Special issues in plastic and reconstructive surgery

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.

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.

The Wittmann Patch s a temporary abdominal closure device after decompressive celiotomy for abdominal compartment syndrome following burn

BACKGROUND

Abdominal compartment syndrome is frequently the result of aggressive fluid resuscitation after burn. Management of the open abdomen following decompressive celiotomy is a major problem.

METHODS

From 2004 to mid-2005, six patients required decompressive celiotomy after developing abdominal compartment syndrome as a result of burn. A Wittmann Patch as used to close the abdominal wound. Patients were re-explored when clinical parameters improved and the abdomen was closed, with long-term follow-up for the abdominal wound.

RESULTS

Of the six patients, five had thermal injury and one had electrical injury. The mean total body surface area affected for thermal burn was 78% and for electrical burn was 37%. Diagnosis of abdominal compartment syndrome was based on elevated bladder pressure and organ dysfunction. The patients were treated with decompressive celiotomy and Wittmann Patch closure. Survivors subsequently underwent primary abdominal closure, with no evidence of ventral hernia at long-term follow-up.

CONCLUSION

In burn cases with abdominal compartment syndrome, a Wittmann Patch ay prove a helpful method of temporary abdominal closure, followed by primary closure with no complications.

Closure of massive abdominal wall defects: a case report using the abdominal reapproximation anchor (ABRA) system

Closure of massive abdominal wounds can be a challenging surgical problem. Presented here is a novel technique for reconstitution of the abdominal wall after severe internal injuries complicated by sepsis required a prolonged period of open abdominal dressing changes. By using an innovative and effective progressive tension band system, the fascial edges could be reapproximated over time allowing primary wound closure. This system is recommended as an effective instrument to accomplish closure of these difficult wounds.

Liposuction anesthesia techniques

This article discusses intravenous sedation, the authors' anesthesia of choice when performing most esthetic body contour refinement procedures. This technique is comfortable, safe, contemporary, and beneficial to the patient and medical crew. The preanesthesia evaluation is emphasized as a safety and high-quality action to any anesthesia procedure. Alternative anesthesia techniques are also discussed, including their possible advantages, disadvantages, indications, and counterindications.

Abdominal Wall Necrotizing Fasciitis from Dislodged Percutaneous Endoscopic Gastrostomy Tubes: A Case Series

We report three cases of abdominal wall necrotizing fasciitis that occurred as a result of leakage from displaced percutaneous endoscopic gastrostomy tubes. This is the first report of such a series. Patients underwent extensive operative excisions of their abdominal walls down to their posterior fascia. All patients tolerated their initial surgery, however, two patients ultimately expired from respiratory complications. The surviving patient underwent multiple repeat debridements and reconstructive abdominal wall surgery. We review the epidemiology of patients at risk for this complication and discuss its presentation, as well as the appropriate workup and management. We also address the issues of closure of large abdominal wall defects and future alimentation in this patient group. Finally, abdominal wall necrotizing faciitis from gastrostomy tube leakage is a devastating complication, and the development of preventative strategies for patients at risk is of paramount importance.

Necrotizing soft tissue infection from decubitus ulcer after spinal cord injury

STUDY DESIGN

A case of necrotizing soft tissue infection in a patient with spinal cord injury with extension of infection into the spinal canal and spinal cord is presented.

OBJECTIVE

To review the history, risk factors, pathophysiology, diagnosis, treatment, and morbidity and mortality regarding necrotizing soft tissue infection as they relate to spinal cord injury.

SUMMARY OF BACKGROUND DATA

Necrotizing soft tissue infection related to decubitus ulcers is rare. To our knowledge, this is the first report of this disease related to a sacral decubitus ulcer with extension of the necrotizing infection into the spinal canal.

METHODS

The clinical, radiographic, and pathologic features associated with necrotizing soft tissue infection are presented. The patient presented with a late-stage necrotizing soft tissue infection requiring extensive de-bridement of necrotic tissue, which the patient underwent on admission.

RESULTS

The patent died of refractory septic shock and multiple-organ failure after surgery.

CONCLUSION

Necrotizing soft tissue infections from decubitus ulcers are rare and unpredictable, and ultimately have a progressively aggressive course. The case reported herein is the first report of necrotizing soft tissue infection from a decubitus ulcer in a patient with spinal cord injury with extension into the spinal canal and spinal cord.