In the head and neck region, there are many functions such as respiration, ingestion, phonation, etc. So the reconstructive surgery not only the functional but also in the cosmetic point is necessary after cancer resection. With the development of microvascular surgery, it has become possible to transplant the free flap. From this point, the head and neck surgeon should master this technique. So we show the process how to get microvaslular technique and cases using scapular osteocutaneous and rectus abdominis musculocutaneous flap.

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Cardiovascular surgical techniques commonly used in coronary artery-aortic bypass grafting were applied to vascular anastomosis in reconstructive head and neck surgery, and the availability of this procedure was discussed. The donor vessels were anastomosed to the recipient's external carotid artery and internal or external jugular vein by end-to-side technique. Since the end of the donor vessel was prepared by slitting and the caliber was enlarged, the vessels were anastomosed without a high technical skill required in end-to-end microvascular anastomosis. Arteriotomy clamp and scalpel were used for opening the side of artery in order to aboid damages of the wall with arteriosclerosis. The vessels were sutured by a continuous over-and-over stitch, and the posterior wall was anantomosed by an intraluminal technique. End-to-side anastomosis was able to be completed firmly in a short time by using a continuous suture. The survival rate of the free flaps transferred by using end-to-side vascular anastomosis was 90%.

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A carotid artery occlusion test was performed in 18 patients and ligation was performed in 8. The patients in whom decrease of stump pressure was under 40mmHg (<30%) and decrease of CBF was under 25ml/100g/min (<65%) exhibited permanent neurological deficit.

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Concerning actual harvesting of peroneal osteocutaneous flap, regional anatomy, how to find the cutaneous branch, cautious points before, during and after making the flap, were discussed. This peroneal osteocutaneous flap offers the following advantages: 1) Resection of the tumor and harvesting of the flap can be performed at the same time due to the remote sites, 2) The flap is thin and two flaps can be used, 3) The peroneal artery is about 2mm in diameter and its pedicie is long, 4) A relatively long bone can be used with skin, 6) The donor site is not conspicuous. The indication of this flap is reconstruction of 1) the mandible with adjacent mucosa or skin, 2) oral and pharyngeal mucosa, and 3) facial skin.

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Free flap transfer has become a widely accepted method in head and neck reconstruction. Many kinds of free flaps are available today. A suitable flap can be selected according to the condition of the defect. The scapular osteocutaneous free flap is a method of choice for the simultaneous repair of the defect consists of both soft tissue and skeletal one, because 1) Both the skin flap and bone flap can be transplanted with a single pair of vascular pedicle, 2) blood supply to the bone flap is excellent, and 3) Osteotomies within the flap can be done safely due to the double pedicle of the bone flap. The operative procedure of harvesting scapular osteocutaneous free flap is presented. Our strategy is in brief as follows.1. Detection of triangular space by palpation.2. Marking of the courses of cutaneous branches.3. Elevation of skin flap at the deep fascial plane, from distal to proximal.4. Dissection of circumflex scapular vessels within the triangular space, and preservation of osteal branch.5. Severance of teres major and teres minor muscles.6. Identification and preservation of the angular branch.7. Cutting out the bone flap from lateral edge of the scapula.8. Dissection of the circumflex scapular vessels toward the subscapular vessels, further more to the axillary vessels.9. Pulling out of the flap through a counter incision made in the axilla.10. Closure of the donor wound and change of the patient's position from lateral to supine.

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The pedicled latissimus dorsi musculocutaneous flap (PLDMCF) is one of the most reliable and versatile flap of which head and neck surgeons must learn about the operative technique. We have performed 10 head and neck reconstruction using PLDMCF for the reconstruction of 4 intraoral, one intraoral and extraoral defects combined, 2 mesopharyngeal, one hypopharyngeal, 2 anterior chest wall (mediastinal tracheostomy) defects. There has been no flap loss, but two minor leakage. Although PLDMCF elevation required that the patient be placed in a lateral position, it was thought the first choice reconstructive procedure for the cases which require the plural skin flaps, for women and for the mediastinal tracheostomy.

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The rectus abdominis musculocutsneous flap based on the deep inferior epigastric vessels has many useful merits as a free flap for the head and neck reconstructions. In this paper, clinical techniques removing the flap were mentioned about flap designs, preparations of the musculocutaneous flap and deep inferior epigastric vessels, regulation of the flap volume and preventive measures against postoperative abdominal herniation.

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Several advantages and disadvantages of the forearm flap and the surgical technique of the flap dissection are described.The important points for avoidance of the trouble are as follows ;1) Preoperative Allen's test should be performed in order to assess the sufficient blood supply of the hand via the ulnar artery.2) The flap should be elevated as a f asciocutaneous flap in order to preserve the vascular network in the superficial surface of the deep fascia.3) The paratenon should be preserved for acceptance of the split-thickness skin grafts on the skin defect.

