LAUSR

Lower extremity reconstruction is one of the challenging areas for reconstructive surgeons. The reliability of the vascularity of a perforator flap is important in reconstructive surgery. To increase flap viability and to prevent venous insufficiency we performed an extra vein anastomosis in pedicled propeller perforator flap concept. This letter presents the reconstruction of a tissue defect after radical excision of an acute variant type of Marjolin’s ulcer in the lower extremity using a superdrained propeller perforator flap. A 61 year old male was referred to dermatology outpatient clinic with a leg ulcer. Six months earlier, he had a car accident and two ulcers developed on his leg: one healed within a few weeks, while the other persisted. Initially, the ulceration was deep. With time, the ulcer changed shape; the base of the ulcer rose toward the surface and became wartlike in appearance. Clinically, there was a 3-cm diameter, yellow, verrucous, indurated mass on the right anterior tibia. A 4-mm punch biopsy was taken from the lesion. The patient’s history and histopathological findings led to a diagnosis of Marjolin’s ulcer. The patient underwent surgical treatment at the Department of Plastic Surgery. The anterior tibial artery perforator was located using an 8-Hz hand-held Doppler. The lesion was excised with a 2-cm surgical margin above the periosteum of the tibia (Fig. 1A). A flap was designed based on the perforators medial and distal to the defect to cover the anterior surface of the tibia. The vein medial to the flap was included in the flap during dissection, and the flap was harvested over the anterior tibial artery perforator (Fig. 1B). The flap was rotated clockwise by 150 degree and adapted to the defect. The vein on the flap was anastomosed with a superficial recipient vein, providing superdrainage of the flap (Fig. 1C). The donor area was closed with a full-thickness skin graft. No postoperative complications such as venous congestion, venous insufficiency, or partial flap loss were observed. Wound healing was uneventful. The surgical margins were tumor-free. There were no problems after follow-up for 24 months. Although various etiological factors have been implicated, the exact pathogenesis of Marjolin’s ulcer is still unknown. Prolonged healing of skin conditions have potential risk due to the effect of keratinocyte biology. In this case, Marjolin’s ulcer was diagnosed 6 months after the injury. Even though in the acute type of Marjolin’s ulcer basal cell carcinoma is the most common tumor, squamous cell carcinoma was detected in this case. Reconstructive options for lower extremity soft tissue defects, especially over the anterior tibia, are limited by the etiology of the disease and the delicacy of the soft tissues over the tibia. Local propeller flaps can be an option in reconstruction of such defects. With venous congestion, propeller perforator flaps are subject to partial or total flap loss, especially with a single perforator, because of torsion of the pedicle causing venous flow insufficiency. Therefore, we report the use of a superficial vein in an anterior tibial artery propeller perforator flap, anastomosed with a vein in the recipient site. We called this technique as “super-drainage”; it enhances the vascularity and improves the venous drainage. There is no additional donor site morbidity or the need to sacrifice a major recipient vessel when *Correspondence to: Osman Kelahmetoglu, M.D., Bezmialem Vakif University, Medical Faculty, Department of Plastic, Reconstructive and Aesthetic Surgery, Adnan Menderes Bulvarı, Fatih/_ Istanbul, T€ urkiye. E-mail: osmankelahmetoglu@ gmail.com Received 20 October 2015; Revision accepted 20 January 2016; Accepted 17 March 2016 Published online 4 April 2016 in Wiley Online Library (wileyonlinelibrary.com). DOI: 10.1002/micr.30050