Eight Tales of Cervical Necrotizing Fasciitis and Free Tissue Transfer

Abstract

Objectives:

Aggressive surgical debridement is required in cervical necrotizing fasciitis, and in severe defects, subsequent free tissue transfer might be necessary. However, there is concern that the inflammatory environment of the infection site may threaten free flap viability, particularly with concerns for thrombosis of feeding vessels and compromised tissue integration. Cases in the head and neck area are rare, so there are limited data regarding outcomes of free tissue transfer in these patients.

Methods:

A retrospective chart review assessed patients with cervical necrotizing fasciitis treated at an academic tertiary hospital between 2015 and 2021. Twenty-five patients were identified, and eight required free tissue transfer after adequate surgical debridement. Treatment, hospital course, and demographic data were collected on these eight patients.

Results:

All flaps had full survival at follow up (median follow up 3 months, range 1–39 months) without concerns for vascular compromise.

Conclusion:

These data suggest that in patients with large soft tissue defects due to cervical necrotizing fasciitis, free tissue transfer may be a safe treatment modality.

Introduction

Necrotizing fasciitis is an aggressive and rapidly progressing infection of soft tissue and skin. While it is most common in the extremities and trunk, 1–10% of cases involve the head and neck area¹. Infections in this area are most frequently due to odontogenic or pharyngeal sources¹. Mortality rates have been estimated to be as high as 35%, with higher mortality associated with cases involving the mediastinum or progressing to septic shock^2,3. Due to the rapidly progressive nature of necrotizing fasciitis, early and aggressive surgical debridement in conjunction with broad-spectrum antibiotics are cornerstones in management⁴.

Surgical management of necrotizing fasciitis in the head and neck presents unique challenges because appropriate control of disease often leads to significant tissue loss with exposure of important structures, including the great vessels and laryngeal framework. These cases are not adequately addressed by vacuum-assisted closure (VAC), skin grafts, and local flaps, and may necessitate free tissue transfer to cover the resulting defect. Many comorbidities associated with necrotizing fasciitis, such as diabetes, alcoholism, immunosuppression, intravenous drug abuse, malignancy, and vascular disease, are also associated with free flap failure⁵. Additionally, the inflammatory pathophysiology of necrotizing fasciitis raises concern for thrombosis, which is the primary cause of flap loss⁶. These reasons, coupled with the relative dearth of literature on free tissue transfer in the management of necrotizing fasciitis, has led to uncertainty regarding the success of such treatment.

Due to the rarity of this condition, even systematic reviews on free tissue transfer in necrotizing fasciitis and cervical necrotizing fasciitis have limited mention of this type of treatment^1,3. This case series aims to add insights regarding the safety and outcomes of free tissue transfer in patients with cervical necrotizing fasciitis by analyzing eight patients who were treated with free tissue transfer and microvasculature reconstruction.

Methods

A retrospective chart review was performed between January 1, 2015, and December 31, 2021 to identify patients treated for cervical necrotizing fasciitis at Washington University in St. Louis, School of Medicine. Twenty-four patients were identified, and eight patients required free tissue transfer with microvascular reconstruction. Two of these patients required two flaps: one concurrent and one sequential. The data collected included patient demographics, surgical and medical management details, free flap information, hospital course, and outcomes. This study was approved by the Washington University School of Medicine Institutional Review Board (IRB #202111093).

Results

Of the eight patients, median age was 51 (range 28–68) years, and there were 3 females. The most common source of infection was odontogenic (n=5), with the remainder of unknown origin (n=2) or originating from the oral mucosa (n=1). All patients had a different variety of causative organisms, with one patient’s tissue culture yielding no identifiable types. Three patients were observed via imaging to have mediastinal involvement. Additionally, three patients had growth on blood cultures, yielding different organisms for each patient. A summary of demographics, infection information, and medical management is provided in Table 1.

Table 1.

Demographics and infection information.

