Objective: Necrotizing fasciitis (NF) is an aggressive bacterial infection of subcutaneous tissue that more commonly affects the extremities, perineum, and trunk. NF of the midface region is very rare. A literature review of 116 midface NF cases is presented (largest review to date). The pathophysiology, treatment, and reconstruction options are discussed. We report an additional case with reconstruction of the midface with a cervicopectoral advancement flap and the eyelids with a prepuce (foreskin) full-thickness skin graft.

Patients and methods: Ovid Medline search in four languages (English, French, German, Spanish) from the years 1948–2011 of cervicofacial NF revealed 218 articles, 115 of which were pertinent for review. Patients’ health, etiology, microbiology, antibiotic therapy, surgical treatment, reconstruction, complications were recorded.

Results: 84% of reported cases were published after 1990. Patient characteristics: male 52%, alcoholism 20%, neutropenia 13%, diabetes 11%. Etiology: facial trauma 42%, idiopathic 22%, postsurgical 9%, odontogentic 3%. Microbiology: streptococcus/staphylococcus 70%, streptococcus alone 54%, pseudomonas 13% (100% of neutropenic patients), polymicrobial 7%. 85% required surgical debridement and 36% required some form of skin grafting. There were no reports of prepuce grafting. Complications: sepsis 40%, death 14%. Our patient was an alcoholic male who sustained facial trauma, streptococcal infection with sepsis, requiring extensive debridement and reconstruction.

Conclusions: Midface NF is a rare but dangerous disease that may be increasing in incidence. The prepuce is an overlooked full thickness skin graft that may be of use in periorbital reconstruction among male patients.

Conflict of interest: None declared.