1) The patient is a 67-year-old male with a history of stroke and diabetes who presented with a large gangrenous wound on his right thigh and toe. Physical examination revealed a foul smelling wound extending from his right hip to lower back. 2) Laboratory investigations showed anemia and elevated markers of infection. Imaging found extensive deep vein thrombosis in his right leg. He was diagnosed with necrotizing fasciitis. 3) Treatment involved antibiotics, extensive wound debridement through serial surgeries, and management of his medical comorbidities with a multidisciplinary team. The case report discusses the presentation, diagnosis, and surgical management of this severe soft tissue infection.

1. Plastic Surgery
Presented by,
Dr. Damodhar. M.V
Case Report

2. Case Report - 1
Evaluation Classification Reversible tx Surgery
Plastic
Personal data
Name: Ali Mohammed Yahya Gamre (Fighter)
Age: 67 y/o
Sex: Male
MRN: 27902
Marital status: Married with children
Chief Complaint
Right thigh lateral aspect bed sore, Gangrenous
superficial patch at the tip of his right big toe.

3. Personal data / past history
Evaluation Classification Reversible tx Surgery
Plastic
Past history
Previous cerebellar stroke
Type 2 DM,
Irritable bowel syndrome
Past Surgical history

4. Case presentation Plastic & Reconstruction surgery
> Clinical examination
> History
> Investigations
> Multidisciplinary approach
> Surgical procedures

5. Physical examination
Evaluation Classification Reversible tx Surgery
Plastic
Physical examination (systemic)
General appearance: Poorly built, Severely malnourished, emaciated
Vital sign: BP:138/64mmHg, PR: 72/min, RR: 22/min, BT:35.2
>
>
> Chest & Lung: percussion: normal; auscultation: wheezing(+), rales(+)
Heart: Regular heart beat, No murmus
Abdomen: Soft, lax,
Extremities: Joint stiffness(+),
CNS: GCS 7, sluggish pupillary reaction.

6. Local examination
evaluation classification reversible tx surgery
Plastic
Foul smelling, discharging wound extending from the
right hip to back almost up to the lower scapular
region on the right side.. Skin hot and tender up to
the lower scapular region.
Wound

7. Case presentation Plastic & Reconstruction surgery
> Clinical examination
> History
> Investigations
> Multidisciplinary approach
> Surgical procedures

8. Laboratory investigations
evaluation classification reversible tx surgery
Plastic
Wound culture
Hb: 8.1
Hematocrit- 24.9
Leucocytes: 10.8
D-Dimer-1.7
LDH-335
Blood work up

9. Radiological Study
Evaluation Classification Reversible tx Surgery
Plastic
Conclusion:
-Extensive DVT of the right lower limb as described .
-Soft tissue edema at the right leg
X-ray and Doppler

10. Case presentation Plastic & Reconstruction surgery
> Clinical examination
> History
> Radiologic investigations
> Multidisciplinary approach
> Surgical procedures

11. Multidisciplinary approach
Evaluation Classification Reversible tx Surgery
Plastic
Internal medicine:
Managing Type 2 DM, previous stroke, patient was on ventilator on
and off due to impaired lung function
Surgical:
Insertion of feeding gastrostomy and regular care of gastrostomy
tube.
Plastic Surgery:
Wound debridement and serial debridement's was done at regular
intervals.

12. Case presentation Plastic & Reconstruction surgery
> Clinical examination
> History
> Investigations
> Multidisciplinary approach
> Clinical diagnosis & treatment plan
> Surgical procedures

13. evaluation classification reversible tx surgery
Plastic clinical diagnosis & treatment plan
Type 2 DM, previous stroke with on
and off respiratory distress
Primary Diagnosis
wide spreading wound over the right hip
and back suggestive of Necrotizing
Fasciitis
Clinical diagnosis and
staging:
Necrotizing fasciitis
Type 2
Secondary Diagnosis

14. evaluation classification reversible tx surgery
Plastic
To stop the spread of infection:
• Cefotaxime,
• Cefuroxime
• Ciporfloxacin
Surgical Debridement
• Wide excision and through
debridement of wound.
• Regular change of dressing
• Serial debridement's was planned.
Clinical diagnosis & treatment plan

15. Case presentation Plastic & Reconstruction surgery
> Clinical examination
> History
> Investigations
> Multidisciplinary approach
> Clinical diagnosis & treatment plan
> Surgical procedures

16. Surgical procedures
evaluation classification reversible tx surgery
Plastic
Wound debridement

17. Case presentation Plastic & Reconstruction surgery
Necrotizing Fasciitis- Review

18. Necrotizing fasciitis
Evaluation Classification Reversible tx Surgery
Plastic
History
- Hippocrates in the 5th century BC noted it,
known as malignant ulcer, gangrenous ulcer putrid ulcer.
- Was termed as hospital gangrene in the 18th century
- In1871 after the Civil War was called hospital
gangrene by a war surgeon
- In 1924 called hemolytic streptococcal gangrene

19. Necrotizing fasciitis
Evaluation Classification Reversible tx Surgery
Plastic
History
-In 1952 the term “Necrotizing fasciitis” was used.
-It was termed as the “killer bug”, “flesh eating bacteria” by
the media
-1989 toxic shock syndrome and strep A necrotizing fasciitis
reported
-Estimated 10,000-15,000 strep A infections with 5% of
patients developing necrotizing fasciitis

