"Emergency" definitive reconstruction of a necrotising fasciitis thigh debridement defect with a pedicled TRAM flap

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.

[Defect coverage after severe soft tissue infections: when and how?]

Severe infections frequently cause large soft tissue defects which require early defect coverage by plastic surgeons. A number of reconstructive treatment options are available, ranging from local flaps to microvascular free flap reconstructions. In this respect it is important that the selection of the optimal reconstructive technique is made based on individual patient characteristics and in a timely manner. Weeks of inpatient treatment with vacuum dressings often delay defect coverage and should be avoided as they burden both the patient and the healthcare system. Therefore, it is in the best interest of patients to receive early treatment by plastic surgeons. This manuscript presents the essential reconstructive treatment approaches based on highly informative case reports of patients from the plastic surgical practice at a university hospital.

Reconstruction of infected trunk wounds with pedicled rectus abdominis musculocutaneous flaps: a retrospective case series

OBJECTIVE

To completely treat and cover extensively infected trunk defects, reconstruction should be performed using a sufficiently vascularised flap, such as a muscle or musculocutaneous flap after perfect debridement. These reconstructive surgeries are challenging in patients with severe comorbidities. In this case series, we describe extensively infected trunk defect reconstruction, in patients with severe comorbidities, using a pedicled rectus abdominis musculocutaneous flap and suggest an algorithm for reconstruction.

METHOD

Between March 2011 and March 2015, participating patients underwent reconstruction of extensively infected trunk defects using a pedicled rectus abdominis musculocutaneous flap. All patients had diabetes and hypertension, and several patients had severe comorbidities, including heart and renal failure. Bacterial cultures revealed that meticillin-resistant Staphylococcus aureus (MRSA) was present in seven patients (with concurrent Pseudomonas aeruginosa in two patients), multidrug-resistant Acinetobacter baumannii in one patient and Mycobacterium tuberculosis in two patients.

RESULTS

A total of 10 patients underwent the procedure. The pedicled rectus abdominis musculocutaneous flaps survived completely in all 10 patients. There were no complications related to the flaps, although two patients developed minor wound dehiscence, which may be due to their comorbidities. There were no signs of recurrent infection during the follow-up period in each case.

CONCLUSION

Reconstruction using the pedicled rectus abdominis musculocutaneous flap is a good treatment option for extensively infected three-dimensional trunk defects, even for patients with severe comorbidities.

[Modified anterolateral thigh perforator flap pedicled by cross-bridge microvascular anastomosis for repairing soft tissue defects in middle and lower segments of leg]

Objective

To explore the effectiveness of modified anterolateral thigh perforator flap pedicled by cross-bridge microvascular anastomosis in treatment of soft tissue defects in the middle and lower segments of the leg.

Methods

Between March 2011 and June 2015, 15 cases with skin and soft tissue defects in the middle and lower segments of the legs were treated. There were 9 males and 6 females, aged 22-48 years (mean, 32.6 years). Of whom, 8 patients caused by traffic accidents, 5 by machine twist, and 2 by crash injury of heavy object. The mean interval from injury to admission was 82.6 hours (range, 2 hours to 1 week). The area of defect ranged from 13 cm×9 cm to 23 cm×16 cm. After primary debridement and vaccum sealing drainage treatment, the defects were repaired with modified anterolateral thigh perforator flap pedicled by cross-bridge microvascular anastomosis. The size of flap ranged from 15 cm×10 cm to 25 cm×15 cm. The donor sites were sutured directly or repaired with the skin grafts. The pedicle division was done at 4 weeks after operation.

Results

After operation, venous crisis occurred in 1 case and distal skin necrosis in 2 cases which was healed by dressing change. The other tissue flaps survived successfully and wounds healed by first intention. All skin grafts at donor site survived after operation, and primary healing of wound was obtained. All patients were followed up 6-24 months (mean, 13 months). All flaps were characterized by soft texture, satisfactory appearance, and restoring the protective sensation. Moreover, the two-point discrimination ranged from 15 to 28 mm (mean, 19.5 mm) at 6 months after operation. The function of both lower extremities were normal without obvious contracture of scar at donor site.

Conclusion

Modified free anterolateral thigh perforator flap, with little damage in donor site, a reliable blood supply by making a cross-bridge microvascular anastomosis with pretibial or posterior tibial blood vessel on normal leg, is a reliable alternative method for repairing soft tissue defects with the main vessels of serious injury in the middle and lower segments of the leg.