eComment: The reconstructive ladder in necrotizing fasciitis of the chest wall Free

We read with great interest the recent report by Dr. Birnbaum and colleagues and we would like to congratulate them for the successful clinical outcome [1]. Chest wall involvement is a rare manifestation of necrotizing fasciitis with often fatal outcome. We have just lost a 64-year-old male suffering necrotizing fasciitis of his right arm, right shoulder and upper chest albeit aggressive serial radical debridements due to a candida albicans sepsis after fourteen days of broad spectrum antibiotic treatment.

In 1982, Mathes and Nahai introduced the reconstructive ladder in plastic reconstructive surgery to address tissue defects [2]. The reconstructive ladder starts with primary and secondary closure of wounds followed by autologous skin grafting. Regional and local pedicled flaps, tissue expansion and free tissue transfer are further steps.

Usually, autologous skin grafting as a second step on the reconstructive ladder is applied subsequent to debridement for defect coverage in necrotizing faciitis [3]. In contrast, free flaps at the top of the reconstructive ladder are quite rare as a defect closure. In 2006, a latissimus dorsi free flap was used for pleural reconstruction and chest wall stabilization in a patient suffering necrotizing fasciitis following a perforating thoracic wound [4]. A rectus muscle free flap was used in 2002 to cover a hand defect following necrotizing fasciitis in combination with hyperbaric oxygenation therapy [5]. Thus, the aforementioned case study by Dr. Birnbaum is unique for both, the location and the type of coverage, e.g. a latissimus dorsi free flap.

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