ID	Age	Sex	Comorbiditiesa	Infection Source	Tissue Organisms	Antibioticsb	Mediastinal involvement	Blood culture organism(s)
1	58	Female	Alcoholism, hypertension	unknown	Streptococcus anginosa, MSSA	Vancomycin, Clindamycin, Piperacillin-tazobactam, Cefepime	Yes	none
2	32	Male	none	odontogenic	Actinomyces odontolyticus, Candida albicans	Micafungin, Vancomycin, Piperacillin-tazobactam, Cefepime, Metronidazole, Clindamycin	Yes	Streptococcus Mitis, Aggregatibacter Segnis
3	46	Male	HIV w/ AIDS	oral mucosa (R cheek)	Candida albicans, coagulase-negative Staphylococci	Vancomycin, Cefepime, Metronidazole, Micafungin, Ampicillin-sulbactam	No	Campylobacter Rectus
4	43	Male	none	unknown	GAS	Vancomycin, Piperacillin-tazobactam, Cefepime, Clindamycin	No	GAS
5	68	Male	Hypertension	odontogenic	Not identified	Vancomycin, Clindamycin, Piperacillin-tazobactam, Cefepime	Yes	none
6	28	Male	none	odontogenic	Streptococcus constellatus, Streptococcus anginosis, Candida albicans	Vancomycin, Piperacillin-tazobactam, Micafungin, Ceftriaxone, Metronidazole, Fluconazole	No	none
7	60	Female	Diabetes mellitus	odontogenic	Streptococcus constellatus	Vancomycin, Cefepime, Metronidazole, Clindamycin, Ceftriaxone	No	none
8	56	Female	Diabetes Mellitus, Malignancy	Unknown	Coagulase - Staphylococci	Vancomycin, Cefepime, Metronidazole, Piperacillin-tazobactam, Meropenem, Ampicillin-sulbactam	No	none

Abbreviations: HIV: human immunodeficiency virus, AIDS: acquired immunodeficiency syndrome, MSSA: methicillin susceptible staphylococcus aureus, GAS: group A streptococcus

^aComorbidities included diabetes mellitus, alcoholism, history of malignancy, immunosuppression, HIV, vascular disease and IV drug abuse

^bIncludes all antibiotics used during hospital course

The median number of days from 1^st debridement to flap placement was 12.5 (range 6–18). The median number of debridements was 4.5 (range 3–5). The flap sizes ranged from 8cm × 6cm to 13cm × 40cm (48cm² to 520cm²). A summary of the debridement information, flap type and size, and vessels used is included in Table 2.

Table 2.

Surgical and free flap information.

ID	Number of debridements	Days to flap from 1st debridement	Free flap type	Artery used for anastomosis	Vein used for anastomosis	Secondary reconstruction cm × cm (cm2)	Defect size cm × cm (cm2)
1a	5	11;18	L ALT; R ALT	External carotid; R facial	Internal jugular; main facial	Adjacent tissue transfer 40 × 20 (800)	9 × 30 (270)(L); 30 × 10 (300)(R)
2	5	18	R ALT	L external carotid	Facial	None	15 × 8 (120)
3b	3	15	L RF; R gracilis	Facial	Facial	None	8 × 6 (48)(RF); 14 cm length (gracilis)
4	3	8	R ALT	R transverse cervical	R transverse cervical	None	13 × 40 (520)
5	4	8	R ALT	Facial	Ranine	None	Not specified
6	5	17	R ALT	Internal mammary	Internal mammary	None	10 × 14 (140)
7	5	14	L ALT	Facial	Facial	None	15 × 20 (300)
8	2	6	L ALT	L transverse cervical	L external jugular	None	10 × 15 (150)

Abbreviations. L: left, R: right, ALT: anterolateral thigh, RF: radial forearm

^aThis patient received sequential flaps. Information is for 1^st flap; 2^nd flap

^bThis patient received concurrent flow-through flaps

None of the eight patients experienced any vascular compromise to their free flap construction, and all flaps had full survival. The most common complications were hematoma (n=2) and suture dehiscence (n=2). The median intensive care unit (ICU) length of stay was 10.5 days (range 3–30), and the median hospital stay was 23 days from admission to discharge (range 14–47). Median length of follow up was 3 months (range 1–39). The median length of intubation was 9 days (range 2–28). Three out of the eight patients required tracheostomy for a range of 15–57 days. A summary of vascular events, flap outcomes, follow-up length, complications, and ICU and hospital stay is demonstrated in Table 3.

Table 3.

