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

Figure 1: 64 year old female presenting with necrotizing fasciitis of the back TBSA of 18%.

1a: Initial presentation.

1b: Pre-operative appearance: pre-excision and debridement.

1c: Post-debridement.

1d: Placement of wound VAC to stimulate granulation tissue.

1e: Pre-operative: pre-excision.

1f: Post excision: area of concern was the sacrum which was debrided using a rongeur until punctate bleeding was observed.

1g: Application of the intact fish skin using the multilayered stacked approach on the sacrum 3 layers (blue arrow), as well as rolled product to tunneling areas (green arrows, NPWT applied).

1h: Healthy granulation and ready for grafting. Note the sacrum with granulation tissue. Tunneling incorporated from ‘rolling the intact fish skin’ between lateral skin flaps and primary closure, although one area on the right remains.

Results

After multiple surgical debridements, Application of intact FSG resulted in a viable granulation and neo-dermis. Utilization of intact FSG allowed for reduction in fluid, protein loss and minimized microbial invasion. The ‘stack and roll’ method allowed for contraction of the large soft tissue defect from 45cm x 50cm to 35cm x 30cm.

The adjuvant use of NPWT allowed for over 90% intact fish graft incorporation and good wound bed formation. Incorporation of the intact fish skin over the sacral bone was observed on day 36 of the hospital stay. On the 45th day of hospitalization the incorporation of autologous skin cell with a ratio of 4:1 STSG was applied. The graft was inspected on the 51st hospital day and over 80% take was observed to the gluteal, upper and lower back areas. Despite our efforts, the patient unfortunately succumbed to her injuries.