One of the methods of adjusting the difference in vascular diameters and improving the success rate of microvascular anastomosis is end-to-side anastomosis. The end-to-side version of end-to-end (ESEE) anastomosis (where one blood vessel is anastomosed with the lateral wall of another blood vessel and tied to intercept the blood stream) is one type of such end-to-side anastomosis. Nonetheless, this method fatally makes a blind loop on the blood vessel, sometimes causing thrombus formation after the surgical procedure.
We carried out some ESEE anastomoses with differences in size between the arteria circumflexa iliaca superficialis and the femoral artery in rats. In addition, the effect of the length of the blind loop on blood vessel patency rate was investigated by observing graft survival rate of groin flaps which require the blood vessel from the femoral artery as a feeding vessel.
The results demonstrated that the blood vessel patency rate of end-to-end anastomosis was significantly high compared with that of ESEE anastomosis, irrespective of the difference in the length of the blind loop. We concluded that conventional end-to-end anastomosis is preferable to ESEE anastomosis when anastomosing blood vessels of different sizes, especially when the bloodstream advances to a thin blood vessel from a big one.

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At the Department of Plastic Surgery, Osaka University, we provide simulation surgery under a microscope as a policlinic exercise to all medical students. The curriculum for this microscopic simulation surgery appears to have a significant effect on undergraduate education. Here, we describe our education system and a survey conducted through a questionnaire about impressions on microscopic exercises. Our system comprises a lecture, observation of an operation and an exercise in microscopic simulation surgery. In the simulation exercise, medical students anastomosed Silastic tubes (2mm in diameter), as a substitute for vessels, with 10-0 monofilament nylon under a microscope. A questionnaire about our undergraduate education was then distributed to all 6th year students (100 in total) ; 94 students responded. The contents found valuable were the medical simulation exercise (86 students, 91.5%), observation of operations and diagnostic examinations (65 students, 69.1%), and lectures in each medical department (63 students, 67.0%). Eighty-nine students (94.7%) considered the simulation exercise useful and 32 (34.0%) considered the microscopic technique suitable for them. Our survey suggests that the microscopic simulation surgery exercise increases medical students' interest and knowledge.

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The range of movement of replanted fingers in Tamai's zone IV or V may not always be satisfactory due to joint stiffness or tendon adhesion around the replantation site. Here, we describe the results of tenolysis in 17 replantations over a 10-year period. Fifteen replantations involved partial amputation of more than two digits, and two involved injury of one digit. The level of amputation included 14 digits in zone IV and three digits in zone V. Initial tenolysis was carried out at an average of 9 months after replantation. Flexor tenolysis was conducted in 14 digits and extensor tenolysis combined with a pedicled fat flap in three. Overall, the total range of active motion (TAM) averaged 87° (range, 40° to 180°). According to Yoshizu's assessment, 10% recovery of TAM was achieved by flexor tenolysis and 15% by extensor tenolysis. Since this series included many multiple digital amputations, we evaluated flexor tenolysis as unfavorable. Our findings suggest that an adipofascial flap underneath the extensor tendon is conducive for extensor tenolysis in replanted digital units.

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Digital periarterial sympathectomy (PAS), first introduced by Flatt in 1980, has been one surgical option in the treatment for ischemic problems of the hand. Several studies have reported good results in the short term after surgery ; long-term efficacy of the procedure has, however, not been evaluated in detail previously. Here, we describe our middle-to long-term results of PAS carried out on 21 hands in 14 patients aged 18 to 61 years (average 45 years) at surgery. The etiology was Buerger's disease in 9 hands, collagen disease in 8, and repeated trauma of digits in 4. The average follow-up period was 7 years and 10 months (range: 20 months to 14 years and 8 months). Postoperatively, PAS was defined as effective in 8 hands by thermography, as good in 48 digits, and as effective in 37 digits by plethysmography. In the hands with collagen disease, subjective symptoms were worse than in those with other etiologies, pre-and postoperatively. PAS was found effective even in cases that were followed-up after 10 years.

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We reviewed 6 cases of thumb amputation caused by rope injuries incurred while leading cattle. Incorrect gripping of the halter rope resulted in the injury. Five cases needed microvascular repairs, including 3 that required vein grafts. The survival rate was only 20% (1 of 5) in this study, whereas the overall rate of successful thumb replantation has been 79% (79 of 100) in our institution. Thumb amputations resulting from leading cattle have a poor rate of success compared with those from other causes, because they include elements of both avulsion and crushing. Since vascular and soft tissue damage extends beyond the edge of the wound, improving the rate of success, and conducting good debridement and vascular repair with a vein graft are requisite.

