Innervated distally-based superficial sural artery flap

* This paper will be presented, in part, at the 4th Congress of theWorld Society for Reconstructive Microsurgery.

1258 Correspondence and communications

a combination of vitamin C and manganese, with or withoutproline; a combination of zinc sulfate and vitamin C; andgrowth hormone have been suggested.2e5 We do believethat preoperative withdrawal of all topical steroids isa critical point in prevention of postoperative complica-tions such as infection and wound dehiscence. Moreover,we suggest that continuous use of intraoral vitamin C mayhave a role in the prevention of recurrent skin ulcerations.

Although this enzyme deficiency is a very rare syndrome,these patients may need plastic surgical operations. Thesurgeon must be aware of potential wound healing prob-lems in these patients and should prepare optimum condi-tions preoperatively. The patient should be told to takingtopical steroids a few weeks before surgery. Moreover, thecoagulating tests must be checked carefully before anyattempt at surgery. Although there has been no report onthe medical treatment modalities for presurgical prepara-tion and postoperative care of this group of patients, on thebasis of our experience with this patient, we do believethat using the aforementioned pre- and postsurgicaltreatment modality, reconstructive surgery can be donesafely in patients with PDS.

In conclusion, in this report, we present a pre- andpostoperative treatment modality to obtain better woundhealing in this group of patients. In addition, the potentialcomplications of surgery in this syndrome are discussed. Toour knowledge, this is the first report of reconstructivesurgery in a patient with PDS.

References

1. Goodman SI, Solomons CC, Muschenheim F, et al. A syndromeresembling lathyrism associated with iminodipeptiduria. Am JMed 1968;45:152e9.

2. Trent JT, Kirsner RS. Leg ulcers secondary to prolidasedeficiency. Adv Skin Wound Care 2004;17:468e72.

3. Powell GF, Rasco MA, Maniscalco R-M. A prolidase deficiency inman with iminopeptiduria. Metabolism 1974;23:505e13.

4. Milligan A, Graham-Brown RA, Burns DA, et al. Prolidasedeficiency: a case report and literature review. Br J Dermatol1989;121:405e9.

5. Arata J, Hatakenaka K, Oono T. Effect of topical application ofglycine and proline on recalcitrant leg ulcers of prolidasedeficiency. Arch Dermatol 1986;122:626e7.

Daghan IsikDepartment of Plastic and Reconstructive Surgery,

Gaziantep Avukat Cengiz Gokcek Government Hospital,Gaziantep, Turkey

E-mail address: daghanmd@yahoo.co.uk

Mehmet BekereciogluMehmet Mutaf

Department of Plastic, Reconstructive andAesthetic Surgery, Gaziantep University Faculty of

Medicine, Gaziantep, Turkey

ª 2008 British Association of Plastic, Reconstructive and AestheticSurgeons. Published by Elsevier Ltd. All rights reserved.

doi:10.1016/j.bjps.2008.01.033

Innervated distally-based superficial sural artery flap*

The distally-based superficial sural artery flap was firstreported in 1992 by Masquelet as a distally-based neuroskinflap of the sural nerve.1 The medial and lateral suralcutaneous nerves are located on the deep fascia in the suralregion and innervate the medial and lateral sural areas,respectively. To reconstruct sensation, we included thelateral sural cutaneous nerve in the flap and anastomosed itto a cutaneous branch of the medial plantar nerve, withgood results.

