Outcomes in Fournier's Gangrene Using Skin and Soft Tissue Sparing Flap Preservation Surgery for Wound Closure

An Alternative Approach to Wide Radical Debridement

Travis L. Perry, MD; Lindsay M. Kranker, MD; Erin E. Mobley, PA; Eileen E. Curry, MD; R. Michael Johnson, MD, MPH


Wounds. 2018;30(10):290-299. 

In This Article

Materials and Methods

A retrospective review of 17 consecutive patients with FG treated at Miami Valley Hospital Regional Adult Burn and Wound Center between 2008 and 2018 was conducted. The criteria for inclusion was the clinical suspicion of FG based on genital and perineal cellulitis, fever, leukocytosis, and confirmation of tissue necrosis upon surgical exploration. Most of the cases (12/17; 70.59%) in this series underwent an initial exploration by another surgeon. After the burn and wound surgeon (TP) was consulted for patient evaluation, all patients underwent further skin sparing debridement and reconstruction. Patients not treated with skin sparing surgical debridement or with wounds lacking the ability to maintain a NPWT dressing seal were excluded from this series.

Collected patient demographic data included age, sex, and medical comorbidities (eTable 1). Comorbidities are important, as an association exists between NSTI and obesity, diabetes mellitus (DM), compromised immune system, peripheral vascular disease, and alcoholism, though NSTIs also can occur in otherwise healthy individuals.[3,5] Laboratory values consisted of white blood cell count, glucose level, and FG severity index (FGSI), a numerical score derived from a combination of physiological markers that are predictors of mortality.[23,25–27] A FGSI > 9 is a sensitive and specific indicator of mortality.[10] Clinical outcomes were determined based on intensive care unit (ICU) LOS, hospital LOS, days treated as an outpatient, and mortality rate. Surgical outcome data were measured in total number of surgeries, initial wound size, percent of DPC, split-thickness skin graft (STSG) size, ostomy requirement, and days to complete closure. None of the patients in this series underwent the traditional plastic surgery techniques using testicular thigh pouch placement, adjacent tissue transposition, advancement, or free flap reconstruction.[28]

Written informed consent for photo evidence was obtained from patients for publication. This case series was approved by the Miami Valley Hospital Human Investigation Research Committee (#SC 6409).

Surgical Modus and Decision Making

The patient is taken to the operating room (OR) for surgical exploration, infection control, and uncompromised devitalized tissue extirpation. The sentinel area of infection (necrosis, fluctuance, ecchymosis, and purulent drainage) is identified (Figure 3A). The design of the exploratory incision is based largely upon the natural cavitation of the wound generated by the infection. Full-thickness exploratory incisions are created after using a blunt probe to externally map the direction of tunneling and undermining (Figure 3B). The incisions are made by balancing the need for additional exposure to extirpate necrotic tissue and firewall the centrifugal spread of deep infection. The leading edge of purulence, necrosis, and infected fascia and soft tissue is identified and completely excised while using sharp and blunt finger dissection. Meticulous and detailed exploration of the wound using blunt instrument probing and finger dissection helps to avoid missed areas of infection within deep subcutaneous soft tissue recesses and fascial planes. The authors have found the use of hydrosurgery (VERSAJET Hydrosurgery System; Smith and Nephew, London, UK) beneficial for determining the areas of viability while removing necrotic debris and cleaning infected tissue. Careful consideration is given to the amount of skin and soft tissue on either side of the exploratory incision(s) for future reconstruction (Figure 3B, 3C). This maximizes salvageable flap preservation surface area and avoids the need for additional surgical undermining or tissue advancement. Dermal hemorrhage, dermal necrosis, and microvascular thrombosis in subdermal soft tissue are used as benchmarks for extensive vertical conveyance of infection in zone 1 (Figure 3A). Necrosis and infection in this area requires complete surgical excision. The skin at the transitional area between zones 2 and 3 tends to be cellulitic in nature, only with less extensive vertical transmission of infection (Figure 3A). This technique specifically does not excise all cellulitic skin at the initial debridement, which has been found to be unnecessarily radical.

