Freestyle Perforator-Based Fasciocutaneous Flap Reconstruction in Nicolau Syndrome-Related Tissue Necrosis

Abstract

The actual pathology of the Nicolau syndrome (NS) is still unknown. It is thought to involve direct vascular damage and vasospasm. Many NS cases were reported in the literature but a treatment protocol is still not established. However, after demarcation of the necrotic tissue, surgical intervention is mandatory. Five NS cases with extensive tissue necrosis on the upper lateral gluteal region were analyzed retrospectively. Operative technique was described in details for freestyle perforator-based fasciocutaneous flaps from the gluteal region to reconstruct defects of NS-related tissue necrosis. Freestyle perforator-based fasciocutaneous flaps were used for defect closure in all patients. All flaps survived totally. No complications occurred during the follow-up period. Although rare, NS is a serious complication of inadvertent intramuscular injections. Prevention is the best treatment. However, in case of large-tissue necrosis, freestyle perforator-based fasciocutaneous flaps harvested from the gluteal region is a satisfactory option for reconstruction.

Nicolau syndrome caused by non‐steroidal anti‐inflammatory drugs: Systematic literature review

“…The chance‐adjusted agreement between the two investigators on the application of the inclusion and exclusion criteria was 0.88. A total of 45 eligible reports 6‐50 published between 1996 and 2019 in English (N = 44) or Spanish (N = 1) were identified. The reports were primarily (N = 41, 91%) from Europe (Turkey, N = 17; Italy, N = 4; Belgium, N = 1; Germany, N = 1; Switzerland, N = 1) and Asia (India, N = 9; South Korea, N = 5; China, N = 1; Israel, N = 1; Qatar, N = 1).…”

“…The aforementioned 45 reports included 62 previously healthy subjects (40 females and 22 males aged from 13 to 81, median 57 years) with Nicolau syndrome occurring after intramuscular 6‐11,13‐50 or local 12 injection of a non‐steroidal anti‐inflammatory drug, as shown in Table 1. The vast majority of cases (N = 53; 85%) occurred following administration of diclofenac.…”

Síndrome de Nicolau. Manejo conservador. Caso clínico

“…En República Dominicana se registra el primer caso en el año 2017, el cual fue manejado con tratamiento convencional. [1][2][3][4][5][6][7][8][9][10][11][12][13][14] Se considera una complicación rara tras la administración de inyecciones intramusculares, subcutáneas, intravenosas o intraarticulares de medicamentos, entre los que podemos citar: AINES, vitamina K, penicilina, antihistamínicos, corticosteroides, anestésicos locales, vacunas, polidocanol e interferón pegilado alfa 1,14 .…”

“…Tres hipótesis se han señalado basadas en los hallazgos observados en la biopsia de tejidos: 1) inflamación causada por la inyección perivascular del medicamento administrado, induce a lesiones en las arterias que lleva a necrosis de la piel; 2) la inyección periarterial o perineural al conducir a dolor severo sobreactiva el sistema simpático, produciendo vasoespasmo y compromiso circulatorio; 3) la inyección intraarterial provoca oclusión embólica de las arterias cutáneas con necrosis tisular 3,10 .…”

“…En relación con la prevención, es importante tener en cuenta que las inyecciones en todo caso pueden provocar síndrome de Nicolau, por lo que debemos tomar precauciones y evaluar en toda su magnitud la necesidad del uso de esta vía. Es necesario aspirar para verificar presencia de sangre, usar la técnica Z-track, definir el sitio adecuado, valorar la necesidad de aplicación de grandes dosis y el cambio regular de sitios, si se van a administrar múltiples inyecciones, considerando que se pueden utilizar otras vías, ya que se han descrito múltiples complicaciones, incluso la muerte 1,10 .…”