Flap coverage for necrotising soft tissue infections: A systematic review

Free Flap Reconstruction of Abdominal Wall Defects: A Systematic Review and Pooled Analysis

BACKGROUND

Reconstruction of extensive abdominal wall defects poses significant challenges, often requiring free tissue transfer when traditional methods are inadequate. This review examines the past decade's literature on free flaps for abdominal wall reconstruction to guide decision-making.

METHODS

A systematic review following PRISMA guidelines was conducted on July 17, 2024, using PubMed, Cochrane Library, Web of Science, Embase, and Scopus. Studies from 2013 to 2023 involving free flap reconstruction with at least 3 months follow-up were included. Surgical complications and outcomes were analyzed.

RESULTS

Of 2269 articles, 32 met inclusion criteria, involving 104 free flaps. There were no reports of flap loss. The average defect size was 330.0 ± 200.8 cm2. Oncologic resection was the leading indication (57%), with the latissimus dorsi flap used most frequently (36%). The most common recipient vessels were the deep inferior epigastric vessels (66.7%). The most common recipient vessels were the deep inferior epigastric vessels (66.7%). Mesh was used in 53% of cases, predominantly in a sublay position. The majority of reconstructions were immediate (52.9%), followed by delayed (31.8%) and staged (15.3%). Complications included partial flap necrosis (5.8%), surgical site infection (5.8%), and hernia development (4.8%). There were no significant differences in outcomes when stratified by reconstruction timing, flap choice, recipient vessels, or mesh characteristics. Infection as the defect etiology independently predicted surgical site infection (p = 0.03), whereas mesh usage (p = 0.07) and diabetes (p = 0.09) trended toward increased infection risk. Donor site complications were minimal.

CONCLUSION

Free flap reconstruction is safe and effective for large abdominal wall defects, with similar outcomes across flap types. Infection as the initial etiology was the strongest predictor of postoperative infection. Further studies are needed to establish guidelines for patient and flap selection.

Managing Necrotizing Soft Tissue Infections of the Lower Limb: Microsurgical Reconstruction and Hospital Resource Demands-A Case Series from a Tertiary Referral Center

Background: Necrotizing soft tissue infections (NSTIs) of the lower extremities represent a surgical emergency with high morbidity, complex reconstruction, and considerable healthcare demands. Free tissue transfer (FTT) is increasingly utilized for limb salvage in extensive soft tissue defects, yet its implications for hospital resource utilization remain unclear. This study aims to compare clinical outcomes and perioperative resource demands between FTT and local flap (LF) reconstruction in NSTI patients. Methods: A retrospective case series was conducted at a tertiary referral center between September 2022 and January 2025, including eight patients with NSTI of the lower extremity (FTT, n = 4; LF, n = 4). Demographic data, comorbidities, surgical timing, complication profiles, and resource utilization metrics-including operative duration, hospitalization length, and number of procedures-were analyzed. All FTT cases underwent preoperative CT angiography as part of institutional protocol. Results: Mean time to definitive reconstruction was longer in the FTT group (17.25 vs. 8 days, p = 0.15), reflecting staged infection control. FTT procedures demonstrated significantly longer operative times (331.75 vs. 170.25 minutes, p = 0.015), but there was no significant difference in total hospital stay (34.75 vs. 27.71 days, p = 0.65). No cases of flap loss or venous congestion were observed, and outcomes were optimized via delayed dangling protocols. Conclusions: FTT is a viable and effective reconstructive modality for lower extremity NSTIs. Despite increased surgical complexity, FTT did not significantly increase hospital resource utilization, supporting its role in limb preservation among appropriately selected patients.

Appropriate surgical management in skin and soft tissue infections

PURPOSE OF REVIEW

To present standards and recent technical innovations in the surgical management of skin and soft tissue infections (SSTI).

RECENT FINDINGS

SSTI are a frequent cause of presentation in the acute care setting. They can range from simple and uncomplicated to severe and necrotizing infections. Surgical management plays an important role in the treatment of uncomplicated SSTI. Recent evidence indicates that a subgroup of patients (e.g. immunocompromised patients) profits from a postoperative course of antibiotic treatment of 5-7 days. In diabetic foot infections (DFI), repeated debridement to remove necrotic tissue and control infection can prevent minor and major amputation. In necrotizing soft tissue infections (NSTI), early and aggressive surgical debridement is paramount. Recent advancements have explored skin-sparing techniques in selective cases.

SUMMARY

The management of SSTIs requires a combination of surgical and antimicrobial strategies tailored to the type and severity of the infection. Further clinical research is necessary in order to define more accurately those collectives in severe SSTI who profit from a less aggressive surgical approach.

Negative pressure wound therapy on a musculocutaneous free flap in no skin edge wound bed: A case report

INTRODUCTION

Necrotising soft tissue infection (NSTI) is an exceptionally dangerous infectious disease targeting soft tissues with high mortality as well as morbidity. The aim of reconstructive surgery after initial debridement is to maintain function as well as to achieve a satisfactory cosmetic result.

PRESENTATION OF CASE

A 50-year-old male presented with necrotising soft tissue infection on the thorax and left upper arm following mastectomy for breast cancer. He underwent aggressive debridement and was left with a large complicated soft tissue defect on the thorax, abdomen and left axilla with a wound bed consisting of exposed bone, nerves and vessels. There were close to no adjacent skin edges to fixate the flap, due to the size of the defect. Reconstruction with a free musculocutaneous latissimus dorsi (LD) and split skin grafting was performed. Vacuum therapy was applied immediately over the free flap and the vascular pedicle, as well as the skin graft.

