Severe Fournier’s gangrene—a conjoint challenge of gynaecolo
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A 46-year-old female patient developed large-scale, map-like necroses of the mons pubis and the right inner thigh. The comorbidities of the patient were hypertension, obesity, type 2 diabetes mellitus and nicotine abuse. At admission, the patient developed a septic shock as well as skin necroses, reddening, and skin hyperthermia (Fig. 1). Since the patient’s symptoms rapidly progressed, she was immediately taken to the operation theatre and a radical necrosectomy of the affected areas was performed. The real extent of the disease was observed intraoperatively, since the area of lytic fascia, grey fluid (‘dishwater pus’) and infected soft tissues far exceeded the initially visible necrotic zones.

A calculated triple antibiotic treatment with penicillin, clindamycin and meronem was applied. Postoperatively, the patient required catecholamines and was admitted to the burn unit. In the histopathological analysis, the suspect diagnosis of an NF was confirmed. Necrotic fibrous, connective tissue with granulocytic infiltrations and a septic thrombovasculitis were observed. A two-stage reconstructive approach could be planned. During the first procedure, the femoral vessels, which were exposed on both sides, were covered by two pedicled sartorius flaps. Additionally, the open wound area was reduced using split-thickness skin grafting. Here, a pedicled fasciocutaneous anteromedial thigh (AMT) perforator flap was applied for reconstruction. The flap was pulled under the sartorius muscle and was inserted into the defect.

Five months postoperatively, the results were functionally satisfying. However, further reconstructive procedures were performed after 11 months to resolve a painful scar cranial to the clitoris and to reconstruct the external genitalia. An interdisciplinary plastic reconstruction was performed including gynaecologists and plastic surgeons. Here, a perforator-based flap from the left thigh/buttocks as well as an advancement of the AMT flap were performed. In the final clinical check-up 4 months later, the patient reported having recovered a sufficiently good quality of life, especially the ability for cohabitation.

Source: https://academic.oup.com/jscr/article/2017/12/rjx239/4711727?searchresult=1
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