Fournier's Gangrene Surgical Reconstruction: A Systematic Review

Abstract

Fournier's gangrene (FG) is a rare form of necrotizing fasciitis of the perineal, genital, or perianal region. It is characterized by an aggressive course and high mortality rate, over 20%. FG demands immediate treatment including resuscitation maneuvers, intravenous antibiotic therapy and early surgical debridement. Background/Objectives: The gold-standard treatment for FG is surgical reconstruction. However, up to date, no precise guidelines exist. Thus, we decided to systematically review the literature, focusing on FG contemporary approaches to reconstructive surgery, aiming to analyze the various reconstructive strategies and their specific indications. Methods: A systematic review was carried out according to the PRISMA statement by searching various databases from April 2014 to April 2024, using the terms ''Fournier Gangrene OR Fournier Gangrene Reconstruction OR Fournier Gangrene Treatment OR Fournier Gangrene Plastic Surgery OR Necrotizing Fasciitis OR Necrotizing Fasciitis AND Reconstruction". The eligibility criteria included original studies aimed at discussing FG reconstruction with at least three clinical cases. Results: The final synthesis included 38 articles, and 576 reconstructions were described. Of these, 77.6% were minimally invasive strategies (direct closure, secondary healing, grafts, and local random flaps), while more invasive reconstructions (loco-regional flaps based on known vascular anatomy) were adopted in 22.4%. No free flaps were reported. Conclusions: FG requires immediate medical interventions including broad-spectrum antibiotic therapy, surgical debridement, adjuvant therapies, and reconstructive surgeries. Taking into account the anatomical characteristics of the inguinal-crural region, skin grafts and local random flaps could offer versatile and effective reconstructions for most FG cases, while the more invasive strategies should be reserved for very few cases. Future research is warranted to define an FG dedicated reconstruction protocol.

Keywords: Fournier gangrene; Fournier gangrene plastic surgery; Fournier gangrene reconstruction; Fournier gangrene treatment; necrotizing fasciitis; necrotizing fasciitis and reconstruction.

Figure 1

PRISMA 2020 flow diagram summarizing research results.

Figure 2

Seventy-two-year-old man with testicular exposure and penile degloving following FG. The patient was first subjected to surgical debridement. After 25 days, the loss of substance was covered with a split-thickness graft. (A) preoperative; (B) graft inset; (C) 1-month follow-up.

Figure 3

Sixty-five-year-old male patient with testicular exposure following FG. Twenty-one days after surgical debridement, the extensive loss of substance was covered with a bilateral advanced local flap (random vascular anatomy). (A) preoperative; (B) flap dissection; (C) immediate postoperative result; (D) one-year follow-up.