<p class="abstract">Necrotizing fasciitis (NF) is a life-threatening soft tissue infection with a high misdiagnosis rate. Here, we present the case of NF with hypoesthesia due to prior leprosy in a limited resource area. Laboratory risk indicator for NF (LRINEC) score was used to determine the diagnosis of NF. Resuscitation and broad-spectrum antibiotic were initiated, followed by surgical debridement due to lack of wound improvement and skin graft to cover the wound was done. This case report highlights the usage of LRINEC score to reduce misdiagnosis, ensure early diagnosis, and improve patient management in NF with masking effect.</p>

The aim of the study is to compare the systematic injection patterned-technique of 1-permil tumescent solution versus the random patterned-technique. Several incidences of perforator flap necrosis have been encountered with tumescent technique. Among the possible causes, the most probable cause is the injury of perforator artery due to the multipassing needle injections. Thus, an evaluation regarding the needle injection pattern needs to be done in order to avoid necrotic flap incidence. A randomized controlled experimental study was conducted on both groins of 20 healthy Wistar stained-Rattus novergicus weighing 220 to 270 g. A comparison of a systematic injection pattern and a random injection pattern was performed. Three mL of 1-per-mil tumescent solution was injected subcutaneously before elevation of the islanded groin flap. Clarity of the operative field along with the size of the pedicle were recorded. The photos of survival area of the skin flap on postoperative day 7 were analyzed using Analyzing Digital Images. Totally bloodless operative field was observed in all subjects. Three out of 19 flaps in group A (15.78%) and 4 out of 18 flaps in group B (22.22%), were found to be necrotic, either total or partial. No significant difference (P. 0.05) was found between the injection technique groups, in terms of flap necrosis. Although the 1-per-mil tumescent technique is advantageous in a way that it provides a totally bloodless operative field, the systematic injection patterned-technique was not found to be more superior compared to the custom random patterned-multi-passing needle injection technique.

Background: In reconstructing challenging defects, surgeons are considered fairly fortunate when they are able to obtain a similar donor tissue quality to that of the missing tissue; in regards to their color, texture, size, and the ease of donor transfer to the defect. Several methods may be used, which frequently include the free tissue transfers using microvascular anastomoses bearing their specific consequences. We report a select of challenging cases which were successfully reconstructed using the Keystone flaps and avoid microvascular anastomoses, where otherwise the free tissue transfers would be the typical option for closure in such defects. Patient and Method: Nine cases of relatively large defect in various locations were reconstructed using the Keystone flaps supplied by either non-identified perforators or identified reliable perforators. Result: Out of the 9 defects located on various region of the body (lumbar, thorax, dorsum of the foot, plantar of the foot, posterior leg, sacrum, and cervicofacial) only the first 2 cases had identifiable perforators. All flaps survived completely without problem of vascularization. Summary: The Keystone flap is a useful and reliable random perforator-based flap even when the perforator vessels are not identified.