A brief revision of the management of necrotising fascitis of the breast; a common problem among lactating mothers in the developing world. This is a copy of a presentation I made at the Breast and Endocrine Surgery Unit of the Division of Genera Surgery, Ahmadu Bello University Teaching Hospital Zaria.

1. MANAGEMENT OF
NECROTISING
FASCIITIS OFTHE
BREAST
BY KABIRABDULKAREEM

2. OUTLINE
■ INTRODUCTION
■ CLINICAL PRESENTATION
■ INVESTIGATIONS
■ TREATMENT
■ COMPLICATIONS
■ CONCLUSION
■ REFERENCES

3. INTRODUCTION
■ The management of necrotizing fasciitis of the breast is
multidisciplinary involving
– Breast surgeon
– Plastic surgeon
– Infection disease specialist
– microbiologist
– Pathologist
■ Combination of early diagnosis and prompt treatment is critical to
ensuring pt survival
■ Diagnosis of necrotizing fasciitis can be difficult and requires a high
degree of suspicion –can easily be treated as lactational mastitis!

4. CLINICAL PRESENTATION
■ History
– Typically presents following an apparent crack on the breast
skin
– With intense burning pain over the skin of the affected breast
– Pain usually out of proportion to the physical findings
– Followed by rapidly progressing development of purplish and
dark patches
– With of without ulceration
– There may be discharge of purulent fluid
– Associated swelling of the affected breast
– Constitutional symptoms like fever, malaise, nausea and
vomiting

5. ■ History of risk factors such as
– Diabetes mellitus
– Immunodeficiency states’
– Illicit drug use
– Malnutrition
■ In this environment, the patients are typically
lactating
■ Application of traditional concoctions

6. ■ PHYSICAL EXAMINATION:
– The patient is typically toxic, febrile, pale
– Swollen, erythematous breasts, tender, with discharge of
foul smelling ‘dish water’ fluid
– With visible areas of necrotic and undermined skin
surrounded by wide area of erythema
– Crepitus may be present

7. – The initial necrosis appears as a massive undermining of
the skin and subcutaneous layer.
– If the skin is open, gloved fingers can pass easily between
the 2 layers and may reveal yellowish-green necrotic
fascia
– The normal skin and subcutaneous tissue become
loosened
– Anesthesia in the involved region may be detected

10. ■ Patients usually present with signs of systemic inflamation
■ The FingerTest
– Used in the diagnosis of patients who present with necrotizing
fasciitis.
– The area of suspected involvement is first infiltrated with local
anesthesia.
– A 2-cm incision is made in the skin down to the deep fascia.
– Lack of bleeding is a sign of necrotizing fasciitis.
– A dishwater-colored fluid is noticed seeping from the wound.
– A gentle, probing maneuver with the index finger covered by
glove is then performed at the level of the deep fascia.
– If the tissues dissect with minimal resistance, the finger test is
positive.

11. INVESTIGATIONS
■ LABORATORY INVESTIGATIONS
– Haematology; Fbc &Diff Leucocytosis, left shift; anemia
– Chemical pathology; U, E, Cr, CRP,
– Microbiology;
■ percutaneous needle aspiration followed by prompt Gram
staining and culture; aspirate should be taken on the advancing
edge of the infection
■ Excisional deep skin biopsy may be helpful in diagnosing and
identifying the causative organisms,
■ Specimens should be taken from the spreading periphery of the
necrotizing infection or the deeper tissues during surgical
debridement

12. ■ HISTOLOGY
– Tissue biopsies can be sent for frozen section analysis 
■ The characteristic histologic findings are obliterative vasculitis
of the subcutaneous vessels, acute inflammation, and
subcutaneous tissue necrosis
■ Radiology;
– Breast USS: may reveal:
■ presence or the absence of occult abscess formation in the
breast
■ subcutaneous emphysema spreading along the deep fascia

13. LRINEC Scoring
■ Laboratory Risk Indicator for Necrotizing Fasciitis is a Robust
score capable of detecting clinically early cases of Necrotizing
fasciitis
■ Patients with a score of >or = 6 should be carefully evaluated
for necrotizing fasciitis

15. TREATMENT
■ Once the diagnosis of necrotizing fasciitis is confirmed,
treatment must be initiated without delay
■ Because necrotizing fasciitis is a surgical emergency, the
patient should be admitted and patient prepared for
immediate surgical debridement once stable
■ Hemodynamic parameters should be closely monitored, and
aggressive resuscitation initiated immediately if needed to
maintain hemodynamic stability
■ Empiric antibiotics should be started immediately.
■ Initial antimicrobial therapy should be broad-based, to cover
aerobic grampositive and gram-negative organisms and
anaerobes

16. ■ Surgical Debridement;
– Surgery is the primary treatment for necrotizing fasciitis
of the breast
– early and aggressive surgical debridement of necrotic
tissue can be life-saving and may minimize tissue loss,
eliminating the need for radical surgeries like mastectomy
– It involves wide, extensive debridement of all tissues
that can be easily elevated off the fascia with gentle
pressure.
– Care should be taken to preserve the nipple-areaola
complex if possible. Remove if there’s evidence of
necrosis!

17. ■ During debridement, the wound should be well irrigated and
hemostasis secured
■ Wound should then be evaluated on daily basis
■ The patient may return as often as necessary for further
surgical debridement

18. ■ Dressings
– Following each debridement of the necrotic tissue, daily
antibiotic dressings are recommended
– Silver sulfadiazine remains the most popular
antimicrobial cream.
■ it has broad-spectrum antibacterial activity and is
associated with relatively few complications in these
wounds
– If the patient is allergic to sulfa, alternative agents
include Polysporin, Bacitracin, and Bactroban
– Mafenide is an alternate agent that penetrates eschar
more effectively than silver sulfadiazine

19. ■ Breast Reconstruction
– Consult should be sent to plastic surgeons for skin grafting
once health granulation tissue forms as early as possible

20. ■ SupportiveTreatment
– Nutritional support
■ Nutritional support is also an integral part of treatment
for patients with necrotizing fasciitis.
■ This supplementation should be initiated as soon as
hemodynamic stability is achieved.
■ Enteral feeding should be established as soon as
possible to offset the catabolism associated with large
open wounds.
– Use of Polyspecific IVIG
– HyperBaric OxygenTherapy

21. COMPLICATIONS
■ Complications may include the following:
– Renal failure
– Sepsis
– Septic shock with cardiovascular collapse
– Scarring with cosmetic deformity
– Toxic shock syndrome
– Depression

22. CONCLUSION
■ Necrotizing fasciitis of the breast is a relatively
common, disfiguring and potentially life threatening
condition in this environment.With early diagnosis
and prompt aggressive surgical debridement, its
associated morbidity and mortality can be limited

23. ■Thank you for listening

24. REFERENCES
■ Steven AS, Michael SB , Nectotizing Fasciitis: Medscape Article. 2018
■ HakkarainenTW, Kopari NM, PhamTN, Evans HL. Necrotizing soft tissue infections:
review and current concepts in treatment, systems of care, and outcomes. Curr Probl
Surg. 2014 Aug. 51 (8):344-62
■ Nizami S, Mohiuddin K, HasnainZ. Necrotizing Fasciitis of the Breast.The Breast
Journal. 2006