Outcomes in Fournier’s Gangrene Using Skin and Soft Tissue Sparing Flap Preservation Surgery for Wound Closure: An Alternative Approach to Wide Radical Debridement

Introduction. Fournier’s gangrene (FG) remains a forbidding necrotizing soft tissue infection (NSTI) that necessitates early recognition, prompt surgical excision, and goal-directed antibiotic therapy. Traditionally, surgical management has included wide radical excision for sepsis control, but this management often leaves large, morbid wounds that require complex wound coverage, prolonged hospitalizations, and/or delayed healing. Objective. The purpose of this case series is to report the outcomes of FG using a surrogate approach of concurrent debridement of spared skin and soft tissue, negative pressure wound therapy (NPWT), and serial delayed primary closure (DPC). Materials and Methods. A retrospective review of 17 consecutive patients with FG treated with concurrent skin and soft tissue sparing surgery, NPWT, and serial DPC at Miami Valley Hospital Regional Adult Burn and Wound Center (Dayton, OH) between 2008 and 2018 was conducted. Patients were included if the following were noted: clinical suspicion of FG based on genital and perineal cellulitis, fever, leukocytosis, and confirmation of tissue necrosis upon surgical exploration. Patients not treated with skin sparing surgical debridement or wounds with an inability to maintain a NPWT dressing seal were excluded. Results. The mean number of total surgeries including simultaneous debridement and reconstruction was 5.5. The average intensive care unit and hospital length of stay was 3.2 and 18.9 days, respectively. The average number of days from initial consult to wound closure was 24.3. The need for colostomy and skin grafts were nearly eliminated with this surrogate approach. Using this reproducible technique, DPC was achieved in 100% of patients. Only 11.8% (2/17) required split-thickness skin grafting as part of wound closure. The majority (9/17; 52.9%) were partially managed as an outpatient during wound closure. During staged DPC, the mean number of outpatient management days was 16.0. There were no mortalities in this series of patients. Conclusions. To the best of the authors’ knowledge, this is the largest case series reported in the literature using skin and soft tissue sparing surgery for wound closure of a FG NSTI.

Fournier’s gangrene (FG) is an infrequent yet rapidly advancing, life-threatening necrotizing soft tissue infection (NSTI). Even Hippocrates, in the earliest known written description of NSTIs, singles out FG’s particularly devastating effects, writing “But the most dangerous cases of all cases were when the pubes and genital organs were attacked.”¹ The eponym is assigned to Jean-Alfred Fournier, a Parisian dermatologist and venereologist, who published a case series in 1883 describing “fulminant gangrene” of the penis and scrotum in 5 otherwise healthy young men.² There are only 1000 NSTI cases in the United States annually,³ but the incidence appears to be increasing.^4-6 Conclusive diagnosis is established upon surgical exploration. The fundamental surgical goals are immediate abolishment of purulent and necrotic tissue to eliminate further vertical and centrifugal transmission of infection during the primary exploration.^7,8

The mortality rate of NSTI has decreased over the last 10 years due to increased emphasis on high degree of suspicion, early diagnosis, sepsis protocols with early broad-spectrum antibiotics, and surgical intervention. Traditionally reported mortality rates range from 3.6% to 40%,^3,4,9-18 with even higher rates reported,^19,20 but recent National Surgical Quality Improvement Program data suggest a modern mortality of about 10%.⁵ Historically, surgical management of FG, which includes wide radical excision of the sentinel area of necrosis as well as potentially viable surrounding skin and soft tissue, has remained relatively unchanged. Patients are left with large, morbid perioperative wounds that often necessitate multiple surgical debridements prior to reconstruction; other centers report 2.64,¹² 5.02,⁴ and 5.55²¹ debridements.Increased length of stay (LOS) is inextricably linked to these large, complex wounds. Studies report LOS consistent with 69.3 days,⁴ 41 days,²² 36 days,⁹ 19.7 days,²³ 18 days,⁵ and 12 days.¹² These large, complex wounds also create formidable challenges in regards to postoperative wound care, quality of life, functionality, and acceptable cosmetic outcomes. Many of these wounds are still allowed to close by secondary intention wound healing; even with superior care, 18% remain partially open at 6-month follow-up.¹² Patients experience long-term decreases in quality of life even after the physical wounds have healed.²⁴

