Re: Necrotising fasciitis
The otherwise accurate article on Necrotising fasciitis (BMJ 2020;369:m1428) states that this condition spreads rapidly with little muscle sparing, and gives a reference from a paper published in 1952 to support this statement, but which the authors may have misquoted. The condition certainly does spread rapidly, often in a fulminating way, but actually shows remarkably little muscle involvement, an observation also supported by the more recent literature (BMJ 2005;330:830).
The necessary surgical excision of affected tissue almost always results in extensive skin and soft tissue loss as in the illustration accompanying the article. These defects are in many ways analogous to those following major burn wound excisions. The majority of surgical reconstructions in both of these situations are done by plastic surgeons, using skin grafts sometimes with adjuvant vacuum assisted closure along with transposition tissue transfers (“flaps”) if major neurovascular structures or open joints are exposed.
Because of their familiarity and confidence with extensive skin grafting and reconstruction, plastic surgeons are ideally placed to do the resections for necrotising fasciitis as well as their subsequent repair. They are less likely to compromise on the aggressive surgical debridement which is the mainstay of life-saving treatment and avoidance of progression to severe sepsis and multi-organ failure.
Your readers may be interested in the recent UK National Flap Registry (UKNFR) Report 2019 (ISBN 978-1-9160207-0-2) which in its analysis of over 5000 reconstructive tissue transfer procedures confirms the leading role played by plastic surgeons in high quality complex reconstructive surgery for a wide variety of indications, predominantly for cancer and trauma.
Two further articles recently published in the BMJ on non-melanoma skin cancer and on Bowen’s disease (21 March 2020 and 28 March 2020 respectively) also failed to even mention the involvement of plastic surgery as a specialty. These have been missed opportunities to remind your readers of this specialty’s important role in management of these three conditions, and also its participation in multidisciplinary teams (MDTs). In my Trust most of the 2 week wait rapid skin cancer referrals are managed by the plastic surgeons who sit alongside dermatologists in the skin cancer MDT.
Mr R P Cole ChM, FRCS(Plast)
Consultant plastic surgeon Salisbury NHS Foundation Trust
Design & data analysis lead for UKNFR
Competing interests: No competing interests