Effectiveness of Fasciocutaneous Superomedial Thigh Flap in Reconstruction of Fournier Gangrene Defects

Özcan Öcük, MD; Fatma Hilal Yağın; Orhan Gazi Dinç, MD; Cemal Fırat, MD

Disclosures

ePlasty. 2022;22(e26) 

In This Article

Abstract and Introduction

Abstract

Background: Fournier gangrene (FG) is a necrotizing fasciitis involving perianal and abdominal regions. It progresses quickly and requires urgent intervention. With the use of vacuum-assisted closure (VAC) treatment applied during clinical follow-up and the use of superomedial thigh flap in the region, the treatment is completed with an effective, functional, and rapid approach. This study examines the clinical details of this method for reconstruction.

Methods: The study included 15 patients who underwent superomedial thigh flap in VAC treatment reconstruction for tissue defect after FG debridement from 2016 to 2020. The patients were examined in the form of clinical evaluation with hospital admission and surgical evaluation in the postop process.

Results: In patients with wound maturation and sufficient granulation, superomedial thigh flap application followed by VAC treatment soon after shortened the operation time, shortened the postop drain time, and provided effective treatment of dead space. An aesthetic and functional result was obtained with the proximity of the flap to the area. In addition, due to the sensory branches present in the flap, a sensory result was obtained according to the ratio of flap size.

Conclusions: Superomedial thigh flap provides a practical, effective, and fast solution to the tissue defect that occurs after FG debridement. Effective results can be obtained when combined with VAC therapy.

Introduction

Fournier gangrene (FG) was first described as a clinical syndrome in 1883 by Jean Alfred Fournier, a French venereal disease specialist.[1] It is a rapidly progressing necrotising fasciitis that involves the skin and subcutaneous tissues in the perineum, anal region, and abdominal wall. The clinical situation is life-threatening and requires urgent treatment. FG is a type of obliterative endarteritis involving the vascular plexus of the skin. Involvement progresses very quickly and spreads to the skin in the genital and abdominal region. Though the mortality rate is 3 to 67% in recent years, the incidence is 1:7500 to 1:750000. Diseases such as herpes simplex, gonococcal balanitis, allergic vasculitis, warfarin necrosis, and erythema gangrenosum in this region should be considered as differential diagnosis.[2,3] Although a definite etiological cause has not been determined, alcoholism, atherosclerosis, peripheral artery disease, trauma, malnutrition, immunosuppression, HIV infection, and especially diabetes can be considered as risk factors.[2] Based on the existing risk factors, this disease begins with polymicrobial (aerobic and anaerobic bacteria) infection and microthrombi in the subcutaneous fascia and progresses rapidly as it spreads to large vessels.[2,4] Advanced age and low socioeconomic status are among other important risk factors.[5] Although FG affects both sexes, the male-to-female ratio is 1:10, and it is most frequently seen in the 5th and 6th decades.[3] It also rarely affects children.[3,4] The disease begins with pain, redness, softness in the tissue, and shine in the skin in the affected area. Black spots, named the Brodie sign, appear on the skin when inflammation starts.[2] The disease begins physiopathologically due to bacterial invasion in the region as a result of a simple rupture in the skin. After this process, there are nonspecific findings such as tenderness and swelling in the soft tissue in the lesion area. Then, depending on the decrease in cutaneous defense and oxygenation, the physiopathological process accelerates. In this period, rapid diagnosis and treatment gain importance.

Among the polymicrobial agents, E coli is the most common, followed by E faecalis.[3] Other common agents include B fragilis, P aeruginosa, Candida species, Streptococcus, and Cytaphylococcus species.[3] Infection follows a rapidly progressing clinical course that subsequently causes sepsis and death; therefore, early diagnosis and surgical debridement are important in FG treatment.[6] Correction of fluid deficit, a broad-spectrum antibiotic treatment protocol, and intensive care conditions are other important points in the treatment, together with rapid surgical debridement.[7] The aim of the treatment is to cover the exposed testicle, preserve testicular functions, and provide an acceptable aesthetic result.[5]

The superomedial thigh flap was first defined by Hirschowtiz. It is a workhorse flap and has safe arterial blood flow.[8] The flap provides blood flow from the external pudendal artery, the anterior branch of the obturator artery, and the medial femoral circumflex artery.[8,9] It provides ease of use as the flap is well adapted to the region. Maturation of the exposed tissue after deduction and ensuring adequate granulation is as important as closing the defect. Vacuum-assisted closure (VAC) therapy has been used for years to provide granulation in the wound.[10] VAC treatment provides positive gains in many ways by preventing secondary infection in the wound, providing new vessel formation, accelerating epithelization, and reducing pain and edema.[7,10] Because the general clinical condition of patients with FG is unstable, the reconstruction should be short-term and should be effective. One of the important factors for achieving effective results is granulation. With VAC treatment applied after debridement, granulation accelerates.[10] This case series examines the effectiveness of reconstruction with quick application of a superomedial thigh flap combined with VAC treatment.

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