related quality of life. Distress regarding confidence with appearance affects mental quality of life, whereas the size of the injured area impacted physical quality of life. These findings can help guide targeted interventions that could potentially improve recovery from NF.