Concurrent external and intraluminal vacuum‐assisted closure in head and neck necrotizing fasciitis

INTRODUCTION Necrotizing fasciitis of the head and neck is characterized by pervasive necrosis of fascia and subcutaneous tissues, resulting in significant morbidity and mortality. Successful management requires rapid identification of the disease, parenteral antibiotics, and repeated, thorough debridement. The aggressive extent of such debridement often results in defects requiring complex wound care followed by vascularized tissue reconstruction. The utility of negative pressure therapy (NPT) using vacuum-assisted closure (VAC) for soft tissue wounds has been well-established. The proposed benefits include the removal of fluid and exudate from the wound bed, maintenance of a moist healing environment, reduction of bacterial burden, and increased blood flow. Although the use of the VAC has been extended to the treatment of necrotizing fasciitis, studies in the head and neck literature remain limited. A combined defect involving the external skin and pharynx in the setting of severe soft tissue infection represents a challenging aspect of neck wound management. In these cases, the wound bed is constantly exposed to oral secretions, which may inhibit healing, increase the risk of carotid rupture, and necessitate intensive wound care with frequent dressing changes. Once infection has been cleared from the wound, the defect must be assessed for reconstruction. Considerations include skin loss, vessel or bone exposure, pharyngeal violation, and airway protection. Regional flaps may save operative time and require less specialized microsurgical techniques and equipment, however, they lack the customization and tailoring often provided by microvascular transfer. Flap choice depends on the location and extent of the defect, as well as the status of the neck vasculature in the setting of inflammation and possible infection. Herein, we describe a severe case of necrotizing fasciitis of the neck and pharynx, resulting in a throughand-through defect that was managed with double VAC therapy in the form of an external sponge on the anterior neck combined with an intraluminal pharyngeal sponge. Staged reconstruction was performed with bilateral supraclavicular artery island flaps (SCAIF). To our knowledge, the use of concurrent external and intraluminal negative pressure therapy has not been previously described in the head and neck literature.