An Unusually Large Carbuncle of the Temporofacial Region Demonstrating Remarkable Post-debridement Wound Healing Process: A Case Report

Skin carbuncles are debilitating skin infections commonly seen in elderly patients with diabetes. These infections develop when a cluster of adjacent furuncles coalesce to form one inflammatory mass. While they commonly occur on the nape of the neck and back, rarer sites involving the face and head have been noted. Management of these rare sites is urgent because of the potential intracranial complications and the surgical outcome is often unsatisfactory due to associated facial scarring. Intraoral drainage is advocated to avoid this; however, when the carbuncle involves a larger area, debridement from the exterior is necessary. The resultant soft-tissue defect requires a skin graft or a flap for coverage, but this may still lead to an unsatisfactory cosmetic outcome. The authors report a case of a carbuncle involving an extensive area over the right temporofacial region, including its management and the remarkable post-debridement cosmetic outcome despite avoidance of plastic surgery techniques due to the patient’s high risk associated with anesthesia. 

Skin carbuncle is a necrotizing infection of the skin and subcutaneous tissues.¹ It is composed of a cluster of furuncles, which coalesce into an inflammatory mass with multiple pus-draining sinuses.² It is also described as an infective gangrene of the skin and subcutaneous tissues¹ and is most commonly associated with patients with diabetes.^2,3 While the most common sites of skin carbuncles are the nape of the neck and back,¹ carbuncles involving the face and head have also been described as case reports.^4,5 Furthermore, it is only in rare cases that furuncles and carbuncles of the face progress to form an abscess requiring incision and drainage that can in turn lead to facial scarring⁶ and a poor cosmetic outcome. While incision and drainage via an intraoral route may avoid this,⁶ debridement of dead tissue from exterior is additionally necessary and can result in large soft-tissue defects not amenable to direct skin closure when carbuncles involve large areas. The cosmetic outcome of this may still be unsatisfactory even after the use of plastic surgery techniques.⁷ Presented herein is a case of a previously unreported, unusually large carbuncle involving the right temporofacial region of the head, with its management and its remarkable post-debridement cosmetic outcome despite no use of plastic surgical techniques for skin cover.

A 63-year-old man with uncontrolled diabetes and chronic renal failure presented with swelling over a large area of the right temporofacial region measuring approximately 10 cm x 15 cm in maximum anteroposterior and craniocaudal dimensions, respectively. It had started as a boil in the preauricular region and increased in size over a 2-week period. The patient refused treatment as he had minimal pain; however, he developed a high-grade fever and severe intractable headache 3 days prior to presentation. 

On examination, he was in severe sepsis with anemia and bilateral pedal edema. There was a large area of edematous necrotic skin with multiple pus-discharging points over his right temporal region encroaching upon his right cheek below the right eye (Figure 1). The patient also had right-side periorbital edema. The tragus of his right ear was also involved in the disease process; however, the ear did not have any discharge. Oral cavity examination and the rest of his systemic examinations were unremarkable except for harsh vesicular breathing. The patient was admitted and started on broad-spectrum intravenous (IV) antibiotics (1 g cefoperazone IV 2x/day and 500 mg metronidazole IV 3x/day) and subcutaneous insulin (regular insulin on 8-hour sliding scale) for blood sugar control. Computerized tomography (CT) scan was advised to rule out intracranial complications as the patient had intractable headache. Nephrology opinion was sought as his serum creatinine was 3.8 mg/dL. 

Figure 1. Carbuncle of the temporal region encroaching upon the face just prior to debridement.

Patient underwent incision, drainage, and wide surgical debridement of the involved area under high-risk general anesthesia as his physical status according to the American Society of Anesthesiologists (ASA) Physical Status classification system was ASA 4. During the procedure, all necrotic tissue down to the temporalis fascia was debrided. A rim of surrounding inflamed skin and subcutaneous tissue were left in order to preserve as much viable skin as possible. A friable superficial temporal artery was also encountered, which was avulsed despite gentle handling. Hemostasis was secured by suture ligation at its lower end, which was the only part of the vessel healthy enough to bear suture. At the end of the procedure, the patient had a large soft-tissue defect encroaching over the posterior aspect of the cheek below the right eye anteriorly and over the tragus posteriorly (Figure 2). 

Figure 2. Soft-tissue defect created after debridement with forceps showing ligated superficial temporal artery.

After a postoperative 2-day stay in the intensive care unit (ICU), the patient was discharged on postoperative day 7. His headache had gradually resolved during his admission. He was continued on the same broad-spectrum IV antibiotics regimen throughout the ICU stay, post ICU admission, and post-discharge period for a total of 14 days as a culture and sensitivity of pus specimen taken during the surgery had revealed no growth. Daily dressings were advised initially with Edinburgh University Solution of Lime. Once slough had disappeared from the wound, daily dressings with povidone-iodine were advised. During this period, blood sugars were managed by a combination of regular and isophane (NPH) insulin under care of a medical specialist.

