# Circumferential Skin and Subcutaneous Tissue Necrosis of the Left Lower Leg Secondary to a Chronic Arterial Ulcer Complicated by Bullous Cellulitis: Staged Debridement, NPWT, and Split-Thickness Skin Grafting for Limb Salvage

## TL;DR

A patient with severe leg tissue damage from a chronic ulcer and infection was successfully treated with staged debridement, NPWT, and skin grafting, avoiding amputation.

## Contribution

This case demonstrates that circumferential ischemic-infective necrosis can be salvaged through a staged NPWT-centered reconstructive strategy.

## Key findings

- Staged debridement and NPWT enabled successful skin grafting in a severe lower-leg wound.
- Limb salvage preserved mobility and quality of life without major amputation.
- NPWT-centered strategy proved effective for graftable wound-bed optimization.

## Abstract

Chronic arterial ulcers are associated with impaired healing and a high risk of infectious complications and limb loss. Bullous cellulitis represents a severe soft-tissue infection phenotype that may progress to extensive tissue necrosis. We report an 83-year-old woman with advanced atherosclerotic disease and a prior contralateral transfemoral amputation who developed bullous cellulitis complicating a long-standing circumferential distal lower-leg arterial ulcer, resulting in complete circumferential loss of skin and subcutaneous tissue with exposure of deep structures. After infection stabilization, the wound was managed with staged mechanical and chemical debridement, negative pressure wound therapy (NPWT) for wound-bed optimization, and definitive split-thickness skin grafting under NPWT bolster. Complete graft take was achieved without early complications. Limb salvage preserved the patient’s mobility and quality of life, avoiding the functional consequences of bilateral major limb loss. The key novelty of this case is that even circumferential ischemic-infective necrosis, often presumed to mandate amputation, can be rendered graftable and salvaged through a strictly staged, NPWT-centered reconstructive strategy.