Staged bilateral reverse sural artery flap reconstruction for severe frostbite of both feet in a patient with schizophrenia: A case report.

rationaleBilateral, weight-bearing heel defects after frostbite are difficult to reconstruct, and outcomes depend heavily on postoperative off-loading and patient cooperation. We report a limb-salvage strategy for severe bilateral foot frostbite that occurred during acute psychosis in a patient diagnosed with schizophrenia. PATIENT CONCERNS: A 25-year-old man developed acute psychotic symptoms and walked barefoot in subzero conditions for about 12 hours, resulting in deep frostbite of both heels and multiple toes. During admission he had poor insight and repeatedly attempted weight bearing despite instructions. DIAGNOSES: MRI/CT showed necrosis of the right first to third toes and bilateral posterior heel soft-tissue necrosis with preserved deep heel structures, supporting flap-based salvage rather than major amputation. Schizophrenia was diagnosed and treated concurrently.

interventionsReconstruction was staged. The right first to third toes were amputated, the right heel was debrided, and coverage was achieved with a reverse sural artery flap (RSAF). Three weeks later, the left great toe underwent debridement with split-thickness skin grafting, and the left heel defect was reconstructed with an RSAF. Strict positioning/off-loading and close multidisciplinary inpatient supervision were used to protect both flaps while psychiatric symptoms were stabilized. OUTCOMES: At the last documented follow-up, 2 weeks after discharge - corresponding to 5 weeks after the left-sided reconstruction and approximately 8 weeks after the right-sided reconstruction - both flaps remained viable, with no total flap loss or flap-related reoperation, and small residual superficial wounds remained. No subsequent clinical follow-up was available. LESSONS: In frostbite patients with severe mental illness, reconstructive choice should balance technical "ideal" options against real-world feasibility. In this patient, staged regional flap reconstruction provided short-term wound coverage while accommodating psychiatric stabilization and limited adherence; however, long-term durability could not be assessed.