The patients in whom I performed digit replantation during a 2-year period were divided into two groups. Postoperative systemic heparin was administered to Group A ( 17 patients with 19 replanted digits ; between May 2013 and April 2014 ), but not to Group B ( 19 patients with 22 replanted digits ; between May 2014 and April 2015 ). There were no other differences between the treatments employed in the two groups, and no significant intergroup differences in factors that were considered to have the potential to influence the study results were found. No significant differences in the frequency of postoperative arterial thrombosis ( Group A, 1 digit ; Group B, 2 digits ; p=1 ), postoperative venous thrombosis ( Group A, 1 digit ; Group B, 2 digits ; p=1), or postoperative vessel spasm ( Group A, 1 digit ; Group B, 1 digit ; p=1 ) were detected. However, postoperative bleeding was significantly more common in Group A ( 7 cases ) than in Group B ( 0 cases ) ( p=0.00233 ). These results suggest that the postoperative use of heparin has no effect on the incidence of microvascular thrombosis after digit replantation.

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Salvage surgery for postoperative thrombosis that arose after head and neck free flap reconstruction was examined, and cases of arterial and venous thrombosis were compared.
There were 4 cases of arterial thrombosis and 5 cases of venous thrombosis. The venous thromboses were caused by pedicle kinking, twisting, or hematoma compression. All 5 cases were successfully salvaged by thrombectomy and re-anastomosis, resulting in a salvage rate of 100%. The arterial thromboses were caused by pedicle kinking or drainage tube compression in 2 cases ; however, the causes were unknown in the other 2 cases. In the cases with unknown causes, salvage surgery involving thrombectomy and re-anastomosis was performed twice, but these procedures eventually failed, resulting in total flap loss ( salvage rate : 50% ).
The successful salvage of a compromised flap requires the early detection and complete removal of any thrombi, and re-anastomosis to appropriate recipient vessels. In the cases of venous thrombosis, early detection was relatively easy, and the causes of the thrombosis were relatively straightforward and manageable ; thus, we were able to achieve an excellent salvage rate. In contrast, there were 2 cases of arterial thrombosis of unknown cause, and they could not be rescued despite repeated salvage attempts. In such cases, multiple take-backs might not be successful, and another flap transfer should be considered.

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Post-traumatic cold intolerance ( CI ) is used to describe a group of symptoms, such as pain, discomfort, and numbness, that arise after exposure to cold. CI is recognized as one of the most disabling sequelae of upper extremity traumas. The Cold Intolerance Symptom Severity ( CISS ) questionnaire was developed by Irwin et al., and there have been several reports about the reliability of this assessment tool. In this study, we retrospectively investigated patients with complex tissue injuries of the upper extremities. We aimed to evaluate their CISS scores ; to perform statistical analyses of the correlations between the CISS score and the Disabilities of the Arm, Shoulder and Hand ( DASH ) or Hand 20 score ; and to identify prognostic factors related to CI. A CISS score of > 30 was defined as abnormal CI. The mean CISS score of the study subjects ( n=36 ) was 35.6. Thus, the positivity rate was 52.8% ( 19/36 ). The DASH score and Hand 20 score were correlated with the CISS score. A significant statistical difference was detected between age and the CISS score. The CISS questionnaire might be a valuable assessment tool.

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When reconstructing a palmar skin defect after the release of digital flexion contracture, flaps are more useful than skin grafts for preventing recurrent contracture.
There are various flaps that can be used to reconstruct such defects, including digito-lateral flaps, palmar advancement flaps, cross finger flaps, etc.
I examined whether the dorsal skin extends if digital flexion contracture remains untreated for a certain period and developed a new surgical technique, which involved the use of a bilobed propeller flap that was composed of dorsal and lateral skin paddles and contained the dorsal branch of the digital artery.
This new type of flap surgery was performed in 4 cases, including one case of distal interphalangeal joint contracture and 3 cases of proximal interphalangeal joint contracture. The maximum diameter of the palmar skin defects was 15 mm, and additional skin grafts were only required in one case.
All of the flaps completely survived, and the flexion contracture was improved in all cases.
I conclude that the bilobed propeller flap described in this study should become the first-choice treatment for palmar skin defects that occur after the release of digital flexion contracture.

