Necrotizing fasciitis is a rare but potentially lethal soft-tissue infection that can complicate aesthetic surgical procedures in healthy patients. It may initially present as low-grade infectious cellulitis, putting the plastic surgeon in a special dilemma. Early recognition, vigorous fluid resuscitation, broad-spectrum antibiotics, and radical surgical debridement are the cornerstones of successful treatment.
We report the case of a healthy 42-year-old woman who underwent circular abdominoplasty. The early postoperative course was uneventful. On the fourth postoperative day, the patient presented at the office with severe discomfort in the left paraumbilical region. Results of the clinical examination were normal, except for a light erythema in the left paraumbilical region that was painful on palpation. An ultrasound examination showed the absence of a deep abscess. Blood analyses showed a white blood cell count of 19,900 cells/dl, and her C-reactive protein level was 26.7 mg/l; other values where normal. Infectious cellulitis was suspected and appropriate intravenous antibiotics were given. The patient’s general condition deteriorated progressively over the next 12 hours. She developed a high fever (39°C) with signs of septic shock. Purplish-blue stains with little blisters appeared in the left paraumbilical region (Fig. 1). Broad-spectrum intravenous antibiotics were installed and intensive fluid resuscitation was started. The patient was immediately transferred to the operating room, where excisional biopsy confirmed the diagnosis of necrotizing fasciitis.
Radical debridement of superficial fascia, fat, and skin was performed until no suspicious tissue was left. The abdominal wall muscles and muscular aponeurosis were not affected. The resulting soft-tissue defect affected two-thirds of the anterior abdominal wall and one-fourth of the left back (Fig. 2). Bacteriological analysis identified a polymicrobial origin of the infection.
Daily dressing changes were performed with the patient under general anesthesia. Global evolution was rapidly favorable. Partial wound closure was performed on the second postoperative day. Complete wound closure was obtained by meshed split-thickness skin grafts on the sixth postoperative day. The patient was able to leave the hospital on postoperative day 14.
To our knowledge, fewer than 10 cases of necrotizing fasciitis following aesthetic surgery have been described. The involved included liposuction,1 blepharoplasty, and midface lifting.2 Necrotizing fasciitis occurs predominately, but not exclusively, in the debilitated patient. The clinical signs may at first be subtle and nonspecific, such as pain, swelling, and erythema.3 Characteristic skin changes may only occur later in the course of the disease. Pain out of proportion to trauma associated with local skin changes, such as blistering on purple skin, is commonly described as a typical finding in necrotizing fasciitis.3 Progression of the disease without surgical intervention, despite appropriate antibiotherapy, is usually one of rapid deterioration with septic shock and death.
The diagnosis of necrotizing fasciitis is essentially clinical. Biological inflammatory signs are present. Magnetic resonance imaging is the most reliable noninvasive tool of diagnosis, even in the early stages.4 Frozen-section biopsies are the accepted standard for the diagnosis.5 The biopsy should include the skin, subcutaneous fat, and fascia in the affected area.
Treatment includes broad-spectrum antibiotics, due to the mostly polymicrobial nature of necrotizing fasciitis, and vigorous fluid resuscitation. Most important, however, is early radical surgical debridement with mandatory re-exploration after 24 hours.3
Florian M. Gaede, M.D.
Aous Ouazzani, M.D.
Serge de Fontaine, M.D.
Department of Plastic and Reconstructive Surgery
Erasme University Hospital
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3. Sudarsky, L. A., Laschinger, J. C., Coppa, G. F., et al. Improved results from standardized approach in treating patients with necrotizing fasciitis. Ann. Surg.
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