Outcomes and hospital course

ID	Vascular Compromise	Flap outcome	Length of follow up (months)a	Complications	Complication treatment	ICU length of stay	Overall length of hospitalization	Duration of intubation (days)	Duration of tracheostomy (days)b
1	None	Full survival	3	Superior suture dehiscence	Daily saline-soaked kerlix packing	30	47	28	57
2	None	Full survival	2	Hematoma	Chest wall exploration for evacuation of hematoma	24	25	15	16
3	None	Full survival	3	None	None	4	28	3	0
4	None	Full survival	1	Hematoma	Neck exploration for evacuation of hematoma	3	21	2	0
5	None	Full survival	39	None	None	8	14	7	0
6	None	Full survival	8	None	None	5	21	8	15
7	None	Full survival	6	Posterior and anterior suture dehiscence	Twice daily saline-soaked kerlix packing	16	29	14	0
8	None	Full survival	1	None	None	13	20	10	0

^aMost recent follow up appointment since flap procedure

^bDate of placement through date of decannulation

Figure 1 displays images from the surgical course of patient ID # 1. This patient underwent two sequential flaps. The pictures show the complete defect, the outcome of the staged flap procedures, and the patient at follow-up.

Figure 1.

Patient ID #1 underwent five debridements for cervical necrotizing fasciitis with a resulting defect of 570 cm². The complete defect (A) demonstrates exposed right sternocleidomastoid (SCM), left omohyoid (OMO), thyroid lobes (*), thyroid cartilage (arrow), and left internal jugular vein (arrowhead). A staged double flap (B and C) was performed on hospital days 11 and 18 given the overall size of the defect. In panel B, * marks the first anterolateral thigh free flap after inset, arrowhead indicates the venous coupler (facial vein) of the second anterolateral thigh free flap, and arrow denotes an implantable doppler over the anastomosed artery (right facial artery). Patient ID #1 was discharged on hospital day 47 and was seen in clinic 3 months later (D) with complete integration of both free flaps and closure of prior tracheostomy stoma.

Discussion

In this series of eight patients with cervical necrotizing fasciitis who underwent 10 free flap reconstructions in total, there were no flap failures, including partial losses. The infections described in this case series predominantly affected the deep neck spaces. Patient ID#3 was the only patient with extension into the buccal space, requiring debridement of a substantial portion of the cheek (Table 1). This defect was repaired with concurrent flow-through flaps using the left radial forearm and right gracilis muscle. Additionally, the hospital course, including ICU length of stay and total hospital length of stay, appear to be similar to cases without free tissue transfer.

Cervical necrotizing fasciitis is a rare and rapidly spreading soft tissue infection with significant mortality rates. Due to the anatomic location, progression to mediastinitis is a common progression and is associated with decreased survival⁷. Surgical debridement is a necessary treatment, but in severe cases it can lead to exposure of the great vessels and even airway structures. While skin grafting is usually sufficient, free tissue transfer is sometimes required for large defects. However, many comorbidities associated with cervical necrotizing fasciitis are also associated with free flap failure. This begs the question about feasibility of free flaps and their survival in this context.

Thrombosis is a common complication in necrotizing fasciitis due to the immune response and subsequent ischemia inducing tissue damage and cell death⁸. Post-flap thrombosis is associated with extremely low rates of flap survival and thus is a concern in treating a condition which frequently causes blood clots⁹. When treated with adequate debridement and complete removal of infected tissue beforehand, the release of inflammatory mediators should be halted and allow for healthy blood flow¹⁰. The largest literature review to date reports a mean range of 2–5 surgical debridements per case¹. Our median number of debridements were consistent with the literature (Table 2). Additionally, there were no instances of vascular compromise in any of our patients after flap surgery (Table 3). This suggests that extent of surgical debridement is similar in patients who require free tissue transfer and those who do not, and that thrombosis can be avoided with sufficient debridement.