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In cases in which it is necessary to place another flap in an area adjacent to a previously transferred flap, it might be possible to elevate a perforator flap from the previous flap. When planning and elevating such perforator flaps it is very useful to identify and assess the quality of perforator vessels using color Doppler ultrasound. When examining the perforators in a flap using ultrasound, we occasionally find that the blood flow velocity and diameter of such vessels increase over a few months. When we encounter cases in which it is necessary to elevate a flap adjacent to a previous flap, we always consider elevating a perforator flap from the previous flap. In this report, four perforator flaps that were elevated from previous flaps are presented. The flaps were elevated at 9 to 18 months after the previous flap surgery and survived completely, which was aided by the use of color Doppler ultrasound before and during the operation.

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Background : In our quest to perform safe and reliable breast reconstruction using autologous free flap transfer, we hereby introduce the concept of lean breast reconstruction ( LBR ).
Method : The LBR concept consists of the following three approaches : avoiding any complicated arrangement or placement of the flaps, using deep inferior epigastric artery perforator free flaps or MS2 transverse rectus abdominis musculocutaneous free flaps based on the safety of the flap-harvesting procedures, and using lateral thoracic vessels as the first-choice recipient vessels for microvascular anastomoses whenever appropriate. We compared two patient groups : the conventional reconstructive surgery group and the LBR surgery group.
Results : The cases of 16 patients were reviewed in this study. The reconstruction time did not change significantly after the introduction of the LBR concept, although it tended to be shorter. However, the patients' postoperative hospital stay was significantly reduced, and the perioperative complications rate improved.
Discussion : As the LBR concept is simple, and easy to understand and perform, it can improve the learning curves of surgeons, assistants, and other medical staff. Thus, the LBR concept might enable reliable breast reconstruction to be performed in more patients and improve the surgical outcomes of such reconstructive procedures.

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This case involved the traumatic amputation of the whole middle phalanx, the proximal two-thirds of the distal phalanx, and the dorsal skin of the affected digit, which are very rare injuries. Although several reconstructive options were available in the present case, we reconstructed the whole middle phalanx in addition to the proximal interphalangeal ( PIP ) joint using a free costal osteochondral graft wrapped in a corticoperiosteal flap from the medial condyle of the femur. The dorsal skin defect was covered by placing a skin graft on the vascularized periosteum. The corticoperiosteal flap and skin graft survived without any problems. The part of the free costal graft that was wrapped in the corticoperiosteal flap was gradually remodeled, although the unwrapped region was gradually absorbed. The corticoperiosteal graft from the femur prevented the free costal bone from undergoing atrophication and absorption. Although we performed a joint mobilization operation for the PIP joint and flexor tenolysis, a sufficient active range of motion could not be achieved in the PIP joint due to the lack of an A2 pulley.

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The free arterialized venous flap is thin, pliable, and easy to elevate and causes minimal donor site morbidity. In addition, it is easy to perform vascular anastomosis using this flap because of the large caliber of its vessels. However, the size of such flaps seems to be limited, and congestion and partial necrosis are common due to the flap's non-physiological circulation. When elevating a venous flap, some perforators can be detected under a microscope. Sometimes, sizable perforators that are well matched with the recipient arteries are encountered, and it is possible to convert the venous flap into a perforator flap in such cases. If a flap does not contain a sizable perforator or the vascular anastomosis of the perforators to the recipient arteries is unsuccessful, the grafting of the venous flap can be performed in the usual manner. Microsurgeons who are familiar with venous flaps can safely adapt the supermicrosurgery techniques they employ in this manner. Preoperative screening using color Doppler Ultrasonography is very useful for aiding the efficient identification of sizable perforators that are suitable for anastomoses and tracing them to their deep main trunks. Free-style free perforator flaps can be designed and harvested from the standard venous flap harvesting sites.

