- Email: [email protected]
Innervated distally-based superficial sural artery flap
1258
Correspondence and communications
a combination of vitamin C and manganese, with or without proline; a combination of zinc sulfate and vitamin C; and growth hormone have been suggested.2e5 We do believe that preoperative withdrawal of all topical steroids is a critical point in prevention of postoperative complications such as infection and wound dehiscence. Moreover, we suggest that continuous use of intraoral vitamin C may have 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. The surgeon must be aware of potential wound healing problems in these patients and should prepare optimum conditions preoperatively. The patient should be told to taking topical steroids a few weeks before surgery. Moreover, the coagulating tests must be checked carefully before any attempt at surgery. Although there has been no report on the medical treatment modalities for presurgical preparation and postoperative care of this group of patients, on the basis of our experience with this patient, we do believe that using the aforementioned pre- and postsurgical treatment modality, reconstructive surgery can be done safely in patients with PDS. In conclusion, in this report, we present a pre- and postoperative treatment modality to obtain better wound healing in this group of patients. In addition, the potential complications of surgery in this syndrome are discussed. To our knowledge, this is the first report of reconstructive surgery in a patient with PDS.
References 1. Goodman SI, Solomons CC, Muschenheim F, et al. A syndrome resembling lathyrism associated with iminodipeptiduria. Am J Med 1968;45:152e9. 2. Trent JT, Kirsner RS. Leg ulcers secondary to prolidase deficiency. Adv Skin Wound Care 2004;17:468e72. 3. Powell GF, Rasco MA, Maniscalco R-M. A prolidase deficiency in man with iminopeptiduria. Metabolism 1974;23:505e13. 4. Milligan A, Graham-Brown RA, Burns DA, et al. Prolidase deficiency: a case report and literature review. Br J Dermatol 1989;121:405e9. 5. Arata J, Hatakenaka K, Oono T. Effect of topical application of glycine and proline on recalcitrant leg ulcers of prolidase deficiency. Arch Dermatol 1986;122:626e7.
Daghan Isik Department of Plastic and Reconstructive Surgery, Gaziantep Avukat Cengiz Gokcek Government Hospital, Gaziantep, Turkey E-mail address: [email protected] Mehmet Bekerecioglu Mehmet Mutaf Department of Plastic, Reconstructive and Aesthetic Surgery, Gaziantep University Faculty of Medicine, Gaziantep, Turkey
Innervated distally-based superficial sural artery flap* The distally-based superficial sural artery flap was first reported in 1992 by Masquelet as a distally-based neuroskin flap of the sural nerve.1 The medial and lateral sural cutaneous nerves are located on the deep fascia in the sural region and innervate the medial and lateral sural areas, respectively. To reconstruct sensation, we included the lateral sural cutaneous nerve in the flap and anastomosed it to a cutaneous branch of the medial plantar nerve, with good results.
Case report A 59-year-old male sustained a burn to the right sole during infancy. Skin grafting was not undertaken at the time. He presented with a 6-month history of ulceration of the central part of the scar. A diagnosis of squamous cell carcinoma was made by incisional biopsy. At presentation to our hospital, he had a 6 4 cm ulceration of the central area of the burn scar on the heel. Radiographic examination did not show any regional metastases (pT3, N0, M0) (Figure 1). The tumour was resected with a surgical resection margin of 2 cm around the scar and extensive resection of the deep area including the plantar fascia. Intraoperative pathological examination confirmed the absence of tumour cells at the surgical margin (Figure 1). A 15 8 cm skin flap was designed over the small saphenous vein 4 cm distal to the politeal line. The pivot point was 4 cm cranial to the lateral condyle of the tibia. The lateral sural cutaneous nerve was identified on the deep fascia of the lateral part of the flap and dissected proximally. The flap was raised including the deep fascia and containing this nerve. The pedicle was formed by 1.5 cm of tissue on each side of the small saphenous vein, and was raised on the deep fascia to the pivot point. The flap was transferred to the sole. Using a microscope, end-to-end anastomosis was performed between the lateral sural cutaneous nerve and a branch of the medial plantar nerve with 8/0 nylon, and the skin flap was fixed to the heel. The defect in the sural region was covered with a 0.012 inch split-thickness skin graft from the back.
Results In the early postoperative period, the distal side of the flap became ulcerated. We performed a small skin graft. Two years after the operation, the flap was firmly fixed to the flap bed at the heel without shifts, and no plantar ulceration was observed (Figure 1). Due to his diabetes mellitus, the patient walked 10 000 steps/day with a pedometer as exercise therapy and played golf once a week. The static Semmes-Weinstein monofilament test sensory threshold was 3.84 g/mm2 on the reconstructed heel, 3.22 g/mm2 on the contralateral heel and 3.61 g/mm2 in the sural region of
ª 2008 British Association of Plastic, Reconstructive and Aesthetic Surgeons. Published by Elsevier Ltd. All rights reserved. doi:10.1016/j.bjps.2008.01.033
* This paper will be presented, in part, at the 4th Congress of the World Society for Reconstructive Microsurgery.
