Author’s Name(s): Michael Kryshtalskyj, Carson Schell, Matthew Lee-Wing, Julie Morin, Brett Byers, Karim Punja

Author’s Disclosure Block: Michael Kryshtalskyj, none; Carson Schell, Consultant: AbbVie; Matthew Lee-Wing, none; Julie Morin, none; Brett Byers, none; Karim Punja, none

Abstract Body
Purpose: Jurisdictions across Canada have reported a recent epidemic of GAS infections, with rates increasing by up to 77% from 2022-2023.1,2 We report a multicentre series of aggressive, periocular necrotizing fasciitis (NF), and the diverse techniques used to debride and reconstruct. Study Design: Case series. Methods: Charts of patients with periocular necrotizing fasciitis between 2022-2024 were reviewed. Written consent for patient information to be collected was obtained. Approval was waived from the University of Calgary Conjoint Health Research Ethics Board. Results: 17 patients were identified. Ages ranged from 4-69 years (median 55.5 years), and 14 (82%) were male. 6 (35%) had concurrent substance use, 5 (29%) had diabetes, 2 (12%) were immunocompromised, and 4 (24%) were healthy. Distribution of NF included preseptal upper eyelid (100%), preseptal lower eyelid (7, 41%), and posterior upper and lower eyelids in 2 cases. 5 (29%) cases were bilateral. Regional or distant infected wounds (forehead, palate and nasopharynx, 5th finger) were associated in 3 cases, and extensive metastatic NF was observed in 1 delayed presentation (occiput, neck, leg, and scrotum). 5 cases were associated with fasciitis tracking down the neck via co-planar superficial temporal fascia. A conservative, skin-sparing debridement was attempted in 8 cases (47%). 100% of cases grew GAS, and 4 cases were polymicrobial (commonly with Staphylococcus aureus). Coronavirus-19 or influenza tested positive in 2 patients. Reconstructions included skin grafting in 7 cases (41%) and delayed primary closure in 5 cases (36%). 2 bare-bone defects were addressed using a temporalis turnover flap and biodegradable temporizing matrix prior to skin grafting. 1 case received a paramedian forehead flap. 1 case with full-thickness necrosis of the upper and lower eyelids received a periosteal flap and contralateral free tarsal graft to reconstruct posterior lamellar support, a forehead rotation flap, and bladder matrix to temporize. Amniotic membrane was used in 1 case. 4 patients received negative pressure wound therapy to promote granulation before reconstruction, and 1 patient received hyperbaric oxygen. 3 patients received steroids after infection had cleared. Considering initial defects, outcomes were reasonable at median follow-up (4 months, range 0.5-12 months). Major complications included severe exposure keratopathy (n=1), skin graft failure (n=1), superonasal pedicle loss (n=1), and death in the 1 case with metastatic NF. Mild lagophthalmos was seen in 4 patients. Conclusions: This series illustrates the diversity and complexity of NF presentations and the wide array of approaches used by different surgeons to debride and reconstruct. With GAS on the rise worldwide, providers should remain vigilant for periocular NF and treat it early and aggressively with tissue- and globe-sparing approaches.