Previous studies have characterized the degrees of skin and soft tissue viability in a similar manner to thermal wound theory, which describes injury zones of coagulation, stasis, and hyperemia.⁷ As described by Wong et al,⁷ zone 1 is the area of nonviable skin at the epicenter of infection and exhibits hemorrhagic bullae, dermal hemorrhage, and frank dermal gangrene. Zone 2 surrounds zone 1 and is marked by exquisite tenderness, erythema, and warmth. Zone 3 is normal skin not yet infected. Although necrosis within zone 1 must be resected in its entirety, zones 2 and 3 depict potentially salvageable skin and soft tissue to be used for future reconstruction (Figures 1, 2).⁷ These observations closely evaluate the somatic clues of skin and soft tissue viability. They also promote recognition of collateral blood flow from the dermal and subdermal plexus to viable skin and soft tissue. This insight afforded the authors the opportunity to develop a technique that promotes complete surgical excision with safe skin and soft tissue flap preservation.

This 17-patient case series reports the outcomes of FG using a surrogate approach of concurrent debridement of spared skin and soft tissue, negative pressure wound therapy (NPWT), and serial delayed primary closure (DPC). The treatment in these cases serves to contrast the traditional surgical management team approach. The authors approached each case through exploratory incisions that allowed full access to the underlying infection and necrosis while considering future reconstruction using spared skin and soft tissue. This illustrates the Miami Valley Hospital Regional Adult Burn and Wound Center (Dayton, OH) approach of meticulous serial debridement with simultaneous DPC of spared skin and soft tissue flaps in FG.

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.

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.

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

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.

The authors evaluated a total of 17 cases of FG. An average of 5.5 operative interventions were performed, including simultaneous debridement and reconstruction. The average ICU and hospital LOS was 3.2 and 18.9 days, respectively. The average number of days from initial consult to wound closure was 24.3. Only 1 patient required an ostomy due to complete lack of viable perianal skin. Delayed primary closure was achieved in 100% of patients. Only 2 patients required a STSG as part of wound closure. Of those 2, the area of skin grafting required was well-below 15% of the total initial wound area. Nine of 17 patients were partially managed as an outpatient during wound closure; for these 9 patients, the mean number of outpatient management days was 16.0. There were no mortalities in this series of patients.

The following serve as exemplary cases of the 17 patients with FG treated with the reported surgical technique and wound healing course of treatment. eTable 2 documents all surgical and clinical outcome data for the 17 patients.

Case 2

A 42-year-old Caucasian man presented with a 5-day history of pain in the left buttock. The patient initially was seen at an outside hospital 5 days prior to presenting to the authors’ institution and was treated for left thigh cellulitis with oral trimethoprim/sulfamethoxazole 800 mg to 160 mg twice daily for 10 days. His symptoms worsened prior to completion of this antibiotic course to include fever, malaise, and nausea. A computed tomography (CT) scan was consistent with extensive gas throughout the buttock, perineal region, and left hemiscrotum, with evidence of abscess in the left perianal region suggestive of FG.

On presentation, the patient received a 1-time dose of intravenous (IV) vancomycin 1000 mg, IV piperacillin/tazobactam 3.375 g, and IV clindamycin 300 mg. Infectious disease was consulted given this patient’s status as a kidney transplant recipient. The IV clindamycin dosage was increased to 600 mg and continued for 3 additional doses. Intravenous daptomycin 750 mg was administered every 48 hours for 2 doses. The patient also was started on IV meropenem 1 g twice daily, which after 3 days was increased to 3 times daily for 11 additional days. This was later changed to IV ertapenem 1 g daily for 9 days (for a total 21-day course). In addition, he received recommended preventative antimicrobials, including oral trimethoprim/sulfamethoxazole 160 mg to 800 mg every Monday, Wednesday, and Friday (for Pneumocystis carinii pneumonia prevention) and oral valganciclovir 450 mg daily (for Cytomegalovirus disease prevention).