DISCUSSION

Application of NPWT to the entire reconstructed area, including the free flap, in terms of achieving better and faster healing, is somewhat novel. Applying negative pressure wound therapy (NPWT) on free flaps is not a new practice but it has mostly been used as incisional therapy or when complications have occurred.

CONCLUSION

Our case shows a successful microsurgical reconstruction in a challenging area, with the direct application of NPWT perioperatively, without compromising flap survival, and with good patient outcome.

Wide exposure VS. stab surgical incisions in necrotizing fasciitis of the head and neck: a retrospective analysis of 22 cases

PURPOSE

Necrotizing fasciitis of the head and neck is a rare, rapidly progressing bacterial infection with high mortality. Traditional surgical management involves wide exposure incisions, but minimally invasive stab incisions have emerged as a potential alternative. This study aimed to compare outcomes between wide exposure and stab surgical incisions in the management of head and neck necrotizing fasciitis.

MATERIALS AND METHODS

A retrospective analysis was conducted on 22 patients treated for necrotizing fasciitis of the head and neck between January 2006 and January 2023. Patients were divided into two groups based on the surgical approach: wide exposure incisions (N = 15) and stab surgical incisions (N = 7). Data on mortality, hospital stay, hypertrophic scarring, neck contractures, and tracheostomy tube dependence were collected.

RESULTS

The overall mortality rate was 9.1%, with 6.7% in the wide exposure group and 14.3% in the stab surgical incision group (p > 0.05). Hypertrophic scarring occurred in 59.1% of patients, all of whom underwent wide exposure incisions. Neck contractures were observed in 9.1% of cases, also in the wide exposure group. Tracheostomy was performed in 63.6% of patients, with successful decannulation achieved in 91.7%. The median hospital stay was longer in the stab surgical incision group (p < 0.05), partly due to the need for revision surgeries.

CONCLUSION

Wide exposure incisions remain the standard treatment for necrotizing fasciitis of the head and neck due to their effectiveness in managing extensive tissue necrosis. However, stab surgical incisions offer the advantage of reduced morbidity and functional impairment. These benefits are offset by a slightly higher mortality rate and the potential need for additional interventions. Stab incisions may be a viable option in carefully selected patients, particularly those without extensive comorbidities or advanced disease.

Practical Review of Necrotizing Fasciitis: Principles and Evidence-based Management

Necrotizing fasciitis is a severe, life-threatening soft tissue infection that presents as a surgical emergency. It is characterized by a rapid progression of inflammation leading to extensive tissue necrosis and destruction. Nonetheless, the diagnosis might be missed or delayed due to variable and nonspecific clinical presentation, contributing to high mortality rates. Therefore, early diagnosis and prompt, aggressive medical and surgical treatment are paramount. In this review, we highlight the defining characteristics, pathophysiology, diagnostic modalities, current principles of treatment, and evolving management strategies of necrotizing fasciitis.

Necrotizing Fasciitis-Severe Complication of Bullous Pemphigoid: A Systematic Review, Risk Factors, and Treatment Challenges

Background and objectives: Bullous pemphigoid (BP), the most common subepidermal autoimmune skin blistering disease (AIBD) has an estimated annual incidence of 2.4 to 42.8 new cases per million in different populations, designating it an orphan disease. Characterized by disruption of the skin barrier combined with therapy-induced immunosuppression, BP could pose a risk for skin and soft tissue infections (SSTI). Necrotizing fasciitis (NF) is a rare necrotizing skin and soft tissue infection, with a prevalence of 0.40 cases per 100,000 to 15.5 cases per 100,000 population, often associated with immunosuppression. Low incidences of NF and BP classify them both as rare diseases, possibly contributing to the false inability of making a significant correlation between the two. Here, we present a systematic review of the existing literature related to the ways these two diseases correlate. Materials and methods: This systematic review was conducted according to the PRISMA guidelines. The literature review was conducted using PubMed (MEDLINE), Google Scholar, and SCOPUS databases. The primary outcome was prevalence of NF in BP patients, while the secondary outcome was prevalence and mortality of SSTI in BP patients. Due to the scarcity of data, case reports were also included. Results: A total of 13 studies were included, six case reports of BP complicated by NF with six retrospective studies and one randomized multicenter trial of SSTIs in BP patients. Conclusions: Loss of skin integrity, immunosuppressive therapy, and comorbidities commonly related to BP patients are risk factors for necrotizing fasciitis. Evidence of their significant correlation is emerging, and further studies are deemed necessary for the development of BP-specific diagnostic and treatment protocols.

WSES/GAIS/WSIS/SIS-E/AAST global clinical pathways for patients with skin and soft tissue infections

Skin and soft-tissue infections (SSTIs) encompass a variety of pathological conditions that involve the skin and underlying subcutaneous tissue, fascia, or muscle, ranging from simple superficial infections to severe necrotizing infections.Together, the World Society of Emergency Surgery, the Global Alliance for Infections in Surgery, the Surgical Infection Society-Europe, The World Surgical Infection Society, and the American Association for the Surgery of Trauma have jointly completed an international multi-society document to promote global standards of care in SSTIs guiding clinicians by describing reasonable approaches to the management of SSTIs.An extensive non-systematic review was conducted using the PubMed and MEDLINE databases, limited to the English language. The resulting evidence was shared by an international task force with different clinical backgrounds.