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aDepartment of Plastic Reconstructive and Aesthetic Surgery, Singapore General Hospital, Outram Road, Singapore16

2008 Elsevier Inc. All rights reserved.

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The American Journal of Surgery (2008) 196, e19e24In the spectrum of soft tissue infections, necrotizingciitis is perhaps the most fulminant and deadliest, withreported mortality rate ranging from 6% to 76%.1 It is

equivocal that delay in diagnosis and surgical debride-nt increases morbidity and mortality.112 While it isiversally accepted that aggressive debridement is crucialcontrol this fulminant infection, a detailed description ofw to perform this often massive debridement is lacking in

literature. Furthermore, because of its rarity, most sur-ons will probably encounter only a handful of cases inir career and therefore familiarity with this disease willdom be achieved by most. Often, the surgeon adoptsgical approaches used for more common infections such

as abscesses. This lack of a focused, tactical approach whenconfronting this severe infection often results in suboptimaldebridement and failure to rapidly get above the infectionand halt its progression. This report describes our surgicalapproach to debridement in necrotizing fasciitis, stressingthe concept of radical excisional debridement as the defin-itive action to halt the progression of necrotizing fasciitis.While this description is aimed at the first debridement,these principles and techniques are also applicable if sub-sequent debridements are necessary.

Classification of Skin and Subcutaneous9608; bDepartment of Hand Surgery, Singapore General Hospital, Singapore

Abstract. Aggressive debridement is a cornerstone intervention in necrotizing fasciitis. Our approachconsists of 4 steps: (1) confirming the diagnosis and isolate the causative organism; (2) defining theextent of fasciitis; (3) surgical excision; and (4) post-excision wound care. The extent of the infectionis defined by probing the wound bluntly. Systematic excision follows. Fascial excision must becomplete and uncompromising with the full extent of the involved wound laid open. We classify theinfected skin into zones 1, 2, and 3. Zone 1 is necrotic tissue. Zone 2 is infected but potentiallysalvageable soft tissue, and zone 3 is non-infected skin. Zone 1 is completely excised. Zone 2 ismeticulously assessed and cut back as necessary to remove nonviable tissue while maximally preserv-ing salvageable tissue. Zone 3 is left alone. The aim of surgical debridement is to remove all infectedtissue in a single operation. This halts the progression of the fasciitis and minimizes unnecessary returnsto the operating room.

KEYWORDS:Necrotizing soft tissueinfection;Aggressive;Control;Mortality;Morbidity;Systematicw I Do It

pproach to debridement in

in-Ho Wong, M.B.B.S., M.R.C.S. (Ed), Mdrew K.-T. Yam, M.B.B.S., M.R.C.S. (Ed)nes B.-H. Tan, M.B.B.S., F.R.C.S., F.A.M.lin Song, M.B.B.Ch., F.R.C.S., F.A.M.S.aTis

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* Corresponding author. Tel.: 65 6321 4686; fax: 65 6220 9340.E-mail address: wchinho@hotmail.comManuscript received April 12, 2007; revised manuscript July 26, 2007

2-9610/$ - see front matter 2008 Elsevier Inc. All rights reserved.:10.1016/j.amjsurg.2007.08.076rotizing fasciitis

. (Surg)a,*,Med. (Surg)b,sue Involvement

Skin and subcutaneous infection commonly results fromrtical spread from the primary site of pathology, ie, the

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e20 The American Journal of Surgery, Vol 196, No 3, September 2008ep fascia. Fascial edema and inflammatory thrombosisromboangiitis obliterans) occlude the cutaneous perfora-s that run through the deep fascia to supply the skin. Theulting ischemia and necrosis promote the spread of in-tion. All skin and subcutaneous tissue located over theolved fascia is therefore at risk. Skin necrosis spreads inentrifugal manner away from the center of the fasciitis, indem with its advancing edge. The skin and subcutaneous

sue at the advancing edge of the fasciitis survive onllateral circulation from the dermal and the subdermalxus coming from the surrounding unaffected tissue, andy survive surgical excision of the underlying infectedcia.To facilitate decision-making during skin excision, wessified the skin and subcutaneous component into 3 sur-al zones: zones 1, 2, and 3. Zone 1 is the area ofnviable skin at the epicenter of infection. It demonstrates

classic late signs of necrotizing fasciitis: hemorrhagicllae, dermal hemorrhage, fixed staining, and frank dermalngrene. Adjacent and surrounding this area, usually ex-ding in the direction of advancing infection, is zone 2.is transitional area can potentially be salvaged if theection is rapidly controlled. The signs of early necrotiz-

fasciitis are seen in this area: warm (hot) skin, intensethema, small serous bullae, and woody induration signi-ng underlying fascial involvement. Zone 3 is locatedyond zone 2 and is healthy uninfected tissue (Figure 1).e boundary between zones 2 and 3 often marks the limitthe underlying fasciitis. Clinical assessment of skin via-ity is important in deciding on the extent of skin excisiond will be discussed later.

