The COVID-19 pandemic has affected the entire world tremendously. Particularly during the second wave in India, a dangerous complication followed in the form of COVID-19-associated mucormycosis. On June 7th, 2021, the Indian Union Health Minister stated that 28,252 cases of mucormycosis were reported from 28 states/Union territories in the country.A PubMed search was conducted for English-language studies published from 1988 through May 22, 2021 using the terms "reconstruction AND mucormycosis."The search yielded 102 results. After excluding the articles not describing reconstruction in mucormycosis, 53 abstracts were screened. Then 34 articles dealing with reconstruction in non-ROC regions were excluded. The full text of 16 articles was reviewed. Additionally, 3 articles were identified from the reference search. Due to the aggressive debridements, rhino-orbito-cerebral mucormycosis survivors may be left with complex tissue defects with significant functional and aesthetic impairments. It is essential to offer reconstructive solutions that improve their quality of life. As far as the timing of reconstruction is concerned, the consensus is in favor of delayed reconstruction after ensuring that the infection has been eliminated/controlled and that there are no recurrences. The most common defects encountered were the ones that resulted from orbital exenteration and excision of a varying extent of the involved contiguous bony and soft tissue structures. Reconstruction with pedicled flaps was preferred rather than free flaps, especially in the cases where the infection was not eliminated completely. Adjuvant antifungal therapy was used in most of the cases. Long-term follow-up was considered essential to detect and treat recurrences.A multitude of options are available for reconstruction in rhino-orbito-cerebral mucormycosis including skin grafts, pedicled flaps, free flaps and in some cases implants and prosthetics. These can be utilized to give as much as functional and aesthetic restoration as possible to the patient. 

Reconstruction in Rhino-Orbito-Cerebral Mucormycosis Survivors: A Systematic Review.

Background and Objective The deep inferior epigastric artery perforator (DIEP) flap was first described by Koshima and Soeda in 1989 and is now well-established as the gold standard in breast reconstruction. Lately, this issue has been explored in the context of head and neck reconstruction, highlighting growing interest in the use of the DIEP flap beyond breast reconstruction, but its usage in other anatomical regions appears elusive. Nevertheless, DIEP flap reconstruction may be a viable choice for complex, three-dimensional head and neck deformities while upholding the criteria of minimal donor site morbidity, according to a recent review. To determine whether the DIEP flap may be used successfully in other types of reconstruction, we conducted a review on the use, applications, and outcomes of the DIEP flap in non-breast reconstruction. This is, as far as we are aware, the first comprehensive analysis of all applications of the DIEP flap other than for breast reconstruction. Methods A literature review was performed using PubMed to include all relevant articles in English or French published up to February 2022. Keywords included “DIEP flap” and “deep inferior epigastric perforator flap”. Key Contents and Findings A total of 1,299 articles were identified with 105 on the use of the DIEP flap in non-breast reconstruction. This suggests increasing recognition of the DIEP flap as a feasible option for reconstruction of most anatomical regions, especially in lower limb and head and neck reconstruction, followed by gynecological reconstruction. The DIEP flap was also utilized in the reconstruction of upper limb, thigh and hip defects. Less commonly, it has been used for penoscrotal, groin, sternal, buttock and abdomen reconstruction. Conclusions The scientific body of evidence showed the robustness and versatility of the DIEP flap in non-breast reconstruction, with its relative pros and cons at different anatomical regions.

The deep inferior epigastric artery perforator flap: a narrative review on its various uses in non-breast reconstruction

Background: Cutaneous mucormycosis, while less common than sinonasal or pulmonary infections, can cause widespread tissue necrosis after seemingly innocuous encounters. The most common location of cutaneous mucormycosis is the extremities, and extensive infection has been reported after trauma or orthopedic procedures. Case Report: A 60-year-old female with poorly controlled type 2 diabetes mellitus sustained an open patella fracture after a fall. She underwent washout and internal fixation with cannulated screws and cable tension band wiring. The patient's recovery was complicated by asymptomatic coronavirus disease 2019 (COVID-19) infection and repeated wound dehiscence, with growth of Mucor species initially presumed to be a contaminant. Despite serial washout and debridement, repeat dehiscence and patella exposure were noted. Free tissue transfer to the genicular vessels was selected for coverage of the extensor tendon, patella, and fracture line. In repeat skin cultures, Mucor indicus and Staphylococcus epidermidis grew from the wound. Topical voriconazole and a 6-week course of intravenous isavuconazole and oral doxycycline were started when the Mucor cultures were identified. Conclusion: This case highlights an approach to an indolent mucormycosis infection in the skin over a patella fracture in a patient with poorly controlled diabetes mellitus, including the sequence of surgical care, debridement, and selection of antimicrobials. Major amputation and orthopedic revision were avoided. This patient also underwent successful free tissue transfer after testing positive for COVID-19.

