Fournier's gangrene is lethal necrotizing fasciitis that involves the perineum and external genitalia. We describe the case of a 52-year-old man with Fournier's gangrene who underwent reconstruction of an extensive perineoscrotal defect using three pedicled perforator flaps. Three debridement procedures resulted in a skin and soft tissue defect of 36 × 18 cm involving the perineum, scrotum, groin, medial thigh, buttocks, and circumferential perianal area and left the perforating arteries originating from these locations unavailable for reconstruction. We repaired the defect using left deep inferior epigastric artery perforator (DIEP) (29 × 8 cm) and bilateral anterolateral thigh perforator (ALT) flaps (35 × 8 cm and 22 × 7 cm). The flaps reached the defect without tension, and the defect was successfully covered without a skin graft. No postoperative complications occurred except for epidermal necrosis involving a tiny part of the DIEP flap tip. Nine months postoperatively, the patient experienced no impairment of bowel function or hip joint movement. There was also no avulsion or ulceration of the reconstructed perineal skin, and the cosmetic appearances of the healed wound and donor site were satisfactory. The combination of these three perforator flaps enabled us to achieve a satisfactory outcome while avoiding skin grafts.

Toxic shock syndrome is a rare but life-threatening complication after breast implant surgery. We describe a 77-year-old woman who developed toxic shock syndrome caused by methicillin-resistant Staphylococcus aureus after breast implant reconstruction. Despite a high fever and markedly increased white blood cell count, suggesting severe infection, she initially had no symptoms of local findings, such as wound swelling and redness of the breast. Soon after diagnosis of toxic shock syndrome and removal of her breast implant, she was recovered from the shock state. To date, 16 cases of toxic shock syndrome have been reported, including this case, and they were related to breast implants or tissue expander surgery. The common and noteworthy characteristic of these cases was the lack of local findings, such as swelling or redness, which suggests infection. Therefore, early diagnosis is generally difficult, and the initiation of proper treatment can be delayed without knowledge of this characteristic. Toxic shock syndrome requires early diagnosis and treatment. If the patient has a deteriorated vital sign after breast implant surgery or tissue expander breast reconstruction, toxic shock syndrome should be suspected, even if there are no local signs of infection, and removal of the artifact should be considered as soon as possible.

No abstract