Indocyanine green (ICG) fluorescence angiography imaging is useful for visualizing lymph and blood flows. It can be applied in microsurgical reconstruction. In this study, we retrospectively analyzed 8 cases of the usage of ICG fluorescence for intraoperative blood circulation evaluation and discuss 3 typical cases to illustrate its usefulness. In the first case, ICG fluorescence was used following the surgical resection of finger arteriovenous malformation (AVM) to effectively confirm complete AVM resection and circulation of the finger. As a result, the finger was successfully preserved. In the second case, jejunum circulation failure developed after free jejunum transfer. ICG fluorescence revealed limited blood flow to the graft and jejunum; therefore, reanastomosis was performed and the jejunum was preserved. In the third case, unexplainable renal circulation failure developed after kidney transplantation. ICG fluorescence demonstrated the cause of failure to be arterial thrombosis; therefore, arterial reanastomosis with vein grafting was performed and the transplanted kidney survived. ICG fluorescence can be used to directly visualize blood flow, which makes it advantageous over other visualization methods. It is especially useful to clarify the moving circulation dynamics, small color difference between flaps, and causes of circulation failure.

Background: Performing secondary head and neck reconstructive surgery after radiotherapy is highly challenging. We report the outcomes of this type of procedure.
Methods: We retrospectively reviewed all cases in which patients underwent secondary head and neck reconstructive surgery after radiotherapy at the National Cancer Center Hospital East in Kashiwa, Japan, between January 1999 and December 2018.
Results: We identified 35 free flap transfers performed on patients who previously underwent head and neck reconstruction and radiotherapy, including 19 between 1999 and 2008, and 16 between 2009 and 2018. Reasons for the second head and neck reconstruction included recurrence (14 patients between 1999 and 2008, and 7 between 2009 and 2018) , development of new lesions (1 patient between 1999 and 2008, and 4 between 2009 and 2018) , and to cure osteoradionecrosis of the jaw (2 patients between 1999 and 2008, and 3 between 2009 and 2018) . Postoperative complications developed in 10 patients between 1999 and 2008, and in 11 between 2009 and 2018. Total flap failure developed in one patient during the second decade.
Conclusions: Over the two-decade study period, we observed a decrease in the incidence of recurrence, an increase in patients with new lesions, and an increase in cases involving osteoradionecrosis of the jaw. The number of postoperative complications did not change.

Background: Many studies have compared head-up surgery and conventional microscopic surgery from an ergonomical viewpoint. We report the results of a user questionnaire survey about the initial experience with the surgical exoscope 4K3D ORBEYE and clarified its characteristics. We also report the results of head-up surgery combined with endoscopy.
Materials: We conducted a questionnaire survey on the initial experience of using the surgical exoscope 4K3D ORBEYE. There were 12 survey items, including image quality, eye strain, and endoscope movement function. Surgeries performed within the target period included tumor or hematoma removal, cerebral aneurysm clipping, and direct vascular anastomosis. In all cases, surgery was performed using a 4K3D 55-inch monitor with 3D glasses. Furthermore, the advantages and disadvantages of endoscopy combined with surgery were examined.
Results: Overall, 466 valid responses to the questionnaire survey were received from 22 subjects during the target period; 79.4% of subjects responded with “Good”. Moreover, 85.7% of subjects responded with “Good” for surgery combined with endoscopy.
Conclusions: Based on the limited initial experience, the ORBEYE outperformed the microscope from an ergonomic perspective. It is necessary to become accustomed to head-up surgery using 3D glasses.

We examined cases of complete finger amputation without emergency surgery on the day and replantation at a later date. According to several reports, it is possible to extend the time of finger amputation without re-refluxing by proper storage. There is also a report that replantation after 48 hours is possible. Based on this study, the success rate using preserved cut fingers did not decrease compared with emergency surgery. Finger amputation is an emergency operation, but it can be performed after 24 hours if it is managed correctly. We were able to preserve and store the finger for replantation the next day, which we termed waiting replantation.

Replantation of subzoneⅡcomplete fingertip amputation is technically difficult. The difficulty in anastomosis of the central artery is due to the narrow and deep operative field. We therefore added a volar midline incision to expose the central artery in the case of replantation for subzoneⅡcomplete fingertip amputation. The purpose of this study was to report the clinical results of this method.
A prospective study of 14 patients (10 men and 4 women) who underwent artery-only replantation for subzoneⅡcomplete fingertip amputation with a volar midline incision (approximately 4-5 mm) to expose the central artery during the time period of 2010 to 2020 was performed. The mean age of the patients at surgery was 55 years old (range, 23-75) . Vein grafting was performed in 7 patients.
Twelve of 14 (86%) replanted fingertips survived.
The survival rates of subzoneⅡcomplete fingertip amputation without venous anastomosis were 62-88%. The results of this prospective study were comparable to those of previous reports. We concluded that a volar midline incision to expose the central artery is a useful option for subzoneⅡcomplete fingertip amputation.