/pdf/lower-extremity-salvage-in-a-diabetic-patient-with-cutaneous-3us6udi0.pdf

Lower Extremity Salvage in a Diabetic Patient With Cutaneous Mucormycosis and COVID-19 After Open Patella Fracture

Mucormycosis is a common pathogen infecting acute lymphoblastic leukemia patients in bone marrow suppression period after chemotherapy. Infection of mucormycosis on skin is relatively rare. In this study, we present a 7-year-old boy diagnosed as acute lymphoblastic leukemia with myeloid expression and mucormycosis infection on skin. Cutaneous mucormycosis occurred on the right forearm after chemotherapy with increasing manifestations of recurrent fever, local skin necrosis and eschar, skin temperature elevation, and swelling painful feeling of right forearm. Tissue smear examination and cell culture results showed that the patient was with mucormycosis infection. Local debridement was carried out and amphotericin B applied for anti-fungal infection treatment. Although constitutional symptom was controlled after anti-infection therapy, surrounding muscles that were affected by the local necrosis kept getting worse. Therefore, free flap transplantation was undertaken along with surgical debridement, and the patient was cured with right hand function preserved completely. Follow-up examination showed that the child entered the maintain chemotherapy stage for leukemia and the local skin was growing well without infection again. In summary, our result indicated that although mucormycosis is hazardous and fatal, early detection and treatment can significantly reduce the mortality whereas drug therapy combined with surgical treatment could further enhance the cure rate.

/pdf/cutaneous-mucormycosis-in-an-acute-lymphoblastic-leukemia-37trph11b4.pdf

Cutaneous mucormycosis in an acute lymphoblastic leukemia child during bone marrow suppression: A case report

Necrotising fasciitis is a life-threatening infection that requires radical debridement, usually accompanied by antibiotic therapy and physiologic support. Patients are often left with disabling or disfiguring soft tissue defects. Traditionally, simple reconstructive methods such as skin grafting and local flap coverage have been used to address these defects, due to concerns that free tissue transfer may increase the risk of thrombosis following infection and inflammation. We argue that once the infection has been cleared and the patient regains stability, free tissue transfer is a viable reconstructive option that may provide better functional and cosmetic results in selected cases.

/pdf/is-free-tissue-transfer-following-necrotising-fasciitis-safe-4f35xra1hg.pdf

Is free tissue transfer following necrotising fasciitis safe? A case report and review

Summary Background Mucormycosis is a very rare infection caused by fungi from the order Mucorales, it rarely involves the skin. We report a case of necrotizing fasciitis of the upper limb which required an aggressive surgical debridement, antifungal therapy and coverage of the defect with a free DIEP flap, a review of the literature was also done regarding indications of reconstruction with free flaps. Case presentation Here we present a case of cutaneous mucormycosis of the right upper limb in a 49-year-old immunocompetent woman after having an open fracture associated with massive contamination during a motor vehicle collision. In early postoperative period, she had multiple skin necrotic lesions. Serial surgical debridements were performed and ended up with interscapular-thoracic amputation associated with a total mastectomy. Following diagnosis confirmation of mucormycosis infection, the patient was started on antifungal therapy for several months. After disease control, the large defect was successfully covered by a DIEP flap. Conclusion Cutaneous mucormycosis requires antifungal therapy along with aggressive debridement, reconstruction by a free flap seems to be a good solution to cover these large defects.

Using free flaps for reconstruction during infections by mucormycosis: A case report and a structured review of the literature.

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Using free flaps for reconstruction during infections by mucormycosis: A case report and a structured review of the literature.