A Novel Concept for Treating Large Necrotizing Fasciitis Wounds With Bilayer Dermal Matrix, Split-thickness Skin Grafts and NPWT
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Abstract: Treatment of necrotizing fasciitis (NF) includes radical surgical debridement often resulting in large wounds that need to be closed with methods including split-thickness skin grafts (STSG), local flaps, or guided tissue regeneration procedures. In this case report, a 45 year-old Caucasian male was surgically treated for a benign left groin hernia, developed NF, and was transferred to the authors’ burn unit. The wound was treated initially with wide debridement and with a brief delay before finally closing the wound. A collagen matrix such as Integra® Dermal Regeneration Template (Integra LifeSciences, Plainsboro, NJ) in combination with STSG and negative pressure wound treatment, can provide fast recovery resulting in pliable, functional skin.
Address correspondence to:
Fredrik R.M. Huss, MD, PhD
Department of Plastic, Hand, and Burn Surgery
University Hospital of Linköping
581 85 Linköping
Phone: 46 13 222000
Necrotizing soft tissue infections (NSTI) represent a large variety of clinical entities ranging from mild pyodermas to life threatening necrotizing fasciitis (NF). Streptococcus spp appears to be the most common causative organism, and aggressive treatment with surgery and antibiotics is warranted in most cases.1–3
At our burn clinic, we have used Integra® Dermal Regeneration Template ([DRT] Integra LifeSciences, Plainsboro, NJ) infrequently in the treatment of necrotizing wounds since 1999. This DRT has been reported to reduce scarring and improve skin pliability compared to wound closure by conventional meshed split-thickness skin grafts.4 These findings have broadened the indications for DRT to also be used in treating revised major soft tissue infections.5 Using negative pressure wound therapy (NPWT) dressings to stabilize (and conform to the shape of the wound surface) with STSG and DRT has previously been described with good results.6,7 Furthermore, NPWT is a method used to treat wounds of different stages as it decreases tissue edema, lowers bacterial count, enhances neovascularization, thus stimulating wound healing.8,9 To the authors’ knowledge, this is the first published case report that describes successful treatment of a patient suffering from NF by combining DRT and NPWT. This novel protocol enabled us to manage and prepare the wound surface and apply the DRT sheets successfully. This report also shows that NPWT significantly decreased the time needed for guided dermal regeneration. Complete wound closure and patient discharge was achieved within 32 days.
A 45-year-old previously healthy Caucasian male was surgically treated for a benign left groin hernia on an outpatient basis. Pre- and postoperative periods were uneventful. The patient began to feel ill on the night of the procedure. Thirty-six hours later he had high fever and a painful, red, and swollen left groin. He presented to the emergency department where local infection was diagnosed.
The skin of the penis and lower abdomen was erythematous, warm, and tender. A minor abscess with associated ascending cellulitis was suspected. He was started on broad-spectrum intravenous (IV) antibiotics and underwent surgical debridement and drainage (the Prolene net was removed). The wound was left open. Over the next 6 hours his condition rapidly deteriorated and he became increasingly septic. At that point (day 0), the patient was referred to the authors’ burn unit with signs of septic shock. He arrived at the ward with systolic blood pressure of 50 mmHg, highly elevated C-reactive protein 248 mg/L, creatinine 207 µmol/L, and myoglobin 6400 µg/L. White blood cell count was normal. The patient was intubated and put on plasma-expander, norepinephrine, dobutamine, epinephrine, cortisone, and diuretics along with tobramycin, clindamycin, and imipenem.
1. Kaul R, McGeer A, Low DE, Green K, Schwartz B. Population-based surveillance for group A streptococcal necrotizing fasciitis: clinical features, prognostic indicators, and microbiologic analysis of seventy-seven cases. Ontario group A streptococcal study. Am J Med. 1997;103(1):18–24.
2. Stevens DL, Tanner MH, Winship J, et al. Reappearance of scarlet fever toxin A among streptococci in the Rocky Mountain West: severe group A streptococcal infections associated with a toxic shock-like syndrome. N Engl J Med. 1989;321(1):1–7.
3. Bisno AL, Stevens DL. Streptococcal infections of skin and soft tissues. N Engl J Med. 1996;334(4):240–245.
4. Frame JD, Still J, Lakhel-Le Coadou A, Carstens MH. Use of dermal regeneration template in contracture release procedures: a multicenter evaluation. Plast Reconstr Surg. 2004;113(5):1330–1338.
5. Akhtar S, Hasham S, Abela C, Phipps AR . The use of Integra in necrotizing fasciitis. Burns. 2006;32(2):251–254.
6. Schneider AM, Morykwas MJ, Argenta LC. A new and reliable method of securing skin grafts to the difficult recipient bed. Plast Reconstr Surg. 1998;102(4):1195–1198.
7. Molnar JA, DeFranzo AJ, Hadaegh A, Morykwas MJ, Shen P, Argenta LC. Acceleration of Integra incorporation in complex tissue defects with subatmospheric pressure. Plast Reconstr Surg. 2004;113(5):1339–1346.
8. Morykwas MJ, Argenta LC, Shelton-Brown EI, McGuirt W. Vacuum-assisted closure: a new method for wound control and treatment: animal studies and basic foundation. Ann Plast Surg. 1997;38(6):553–562.
9. Morykwas MJ, Argenta LC, Shelton-Brown EI, McGuirt W. Vacuum-assisted closure: a new method for wound control and treatment: clinical experience. Ann Plast Surg. 1997;38(6):563–576.
10. Burke JF, Yannas IV, Quinby WC Jr, Bondoc CC, Jung WK. Successful use of a physiologically acceptable artificial skin in the treatment of extensive burn injury. Ann Surg. 1981;194(4):413–428.
11. Thompson J, Marks M. Negative pressure wound therapy. Clin Plast Surg. 2007;34(4):673–684.