Journal of Plastic, Reconstructive & Aesthetic Surgery (2012) 65, 399e401

CASE REPORT

A well vascularised muscle flap e Drug user’s dream

Srinivasan Iyer*, Amit Pabari, Christopher T. Khoo

Department of Plastic and Reconstructive Surgery, Wexham Park Hospital, Berkshire SL2 4HL, United Kingdom

Received 3 August 2011; accepted 7 August 2011

KEYWORDSIntravenous drug user;Shooter’s patch;Skin popping;Muscle flap

* Corresponding author. Tel.: þ44 77E-mail address: drsriiyer@hotmail.

1748-6815/$-seefrontmatterª2011Bridoi:10.1016/j.bjps.2011.08.015

Summary It is estimated thatworldwide, 16millionpeople, aged15e64years inject illicit drugsregularly.Whenperipheral venous access becomes obliterated, drug users start injecting into thesubdermal areaof the skine “skin popping”.When this areaulcerates, thewell vascularisedgran-ulation tissue called a “shooter’s patch" is maintained as a portal for continuing injection. These“shooter’s patches” are usually on the limbs, but have been reported on the breast and the penis.Wepresentacaseofa reconstructivemuscleflapbeingused inanunforeseenmannerasa shooterspatch. Surgeons rely onmuscle flaps to provide a robust reconstructive option, butwe have learntthat drug users value them for their rich vascularity and high absorption.ª 2011 British Association of Plastic, Reconstructive and Aesthetic Surgeons. Published byElsevier Ltd. All rights reserved.

Case report

A 48-year-old gentleman attended our service with recur-rent ulceration of his right knee over a period of 2 years. Hehad been a heroin addict for last 15 years. Apart from beingoverweight with a BMI of 30 he had no other medicalproblems. He was seen by the drug rehabilitation team andstarted on a methadone replacement therapy. Clinically, hehad a large 15 cm2 area of ulceration over the anterolateralpart of the left knee which he had been using asa “shooter’s patch” (Figure 1). The wound was colonised byStaphylococcus aureus, coliforms and anaerobes and theradiographs suggested the involvement of knee joint(Figure 2). The ulcer was widely excised and the wound

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thoroughly debrided. The lateral quadriceps mechanisms,lateral edge of patella and knee joint capsule on the lateralaspect were excised. A definitive reconstruction wasundertaken with an Islanded lateral gastrocnemius flap,with its origin and insertion completely released. Themuscle flap was covered with a split thickness skin graft(Figure 3). The flap healed well and the patient wassubsequently discharged home on the tenth post-operativeday with a follow up in plastic surgery dressing clinic and anappointment with the drug rehabilitation programme.

The patient re-presented to our services 8 months afterthe initial surgery with a small ulcer over the gastrocnemiusflap and admitted to injecting the drugs again. He hadstopped attending the drug rehabilitation programme andconfessed that the muscle flap was an ideal site for him toinject as he found it painless and could get an immediate“kick”. The small ulcer was treated conservatively but thepatient continued to inject into the flap and default his

tiveandAestheticSurgeons.PublishedbyElsevierLtd.All rightsreserved.

Figure 3 Reconstruction with gastrocnemius flap and splitthickness skin graft.

Figure 1 Ulceration over the anterolateral part of the leftknee used as “shooter’s patch”.

400 S. Iyer et al.

rehabilitation regime. Over the next couple of years fewattempts of debridement and skin grafting of the ulceratedflap were undertaken. 5-years after the initial surgery, hiswound was unmanageable with continued conservativetreatment (Figure 4) and the patient underwent an aboveknee amputation.

Discussion

It is estimated that worldwide, 16 million people, aged15e64 regularly inject illicit drugs.1 These “shooter’spatches” are usually on the limbs, but have been reported

Figure 2 Radiograph of the left knee at initial presentation.Extensive overlying soft tissue demonstrating the “shooter’spatch”.

on the breast and the penis.2e4 Narcotics are diluted (‘cut’)with impurities prior to being sold. The drug is preparedprior to injection by dissolving often in lemon juice andheated until the powder dissolves. The resulting solution isfiltered and injected. The acidic nature of the solutioneventually scleroses all the available veins and the userresorts to injecting the fix into subdermal area - “skinpopping”. These areas necrose and turn into smallabscesses and then ulcerate and the users maintain them asa portal for drug injection e ‘shooter’s patch’.5 Thismethod of drug delivery is widely known amongst the drugaddicts and they report a slightly delayed but sustained‘kick’ compared to an intravenous injection.

Figure 4 Insensate and well vascularised muscle flap con-verted into a portal for injecting drugs.

Shooter’s patch in a flap 401

Our patient was injecting into a well vascularised muscleflap confessed it to be a better method than intravenousdelivery. It was painless and he did not have to use a tourni-quet and try multiple attempts to enter a vein. He reportedthat the kick was immediate and was sustained, he alsothought that the doses he had to take were smaller but thiscould be due to the rehabilitation he had with methadone.

Reconstructive surgeons treating similar wounds shouldbe aware of the potential conflict of interest in getting thewounds healed. Patients will want to maintain an area ofgranulation tissue to continue to inject the drugs, henceinterfere with the wound to prevent it from healing.5

Effective treatment requires a multidisciplinary approachand drug rehabilitation programme is the key. Somesurgeons recommend withdrawal of treatment as the ulti-mate sanction for a non compliant patient.

In our patient we achieved a short term healing butfailed in the longer term and learnt that a well vascularisedmuscle flap may not be the correct reconstructive choice.Perhaps a sensate skin flap may deter injections into theflap. However a drug user who does not comply with the de-addiction programme will probably not achieve a long termsurgical success, whatever surgical option is chosen.

Funding

None.

Conflict of interest

None.

References

1. Mathers BM, Degenhardt L, Phillips B, et al. Global epidemiologyof injecting drug use and HIV among people who inject drugs:a systematic review. Lancet 2008;372(9651):1733e45.

2. Alvi A, Ravichandran D. An unusual case of breast ulceration.Breast 2006;15(1):115e6.

3. White WB, Barrett S. Penile ulcer in heroin abuse: a case report.Cutis 1982;29(1):62e3. 69.

4. Tice AD. An unusual, nonhealing ulcer on the forearm. N Engl JMed 2002;347(21):1725e6.

5. Williams AM, Southern SJ. Conflicts in the treatment of chroniculcers in drug addictsecase series and discussion. Br J Plast Surg2005;58(7):997e9.