Periocular Necrotizing Fasciitis with Toxic Shock Syndrome

Periorbital Facial Necrotizing Fasciitis in Adults: A Rare Severe Disease with Complex Diagnosis and Surgical Treatment-A New Case Report and Systematic Review

(1) Background: Necrotizing fasciitis (NF) is a severe and aggressive pathology with a rapid progression and high mortality risk. Periocular NF is a rare condition associated with a lower mortality risk but significantly higher disabling sequelae. (2) Methods: We present the case of a 67-year-old homeless patient, a victim of assault, with multiple untreated comorbidities (diabetes mellitus, cardiac conditions, and schizophrenia) and a delayed diagnosis of periocular necrotizing fasciitis. The condition showed a cyclical evolution influenced by the existing comorbidities, and the patient underwent both surgical and medical treatment with a multidisciplinary team. Additionally, we report a systematic review of cases from the literature. (3) Results: The patient's survival outcomes were favorable; however, the sequelae were disabling, not only concerning aesthetic aspects but also due to the loss of the affected eye globe. The systematic review revealed the rarity of such cases and the peculiarities of the presented case compared to those reported in the literature up to this point. (4) Conclusions: Understanding the signs, symptoms, and predisposing factors, as well as the potential rare localizations of NF, including the periocular region, can lead to the early diagnosis and treatment with good functional and aesthetic outcomes, minimizing significant disabilities.

Eyelid and periorbital necrotizing fasciitis, a severe preseptal infection, a systemic review of the literature and anatomical illustrations

In necrotizing fasciitis, aggressive surgical debridement and broad-spectrum antibiotics are the cornerstone of treatment but cannot be proposed for the eyelid and periorbital area because of the risk of blindness, eyeball exposure and disfiguration. The aim of this review was to determine the most effective management of this severe infection while preserving eye function. A literature search of the PubMed, Cochrane Library, ScienceDirect and Embase databases was conducted for all articles published up to March 2022; 53 patients were included. Management was probabilistic, combining antibiotic therapy with skin (+/- orbicularis oculi muscle) debridement in 67.9 % of cases, and probabilistic antibiotic therapy alone in 16.9% of cases. Radical surgery with exenteration was performed in 11.1% of patients; 20.9% of patients had complete loss of vision, and 9.4% died of the disease. Aggressive debridement was rarely necessary possibly because of the anatomical particularities of this region.

The acute necrotizing periorbital fasciitis. Clinical case

BACKGROUND: A rare severe, characterized by high mortality in some localizations (up to 70%) necrotizing periorbital fasciitis has not been described previously in the national literature. AIM: to show a multidisciplinary approach to the treatment and rehabilitation of patients with periorbital necrotizing fasciitis on the example of the clinical case. CLINICAL CASE: Patient with the acute necrotizing fasciitis of both eyelids, with the dissemination to the superficial face and neck fascies, the sepsis development is given. Monitoring of vital functions, homeostasis indicators, repeated inoculations, computed tomography, regular examination by an ophthalmologist included the control of visual functions, anterior and posterior segments, closure of the eye fissure. Conservative and surgical treatment applied by a multidisciplinary team is presented, which allowed to save the patients life, overpass the purulent-necrotic, and then the rough scar process and to achieve satisfactory anatomical and functional results. CONCLUSION: Timely multidisciplinary treatment of periorbital necrotizing fasciitis is necessary for the life preservation, prevention of severe complications from the eye. With the threat of developing lagophthalmos, it is necessary to perform permanent blepharoraphy for 36 months after the first surgery and further surgical and pharmacological correction of scarring processes.

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.