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Sixteen patients were, between 2000 and 2008, treated for soft tissue sarcoma of the extremities, where soft tissue reconstruction was requisite for limb salvage. The mean age of the patients (14 men and 2 women) at surgery was 57 years (range, 0-83 years). Postoperative follow-up extended over more than one year. The thigh was involved in 5 patients, the shoulder and upper arm in 7, the leg in 3 and the forearm in 1. Reconstructive surgery was carried out with vascularized free flaps in 2 patients and with pedicled local flaps in 12; 2 patients underwent nerve and vascular reconstruction. Limb function (ISOLS / MSTS % rating) and oncologic outcome (local recurrence and life prognosis) were evaluated. The flaps survived in all patients. Local recurrence was confirmed in 4 patients. The outcome was CDF in 7 patients, NED in 3 and DOD in 6. The ISOLS % rating score was 73.3 to 97% (average 84.0%). Adequately wide resection and reconstructive procedures (a vascularized free or local flap) are needed for limb salvage with good functional outcome. Vascularized pedicled flaps are effective in the treatment of most cases of soft tissue sarcoma of the extremities.

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We describe a case of finger replantation after stump-plasty. The replantation was successfully carried out, but the case highlighted the importance of proper informed consent from the patient. The patient, a 39-year-old woman who incurred a sharp left middle finger amputation by a meat slicer, received initial treatment at a neighboring general hospital where she underwent stump-plasty. Records from this hospital revealed that treatment options were explained to the patient (replantation vs. stump-plasty) but that the patient had not opted for replantation. Nevertheless, the patient stated that as she had been in a state of distress, she had not fully understood what had been explained and had left the treatment decision to her treating physician. The same day, the patient visited our hospital with the amputated finger and requested a replantation. More than 7 hours had elapsed since the injury, but since the finger was iced and in good condition, we carried out the replantation, which required venous grafting. The postoperative course was without complications and the finger survived completely.
In the treatment of finger amputation, the gold standard is to carry out replantation, unless the patient requests otherwise. At the time of injury, patients are often in distress and lack decision-making capacity, leaving treatment decision solely to the physician. In our facility, we devote ample time to a full informed consent process, explaining treatment options, risks and benefits. This case may have been the result of an inadequate informed consent process at the first facility with the patient not fully understanding the risks and benefits; it also highlights the importance of properly conducted informed consent before surgical treatment.

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In patients with radiation ulcers or radiation sarcoma in the anterior chest, reconstruction with a free flap or a unilaterally pedicled flap is challenging. We describe 2 cases of defects reconstructed in the anterior chest with contralateral pedicled LD flaps.
The first patient, a 71-year-old woman who had suffered from breast cancer and had undergone radiation therapy and surgery 44 years previously, presented with a radiation ulcer in the anterior chest. The ulcer and scar tissue were excised, and the defect was covered with a contralateral pedicled LD flap. The second patient, an 80-year-old woman who had suffered from breast cancer and had undergone radiation therapy and surgery 35 years previously, presented with a mass at the left clavicle. The mass, diagnosed by biopsy as post-radiation sarcoma, was excised, and the defect was covered with a contralateral pedicled LD flap. Neither of the patients demonstrated recurrence or necrosis of the flap.
In conclusion, a pedicled LD flap can cover the defect in the contralateral anterior chest and is useful for reconstruction in patients with radiation ulcers or tumors.

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We describe a wide circumferential skin defect covered with a combined free 17 × 5.5cm scapular flap and a 13 × 3cm parascapular flap in the forearm of a 14-year-old woman. The subscapular artery and veins of the combined flap were anastomosed to the radial artery and veins of the forearm. The donor site was closed primarily. The combined free scapular flap survived completely and good cosmetic appearance was obtained without any donor site morbidity. The combined free scapular and parascapular flap is a suitable option for covering wide circumferential skin defects of the forearm.

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A 57-year-old man underwent reconstruction with a forearm flap after removal of tongue cancer. The patient was given 5,000 units/day of heparin for anticoagulation of anastomosis. Platelet count decreased markedly to 34,000/μl on postoperative day 6, and flap color turned dark red, necessitating emergent surgery. Total thrombosis of the internal and external jugular veins was confirmed. Heparin-induced thrombocytopenia (HIT) was suspected, and all heparin administration including flush solutions of pressure monitoring lines was discontinued. The anti-platelet factor 4/heparin antibody test was carried out and the patient was treated with another anticoagulant regimen with the use of argatroban. On postoperative day 12, the anti-platelet factor 4/heparin antibody test was found positive, and the definitive diagnosis was HIT. The patient recovered and platelet count reverted to the normal level. HIT may occur in patients treated with heparin and may increase the mortality risk if the diagnosis is delayed.
Since heparin sodium is widely used in many microsurgical reconstructions, surgeons should be aware that even a very small quantity of heparin sodium can invite adverse consequences.

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