BACKGROUND Necrotizing fasciitis is a potentially fatal infection of β hemolytic Group-A Streptococcus, often occurring in patients with other comorbidities, but can occur in healthy individuals as well. It commonly affects the extremities, perineum, and abdominal wall. The aim of this study was to highlight various presentations of necrotizing fasciitis in unusual anatomical sites with delayed diagnosis and treatment. METHODS In a retrospective analysis, seven cases of unusual presentations of necrotizing fasciitis were enrolled during a period of five years treated in a tertiary centre. RESULTS The patients were between 23 and 80 years. Four were males and three were females. Four out of seven were diabetic. All patients had septicemia (hypovolemic shock, with leucocytosis, thrombocytopenia and deranged coagulation parameters) on admission in the intensive care unit. All seven patients had minimal cutaneous manifestation and the remote primary pathology was diagnosed in two patients. Six patients out of seven survived and the morbid state continued in one patient in view of malignancy of rectum in one patient. The overall outcome was satisfactory in five out of seven cases. CONCLUSION Pain disproportionate to the local inflammation with florid constitutional symptoms should raise suspicion of necrotizing fasciitis. Early diagnosis, of stabilization of hemodynamics, emergency fasciotomy, staged debridement and the initiation of broad spectrum antibiotics reduced the morbidity and mortality. The disease may manifest with uncommon presentations and sometimes lead to the diagnosis of primary aetiology.

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BACKGROUNDConventional technique of flap inset in buccal mucosa reconstruction is by direct suturing of cutaneous margin of Pectoralis Major Myocutaneous (PMMC) flap to hard and soft palate mucosa and margin of floor of mouth with simple interrupted sutures. We have done a prospective study of the efficacy of anchoring the upper margin of PMMC flap to the hard palate by a modified method in reconstruction of buccal mucosa defects following tumour excision. This is to prevent disruption of suture line from the mucoperiosteum of hard palate and resultant oro-cutaneous fistula. METHODSThis hospital-based prospective study was carried out in the Department of Plastic Surgery at Bangalore, India for a period of 18 months (2015)(2016)(2017). Patients (N=48) with buccal mucosa defects requiring reconstruction with PMMC flap either with conventional (n=24) or modified method (n=24) following tumour excision were included. Clinico-demographic profile of the patients including age, gender, size of defect, staging of illness, site and type of reconstruction, disruption of suture margin in the hard palate, development of oro-cutaneous fistula (OCF), day of starting oral feeds, removal of Ryle's tube and post-operative average length of stay in the hospital were recorded. RESULTSDisruption of suture line in hard palate and Oro-cutaneous fistula were statistically significant in study group in both the variables (P-0.033, P-0.033). The median days on which patients were started with oral clear liquids and removal of Ryle's tube were also statistically significant between study and control groups. Post-operative average length of hospital stay which is the outcome of favourable results in the study group was found to be statistically significant (P-0.021) between the groups. CONCLUSIONOverall, modified technique of anchorage of PMMC flap can be considered as a reliable technique in buccal mucosa reconstruction because of its stability, lower complication rates and shorter length of hospital stay.