ms of the First Debridement in Necrotizingsciitis

Four areas must be addressed at the first debridement.ese are (1) confirming the diagnosis of necrotizing fas-tis and isolating the causative organism; (2) delineatingextent of the infection; (3) complete surgical excision of

ected tissue; and (4) post-excision wound care.

nfirming the diagnosis and organism

A clinical diagnosis of necrotizing fasciitis can be madesed on findings at wound exploration. The followingtures are seen in necrotizing fasciitis: grayish necrotic

ep fascia, a lack of resistance of normally adherent mus-lar fascia to blunt finger dissection, lack of bleeding of thecia, and the presence of foul-smelling dishwater pus.2e muscle itself is not involved. Histology may confirmdiagnosis and is particularly helpful in early necrotizing

ciitis where clinical findings may sometimes be equivo-

.13,14 The histological specimen should be a full thickness whsue specimen incorporating skin, subcutaneous tissue,ep fascia, and a piece of muscle.

lineating the extent of infection

Clinically, the extent of infection is predicted by the limittenderness to palpation. This usually occurs somewheret beyond the interface of zones 2 and 3 in our classifi-ion. Therefore, an extensile incision is planned, endingtally and proximally well into zone 3. If the infection isa limb and appears to have spread circumferentially, ity be necessary to plan 2 separate incisions on oppositefaces to access the entire fascia. At the margin of zone 2

d in zone 3, blunt finger dissection to unyielding fascianfirms the extent. This establishes the perimeter within

ure 1 (Top) Clinical photograph of the involved hand. (Mid-) Classification of the involved skin and subcutaneous tissueo zones 1, 2, and 3 based on skin manifestations of necrotizingciitis. Zone 1 is the area of obvious skin necrosis. This area isracterized by skin gangrene, fixed discoloration, and hemor-gic bullae. Zone 1 will be completely excised as it is clear thats nonviable and heavily infected. Zone 2 is characterized by skinnifestations of early necrotizing fasciitis. This area is charac-ized by red warm skin and exquisite tenderness. Induration mayfelt in this area and small serous bullae may be seen. Particu-ly telling is woody hard quality of the skin that can occasion-

be appreciated here. Zone 2 is the area at risk and with someas potentially salvageable with antimicrobial therapy if its mi-circulation is still patent. This area should be carefully assessed,

progressively cut back to evaluate the tissue quality and foreding. Zone 3 is normal skin that is clinically not infected.ttom) The extent of fascial involvement. This area is defined bybing the wound at the deep fascia level and any area that skinsubcutaneous tissue can be lifted off the muscle is involved.

mplete excision of the involved fascia is mandatory.ich all fascia must be excised.

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e21C.-H. Wong et al. Debridement in necrotizing fasciitismplete surgical excision

Once the perimeter is established, all fascia within iscised completely. We advocate taking a 5- to 10-mmrgin of healthy fascia in zone 3 as well. This firebreakpedes further advancement of the infection beyond thergin of excision. All necrotic skin and subcutaneous

sue in zone 1 is excised, along with any tissue of ques-nably viability in zone 2.

st-excision wound care

The extensive surgical debridement will result in largewounds. Patients, particularly those who are coagulo-

thic from sepsis, are at risk of postoperative hemorrhage.addition, immunocompromised patients are at risk ofondary infection. Wound care aims to minimize both ofse risks. Meticulous hemostasis is essential, with therniquet (if applied) deflated. The wound should be cov-d with non-adherent dressings such as Urgotul (Urgoited, Leicestershire, UK) or tulle gras. An antibiotic

am (eg, Mupirocin) or active silver dressings (eg, Ur-tul SSD, Aquacel Ag; ConvaTec, NJ, USA) may beded. A firm, bulky cotton wool pressure dressing is ap-ed and removed only after 24 hours to inspect the wound.rther dressing changes should be dictated by the condi-n of the debrided wound. While the use of topical nega-e pressure dressings is increasingly popular for largeunds, we do not recommend their use immediately afterfirst debridement, as there is an increased risk of hem-

hage from the raw area. They may be used effectively forsequent dressings.