With an initial wound size of 400 cm², the patient received the previously described operative management and wound care over the course of 32 in-hospital days and 0 outpatient days. The wound closed in 29 days (Figure 7).

Case 3

A 52-year-old Caucasian man presented to an outside emergency department (ER) with perianal redness, swelling, and pain and was prescribed an oral 7-day course of levofloxacin 750 mg tablet daily and 10-day course of metronidazole 500 mg three times daily. His symptoms continued to worsen, and 3 days after initial presentation, he presented to the Miami Valley Hospital ER with a 6-day history of symptoms, including subjective fever, nausea, and vomiting. A CT scan of the pelvis demonstrated gas within the scrotum extending into the perineum concerning for FG.

On presentation, the patient received 1 dose of IV clindamycin 900 mg. He was placed immediately on IV piperacillin/tazobactam 3.375 g three times daily for 19 days and IV vancomycin 1 g twice daily for 18 days. He underwent initial debridement with emergency general surgery upon admission, but surgical care was later transferred to a burn and wound surgeon (TP). This patient also received 1 dose of IV cefazolin 2 g for surgical prophylaxis, which likely was administered in error without realizing the patient was on scheduled antibiotics. Wound cultures were positive for anaerobic gram-positive cocci and anaerobic gram-negative bacilli, beta-lactamase positive.

After receiving the above treatment protocol, the patient received a 35-cm² STSG (initial wound size of 274 cm²), and the wound was closed on treatment day 19 after a hospital LOS of 21 days and no outpatient treatment (Figure 8).

Case 4

A 50-year-old Caucasian man presented to the Miami Valley Hospital ER with a 3- to 4-day history of swelling, redness, and increasing pain to the right buttock that was quickly spreading to the perineum and right testicle. A CT of the pelvis demonstrated subcutaneous edema and gas in the right perineum and scrotum with superficial abscess of the right buttock pathognomonic for FG. The patient underwent surgical debridement by emergency general surgery immediately upon admission. He received IV clindamycin 600 mg once then 900 mg 3 times daily for 3 days. Infectious disease was consulted early and managed the patient’s antimicrobials, including IV vancomycin 1000 mg twice daily for 3 days and IV piperacillin/tazobactam 3.375 g three times daily for 30 days. Intravenous anidulafungin was added due to Candida growth on operative cultures, starting with a 200-mg loading dose followed by 100 mg daily for 20 days. Oral rifaximin 550 mg twice daily for 27 days was continued for treatment of hepatic encephalopathy.

With an initial wound size of 282 cm², the patient’s wound closed in 25 days with 29 in-hospital days following the aforementioned treatment (Figure 9).

Case 5

A 37-year-old Caucasian man presented to a satellite ER of the authors’ hospital with a complaint of right groin and testicular pain with associated fever and chills lasting 4 days. A CT of the pelvis showed subcutaneous gas within the anterior pelvis and medial thigh concerning for FG, so the patient was transferred to Miami Valley Hospital.

He was prescribed IV piperacillin/tazobactam 4.5 g loading dose followed by 3.375 g three times daily for 10 days. He also received IV clindamycin 900 mg loading dose followed by 600 mg three times daily; IV vancomycin 1250 mg twice daily also was administered for 2 days. The patient underwent surgical debridement with emergency general surgery immediately upon admission. Initial blood cultures were positive for gram-negative bacilli, and wound cultures were positive for multiple types of anaerobic gram-positive rods, anaerobic gram-negative bacilli, anaerobic gram-positive cocci, and Prevotella species. Aerobic cultures also grew gram-positive cocci and gram-negative bacilli.

Subsequently, the patient developed a rash that was attributed to piperacillin/tazobactam. He then was transitioned to IV vancomycin 1250 mg twice daily (later 1.5 g 2x/day), IV levofloxacin 750 mg daily, and IV metronidazole 500 mg three times daily for 9 additional days; IV fluconazole 400 mg daily also was added for 8 days.