Figure 3.

(A) Preoperative illustration of zones 1–3; (B) blunt probe at portal of entry used to externally map tunneling and underminding created by infection. Full-thickness exploratory incision was created and extended to gain access to the (C) underlying infection. Exploratory incisions are created while keeping adequate skin and soft tissue on either side in mind for future reconstruction.

Zone 2 viability is evaluated by lifting the skin and soft tissue flaps and examining the vessels within the deep subcutaneous tissue (Figure 4A, 4B). The presence of microvascular thrombosis is traced proximally and surgically excised until patent bleeding vessels are encountered. Punctate bleeding indicates a viable subdermal plexus and is used to guide the extent of surgical excision for potential flap viability and preservation through collateral circulation. Therefore, healthy fascia, skin, and soft tissue are left intact. Counter exploratory incisions are created as needed to ensure complete surgical excision of infection and necrosis at sites distant to the sentinel area of infection (Figure 4C, 4D). Counter exploratory incisions afford full access for a complete necrosectomy of distant underlying infection while sparing surrounding skin and soft tissue.

Figure 4.

(A) Thrombosed blood vessel warranting further skin excision (white arrow); (B) skin flap elevation depicts underlying collateral microvascular preservation; and (C, D) counter exploratory incisions (black arrows) are necessary in some cases in order to firewall distant migratory infection while preserving groin and scrotal skin and soft tissue (white arrows).

Perioperative Wound Care and Closure

Once the wound bed, skin, and soft tissue flaps are clean, a NPWT dressing (Figure 5) is placed within the remaining defect utilizing the V.A.C. GranuFoam dressing (KCI, an Acelity Company, San Antonio, TX). Prior to sealing the NPWT dressing, the soft tissue flaps are approximated to the midline of the exploratory incision using interrupted vicryl sutures (Figure 5A). The NPWT dressing is positioned along the wound bed and between the deep soft tissue flaps. Mechanical creep of the skin and soft tissue is achieved with superficial and deep interrupted sutures, which promote tissue expansion and maintain flap topography of the original exploratory incision (Figures 5B, 6). This dressing change is performed every 4 to 7 days. Advances in wound care such as NPWT have proven to be very useful adjuncts in postoperative wound management to control drainage and improve blood flow to the skin and soft tissue flaps.[29–33]

Figure 5.

Progression of flap preservation and surrogate reconstructive technique using concurrent serial meticulous operative debridement, (A) staged partial complex closures, and (B) negative pressure wound therapy.

Figure 6.

(A) Contamination precautions are implemented by sewing over the negative pressure wound therapy (NPWT) dressing that protects the wound below the dressing as well as creates more surface area (white arrows) for dressing application; (B) application of stoma paste enhances airtight seal in otherwise difficult areas, thereby avoiding the need for an ostomy; and (C) all NPWT dressings are completely removed and replaced between each application.

As an adjunct to reduce bacterial bioburden, antimicrobial irrigations are routinely administered postoperatively. Topical antimicrobial-treated wounds have shown a fewer number of debridements, number of procedures, and higher first-time closures due to the reduction of chronic inflammation.[34] This DPC technique approximates preserved granulated skin and soft tissue flaps to a healthy granulated wound bed in a layered-hem fashion, which again promotes mechanical creep and flap topography maintenance of the original exploratory incision (Figure 5A). This, in turn, significantly reduces the surface area of the initial wound size and with each subsequent closure.

Although fecal diversion devices were used in some cases, only 1 of the 17 patients (5.88%) required a diverting ostomy. To further avoid contamination, Stomadhesive Paste (CovaTec, Inc, Bridgewater, NJ) was used to enhance the dressing seal of wounds near the anus, and skin flaps were sewn over the NPWT dressing (Figure 6).

This concurrent process of surgical excision, partial closure, and reapplication of the NPWT dressing is performed repeatedly until closure. After control of the initial infection and good wound healing progression, some patients are discharged home and return for outpatient surgery until full wound closure.