Case report

A 59-year-old male sustained a burn to the right sole duringinfancy. Skin grafting was not undertaken at the time. Hepresented with a 6-month history of ulceration of thecentral part of the scar. A diagnosis of squamous cellcarcinoma was made by incisional biopsy. At presentation toour hospital, he had a 6� 4 cm ulceration of the centralarea of the burn scar on the heel. Radiographic examinationdid not show any regional metastases (pT3, N0, M0)(Figure 1). The tumour was resected with a surgical resec-tion margin of 2 cm around the scar and extensive resectionof the deep area including the plantar fascia. Intraoperativepathological examination confirmed the absence of tumourcells at the surgical margin (Figure 1). A 15� 8 cm skin flapwas designed over the small saphenous vein 4 cm distal tothe politeal line. The pivot point was 4 cm cranial to thelateral condyle of the tibia. The lateral sural cutaneousnerve was identified on the deep fascia of the lateral part ofthe flap and dissected proximally. The flap was raisedincluding the deep fascia and containing this nerve. Thepedicle was formed by 1.5 cm of tissue on each side of thesmall saphenous vein, and was raised on the deep fascia tothe pivot point. The flap was transferred to the sole. Usinga microscope, end-to-end anastomosis was performedbetween the lateral sural cutaneous nerve and a branchof the medial plantar nerve with 8/0 nylon, and the skin flapwas fixed to the heel. The defect in the sural region wascovered with a 0.012 inch split-thickness skin graft from theback.

Results

In the early postoperative period, the distal side of the flapbecame ulcerated. We performed a small skin graft. Twoyears after the operation, the flap was firmly fixed to theflap bed at the heel without shifts, and no plantar ulcera-tion was observed (Figure 1). Due to his diabetes mellitus,the patient walked 10 000 steps/day with a pedometer asexercise therapy and played golf once a week. The staticSemmes-Weinstein monofilament test sensory thresholdwas 3.84 g/mm2 on the reconstructed heel, 3.22 g/mm2 onthe contralateral heel and 3.61 g/mm2 in the sural region of

Figure 1 (Left) The tumour centred on the heel with a central 6� 4 cm ulceration. (Centre) Tumour resection resulted in an18� 8 cm skin defect. The sole was resected, including the plantar aponeurosis. (Right) Two years follow up. We added a skin graft1 week after the operation because of minor trouble of the flap adaptation (indicated by the arrow). Tumour recurrence or skinulcer was not observed after the operation.

Correspondence and communications 1259

the contralateral foot, suggesting good restoration ofsensation.

Discussion

There have been reports of the use of various skin flaps forreconstruction of the foot weight-bearing area. Toleranceof postoperative friction and weight bearing, and theabsence of shifts, are the most important points to considerin the reconstruction of this region. The sural flap has thinsubcutaneous fat and contains fascia, and is thereforeassociated with minimum instability.

Opinion is divided regarding sensation in the heel.Some studies have shown no correlation between theincidence of ulceration and the restoration of sensation,while others have shown preservation of deep sensationand no problems with flap endurance even without therestoration of sensation.2 In our patient, sensation steadilyrecovered, which may have contributed to the uniformweight bearing during walking and weight transfer duringexercise. The lateral sural cutaneous nerve branches fromthe common peroneal nerve lateral to the popliteal fossa,and supplies branches to the area lateral to the mediansural region, providing sensory innervation to this area.This nerve then joins the medial sural cutaneous nerve toform the sural nerve. Since the distally-based sural flapuses the vascular network around the sural nerve, theinclusion of its cutaneous nerve may be useful for therestoration of sensation. Recovery of sensation afterreconstruction is delayed in the limbs compared with that

in the face, and no complications such as hyperaesthesiahave been reported. We therefore recommend activesensory reconstruction when it can readily be performedas in this case.

In conclusion, the sural skin flap is useful for recon-struction of the heel. We included a cutaneous nerve tocreate an innervated flap and obtained good results.

References

1. Masquelet AC, Romana MC, Wolf G. Skin island flaps supplied bythe vascular axis of the sensitive superficial nerves: anatomicstudy and clinical experience in the leg. Plast Reconstr Surg1992;89:1115e21.

2. Hasegawa M, Torii S, Katoh H, et al. The distally based super-ficial sural artery flap. Plast Reconstr Surg 1994;93:1012e20.

T. NuriK. Ueda

S. ObaDepartment of Plastic and Reconstructive Surgery,

Osaka Medical College, 2-7 Daigaku-cho,Takatsuki City, Osaka 569-8686, Japan

E-mail address: pla042@poh.osaka-med.ac.jp

ª 2008 British Association of Plastic, Reconstructive and AestheticSurgeons. Published by Elsevier Ltd. All rights reserved.

doi:10.1016/j.bjps.2008.01.036