1. Experience with Negative Pressure Wound Therapy over Skin Grafts in Fournier’s Gangrene
Dr Elle Vandervord, Dr Aruna Wijewardena, Dr Joel Rabindran, Dr Jeon Cha
Department of Plastic Reconstructive & Burns Surgery, Royal North Shore Hospital, Sydney, NSW, Australia
Split thickness skin graft (meshed 1:1.5) was secured to the defect with application of NPWT at 100mmHg. The NPWT was well tolerated by all patients. The dressing was removed at day 5 for graft review and in all patients there was over 80% graft take. In 1 patient NPWT was re-applied after graft review to immobilise the graft for a further 3 days. All other patients were changed to 2nd-daily bactigras or jelonet dressings. Patients commenced mobilising between day 7 and 9 post skin grafting.
Loss of occlusive seal occurred in 2 of the 5 patients. In one patient this occurred at day 2 post graft and was addressed by reinforcing the occlusive dressing on the ward. The second patient, with a more extensive defect extending over the mons pubis, penile shaft and perineum, repeatedly lost seal despite several attempted reinforcements. This patient returned to theatre for re-application of NPWT at day 3-post graft.
Time from grafting to date of discharge ranged from 6 to 12 days.
DIscussion
Achieving successful graft take in the regions affected by Fournier’s gangrene is challenging due to the irregular contour and sheering forces which make graft immobilisation difficult. Whilst application of NPWT in this area is time-consuming and technically difficult, we have found it to be a useful dressing modality over split thickness skin grafts. The advantages of this dressing modality include increased patient comfort, reduced dressing change frequency, protection from potential faecal contamination and minimisation of graft shearing during the initial take period. Our experience has found NPWT to be a useful dressing modality over skin grafts in this difficult area, to achieve both a functional and aesthetic reconstructive outcome.
References:
Czymek, R. et al. Fournier's Gangrene: Vacuum-Assisted Closure Versus Conventional Dressings. Am J Surg. 2009; 197:  
Silberstein, J., J. Grabowski, and J. K. Parsons. "Use of a Vacuum-Assisted Device for Fournier's Gangrene: A New Paradigm." Rev Urol 10, no. 1 (Winter 2008):
Background
Fournier’s gangrene is a rapidly progressive infection originating in the genital, perianal or perineal region with a reported mortality rate of 20-30%. Aggressive surgical debridement and antibiotic therapy is the mainstay of initial treatment. The resultant defect is often large and complex and may involve other regions adjacent to genital and perineal regions.
Skin grafting is often the initial reconstructive option following the control of the infective process. The use of negative pressure wound therapy (NPWT) in Fournier’s gangrene to prepare the wound bed has been previously described in the literature. There is however, little published data regarding NPWT as a dressing over perineal/genital skin grafts. NPWT in this context has the advantages of reducing sheer forces, stabilising the graft and contouring to the defect.
We present our unit’s experience with a series of five consecutive patients with Fournier’s gangrene where NPWT was applied over split thickness skin grafts during a 5-year period.
Case series
5 patients (4 male, 1 female) aged between 31 and 86 years were treated for defects resulting from Fournier’s gangrene using the combination of skin graft and NPWT in our unit between 2010 and of the patients had type II diabetes mellitus and were current smokers, 1 patient was taking prednisone and methotrexate for inflammatory polyarthritis and the remaining 2 patients had no predisposing factors for developing a necrotising infection.
Following aggressive debridement, NPWT was used in all cases to prepare the wound bed for reconstruction. 3 of the 5 patients underwent diverting colostomy at initial operation. The remaining 2 patients had a rectal tube inserted as there was minimal involvement of the perianal area.
CASE 1: 86yo male farmer with no predisposing medical conditions, developed a groin haematoma after being kicked by a cow which incised and evacuated himself at home. He presented 2 days later with rapidly progressive perineal erythema and sepsis. Following 2 debridements, diverting colostomy and suprapubic catheter insertion, NPWT was applied to prepare the wound. Skin graft + NPWT was performed, with 95% graft take at day 5 review. Patient was discharged at day 12 post-graft. (a) debrided wound after 3 days NPWT (b) SSG with NPWT (c) Day 5 post skin graft (d)- Day 12 post skin graft (prior to discharge)
a b c d.
CASE 2: 50yo female smoker, presented with necrotising infection of perineum, labia majora and left buttock. Following 4 debridements, diverting colostomy and suprapubic catheter, the wound was grafted. Complete graft take evident at day 5 review and patient was dicharged day 7 post graft (a) following 4th debridement (b) SSG with NPWT (c) Day 5 post skin graft (d)- Day 10 post skin-graft.
a b c d.
a b c d.
CASE 3: 31yo immunosuppressed male presented with sepsis and a 3 day history of severe scrotal pain. Following 4 debridements, SSG and NPWT was applied. Complete graft take at day 5. Patient was discharged day 6 post graft. (a) post 3rd debridement (b) immediately prior to skin graft (c) Skin graft secured, prior to NPWT application (d) Day 5 post skin graft.