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

Disclosures

Wounds. 2018;30(10):290-299. 

In This Article

Discussion

The concept of large skin and soft tissue preservation in NSTIs has been previously described by the authors.[35] The current study extends this concept to the care of patients with FG.

Necrotizing soft tissue infections typically present with a sentinel area of infection from a specific portal of entry site. Surgical exploration remains the most sensitive and specific option to confirm or exclude the presence of gray necrotic tissue, fascial edema, thrombosed vessels, and dishwater purulence via blunt disruption of the deep subcutaneous tissue and fascial juncture with minimal resistance.[11]

The surgical standard of care for FG is still aggressive necrosectomy and eradication of infection that is swift, complete, and without compromise.[8] Some literature reviews propose that excision margins should include both the sentinel area of infection and the full radial extent of cellulitic skin changes;[11] however, a surgical mindset and approach of everything including the kitchen sink is not always indicated. An alternative perspective to this surgical approach may afford the opportunity to better understand and differentiate between the horizontal spread and perpendicular transmission of NSTI.

The vertical transmission of infection can be extensive locally at the portal of entry, but the centrifugal spread of infection migrates in a space between the fascia and deep subcutaneous tissues. Centrifugal spread of infection starts at the sentinel area and spreads in tandem with its advancing edge of the fascia. The skin and subcutaneous tissue at the advancing edge of infection may have salvageable collateral circulation from the dermal and subdermal plexus originating from unaffected tissue in zones 2 and 3 (Figure 2). This collateral circulation may survive surgical excision of the underlying infected fascia and deep soft tissue. Understanding these principles allowed the authors to routinely teach skin sparing surgery techniques to residents on their burn and wound service, thereby affording residents the opportunity to safely spare skin and soft tissue in cases that were initially explored by other surgeons.

Thoughtful contemplation is warranted regarding the fact that radial progression of NSTIs is not always directly proportional to the perpendicular transmission of disease. This may alleviate the need for the dermal and subdermal tissue excision to be as wide as the fascial. Understanding the somatic clues of skin and soft tissue viability is essential to consummating its preservation. Meticulous serial surgical debridement coupled with NPWT may contribute to fostering the development of healthy skin and soft tissue granulation suitable for staged complex closures. Returns to the OR for second looks twice weekly or as needed based on the patient's clinical status ensures the safety of this approach. The authors found that the successful reproducibility of this approach weighed heavily on preservation of skin and soft flaps surrounding the original sentinel area of infection.

As previously noted, comorbidities are important due to the known association with NSTI, even though NSTIs also may occur in otherwise healthy individuals.[3] The study also demonstrated this pattern, with most patients having significant comorbidities. It was interesting to see not only tobacco smoking but also other forms of substance abuse in this series of patients (eTable 1).

Burn centers retain a multidisciplinary team approach for cost-effective acute surgical management, reconstructive, and rehabilitative needs of the NSTI/FG patient group.[36–38]

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