rgical Technique

The operation should be performed under general anes-sia. In the limbs, a tourniquet should be used to reduceod loss. A bloodless field also aids dissection by makingne identification easier. Prior to incision, skin markingsdelineate zones 1, 2, and 3 are as described. A curvi-ear skin incision is also marked running through theter of the infected area, extending through the entire aream normal skin distally to normal skin proximally.The incision should start at zone 1. A full-thicknessision down to muscle is made. The deep fascia is iden-ed as the layer of tissue lying just above the muscles. Anical diagnosis of necrotizing fasciitis is made based ontures described above. At this juncture, 2 tissue speci-ns should be sent for investigation: 1 for aerobic and

aerobic cultures and 1 for histology (frozen sections andmatoxylin and eosin stains). Then, in order to determine

extent of involvement, the surgeon probes his or herger along the deep fascia. Any area where the skin andcutaneous tissue can be lifted off easily is involved.15e incision is then extended proximally in a longitudinal fasnner until healthy fascia adherent to the overlying sub-taneous tissue and underlying muscle is encountered. Therimeter is now established and the wound is then laiden to expose the entire infected bed.Radical fasciectomy is then performed. The fascia is

cised sharply, exposing the underlying muscles and ten-ns, indicating that the fascia has been completely re-ved. The periphery of the wound is checked by tuggingdeep fascia with a rongeur or a hemostat. Healthy fascia

s a glistening appearance and is tough and unyieldingen tugged. Infected fascia on the other hand is dull, soft,

d friable. This should be further cut back until healthycia is seen. Skin excision then follows. Skin in zone 1 iscrotic and the entire zone should be excised. Zone 2uld be carefully assessed for viability. If dermal bleeding

poor, indicating occlusion of the microcirculation due tocrotizing angiitis-type pathology, this skin is not salvage-le and should be excised until healthy dermal bleeding iscountered. The subcutaneous tissue also should be exam-d for signs of tissue viability. Calcifications or liquefac-n of the subcutaneous fat and thrombosis of the subder-l venules indicates impending tissue demise and shouldexcised. We find it useful to observe the microcirculationthe subdermal or subcutaneous vessels. Patent arteriolesd venules are a sign of tissue viability and can be safelyserved. These can be observed by lifting the skin flap and

amining these vessels through the deep aspect of thecutaneous tissue. The presence of thrombosed, phlebotic

in should be traced proximally until a patent segment isted. All tissue surrounding the thrombosed vein is com-mised and should be excised with the vein. The tourni-

et should be deflated upon completion of debridementd the wound checked to confirm tissue viability. Com-mised tissue should be further cut back as necessary.Finally, the tourniquet is deflated and meticulous hemo-sis is achieved by cautery. The wound is washed withpious irrigation and dressed as described earlier. Theund should be inspected again by the same surgeonthin 24 hours to assess tissue viability and for progressionthe infection.

ure 2 The clinical diagnosis of necrotizing fasciitis wasfirmed intraoperatively by a deep incision down to the deepcia.

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e22 The American Journal of Surgery, Vol 196, No 3, September 2008ustrative Case

A 53-year-old man with diabetes mellitus and chronical failure was admitted for congestive heart failure. He

veloped sepsis and collapsed in the ward. He was intu-ted and admitted to the intensive care unit. Left fore-

and hand swelling, redness, and discoloration wereted and a clinical diagnosis of necrotizing fasciitis wasde and an emergency wound exploration was performed.ures 1 through 7 showed the operative finding andgress of the debridement.

mments

The technique we have described is based on our clinicalperience in managing these cases with a clear and focused

of removing all infected tissue at the first operation.ing this technique, we have managed to control the in-tion in a single operation in 15 of 21 cases. Our guidingnciples when devising these strategies are the following:

ure 3 Foul-smelling, turbid dishwater pus seen in necro-ng fasciitis. This photograph also shows a thrombosed cutane-perforator supplying the skin and subcutaneous tissue (arrow).