Correspondence and communications
1259
Figure 1 (Left) The tumour centred on the heel with a central 6 4 cm ulceration. (Centre) Tumour resection resulted in an 18 8 cm skin defect. The sole was resected, including the plantar aponeurosis. (Right) Two years follow up. We added a skin graft 1 week after the operation because of minor trouble of the flap adaptation (indicated by the arrow). Tumour recurrence or skin ulcer was not observed after the operation.
the contralateral foot, suggesting good restoration of sensation.
Discussion There have been reports of the use of various skin flaps for reconstruction of the foot weight-bearing area. Tolerance of postoperative friction and weight bearing, and the absence of shifts, are the most important points to consider in the reconstruction of this region. The sural flap has thin subcutaneous fat and contains fascia, and is therefore associated with minimum instability. Opinion is divided regarding sensation in the heel. Some studies have shown no correlation between the incidence of ulceration and the restoration of sensation, while others have shown preservation of deep sensation and no problems with flap endurance even without the restoration of sensation.2 In our patient, sensation steadily recovered, which may have contributed to the uniform weight bearing during walking and weight transfer during exercise. The lateral sural cutaneous nerve branches from the common peroneal nerve lateral to the popliteal fossa, and supplies branches to the area lateral to the median sural region, providing sensory innervation to this area. This nerve then joins the medial sural cutaneous nerve to form the sural nerve. Since the distally-based sural flap uses the vascular network around the sural nerve, the inclusion of its cutaneous nerve may be useful for the restoration of sensation. Recovery of sensation after reconstruction is delayed in the limbs compared with that
in the face, and no complications such as hyperaesthesia have been reported. We therefore recommend active sensory reconstruction when it can readily be performed as in this case. In conclusion, the sural skin flap is useful for reconstruction of the heel. We included a cutaneous nerve to create an innervated flap and obtained good results.
References 1. Masquelet AC, Romana MC, Wolf G. Skin island flaps supplied by the vascular axis of the sensitive superficial nerves: anatomic study and clinical experience in the leg. Plast Reconstr Surg 1992;89:1115e21. 2. Hasegawa M, Torii S, Katoh H, et al. The distally based superficial sural artery flap. Plast Reconstr Surg 1994;93:1012e20.
T. Nuri K. Ueda S. Oba Department of Plastic and Reconstructive Surgery, Osaka Medical College, 2-7 Daigaku-cho, Takatsuki City, Osaka 569-8686, Japan E-mail address: [email protected] ª 2008 British Association of Plastic, Reconstructive and Aesthetic Surgeons. Published by Elsevier Ltd. All rights reserved. doi:10.1016/j.bjps.2008.01.036
Correspondence and communications
a combination of vitamin C and manganese, with or without proline; a combination of zinc sulfate and vitamin C; and growth hormone have been suggested.2e5 We do believe that preoperative withdrawal of all topical steroids is a critical point in prevention of postoperative complications such as infection and wound dehiscence. Moreover, we suggest that continuous use of intraoral vitamin C may have 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. The surgeon must be aware of potential wound healing problems in these patients and should prepare optimum conditions preoperatively. The patient should be told to taking topical steroids a few weeks before surgery. Moreover, the coagulating tests must be checked carefully before any attempt at surgery. Although there has been no report on the medical treatment modalities for presurgical preparation and postoperative care of this group of patients, on the basis of our experience with this patient, we do believe that using the aforementioned pre- and postsurgical treatment modality, reconstructive surgery can be done safely in patients with PDS. In conclusion, in this report, we present a pre- and postoperative treatment modality to obtain better wound healing in this group of patients. In addition, the potential complications of surgery in this syndrome are discussed. To our knowledge, this is the first report of reconstructive surgery in a patient with PDS.
References 1. Goodman SI, Solomons CC, Muschenheim F, et al. A syndrome resembling lathyrism associated with iminodipeptiduria. Am J Med 1968;45:152e9. 2. Trent JT, Kirsner RS. Leg ulcers secondary to prolidase deficiency. Adv Skin Wound Care 2004;17:468e72. 3. Powell GF, Rasco MA, Maniscalco R-M. A prolidase deficiency in man with iminopeptiduria. Metabolism 1974;23:505e13. 4. Milligan A, Graham-Brown RA, Burns DA, et al. Prolidase deficiency: a case report and literature review. Br J Dermatol 1989;121:405e9. 5. Arata J, Hatakenaka K, Oono T. Effect of topical application of glycine and proline on recalcitrant leg ulcers of prolidase deficiency. Arch Dermatol 1986;122:626e7.
Daghan Isik Department of Plastic and Reconstructive Surgery, Gaziantep Avukat Cengiz Gokcek Government Hospital, Gaziantep, Turkey E-mail address: [email protected] Mehmet Bekerecioglu Mehmet Mutaf Department of Plastic, Reconstructive and Aesthetic Surgery, Gaziantep University Faculty of Medicine, Gaziantep, Turkey
Innervated distally-based superficial sural artery flap* The distally-based superficial sural artery flap was first reported in 1992 by Masquelet as a distally-based neuroskin flap of the sural nerve.1 The medial and lateral sural cutaneous nerves are located on the deep fascia in the sural region and innervate the medial and lateral sural areas, respectively. To reconstruct sensation, we included the lateral sural cutaneous nerve in the flap and anastomosed it to a cutaneous branch of the medial plantar nerve, with good results.
