Staged bilateral reverse sural artery flap reconstruction for severe frostbite of both feet in a patient with schizophrenia: A case report.
Jae Hyun Kim, Myeong Seop Lee, Chan Min Chung
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Case in brief
A 25-year-old man with acute psychosis walked barefoot in subzero conditions for about 12 hours, sustaining deep frostbite of both heels and multiple toes. Imaging showed necrosis of the right first to third toes and bilateral posterior heel soft-tissue necrosis, with deep heel structures preserved. Schizophrenia was diagnosed and treated during admission; poor insight and repeated attempts to bear weight complicated postoperative protection. After right toe amputations and heel debridement, the right heel was covered with a reverse sural artery flap. Three weeks later, the left heel was reconstructed with the same flap and the left great toe treated with debridement and skin grafting. At short-term follow-up, both flaps were viable, with small superficial wounds remaining.
What made this case unusual
The reconstructive challenge combined bilateral weight-bearing heel defects with severe mental illness and limited adherence to off-loading, making postoperative feasibility a central consideration alongside flap choice.
Diagnostic / clinical pearl
In severe frostbite with heel soft-tissue necrosis but preserved deep heel structures, imaging can support flap-based limb salvage; reconstruction and postoperative protection may need to account for psychiatric symptoms and ability to comply with off-loading.
Why it matters
The report documents short-term coverage with staged bilateral reverse sural artery flaps, but follow-up was limited, so long-term durability cannot be inferred.