Necrotising fasciitis involving the periorbita is a devastating infection. Potential outcomes range from severe disfigurement, loss of the eye and even to death. Early recognition is critical, although its initially non-distinctive appearance frequently delays diagnosis and treatment. Herein, the authors have performed a systematic review of previously published cases including clinical features, diagnoses and differential diagnoses, pathological characteristics and management. Periorbital necrotising fasciitis is seen mainly in adults with a female predominance (54%); about one-half (47%) of the patients were previously healthy. The infection can follow local blunt trauma (17%), penetrating injuries (22%) and face surgery (11%), but in about one-third of cases (28%) no cause was identified. Non-specific erythema and localised painful swelling of the eyelids characterise the earliest manifestation of the disease, followed by formation of blisters and necrosis of the periorbital skin and subcutaneous tissues. The causative organism in periorbital infection was mainly β-haemolytic Streptococcus alone (50%), occasionally in combination with Staphylococcus aureus (18%). The overall mortality rate was 14.42%. The main risk factor for mortality was the type of causative organism, since all reported cases of death were caused by β-haemolytic Streptococcus alone or associated with other organisms. Unlike necrotising fasciitis affecting other body sites, there was not a strong correlation with age >50 years or the presence of associated chronic illness. Management of periorbital necrotising fasciitis is then based on early distinction of symptoms and signs and aggressive multidisciplinary treatment. Thus, the delay between initial debridement and initiating parenteral broad-spectrum antibiotic therapy should be considered the most critical factor influencing morbidity and mortality.

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Skin-reducing mastectomy is a single-stage technique that helps us to overcome the cosmetic inadequacy of a Type IV Wise pattern skin-sparing mastectomy (final T-inverted scar) in heavy and pendulous breasts by filling the lower-medial quadrant with adequate volume. It also conceals scars as an aesthetic operation and at the same time provides satisfactory and safe coverage of the implant. We report our experience with 22 skin-reducing mastectomies done for 18 women. We modified part of the original description of raising the dermal flap to refine the anatomical results. This flap was mobilised better by detachment of the lateral part of its insertion along the inframammary fold, and this allowed us to close the dermomuscular pouch inferiorly and laterally without raising the serratus anterior or limiting its rise. The total or partial preservation of the serratus muscle together with the creation of a force directed medially, as indicated by the dermal flap, reduced the risks of lateral dislocation of the implant and improved the lateral breast contour to give a more natural shape. Skin-reducing mastectomy is an oncologically safe skin-sparing mastectomy that solves all cosmetic problems and reduces complications of the original Type IV Wise pattern in medium to large breasts. Doing the mastectomy and reconstruction in a single stage aids the favourable psychological approach of the patient. We emphasise the use of our small modification to refine the contour of the breast and improve the aesthetic outcomes by giving a natural curvilinear profile.

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