The patient presented with a wound measuring 287 cm², had a hospital LOS of 18 days and outpatient treatment of 10 days, and achieved wound closure following 28 days of this treatment (eFigure 10).

Case 6

A 56-year-old Caucasian woman presented to the Miami Valley Hospital ER with complaint of a right labial abscess that had been present for 3 days, with worsening swelling and redness. Previous treatment from the Miami Valley Hospital ER visit 3 days prior to presentation included oral cephalexin 500 mg 4 times per day for 7 days and trimethoprim-sulfamethoxazole 160 mg to 800 mg twice daily for 7 days (neither course was completed). A CT of the pelvis demonstrated a large area of inflammatory change and gas within the right labial soft tissues concerning for gas gangrene. She was treated empirically with IV vancomycin 1750 mg loading dose, then 1500 mg twice daily for 5 days and IV piperacillin/tazobactam 3.375 g three times daily for 13 days. The patient underwent emergent excisional debridement with the gynecology service on admission. Wound cultures were positive for microaerophilic streptococci. She was transitioned to oral amoxicillin-clavulanate 500 mg to 125 mg twice daily for 7 additional days. She also received 2 separate single doses of oral fluconazole 150 mg for urinary fungal infections.

With an initial wound measurement of 475 cm² that took 27 days to close, she had a hospital LOS of 16 days and outpatient treatment of 6 days (Figure 11).

Case 7

A 43-year-old Caucasian woman presented to the Miami Valley Hospital ER with primary complaints of weakness, nausea, and vomiting after experiencing a fall from a standing position. She was found to have an acute kidney injury secondary to dehydration and septic shock requiring pressor support. A right labial abscess present 2 days prior to admission was believed to be the source of sepsis. The gynecologic service was consulted on hospital day 1 and performed a bedside incision and drainage (I&D). The patient then was started on IV clindamycin 600 mg three times daily for 4 doses, then coverage was broadened to include IV vancomycin 1250 mg daily and IV piperacillin/tazobactam 3.375 g every 12 hours for 4 days. Oral fluconazole 50 mg also was administered once at the time of admission. The piperacillin/tazobactam then was discontinued and the patient was started on oral doxycycline 100 mg twice daily for 6 days.

Cultures grew methicillin-resistant Staphylococcus aureus (MRSA), Escherichia coli, and coagulase-negative staphylococci (CoNS). On hospital day 12, she had worsening pain and swelling of the right labia. A CT scan showed evidence of persistent abscess; therefore, she was taken to the OR by the gynecologic service for I&D of the right vulvar abscess with vulvar debridement and partial vulvectomy. Operative cultures grew MRSA and E coli with 1 of 2 blood cultures growing CoNS. Intravenous vancomycin 1000 mg twice daily for 8 days and IV piperacillin/tazobactam 3.375 g every 12 hours were started for 11 days. The surgeon (TP) was consulted on hospital day 14 and performed subsequent debridements and complex closure.

As the vancomycin was discontinued, the oral doxycycline 100 mg twice daily was restarted for 6 additional days. When the piperacillin/tazobactam was discontinued, the patient was transitioned to oral amoxicillin-clavulanate 875 mg to 125 mg twice daily. Both the doxycycline 100 mg twice daily and oral amoxicillin-clavulanate 875 mg to 125 mg twice daily were continued 7 days after discharge.

With an initial wound size of 452 cm², her wound closed in 24 days after an ICU LOS of 9 days, hospital LOS of 11 days, and outpatient treatment of 13 days (eFigure 12).

Case 8

A 53-year-old man, found to be unresponsive and hypothermic, was transferred directly from the authors’ institution’s satellite ER to the Miami Valley Hospital medical ICU with severe diabetic ketoacidosis, lactic acidosis, and acute kidney injury with erythema, pain, and swelling of the scrotum. The patient had noted the scrotal lesion 5 or 6 days prior to presentation. He reported trying to express the area himself but also admitted to active heroin abuse.

