Background: Near-infrared spectroscopy is being increasingly frequently used for postoperative monitoring of free flaps, offering real-time data on regional oxygen saturation and total hemoglobin index. However, comprehensive reports on Hb values and ssfree flaps using near-infrared spectroscopy analyzed the findings.
Methods: Eight types of free flaps were evaluated. The regional oxygen saturation and total hemoglobin index were measured in flap and normal control sites immediately after surgery and on postoperative days 1, 2, 3, 5, and 7. Measurements were taken by the surgeon or assistant. Flap viability was assessed clinically and with near-infrared spectroscopy; reoperation or other interventions were performed as necessary. Data were analyzed using a generalized linear mixed model.
Results: Among 110 monitored flaps, 10 failed; of these, 4 were salvaged, 4 were partially necrotic, and 2 were completely necrotic. Causes included venous thrombus (four), arteriovenous thrombus (two), hematoma (one), and other causes (three). All failures were detected between postoperative days 1 and 4. Successful flaps showed lower regional oxygen saturation and higher total hemoglobin index values than normal controls. The difference in regional oxygen saturation was greater after the first postoperative day than immediately after surgery, while the total hemoglobin index difference remained constant. Radial forearm flaps had higher initial regional oxygen saturation and total hemoglobin index; deep inferior epigastric artery perforator flaps showed lower values throughout.
Conclusions: Near-infrared spectroscopy parameters vary by flap type and should be considered in postoperative monitoring. Differences between the flap and control sites, especially in total hemoglobin index, may serve as useful criteria for flap assessments.
rSO₂: regional oxygen saturation, T-HbI: total hemoglobin index, POD: postoperative day

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Background: The selection of reconstructive procedures for pressure ulcers varies according to the anatomical site and institutional experience. This study aimed to describe the current institutional trends in flap selection for pressure ulcer reconstruction.
Methods: We retrospectively reviewed the records of 74 residents from our department who submitted ten representative cases for the board certification examination of the Japan Society of Plastic and Reconstructive Surgery between 1997 and 2025. The data included the anatomical regions of pressure ulcers and the reconstructive procedures employed.
Results: Of the 74 residents, 63 included one or two cases of pressure ulcers. A total of 39 sacral, 23 ischial, and 13 trochanteric ulcers were reconstructed. Perforator-based fasciocutaneous flaps were predominantly used for sacral ulcers (n = 38), with posterior thigh flaps used in one. Posterior thigh flaps (n = 21) and hamstring myocutaneous flaps (n = 2) were used for ischial ulcers. Trochanteric ulcers were reconstructed using tensor fascia lata myocutaneous flaps (n = 11) and posterior thigh flaps (n = 2). Combined reconstructions were performed in two cases: one involved the simultaneous use of a perforator-based flap for a sacral ulcer and a posterior thigh flap for an ischial ulcer, while the other involved bilateral posterior thigh flaps for sacral and bilateral ischial ulcers.
Conclusions: Perforator-based fasciocutaneous flaps were the most common choice for sacral ulcers, posterior thigh flaps for ischial ulcers, and tensor fascia lata flaps for trochanteric ulcers, reflecting anatomical suitability and evolving surgical practices.

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We herein report a case of mediastinitis treated with a supercharged rectus abdominis flap combined with a pedicled omental flap. A 78-year-old male patient had, in addition to mediastinitis, sternal osteomyelitis and a skin defect between the clavicles. The prosthetic aortic graft was covered with the pedicled greater omental flap, and the sternal skin defect were closed with the pedicled rectus abdominis myocutaneous flap. During surgery, blood flow on the distal side of the rectus abdominis flap was insufficient. The deep inferior epigastric artery and vein of the rectus abdominis flap were anastomosed with the corresponding vessels of the greater omental flap for supercharge and superdrainage. As a result, the rectus abdominis myocutaneous flap survived, and the wound healed without complications. In combined reconstruction with a greater omental flap and a rectus abdominis flap, a vessel distal to the omental flap can be used for supercharge and superdrainage.