20. Necrotizing fasciitis
Evaluation Classification Reversible tx Surgery
Plastic
Definition & Risk Factors
• Immunosuppression
• Diabetes
• Other chronic disease
• Malnutrition
• Advanced age
• Obesity
• Renal failure
• Malignancy
Fulminant, deep-seated infection with
necrosis of fascia and soft-tissue, generally
sparing of muscle and possible sparing of
the skin
-Hasham S, Matteucci P, Stanley PR, Hart NB. Necrotising fasciitis. BMJ. 2005 Apr 9;330(7495):830-3

21. Necrotizing fasciitis
Evaluation Classification Reversible tx Surgery
Plastic
Clinical Features- Early
-Most frequently involved areas :
1) Extremities
2) Perineum
3) Trunk
-Can advance over hours or days
-Early symptoms
Pain, swelling, induration, fever,
tachycardia
Severe pain out of proportion
with exam

22. Necrotizing fasciitis
Evaluation Classification Reversible tx Surgery
Plastic
Clinical Features- Late
- Tense skin
- Color changes
(red-purple->dusky blue->
black)
-Bullae – initially clear-
hemorrhagic
-Crepitus (only about 10-40%)
-Sepsis / Multiorgan failure

23. Necrotizing fasciitis
Evaluation Classification Reversible tx Surgery
Plastic
Diagnosis
- High index of suspicion, mainly a clinical diagnosis.
- Laboratory investigations:
Leucocytosis
Acidosis
Altered coagulation profile
Abnormal renal function
- Plain radiography:
Soft tissue gas
- CT or MRI:
May delineate extent of disease
Soft tissue gas
- Incisional exploration or biopsy (can be done at bedside):
Tissue culture to identify pathogens and sensitivities
-Hasham S, Matteucci P, Stanley PR, Hart NB. Necrotising fasciitis. BMJ. 2005 Apr 9;330(7495):830-3

24. Necrotizing fasciitis
Evaluation Classification Reversible tx Surgery
Plastic
Management
- Aggressive resuscitation and sepsis management
Frequently multi-organ failure (esp. ARF or ARDS)
Broad IV antibiotics
Gram positive, gram negative and anaerobic coverage
clindamycin - inhibiting streptococcal toxin production
Vancomycin- if MRSA concerns
Continue IV antibiotics until debridement's complete
-Anaya D, Dellinger EP. Necrotizing soft-tissue infection: diagnosis and management.
-Clinical Infect Dis. 2007 Mar 1;44(5):705-10

25. Necrotizing fasciitis
Evaluation Classification Reversible tx Surgery
Plastic
Surgical Management
-Early and aggressive debridement important
-Surgery may also be needed for diagnosis
-Serial debridement's until no further necrosis or
infection is seen
-Beware of hemorrhage (DIC common)
-Reconstructive surgery once fully stabilized and
infection eliminated
-Anaya D, Dellinger EP. Necrotizing soft-tissue infection: diagnosis and management.
-Clinical Infect Dis. 2007 Mar 1;44(5):705-10

26. Necrotizing fasciitis
Evaluation Classification Reversible tx Surgery
Plastic
Mortality
• Type I: 20%, *
• Type II: 30-35%*
• Admission to surgery time > 24 hr independent predictor of
mortality after controlling for age, sex, DM, and
Hypotension*
• Amputation does not affect mortality
• Cervical necrotizing fasciitis: ~20%
• Fournier's gangrene: ~20-40%
*Wong CH, Chang HC, Pasupathy S, et al. J Bone Joint Surg Am 2003; 85:1454-1460

27. Case Report – 2 A Very Rare Case Velopharyngeal
Incompetence
Evaluation Classification Reversible tx Surgery
Plastic
Personal data
Name: Muqbel Al Mutairi
Age: 6y/o
Sex: Male
MRN: 27279
Chief Complaint
Defective speech, nasal emmision with regurgitation
of food.
Left side unilateral soft palate aplasia.

28. Velopharyngeal Insufficiency
Evaluation Classification Reversible tx Surgery
Plastic
• He is the only son of a 30-year-old father and 23-year-old mother
with 2nd degree consanguinity. The family history was normal.
• He was assessed by speech and language by ENT specialists in our
hospital.
• Severe consistent hypernasality, consistent nasal emission, cleft-type
misarticulations and nasal grimace were observed.
• Physical examination:
Revealed that the left side of her velum appeared shorter
tonsillar pillar was absent on the left side Nasal
endoscopic examination was done

29. Velopharyngeal Insufficiency
Evaluation Classification Reversible tx Surgery
Plastic
It is hard to explain this rare condition’s
pathogenesis,
but it may occur in three ways:
• The first theory is an atypical cleft case.
• The second theory is that this condition could
occur as a part of branchial arch syndrome.
However, there were no data to support this
theory.
• The last theory involves vasculature during
embryogenesis. A pathology (such as
torsion, occlusion, etc.) in the ascending palatine
artery during embryogenesis would cause this
situation.
The Cleft Palate-Craniofacial Journal 49(4) pp. 494–497 July 2012
’ Copyright 2012 American Cleft Palate-Craniofacial Association
Figen O¨ zgu¨ r, M.D., Haldun Onuralp Kamburog˘ lu, M.D., F.E.B.O.P.R.A.S.
Asymmetric

30. Plastic & Reconstructive SurgeryPlastic
Plastic Surgery Team

31. Thank you,
Dr.Damodhar.M.V