The patient was given piperacillin-tazobactam 3.375 g every 8 hours starting on the first hospital day and continued for 28 days. On hospital day 2, clindamycin 600 mg every 6 hours and vancomycin 1 g daily to 1.25 g twice daily were added and continued for 5 days. On hospital day 8, linezolid 600 mg twice daily was started and continued for 23 days. Wound cultures were positive for MRSA.

The patient had an initial wound size of 261 cm² that took 26 days to close; he spent 22 days in the ICU, 38 in the hospital, and 0 in outpatient care (Figure 13).

Case 12

A 46-year-old woman presented to the Miami Valley Hospital ER with a 6-day history of a “boil” on her left labia that had previously drained but had steadily worsening swelling, redness, and pain spreading to her mons pubis. A CT scan of the pelvis demonstrated gas within the left labia.

On the day of presentation, the patient was given vancomycin 1 g, which was increased to 2 g twice daily through hospital day 3. On hospital day 2, piperacillin/tazobactam 3.375 g three times per day was started and continued for 3 days. Piperacillin/tazobactam then was transitioned to oral amoxicillin-clavulanate 875 mg to 125 mg twice daily for 7 days. On hospital day 10, she was transitioned to clindamycin 600 mg every 8 hours and oral fluconazole 100 mg daily until discharge from the hospital. Wound cultures grew group C beta-hemolytic streptococci, microaerophilic streptococcus, and Corynebacterium.

Following the treatment reported, her initial wound size of 402 cm² had received a 30-cm² STSG and the wound closed in 56 days after 15 days in the hospital and 41 in outpatient treatment (eFigure 14).

Case 13

A 65-year-old woman presented to the Miami Valley Hospital ER with a 6-day history of an abscess to the right labia. She was treated by her family physician with ciprofloxacin 500 mg twice daily for 5 days with no improvement before the abscess spontaneously began to drain purulent fluid with worsening redness and pain spreading to the right buttock and thigh. A CT scan demonstrated right buttock and labial inflammation with fat stranding and no identifiable abscess.

On the day of presentation, the patient received a 1-time dose of vancomycin 1 g and was started on piperacillin/tazobactam 3.375 g three times daily for 8 days. On hospital day 2, she received a 1-time dose of metronidazole 500 mg and was started on linezolid 600 mg twice daily for 14 days. When piperacillin-tazobactam was discontinued, she was transitioned to oral amoxicillin-clavulanate 875 mg to 125 mg twice daily for 7 days. On hospital day 15, she was transitioned from amoxicillin-clavulanate to doxycycline 100 mg daily for 2 days prior to discharge. Wound cultures were positive for MRSA.

The patient’s initial wound measuring 204 cm² closed in 10 days with a hospital LOS of 15 days and no outpatient care following the aforementioned treatment (eFigure 15).

Case 15

A 58-year-old man with a history of type 2 DM, hypertension, and anxiety presented to the Miami Valley Hospital ER with right buttock pain. Initial examination was concerning for perirectal abscess. The patient was admitted and taken to the OR by emergency general surgery for I&D of perirectal and right scrotal NSTI. Burn and wound service was consulted for further management.

On hospital day 2, he was given oral trimethoprim/sulfamethoxazole 500 mg twice daily for 1 day. On hospital day 3, he was started on clindamycin 900 mg every 8 hours, piperacillin-tazobactam 3.375 g twice daily, and vancomycin 1.75 g twice daily; this 3 antibiotic regimen was continued for 2 days. On hospital day 4, those 3 were discontinued, and he was transitioned to ampicillin/sulbactam 3 g every 6 hours and continued for 3 days. He then was transitioned to oral amoxicillin-clavulanate 500 mg to 125 mg twice daily for 3 days, and then an increased dose of 875 mg to 125 mg for the 6 remaining days of hospitalization.

After this course of treatment, his wound, initially measuring 201 cm², closed in 5 days with a hospital LOS of 16 days (eFigure 16).

