Radial forearm free flap reconstruction following periorbital necrotizing fasciitis with orbital involvement: a case report

Periorbital necrotizing fasciitis is a rare but rapidly progressive infection that may lead to vision loss or death, particularly when associated with orbital and intracranial extension. We report a 63-year-old man with diabetes who presented with rapidly progressive right periorbital swelling and visual impairment. Magnetic resonance imaging revealed extensive infection involving both extraconal and intraconal spaces with suspected meningeal involvement. Broad-spectrum intravenous antibiotics were administered immediately, and early, aggressive surgical debridement was performed, followed by negative-pressure wound therapy to optimize the wound bed. Definitive reconstruction was performed using a radial forearm free flap, designed for subsequent staged division to reconstruct both upper and lower eyelids. A palmaris longus tendon sling was incorporated to provide structural support and prevent lower eyelid malposition. The infection resolved completely, and the flap remained viable, with satisfactory globe protection and partial improvement in visual acuity. This case suggests that advanced periorbital necrotizing fasciitis with orbital involvement can be managed through prompt surgical debridement, broad-spectrum intravenous antibiotics, negative-pressure wound therapy, and carefully planned single-flap reconstruction.