Reconstruction After Necrotizing Fasciitis: A Timing-Based Algorithm for the Plastic Surgeon

Survival after necrotizing fasciitis has improved, producing a growing population of survivors whose function and appearance are determined by reconstruction. Guidance on reconstructive timing and technique, however, remains limited. This structured narrative review synthesizes evidence from PubMed/MEDLINE on reconstruction after necrotizing fasciitis from the perspective of the plastic surgeon and proposes a practical, timing-based algorithm. Its central thesis is that reconstruction is planned from the first debridement: wound-bed readiness and patient physiology, rather than a preferred technique, drive flap selection and the timing of definitive coverage. Radical initial debridement, repeated at 12- to 24-hour intervals, defines the final defect and is the biological precondition for durable closure. Skin-sparing debridement reduces the proportion of the wound that requires graft coverage and increases the rate of delayed primary closure. Negative pressure wound therapy, including instillation variants, prepares the wound bed as a bridge to definitive reconstruction. Reconstructive options are matched to the declared defect by anatomic region: delayed primary closure and split-thickness skin grafting for large planar wounds; local and pedicled flaps for perineal and scrotal defects; dermal templates over poorly vascularized beds; and free tissue transfer for defects with exposed critical structures or substantial volume loss. Available small retrospective series suggest high free-flap survival after source control and physiological stabilization, although these estimates are likely affected by selection bias. The evidence base is dominated by small retrospective series with heterogeneous reporting, so recommendations are provisional. A region-based algorithm and priorities for standardized outcome reporting and a multicenter registry are proposed.