Case 16

A 53-year-old man, with a history of uncontrolled type 2 DM, presented with reports of 2 days of ongoing scrotal pain. A CT scan showed mild fat stranding within the perineum with features suggestive of cellulitis. The patient was taken to the OR by emergency general surgery for I&D.

On arrival, the patient was started on piperacillin-tazobactam 3.375 g three times daily, which was continued for 4 days until hospital day 5. He received a 1-time dose of clindamycin 900 mg on hospital day 2. On hospital day 3, he was started on daptomycin 500 mg twice daily, which was continued for 2 days. On hospital day 5 for 16 days, metronidazole 500 mg was administered 3 times daily and ceftriaxone 2 g daily. He then was transitioned to ampicillin/sulbactam 1.5 g three times daily for 5 days until discharge.

His wound measured 330 cm² initially and healed in 16 days following 9 ICU days and 24 hospital days; no outpatient treatment was necessary (eFigure 17).

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 changes¹¹; 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

No clinical study is without limitations. A major limitation in this study is the lack of a control group, which limits the outcome comparison to historical controls of NSTIs in the literature. The different innovations over time and different resource allocation between differing institutions make any statistical comparison impossible. In addition, this study did not evaluate the financial impact of a reduced LOS, the use of topical antibiotics and NPWT versus wet-to-dry dressings. It is possible that there is an overall cost savings to this approach, but further analysis is required. The inability to maintain a seal for NPWT may lead to the impediment of assisted closure using this device. Wounds in which significant gluteal and perianal skin necrosis are present may lead to the inability to achieve wound closure without surgical or nonsurgical fecal diversion. Limitations also include a small sample size and single institution design; however, considering the rarity of this disorder, the sample size is considered representative.

Understanding the somatic clues of skin and soft tissue viability is imperative to optimizing clinical and surgical outcomes using spared skin and soft tissue in wound closure of the NSTI FG. This series of 17 consecutive patients with FG who safely achieved large skin and soft tissue flap preservation were treated using a triad of (1) skin and soft tissue sparing debridement, (2) NPWT with antibiotic irrigation, and (3) serial DPC (eFigure 18). This technique has shown success and reproducibility over a 10-year time period at the authors’ institution as an alternative approach to traditional NSTI treatments, because complete infection control is uncompromised while safely sparing skin and soft tissue for future reconstruction in FG. This allows the reconstruction of preserved skin and soft tissue flaps as a potential and viable adjunct to perioperative wound management in patients with FG. This skin sparing and flap preservation approach yielded acceptable outcomes while avoiding the long-standing dilemma of how to reconstruct such complex NSTI wounds.

In all cases, there was no need for orchiectomies or testicular translocation and rarely a need for skin grafting or colostomy. Skin and soft tissue preservation also obviated the need for management of common surgical complications such as flap loss, skin graft scar contractures, or testicular viability after thigh pouch placement. Reduced LOS, faster healing times, and good cosmesis were achieved. Early meticulous surgical exploration and debridement may minimize the total number of surgeries and hospital LOS. Continued prospective data should be collected on this approach for patients with FG to confirm these promising outcomes.

The authors would like to acknowledge Phillip Heyse, MD, for coauthorship of an earlier case series on NSTIs.³⁵ Coauthor Lindsay Kranker, MD, is the creator of the included graphics in Figure 2.

Travis L. Perry, MD^1,2; Lindsay M. Kranker, MD²; Erin E. Mobley, PA¹; Eileen E. Curry, MD³; and R. Michael Johnson, MD, MPH³

Affiliations: ¹Miami Valley Hospital Regional Adult Burn and Wound Center, Dayton, OH; ²Wright State University, Boonshoft School of Medicine, Department of Surgery, Dayton, OH; and ³Wright State University, Boonshoft School of Medicine, Division of Plastic Surgery

Correspondence: Travis L. Perry, MD, Wright State University, Boonshoft School of Medicine, Department of Surgery, Miami Valley Hospital, One Wyoming Street, Suite 3271, Dayton, OH 45409; tlperry@premierhealth.com

Disclosure: The authors disclose no financial or other conflicts of interest.