A Novel Concept for Treating Large Soft Tissue Defects After Necrotizing Soft Tissue Infection of the Back

Editorial Summary

Necrotizing fasciitis, a life-threatening subcutaneous soft-tissue infection, requires a high index of suspicion for diagnosis. It is vital to consider the diagnosis wherever there is a soft-tissue infection that appears to have rapidly progressing characteristics presenting with edema and erythema, or systemic signs of infection. However, necrotizing fasciitis can be easily missed because the patient may present earlier in the disease process with non-specific signs and severe pain (disproportionate to the clinical findings or anaesthesia over the site of infection). If necrotizing fasciitis is suspected, the patient should immediately be referred for urgent surgical debridement. Necrotizing fasciitis is a clinical diagnosis. Surgical debridement should be repeated as necessary until the patient has no necrotic tissue remaining. Adjunctive antibiotic therapy and supportive care are crucial, as well as starting intravenous empirical antibiotics as soon as blood cultures have been taken. Once culture results are available, antibiotics can be modified to target the causative organism. This article explores the surgical strategy of acellular fish skin in wound bed restoration post necrotizing fasciitis in a case of a diabetic patient diagnosed with extensive necrotizing fasciitis.

Introduction

Necrotizing fasciitis (NF) is defined as a severe and lethal bacterial infection that occurs with a rapid onset resulting in extended soft tissue and fascial necrosis with relative sparing of skin and muscle.1 Necrotizing fasciitis is a destructive infection of the skin and subcutaneous tissues associated with significant mortality and morbidity.2 Survival from the condition often necessitates patient referral for appropriate reconstructive surgery and supportive medical management. The mortality rate is high, ranging from 11% to 22%; this rate is even higher with mortalityassociated risk factors such as diabetes mellitus. Management is complex and multimodal, beginning with early identification and multiple surgical debridement with resultant large soft tissue defects.2,3

Post necrotizing fasciitis reconstruction can prove a challenge for the reconstructive surgeon. With a large amount of tissue debrided during the early process, the challenges vary depending on the anatomical location.

Methods

This case is that of a 64-year-old AfricanAmerican female with diabetes mellitus type 2 who was initially treated at a hospital for a back wound, developed NF, and was diverted and transferred to the burn unit with involvement extending from bilateral upper back to the bilateral gluteal area. The wound was initially treated with wide surgical debridement and reconstruction of the large back and gluteal soft tissue defect with intact fish skin in combination with hyperbaric oxygen therapy and negative pressure wound therapy (NPWT). On assessment the total body surface area (TBSA) of the posterior back was approximately 18%. She underwent early debridement on day 2 of admission, with application of negative pressure wound VAC therapy for 3 days to stimulate a granulating wound bed. Subsequent surgical debridement ensued with the first application of intact fish skin graft (FSG). A method of a 3 layer ‘stacked’ intact FSG was used to ensure adequate coverage and to minimize tissue deficits. A ‘rolled’ configuration of the FSG was placed between the wound bed and skin flaps located on the superior, lateral and inferior edges, which was sutured in place with PDS® II (polydioxanone) Suture, (Ethicon (Johnson and Johnson), Raritan, New Jersey, United States).

A NPWT was put in place for 7 days. After the 4th debridement and fish skin application with NPWT, debridement and excision of the sacral tubercules was completed due to a concern for osteomyelitis. The intact FSG was then stacked on the sacrum. On the 45th hospital day, a split thickness skin graft (STSG), meshed at a ratio of 4:1 was performed along with autologous skin cell suspension. This was buttressed in place with burn mesh gauze and inspected on post-operative day 7. The intact fish skin was re-applied to residual areas where the graft had not taken. On day 63 of hospitalization, a STSG meshed at 2:1 was placed on the sacrum and bilateral gluteal defect.