Cervical necrotizing fasciitis often involves a long and complicated hospital course. General necrotizing fasciitis cases required an average of 24 days in the hospital¹¹, and other studies have found cervical infections to have a median stay of 22 days¹². Except for a notable outlier requiring 47 days and two sequential flaps due to a massive defect (Figure 1), our patients fit into this range (Table 3). ICU admissions are common, with some sources indicating up to 70% of patients require an admission¹³. It is unsurprising that cases severe enough to require free tissue transfer almost always necessitate ICU admission, but among all ICU admissions with necrotizing fasciitis, there do not appear to be differences in length of stay between those requiring tissue transfer and those that do not³. This finding held true in our case series and indicates that patients who receive free tissue transfer do not require extra length in the hospital or additional ICU resources. (Table 3).

Airway management in the setting of cervical necrotizing fasciitis warrants particular discussion. Most patients are intubated at presentation to avoid impending airway compromise. In cases where the infection quickly resolves and there is no longer an airway concern, they may be extubated by the intensive care unit. In cases that require prolonged intubation, a tracheotomy may be considered. Since cervical necrotizing fasciitis may cause significant tissue loss overlaying the trachea, there may not be adequate soft tissue to stabilize a tracheostomy. To address this concern, one may place a surgical airway a few days prior to free tissue transfer to allow the airway to granulate and stabilize the tracheostomy. This approach was taken in three out of eight patients that underwent tracheotomy (Table 3). An alternative approach would be to keep the patient intubated for a prolonged period to avoid tracheotomy altogether (Patients 7 and 8; Table 3).

When considering reconstructive choices for necrotizing fasciitis, defect size and exposure of important structures, such as the trachea and great vessels, should inform the treatment plan. Other case series have described negative pressure wound therapy (NPWT) as a potential method of facilitating wound closure¹⁴. This therapy appears to provide improved clinical outcomes when compared with wound care, but the defects reported in this study were less extensive and did not expose critical structures¹⁴. This contrasts the patients in the present study that had large defects and involvement down to the trachea and great vessels. While there is no particular threshold that indicates free tissue transfer, recruiting epithelialized bulky tissue with relatively low donor site morbidity has a role in reconstructing large defects caused by cervical necrotizing fasciitis. Free tissue transfer has been refined to the point of near universal success rates, with some sources indicating success rates of 95% or higher¹⁵. Reconstruction in cervical necrotizing fasciitis, as with all free tissue reconstruction, is strongly influenced by the dimensions, geometry, and complexity of the defect¹⁶. This cohort demonstrated success with anterolateral thigh flaps, with seven of the eight patients receiving at least one ALT flap (Table 2). Although it is always appropriate to start with more conservative management, such as skin grafts, NPWT, or rotational flaps, free tissue transfer is a viable option for more severe defects. Regarding timing of wound closure, the infection should be resolved, and the wound bed should be clean with evidence of granulation. Collaboration with the intensivist is also recommended to medically optimize the patient before attempting closure.

This study has several limitations. As is natural in a retrospective case series, patient selection may have played a role in the favorable results that we present. In addition, this is a relatively limited case series of free tissue transfer in this setting and the results need to be interpreted in that context. Finally, our results were obtained from a high-volume academic center with a large volume of free tissue transfer cases; thus, the results may not be generalizable to a different setting.

Despite these limitations, this study demonstrates 10 successful cases of free tissue transfer in eight patients following cervical necrotizing fasciitis. The hospital course of patients who require free tissue transfer does not appear to differ significantly from patients who do not require it. Despite significant comorbidities and complications involving sepsis and mediastinitis, no patient experienced flap failure. In patients with tissue defects that cannot be managed by primary closure or skin grafts alone, free tissue transfer offers a different method of reconstruction. While patients with necrotizing fasciitis often have comorbidities that overlap with risk factors for flap failure, adequate debridement and medical management seem to allow for safe tissue transfer.

Future studies could retrospectively compare outcomes of patients who had free tissue transfer and those that did not. Additionally, a prospective cohort study would be beneficial in analyzing long term flap outcomes.

Conclusions

In patients with extensive cervical necrotizing fasciitis, free tissue transfer and microvascular reconstruction may be a viable reconstructive option. In this cohort of eight patients who underwent 10 free tissue transfers, all flaps survived. We believe that the success of our cohort is promising and should encourage consideration of free tissue reconstruction in cervical necrotizing fasciitis. Despite the complex pathophysiology and entwined comorbidities, it appears that in select patients, free tissue transfer can be successfully employed.