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The reconstruction of soft tissue defects around the knee joint is often challenging for plastic and orthopedic surgeons. Well-vascularized tissue is required to ensure wound healing in such cases. Various alternatives, including local cutaneous flaps, fasciocutaneous flaps, muscle flaps, and free flaps, have been reported. In this article, we report the case of an 87-year-old female in whom a reverse-flow anterolateral thigh ( ALT ) flap was used to cover a soft tissue defect of the anterior knee ( the left knee ), which had become infected after a total knee arthroplasty procedure. The perforators of ALT flaps exhibit many anatomical variations, so we used ultrasonography and assessed the skin perforators of the ALT flap and the anastomosis between the descending branch of the lateral circumflex femoral artery and superior lateral genicular artery, which helped us to harvest the flap safely. The reverse-flow ALT flap is a reliable, effective, and durable option for reconstructing soft tissue defects around the knee.

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The combined use of a free superior gluteal artery perforator flap and the medial sural artery for popliteal reconstruction in two cases is described.
Case 1 : The patient was a 79-year-old male. A long-lasting widespread burn scar of the lower leg exhibited repeated ulceration in the popliteal region. The ulcerated scar was excised, and a superior gluteal artery perforator flap ( 20 × 9 cm ) was transferred to the defect. The vessels of the thinning flap were anastomosed to the medial sural vessels in an end-to-end fashion. The patient's postoperative course was uneventful.
Case 2 : The patient was a 43-year-old female. A split-thickness skin graft that was transferred after necrotizing fasciitis caused scar contracture of the knee. The contracture was released, and a superior gluteal artery perforator flap ( 15 × 8 cm ) was transferred to the defect. The graft's vessels were anastomosed to the medial sural vessels in an end-to-side fashion. Relocation of the flap was required due to congestion.
This procedure was performed by two teams working simultaneously, with the patient in the prone position. The diameters of the vessels used for the anastomoses were similar, and the length of the pedicle was adequate. Our experience indicates that this combined approach is a reasonable solution when it is difficult to use local flaps.

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A 33-year-old male injured his wrist when he hit his hand against a rock. At his first visit ( 4 months after the injury ), the scapholunate interval was markedly widened, and the scaphoid ring sign was obvious. We reconstructed the scapholunate ligament with a vascularized bone-ligament-bone graft. The base of the 3rd metacarpal bone, dorsal capsular ligament, and the distal capitate bone were harvested en bloc based on the 2nd dorsal metacarpal artery and grafted to the dorsal aspect of the scaphoid and lunate bones. At 10 postoperative months, his wrist was pain-free, and he had returned to his former job ( delivering gas cylinders to customers ). He exhibited wrist extension and flexion of 30 and 35 degrees, respectively, and the grip strength of the affected hand was 53% of that of the uninjured hand. The patient’s Cooney score was 70 because he had limited wrist motion and grip strength. The use of a vascularized bone-ligament-bone graft to reconstruct the scapholunate ligament has the theoretical advantage of preserving the vascularity of the ligament and bone, which maintains graft strength and promotes early bone union. Long-term follow-up is necessary to confirm the effectiveness of this procedure.

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A retrospective analysis of 24 patients that suffered arterial injuries secondary to limb fractures was performed. The examined cases involved 18 males and 6 females with a mean age of 42.7 years. Two patients with fractures of the distal tibia combined with severe crush injuries underwent primary amputation. In the remaining 22 patients, limb salvage was performed, and 24 arterial injuries ( 2 arterial spasms, 5 intimal injuries, and 17 ruptured arteries ) were repaired by means of adventitectomy, end-to-end anastomosis, and autogenous vein grafting. The mean time from the injury to admission was longer in the patients that were transferred from another hospital ( 4 hours and 6 minutes ) than in the patients that were admitted directly ( one hour ). The functional outcomes of the 20 patients that were followed for? 6 months were no disability in 8 patients and little limitation on daily life in 7 patients. Functional hands could not be obtained in the other 5 patients, who had severe muscle / tendon injuries of the forearm or multiple nerve lacerations of the upper arm. Various issues need addressing in order to improve the clinical results of patients that suffer arterial injuries secondary to limb fractures.

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