is is a useful diagnostic marker of tissue viability. The skin andcutaneous tissue around such a thrombosed vessel is oftenvily infected and nonviable. These tissues surrounding the

ombosed vessel should therefore be excised.Figure 4 The incision was extended into zone 2. Anto control the infection by surgically removing the pri-ry site of pathology, ie, the deep fascia; and (2) to

termine and maximally preserve skin coverage withoutmpromising our aim of removing all infected tissue. Fa-ectomy should therefore be aggressive and uncompro-sing. Skin excision is a little more difficult and requires agree of clinical judgement to balance the need to removevitalized tissue versus the desire to maximally preservetentially salvageable tissue. Failure to remove all devital-d skin is the main reason for multiple returns to the

ure 5 (Top) The incision was further extended until zone 3s reached. Generally, the incision should stop only when normalcia is seen. The cephalic vein and its tributaries were throm-ed and heavily infected. The vein was thus traced proximallyil a patent segment was seen (arrow) and the vein was ligatedabout 3 cm proximal to the thrombosed area. Thrombosis ofcutaneous veins is a useful diagnostic clue of the extent ofrotizing soft tissue infection. All soft tissue around the phlebiticn must be excised.

ure 6 The infected fascia must be completely excised leav-only muscle and tendon in the bed of the wound (white arrow).y fascia left on the wound bed must be excised (black arrow).

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e23C.-H. Wong et al. Debridement in necrotizing fasciitiserating room.2 To facilitate rapid debridement and tous the assessment of skin viability to the area whereeful evaluation is needed most, we have devised a con-t of zoning the skin over the involved site.Proponents of a more conservative approach to debride-nt argue that it is difficult to assess tissue viability in antely infected wound. In the interest of maximally preserv-soft tissue coverage over vital structures, it is prudent to bere conservative and return in 24 to 48 hours to reassess theund. However, this approach is not appropriate and may begerous when applied in the context of necrotizing fasci-.3,58,14 Such patients are severely septic and complete re-val of all infected tissue is the only way to rapidly reversesepsis. Furthermore, failure to remove all infection may

ow it to progress further, resulting in even more tissue loss.We use non-occlusive dressings with large amounts of

uze as a secondary dressing because these are highlyudative wounds. A tight compression-type bandaginguld be applied for hemostasis. Negative pressure therapy

.A.C. dressings; Kinetics Concepts, Inc, San Antonio,) should not be used after the first surgical debridementthe suction may increase postoperative bleeding. How-

er, V.A.C. is a valuable wound management adjunct incrotizing fasciitis and can be applied if the wound is cleaner the first wound inspection, while waiting for the pa-nts general condition to improve prior to wound closureth skin grafts or flaps. The use of hyperbaric oxygenrapy has been demonstrated to decrease mortality andund morbidity in recent retrospective studies and shouldused when a facility is available.14,1619Not all patients will recover with a single debridement.munocompromised patients with poor wound healing po-tial, such as patients with diabetes mellitus and renallure, are particularly difficult to manage. In such patients,en with a successful initial debridement, secondaryund infection may occur due to poor healing and de-ased tissue perfusion. Peripheral vasoconstriction causedinotropic agents (such as epinephrine and norepineph-

e) for hypotension associated with sepsis may compounds problem. Repeat debridement may be needed, and treat-nt is generally supportive while waiting for the systemic

nditions to improve. Amputation also may be necessary

ure 7 Wound at the first inspection 24 hours later. One canove all infected tissue with aggressive debridement and avoidecessary return to the operating room for repeat debridement.some cases. Despite this, we strongly stress the impor-ce of a thorough and systematic initial debridement inse patients as a life-saving procedure. This immediately

lts progression of the necrotizing fasciitis, allowing sepsisd the systemic inflammatory response to reverse rapidly.Wound closure should be optimally timed to ensurecess. In general one should refrain from rushing to closewound. The wound must demonstrate that the healing

ase has firmly set in prior to closure, regardless ofether secondary suture or skin grafts or flaps are to bed. This is done by observing the ability of the wound tom granulation tissue. This process can somewhat bemoted by the use of the V.A.C. dressing. We call this a

ial of V.A.C. therapy; a wound with abundant healthynulation tissue after a 3- to 5-day course of V.A.C.rapy signals an opportune time for closure.