Case report A 59-year-old male sustained a burn to the right sole during infancy. Skin grafting was not undertaken at the time. He presented with a 6-month history of ulceration of the central part of the scar. A diagnosis of squamous cell carcinoma was made by incisional biopsy. At presentation to our hospital, he had a 6 4 cm ulceration of the central area of the burn scar on the heel. Radiographic examination did not show any regional metastases (pT3, N0, M0) (Figure 1). The tumour was resected with a surgical resection margin of 2 cm around the scar and extensive resection of the deep area including the plantar fascia. Intraoperative pathological examination confirmed the absence of tumour cells at the surgical margin (Figure 1). A 15 8 cm skin flap was designed over the small saphenous vein 4 cm distal to the politeal line. The pivot point was 4 cm cranial to the lateral condyle of the tibia. The lateral sural cutaneous nerve was identified on the deep fascia of the lateral part of the flap and dissected proximally. The flap was raised including the deep fascia and containing this nerve. The pedicle was formed by 1.5 cm of tissue on each side of the small saphenous vein, and was raised on the deep fascia to the pivot point. The flap was transferred to the sole. Using a microscope, end-to-end anastomosis was performed between the lateral sural cutaneous nerve and a branch of the medial plantar nerve with 8/0 nylon, and the skin flap was fixed to the heel. The defect in the sural region was covered with a 0.012 inch split-thickness skin graft from the back.
Results In the early postoperative period, the distal side of the flap became ulcerated. We performed a small skin graft. Two years after the operation, the flap was firmly fixed to the flap bed at the heel without shifts, and no plantar ulceration was observed (Figure 1). Due to his diabetes mellitus, the patient walked 10 000 steps/day with a pedometer as exercise therapy and played golf once a week. The static Semmes-Weinstein monofilament test sensory threshold was 3.84 g/mm2 on the reconstructed heel, 3.22 g/mm2 on the contralateral heel and 3.61 g/mm2 in the sural region of
ª 2008 British Association of Plastic, Reconstructive and Aesthetic Surgeons. Published by Elsevier Ltd. All rights reserved. doi:10.1016/j.bjps.2008.01.033
* This paper will be presented, in part, at the 4th Congress of the World Society for Reconstructive Microsurgery.
Correspondence and communications
1259
Figure 1 (Left) The tumour centred on the heel with a central 6 4 cm ulceration. (Centre) Tumour resection resulted in an 18 8 cm skin defect. The sole was resected, including the plantar aponeurosis. (Right) Two years follow up. We added a skin graft 1 week after the operation because of minor trouble of the flap adaptation (indicated by the arrow). Tumour recurrence or skin ulcer was not observed after the operation.
the contralateral foot, suggesting good restoration of sensation.
Discussion There have been reports of the use of various skin flaps for reconstruction of the foot weight-bearing area. Tolerance of postoperative friction and weight bearing, and the absence of shifts, are the most important points to consider in the reconstruction of this region. The sural flap has thin subcutaneous fat and contains fascia, and is therefore associated with minimum instability. Opinion is divided regarding sensation in the heel. Some studies have shown no correlation between the incidence of ulceration and the restoration of sensation, while others have shown preservation of deep sensation and no problems with flap endurance even without the restoration of sensation.2 In our patient, sensation steadily recovered, which may have contributed to the uniform weight bearing during walking and weight transfer during exercise. The lateral sural cutaneous nerve branches from the common peroneal nerve lateral to the popliteal fossa, and supplies branches to the area lateral to the median sural region, providing sensory innervation to this area. This nerve then joins the medial sural cutaneous nerve to form the sural nerve. Since the distally-based sural flap uses the vascular network around the sural nerve, the inclusion of its cutaneous nerve may be useful for the restoration of sensation. Recovery of sensation after reconstruction is delayed in the limbs compared with that
in the face, and no complications such as hyperaesthesia have been reported. We therefore recommend active sensory reconstruction when it can readily be performed as in this case. In conclusion, the sural skin flap is useful for reconstruction of the heel. We included a cutaneous nerve to create an innervated flap and obtained good results.
References 1. Masquelet AC, Romana MC, Wolf G. Skin island flaps supplied by the vascular axis of the sensitive superficial nerves: anatomic study and clinical experience in the leg. Plast Reconstr Surg 1992;89:1115e21. 2. Hasegawa M, Torii S, Katoh H, et al. The distally based superficial sural artery flap. Plast Reconstr Surg 1994;93:1012e20.
T. Nuri K. Ueda S. Oba Department of Plastic and Reconstructive Surgery, Osaka Medical College, 2-7 Daigaku-cho, Takatsuki City, Osaka 569-8686, Japan E-mail address: [email protected] ª 2008 British Association of Plastic, Reconstructive and Aesthetic Surgeons. Published by Elsevier Ltd. All rights reserved. doi:10.1016/j.bjps.2008.01.036