Two months after the initial surgery, bright red healthy granulation tissue appeared in the patient’s large wound, and he was referred to the Department of Plastic Surgery at Dow Medical College and Civil Hospital Karachi for opinion regarding skin closure by skin grafting. However, his attendants opted to continue with dressings at home due to the high risk associated with anesthesia that would be a requirement for the procedure to be undertaken. Dressings with normal saline only were continued from this point onwards. The patient was advised to continue with strict sugar control using insulin as advised by his medical specialist, and he was referred to a nephrologist for regular follow-up visits regarding his renal issue. 

The patient followed up at 4.5 months with findings as shown in Figure 3. The wound had contracted remarkably, with near-normal skin growing at least 2.5 cm backwards from the lateral angle of the right eye and 1 cm forwards over the tragus of the right ear. The scar occupies a small irregular area approximately 5 cm x 7 cm in maximum anteroposterior and craniocaudal dimensions respectively. On frontal view of the patient’s face, the scar is only just visible. Psychologically, the patient is very happy with the result. During this period, his sugars have remained well controlled on insulin and his renal issue had been managed conservatively with his creatinine level remaining between 2 and 3 mg/dL. 

Figure 3. Cosmetic outcome after 4.5 months of daily dressings alone.

Carbuncle is a common dermatological disease process¹ that usually affects the nape of the neck, back, axilla, and buttocks.⁵ It is most commonly caused by Staphylococcus aureus.¹ While there has been very limited data published on carbuncles over the past 2 to 3 decades¹, on a literature search by the authors, carbuncles with such extensive involvement of the temporofacial region have not been reported thus far. Whereas poor hygiene, advanced age, and an impaired immune system seem to be the most important factors in such an extensive spread,⁵ the decreased pain sensation associated with uncontrolled diabetes appears to be an important factor behind this patient’s late presentation. While associated cellulitis may be the cause of headaches in carbuncles of this region, the onset of severe intractable headaches should be investigated further to rule out intracranial complications,⁴ which may necessitate multidisciplinary involvement. Such complications were ruled out in this case by plain CT scan of the head ordered emergently. 

Carbuncles require an early aggressive surgical approach⁵ where complete debridement of necrotic tissue should be planned in a single procedure to avoid further anesthesia in high-risk patients. As is apparent from this case, the need for ligation of the superficial temporal artery should be anticipated and its surgical anatomy reviewed prior to surgery with carbuncles of the temporal region. In this case, a friable superficial temporal artery was indeed anticipated as well as encountered perioperatively. While this patient’s surgery was deferred for 2 to 3 days due to his nephrology issue, delay in such cases should be minimal as the author believes spontaneous bleeding from a friable superficial temporal artery may eventually take place with catastrophic consequences. The additional possibility of development of intracranial complications, especially associated with involvement of the facial region, also merits early and radical surgical intervention.⁵  

While skin grafts or flaps are the recommended techniques for coverage of large carbuncle defects not amenable to direct surgical closure,⁷ the results of continued daily dressings and good sugar control may be quite surprising as evidenced by the remarkable wound healing that occurred in this case — an option of management that was undertaken solely on the behest of the patient’s attendants. This outcome may be related to 2 factors. First, because carbuncles tend to involve loose tissues of the skin, this leads to contraction of the postoperative defect becoming the predominant form of repair.⁵ The second factor relates to the type of procedure employed during surgical debridement,⁸ with the 2 recommended choices of excision of the necrotic center and surrounding cellulitis (saucerization) and incision and drainage with debridement of the necrotic center without removal of the surrounding cellulitis (which is left to respond to antibiotics).⁸ The latter approach was used in this patient not as an aims to avoid skin grafting later on, but to save as much of the scalp and delicate facial skin as possible. However, leaving behind the surrounding cellulitis and continuing with antibiotics leads carbuncle defects to heal quickly with skin grafting required rarely.⁸ These 2 factors in conjunction with optimum management of comorbidities probably led to the better than expected cosmetic outcome in this patient.

By reporting this case, the authors do not advocate conservative management in place of plastic surgical techniques for skin cover of large carbuncle defects especially on the face. Rather, the purpose is to present this rare site of this disease process and to discuss processes of wound healing that may have had an impact on this patient’s remarkable cosmetic outcome despite no use of plastic surgical techniques used for skin coverage. 

From the Department of Surgery, Dow Medical College and Civil Hospital Karachi, Dow University of Health Sciences, Karachi, Pakistan

Address correspondence to:
Humaid Ahmad, MBBS, MCPS, MRCS (Glasgow), FCPS
Assistant Professor of Surgery
Department of Surgery
Dow Medical College & Civil Hospital Karachi
Dow University of Health Sciences
Baba-e-Urdu Road
Karachi, Sindh, Pakistan 74200
dr_humaidahmad@hotmail.com
humaid.ahmad@duhs.edu.pk

Disclosure: The authors disclose no financial or other conflicts of interest.

*Dr. Sheeraz Shakoor Siddiqui is now affiliated with The Indus Hospital, Karachi, Pakistan as Senior Consultant, Department of Surgery.