Daniel Lee John Bunker BE (Aerospace)(Hons) MBBS(Hons) MS,1 Scott Ferris MBS FRACS1
Plastic, Hand and Faciomaxillary Surgery
Name: Daniel Lee John Bunker
Address: Department of Plastic and Reconstructive Surgery
Flinders Medical Centre
Bedford Park, South Australia, 5041
Phone: +61 3 9076 2000
Citation: Bunker DLJ, Ferris S. Is free tissue transfer following necrotising fasciitis safe? A case report and review. Aust J Plast Surg. 2019;2(1):99–102. https://doi.org/10.34239/ajops.v2i1.83
Accepted for publication: 17 August 2018
Copyright © 2019. Authors retain their copyright in the article. This is an open access article distributed under the Creative Commons Attribution Licence which permits unrestricted use, distribution and reproduction in any medium, provided the original work is properly cited.
Section: General reconstruction
Necrotising fasciitis is a life-threatening infection that requires radical debridement, usually accompanied by antibiotic therapy and physiologic support. Patients are often left with disabling or disfiguring soft tissue defects. Traditionally, simple reconstructive methods such as skin grafting and local flap coverage have been used to address these defects, due to concerns that free tissue transfer may increase the risk of thrombosis where there has been recent infection and inflammation. We argue that once the infection has been cleared and the patient regains physiological stability, free tissue transfer is a viable reconstructive option that may provide better functional and cosmetic results in selected cases.
Keywords: necrotising fasciitis, debridement, reconstructive surgical procedures, surgical flaps
A previously healthy 32-year-old male presented with a three-day history of tenderness and spreading erythema of the left arm after a fall. He was septic on admission, requiring transfer to the intensive care unit for inotrope support. Initial examination revealed an erythematous and tender forearm with soft compartments. White cell count on admission was 11x109/L with a CRP of 279.
The following morning he remained septic, requiring ongoing inotropes and with spreading erythema and new skin mottling. He was taken to theatre where necrotic fascia and pus at the medial aspect of the arm extending down the medial intermuscular septum to the neurovascular bundle was noted. Radical surgical debridement was performed and temporary cover achieved with negative pressure wound therapy. Microbiological analysis revealed group A streptococcus and Staphylococcus aureus. Triple intravenous antibiotic therapy was administered in consultation with the infectious diseases team.
Serial debridements and dressing changes were performed on days two, four, eight, 11 and 14 post-admission, leaving a large defect over the volar forearm and medial arm with exposure of the brachial artery, median nerve, ulnar nerve and biceps tendon insertion (Figure 1).
Figure 1. Defect after final debridement
Figure 2. Reconstruction of proximal defect with anterolateral thigh free flap
On day 17 post-admission, with a systemically stable patient and serial negative microbiological tests on wound cultures, definitive reconstruction with an ipsilateral anterolateral thigh (ALT) fasciocutaneous free flap and split skin graft was performed (Figure 2). Priority was given to coverage of the neurovascular structures, biceps tendon and elbow flexural crease. The radial artery and venae commitantes were explored under brachoradialis in a freshly dissected plane and confirmed to be suitable recipients under microscopic examination prior to raising the flap. Arterial anastomosis was performed with 9-0 nylon sutures and venous drainage accomplished with anastomoses using venous couplers. All anastomoses were end-to-end. Follow-up one month after reconstruction revealed a movement range of -100 to 1000 at the elbow and 500 to 750 at the wrist (Figure 3).
Figure 3. One month post reconstruction
Discussion and review
Wound closure after necrotising fasciitis is most commonly achieved with skin grafting, local flaps or amputation. Free tissue transfer is less commonly performed. One concern has been the potential for thrombosis due to a systemic inflammatory state with elevated levels of circulating pro-thrombotic mediators that may predispose the affected area to anastomotic occlusion. A hallmark of these necrotising soft tissue infections is thrombosis of the small vessels as a result of endotoxin and inflammatory mediator release, leading to necrosis—seen pathologically as microvascular occlusion, arteritis and intimal thickening.1,2
A number of documented cases report free flap reconstruction following necrotising fasciitis (Table 1). The largest published series reports on 12 successful free flap reconstructions within a population of 224 necrotising fasciitis cases.3 It should be noted that in this series most of the defects were small and the mean number of debridements prior to definitive coverage was 1.1. This contrasts with the experience at our institution where severe soft tissue infections are treated by serial debridement. We consider a clean wound bed and negative microbiology as prerequisites to definitive reconstruction.
