A 5-year-old white boy presented with soft-tissue cellulitis involving the soft tissue of the lower ear auricle and adjacent neck (Figs 1a and 1b) as a result of a brown recluse spider bite. Wound cultures gave negative results upon initial debridement. The involved area progressed from cellulitis to necrosis of the skin of the lateral neck and lower auricular cartilage (Figs 1c and 1d). The initial management consisted of intravenous antibiotics and debridement. The plastic surgery service was consulted on day 12. The wound was debrided again (Figs 2a and 2b) and cultures returned with methicillin-resistant Staphylococcus aureus sensitive to vancomycin and trimethaprim/sulfamethoxazole. Negative pressure wound therapy was started immediately following the debridement on day 12. Nanocrystalline silver mesh (Acticoat; Smith & Nephew, St. Petersburg, FL) without the absorbent layer was used as a contact layer (Figs 2c and 2d), and polyurethane foam was used as the wound filler.
Because of the difficulty in maintaining a vacuum seal, the NPWT dressing was placed over the entire ear auricle. The external auditory canal was dressed with Xeroform gauze (Fig 33a), and the auricle was incorporated into the dressing (Fig 3c). The dressing was irrigated with sterile water daily through an irrigation tube both to promote exudate clearance and to activate the silver in the dressing. The polyurethane foam was placed directly adjacent to the canal beneath the overlying occlusive dressing (Fig 3c). The wound interface pressure was set to -80 mm Hg, and the dressing was changed and the wound debrided at 3- to 5-day intervals in the operating room. The wound bed was fully granulated after 20 days from the initial debridement and required a total of 7 days of NPWT. It was closed with a meshed, split-thickness skin graft (Figs 4a–4b), and the patient had an uneventful recovery. The patient had a first-stage reconstruction of the ear lobule at 14 months after the injury (Fig 4c) and will undergo 1 more procedure to complete the sulcus restoration and removal of more of the split-thickness graft.
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Division of Plastic and Reconstructive Surgery, Department of Surgery, University of Louisville, Louisville