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A 44-year-old male with Klippel-Trenaunay-Weber syndrome developed necrotizing fasciitis, which was complicated by hand, foot, and mouth disease. The patient was brought to the hospital with a purulent discharge from the scrotum and high fever. Significant hypertrophy of the scrotum was observed, and the testes were not palpable. The left lower limb was amputated because of an infection from an underlying disease, and the stump showed similar hypertrophy. Necrotizing fasciitis was suspected and emergency surgery was performed in multiple departments. Necrotic dartos was removed as much as possible to preserve the testis. After the infection subsided, high fever recurred, and lip erosions and rashes on the hands and feet were observed. The enterovirus antibody titer was positive, and hand, foot, and mouth disease were suspected. Fever was addressed using fluid replacement and antipyretics. The wounds healed conservatively. After seven months, there was no recurrence or problems with gonadal function. Rapid multidisciplinary collaboration was key to saving the patient's life from a severe soft tissue infection caused by congenital vascular malformation. The scrotal skin resembled a turtle shell, and was significantly enlarged and thickened. The testes could not be palpated on the body surface. A frog-egg-like skin nodule was detected on the inner left thigh.

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Dysphagia after total laryngectomy is rare. Even when it occurs, it often improves with bougienage or endoscopic treatment by an otolaryngologist. However, in the present case, the patient’s dysphagia was severe and progressive owing to the effects of radiation therapy, prompting consultation with reconstructive surgery. The contracted pharyngeal mucosa was released under direct visualization, and well-vascularized flap transplantation was performed. Pectoralis major myocutaneous flap reconstruction using a strip of the posterior pharyngeal mucosa has maintained a good swallowing function over the long term. A: Preoperative neck appearance. The skin of the anterior neck is thin and stiff. B: Preoperative swallowing videofluorography. An hourglass-shaped narrowing is observed in the hypopharyngeal region at 8 cm (yellow arrow). C: Preoperative contrast-enhanced computed tomography image. The thickness of the soft tissue overlying the common carotid artery was 2 mm. No commonly used arteries, such as the superior thyroid, transverse cervical, or facial arteries, were identified as potential graft vessels.

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An arteriovenous fistula is a major vascular access site for hemodialysis. Skin breakdown or ulceration occasionally occurs around hemodialysis arteriovenous fistula; therefore, reconstruction using a skin flap is sometimes required. There are several factors, such as vessel calcification, that reduce the blood supply to the flap. Therefore, flaps near the arteriovenous fistula are less likely to survive than those in other areas. We present two cases of reconstruction using pedicled perforator flaps around arteriovenous fistulas and discuss the usefulness of pedicled perforator flaps in the vicinity of arteriovenous fistulas. As few case reports on flap reconstruction around arteriovenous fistulas are available, the efficacy and safety of pedicled perforator flaps in the region of arteriovenous fistulas remain unclear. Nevertheless, a pedicled perforator flap may be a good option for reconstruction around arteriovenous fistulas, provided that the condition of the vessels and blood supply to the flap are carefully evaluated. Brachioradialis and flexor carpi radialis tendons were exposed without the paratenon.

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A 75-year-old man sustained a right femoral neck fracture after a fall and was initially admitted to the orthopedic department of a different hospital. During hospitalization, the patient developed pressure ulcers over the sacrum and left greater trochanter, which failed to improve, thus prompting a referral to our department.
Upon examination, fluctuating erythema, warmth, and swelling were observed to extend from the right gluteal region to the right knee. Computed tomography revealed a large abscess extending from the right hip joint to subcutaneous tissue on the lateral aspect of the right thigh and knee. Repeat debridement and split-thickness skin grafting were performed, and the free bone fragment of the right femoral head was removed. However, treatment was prolonged and complicated due to septic shock and coronavirus disease in 2019.
The origin of the extensive abscess was presumed to be the right hip joint, potentially due to tissue damage and necrosis around the fractured femoral neck, or pyogenic arthritis of the hip. In both scenarios, early diagnosis and debridement of the affected area are critical. Incision and drainage or debridement should be performed while keeping future reconstruction in mind after the infection is controlled. If extensive tissue necrosis and deterioration of the general condition make sufficient reconstruction difficult, methods, such as skin grafting, should be used to reduce the ulcer area. (a) CT axial view. (b) CT coronal view. (c) Macroscopic findings.

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