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Quoting a 42 year old female patient, transparotid extirpation of a parapharyngeal tumor was described. She was introduced to our department because of left inf raauricular swelling noticed two weeks previously. From the findings of preoperative examinations including CT, MRI, carotid angiography and Matas' test, the tumor was diagnosed as being situated both in the pre- and poststyloid portions of the parapharyngeal space, pushing the internal carotid artery medially, being fed by vasa vasorum of the internal carotid artery. The collateral pathway to the brain was kept in good condition.The surgical procedures were as follows. A skin incision was made from the preauricular to the submandibular regions. After detaching the parotid cupsule from the anterior border of the sternocleidomastoid muscle, the surface of the tumor was identified under the digastiric muscle. The trunk of the facial nerve was identified and the inferior ramus was torn to the posterior facial vein. The hypoglossus nerve was preserved but the vagus nerve was cut because of tight adhesion to the tumor. With many ligations of the feeding vessels, the tumor was successfully extirpated. It was histologically a neurinoma. A postoperative course was uneventful except for slight hoarseness and aspiration, which were compensated within a few weeks. A most adequate surgical technique should be chosen from the findings of preoperative examinations as to localization, size, vascularity and pathology.

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Recently, opthalmologists have recognized that marked edema of interstitial tissue of the intracanalicular optic nerve is the main cause of traumatic optic nerve injury with indirect blunt impact; therefore, they do not often ask the surgical therapy for the intracanalicular optic nerve damage to us, ENT doctors, and only tend to rely on conservative treatments (steroid etc) even in severe cases. However, the cases that have severe disturbance of visual acuity and field can not always be cured by conservative therapy. These cases need the surgical treatment which is performed endonasally, removing the bony wall of optic canal in ethmoid or sphenoid sinus under an endoscope. These procedures using an endscope is a little advanced technique of endonasal ethmoidectomy.

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The surgical anatomy necessary for the application of middle cranial fossa (MCF) and extended MCF approaches in vestibular schwannoma was described.The method of identifying the location of the internal auditory canal (IAC) and the 3-D structure of nerves and arteries in the IAE were also discussed. The key points of the surgical technique, with emphasis on the preservation of the facial nerve with stimulator dissectors and scissors specially designed by the author, are briefly reviewed.

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For restoration of facial palsy associated with temporal bone fracture, decompression of the facial nerve between the lesion and the stylomastoid foramen is reliable surgical treatment and valuable to minimize residual palsy and sequela such as synkinesis and contracure of the face. When the fracture involves the geniculate ganglion and its vicinity, a total decompression of the intratemporal facial nerve from the internal auditory canal to the stylomastoid foramen is required. Two surgical approaches, translabyrinthine approach and combined middle fossatransmastoid approach, are available for the total decompression. Surgical techniques in these two approaches are described in detail together with indication for each approach, surgical complications and the results.

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Facial nerve is injured by trauma of the face and skull, tumor invasion and surgical damages developed extratemporally, intratemporally or intracranially. Facial nerve grafting is performed on a case in which the distance of defect between proximal and distal stumps of injured part of the nerve is too far to suture the both ends directly without excessive tension. Well trained technical skills and pre-check of necessary surgical instruments and materials are indispensable to obtain successful results postoperatively. A nerve graft is usually harvested from the great auricular nerve or the sural nerve. In the surgical field proximal and distal cut-ends of the nerve are identified. The prepared nerve graft is placed between the both cut-ends and adjusted. Under microscopic view the epineurium of the nerve stumps is resected for 2-3mm. Perineuriums of the donor and the graft are sutured with 10-0 thread and both stumps are approximated. Number of the suture depends on the size of nerve bundles. Minimum number of the stiches which keep good approximation will be recommended. Epi- and perineural sutures of the branches also result in fairly good functional recovery. Sutured sites are dripped with fibrin glue to support the sutures. Crossface anastomosis of the facial nerve, though the idea is unique, results in not so good recovery as expected. Combination of the nerve grafting to the upper main branch and the facial-hypoglossal anastomosis to the lower main branch is attempted to obtain better functional recovery and less occurrence of synkinesia. Other clinical applications will follow widely.

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A clinical study was conducted of patients with congenital neck masses and fistulas treated surgically in the Department of Otolaryngology, Niigata University School of Medicine between 1981 and 1992. There were 37 cases (male : 22, female :15), which occupied 0.85% of all 4, 340 hospitalized patients. Ages ranged from 4 months to 81 years old, and the median age was 26 years old. In 15 cases, ages were below 20 years old, and in 22 cases, over 20 years old, indicating that the number of patients over 20 years old was not small. There were three cases of first branchial fistula, one case of second branchial fistula, 11 cases of lateral cervical cyst, four cases of pyrif orm sinus fistula, 12 cases of cervical median cyst, two cases of ectopic thyroid gland, three cases of cystic hygroma, and one case of benign infantile hemangioendothelioma of the parotid gland. When congenital diseases were considered in the differential, diagnosis was generally easy from anamnesis and local findings. Efficient radiological examination was important for immediate differentiation in the diagnosis. Essential treatment was complete surgical removal of the lesion. Aspiration and/or open biopsy should be avoided whenever possible.

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The reconstruction of the tracheostoma has been famous for Grillo's technic. However, this technique has many problems as the irradiation therapies, because they had to use the flaps near the tracheostoma. Since 1990, we have done the reconstruction of the tracheostoma incising the center of the skin island of the axial pattern flaps as latissimus dorsi muscurocutaneus flaps. This time, we have done tracheostoma reconstruction using the navel of the extended recutus abdominal musculocutaneus flap. Because the navel is collapsed, so we can suture tracheres with no tension. As a navel is a so called physiological scar tissue, it is possible to cut a navel with enough blood supply. Extended recutus abdominal musculocutaneous flaps are large enough to the tracheostoma reconstruction with the chest and neck skin defects.

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