nclusion

Debridement for necrotizing fasciitis is not a slash andrn-type surgery. The concepts and techniques describedre are common knowledge to many experienced sur-ons. What is more important perhaps is that there shoulda fundamental shift in the surgeons mindset when per-ming this procedure. The surgeon should not perform thebridement expecting to return to find more necrotic tissued repeat the process. Instead, the aim should be to removeinfected tissue in a single operation. Patience, precision,

d meticulous technique improve the outcome and make age difference to the patient.

knowledgment

The authors would like to acknowledge all physiciansd surgeons who have given us the privilege of participat-

in the care of their patients with necrotizing fasciitis ando have taught us so much. We also would like to thanke Wong for her help with illustrations in this article.

ferences

McHenry CR, Piotrowski JJ, Petrinic D, et al. Determinants of mor-tality in necrotizing soft tissue infections. Ann Surg 1995;221:55863.Wong CH, Chang HC, Pasupathy S, et al. Necrotizing fasciitis: clinicalpresentation, microbiology and determinants of mortality. J Bone JointSurg (A) 2003;85:145460.Voros D, Pissiotis C, Georgantas D, et al. Role of early and aggressivesurgery in the treatment of severe necrotizing soft issue infections. Br JSurg 1993;80:11901.Rea WJ, Wyrick WJ. Necrotizing fasciitis. Ann Surg 1970;72:95764.Masjeski JA, Alexander JW. Early diagnosis, nutritional support andimmediate extensive debridement improve survival in necrotizing fas-ciitis. Am J Surg 1983;145:7817.Bilton BD, Zibari GB, McMillan RW, et al. Aggressive surgicalmanagement of necrotizing fasciitis serves to decrease mortality: a

retrospective study. Am Surg 1998;64:397400.

7. Green RJ, Dafoe DC, Raffin TA. Necrotizing fasciitis. Chest 1996;110:2199.

8. Majeski J, Majeski E. Necrotizing fasciitis: improved survival withearly recognition by tissue biopsy and aggressive surgical treatment.South Med J 1997;90:10658.

9. Wang K-C, Shih C-H. Necrotizing fasciitis of the extremities.J Trauma 1992;32:25964.

10. Freischlag JA, Ajalat G, Busuttil RW. Treatment of necrotizing soft tissueinfections: the need for a new approach. Am J Surg 1985;149:7515.

11. Ault MJ, Geiderman J, Sokolov R. Rapid identification of group Astreptococcus as the cause of necrotizing fasciitis. Ann Emerg Med1996;28:22730.

12. Elliot DC, Kufera JA, Myers RA. Necrotizing soft tissue infections:risk factors for mortality and strategies for management. Ann Surg1996;224:67283.

13. Stamenkovic I, Lew PD. Early recognition of potentially fatal necro-tizing fasciitis: the use of frozen section biopsy. N Engl J Med1984;310:168993.

14. Wong CH, Wang YS. The diagnosis of necrotizing faciitis. Curr OpinInfect Dis 2005;18:1016.

15. Andreasen TJ, Green SD, Childers BJ. Massive soft-tissue injury:diagnosis and management of necrotizing fasciitis and purpura fulmi-nans. Plast Reconstr Surg 2001;107:102535.

16. Korhonen K, Kuttila K, Niinikoski J. Tissue gas tensions in patientswith necrotising fasciitis and healthy controls during treatmentwith hyperbaric oxygen: a clinical study. Eur J Surg 2000;166:530 4

17. Riseman JA, Zamboni WA, Curtis A, et al. Hyperbaric oxygen therapyfor necrotizing fasciitis reduces mortality and the need for debride-ments. Surgery 1990;108:84750.

18. Stevens DL, Bryant AE, Adams K, et al. Evaluation of therapy withhyperbaric oxygen for experimental infection with Clostridium per-fringens. Clin Infect Dis 1993;17:2317.

19. Wilkinson D, Doolette D. Hyperbaric oxygen treatment and sur-vival from necrotizing soft tissue infection. Arch Surg 2004;139:1339 45.

e24 The American Journal of Surgery, Vol 196, No 3, September 2008

Approach to debridement in necrotizing fasciitisClassification of Skin and Subcutaneous Tissue InvolvementAims of the First Debridement in Necrotizing FasciitisConfirming the diagnosis and organismDelineating the extent of infectionComplete surgical excisionPost-excision wound care

Surgical TechniqueIllustrative CaseCommentsConclusionAcknowledgmentReferences