The use of a fasciocutaneous free tissue transfer tends to replace what is lost due to necrotising fasciitis. The ALT has proven to be a reliable reconstructive option with minimal donor site morbidity and is the most commonly used donor site. For larger and more central locations, latissimus dorsi musculocutaneous and chimeric free flaps have been used to cover chest and abdominal wall defects.
|Paper||Total free flaps||Recipient sites||Donor sites|
|Whetzel et al12||1||Cervicofacial||Anterolateral thigh|
|Duman et al5||1||Abdomen||Latissimus dorsi|
|Yuen et al8||1||Hand||Rectus|
|Barbosa et al4||1||Chest||Latissimus dorsi|
|Hankins et al9||1||Hand||Anterolateral thigh|
|Ryssel et al7||6||Extremity||Unspecified|
|Pyon et al13||1||Upper limb||Thoracodorsal artery perforator|
|Jordon et al11||1||Cervicofacial||Parascapular|
|Deyeliannis et al6||1 chimeric||Abdomen||Chimeric anterolateral thigh/fascia lata and rectus femoris|
|Reinbold et al10||1||Upper limb||Deep inferior epigastric artery|
|Gawaziuk et al3||12||10 extremity, one head and neck, one perineal||10 anterolateral thigh, one latisimus dorsi, one radial forearm|
This case highlights the successful use of free tissue transfer following necrotising fasciitis in order to facilitate coverage of neurovascular structures and bare tendon, while minimising the chance of long-term contracture. While traditional reconstructive options involve skin grafts or amputation, free tissue transfer provides a viable option that may optimise functional and aesthetic results. When performing such procedures we suggest a clinically clean wound with negative tissue culture, a physiologically stable patient where the systemic inflammatory response has been resolved and, wherever possible, anastomoses performed outside of the immediate zone of infection with recipient vessels ideally identified in a virgin plane and examined prior to raising the flap.
The authors have no financial or commercial conflicts of interest to disclose.
- Cybulsky MI, Chan MK, Movat HZ. Acute inflammation and microthrombosis induced by endotoxin, interleukin-1, and tumor necrosis factor and their implication in gram-negative infection. Lab Invest. 1988;58(4):365–78. PMid:3282123
- Barker FG, Leppard BJ, Seal DV. Streptococcal necrotising fasciitis: comparison between histological and clinical features. J Clin Pathol. 1987;40(3):335–41. https://doi.org/10.1136/jcp.40.3.335 PMid:3558868 PMCid:PMC1140910
- Gawaziuk JP, Liu T, Sigurdson L, Buchel E, Hayakawa TEJ, Shiga S, Logsetty S. Free tissue transfer for necrotizing fasciitis reconstruction: a case series. Burns. 2017;43(7):1561–566. https://doi.org/10.1016/j.burns.2017.04.007 PMid:28536044
- Barbosa RF, Pinho CJ, Costa-Ferreira A, Cardoso A, Reis JC, Amarante JM. Microsurgical reconstruction of chest wall defect after necrotizing fasciitis. Microsurgy. 2006;26(7):519–23. https://doi.org/10.1002/micr.20280 PMid:17001637
- Duman HK, Kayahan C, Celikoz, B. Reconstruction of a large abdominal wall defect resulting after necrotizing fasciitis with free latissimus dorsi flap. Eur J Plast Surg. 2000;23(2):91–3. https://doi.org/10.1007/s002380050023
- Deleyiannis FW, Harry BL. Augmentation of venous outflow for salvage of a combined anterolateral thigh, tensor fasciae latae, and rectus femoris free flap used for abdominal wall reconstruction. J Reconstr Microsurg. 2014;30(2):137–40. PMid:24019171
- Ryssel H, Germann G, Kloeters O, Radu CA, Reichenberger M, Gazyakan E. Necrotizing fasciitis of the extremities: 34 cases at a single centre over the past 5 years. Arch Orthop Trauma Surg. 2010;130(12):1515–522. https://doi.org/10.1007/s00402-010-1101-8 PMid:20499245
- Yuen JC, Feng Z. Salvage of limb and function in necrotizing fasciitis of the hand: role of hyperbaric oxygen treatment and free muscle flap coverage. South Med J. 2002;95(2):255–57. https://doi.org/10.1097/00007611-200295020-00021
- Hankins CL, Southern S. Factors that affect the clinical course of group A beta-haemolytic streptococcal infections of the hand and upper extremity: a retrospective study. Scand J Plast Reconstr Surg Hand Surg. 2008;42(3):153–57. https://doi.org/10.1080/02844310802038223 PMid:18470793
- Reinbold CD, Derder M, Hivelin M, Ozil C, Al Hindi A, Lantieri L. Clinical case: Using free flaps for reconstruction during infections by mucormycosis: A case report and a structured review of the literature. Ann Chir Plast Esthet. 2016;61(2):153–61. https://doi.org/10.1016/j.anplas.2015.05.006 PMid:26113355
- Jordan A, Sharma P, Moss C, Durrani A, Price R. Cervico-facial necrotising fasciitis due to Candida albicans. Eur J Plast Surg. 2013;36(7):453–56. https://doi.org/10.1007/s00238-013-0837-0
- Whetzel TP, Sykes JM, Reilly DA. Acute reconstruction of massive cervicofacial necrotizing fasciitis with Estlander and free scapular/parascapular flaps. Otolaryngol Head Neck Surg. 1999;120(1):101–04. https://doi.org/10.1016/S0194-5998(99)70377-3
- Pyon JK, Lee KT, Lim SY, Bang SI, Oh KS, Mun GH. Postoperative leucocytoclastic vasculitis in free flap mimicking venous insufficiency. J Plast Reconstr Aesthet Surg. 2011;64(12):1705–708. https://doi.org/10.1016/j.bjps.2011.03.044 PMid:21530432