Introduction: The Trauma Research Group was established in 2017 in our region, and a novel concept emphasizing early transfer to a specialty center and early reconstruction was discussed for the management of open limb fractures. This study evaluated the impact of this novel concept for the management of severe open fractures on the clinical outcomes in our department.
Methods: Twenty-eight patients who underwent soft tissue reconstruction for a GustiloⅢb lower limb fracture were retrospectively investigated. We divided the patients into two groups: the previous (P) -group consisting of patients treated between 2011 and 2016, and the recent (R) -group consisting of patients treated between 2017 and 2019. We compared the clinical results between the two groups.
Results: The period from injury to first surgery in our department was significantly shorter in the R-group. The positive rate of bacterial tissue culture from affected cancellous bone was significantly lower in the R-group. Free vascularized bone graft (FVBG) and vein graft were required more frequently during reconstructive surgery in the P-group.
Conclusion: The early transfer and satisfactory management of GustiloⅢb lower limb fractures resulted in a lower infection rate and lower rate of invasive surgery such as FVBG and vein grafting.

The importance of restoring external rotation of the shoulder after brachial plexus injury (BPI) is well known. The first choice for shoulder function reconstruction is nerve transfer. However, some patients with poor recovery have difficulty in using their reconstructed limb. Moreover, there are patients who are not candidates for nerve transfer surgery due to chronicity or unavailability of a donor nerve. In such cases, the options for secondary procedures to improve shoulder function are often limited. We performed contralateral lower trapezius transfer (CLTT) to the infraspinatus in twelve patients in order to restore shoulder external rotation. All patients exhibited improvement in shoulder external rotation and disability of the arm, shoulder and hand (DASH) scores. No donor site deficit was noted in any patient. Two patients had rupture of the suture site at around four weeks after surgery. This study demonstrated that CLTT to the infraspinatus tendon is an effective procedure to improve shoulder external rotation in patients with BPI.

Breast reconstruction using a deep inferior epigastric perforator flap (DIEP flap) harvested from beyond the midline of the abdomen often causes postoperative partial congestion and fat induration in the flap. In such cases, we prophylactically preserve the superficial epigastric veins (SEVs) and perforator vein of the flap, and add a venous outflow system by anastomosis of a combination of candidate intra-flap veins and the inferior epigastric vein to reduce flap congestion when intraoperative findings suggest flap congestion. As a result, fat necrosis was avoided in all 12 cases in which flap congestion was prevented. When intra-flap vein anastomosis is added, appropriate selection of a target vein is required depending on the anatomical position of the blood vessel in each case. The above measures do not require a new arterial anastomosis and may be able to prevent postoperative flap congestion with a relatively simple procedure.

We report the case of a 16-year-old male patient who sustained an open fracture of the right medial malleolus in a traffic accident. Physical examination revealed a comminuted medial malleolus fracture with bone and medial soft tissue defects. The distal part of the medial malleolus was divided into anterior and posterior bone fragments. The anterior fragment exhibited no vascularity, which was more likely to cause nonunion and bone atrophy after osteosynthesis. Therefore, we considered the vascularized periosteum, which had significant osteogenic potential, to be effective for successful bone union. We performed open reduction and internal fixation using a bone graft from the iliac bone. The periosteum vascularized by the distal part of the anterior tibial artery was elevated from the anterodistal side of the tibia and wrapped around the fracture site. The fracture united completely within two months after surgery, and pathological examination revealed that the osteocytes survived even though the anterior fragment had poor vascularity. Vascularized periosteal grafts may be useful for bone reconstruction as they facilitate the preservation of osteochondral fragments with poor vascularity.

The Achilles tendon of a 48-year-old male patient became infected following tendon repair. He was a compromised host with pyodermatitis of unknown cause who underwent dialysis and had taken oral corticosteroids for polyarteritis nodosa. He was infected with Pseudomonas aeruginosa and lost a large amount of soft tissue, including the Achilles tendon, after several rounds of debridement. After the infection was controlled, he received an anterolateral thigh flap with vascularized tensor fascia lata and vastus lateralis muscle. For recurrent infection, he received daily irrigation and repeated debridement with local gentamicin injections. Seven months after the flap surgery, he was able to walk without difficulty and there was no recurrence of infection. Strategic management is important for infection of the extremities, especially in compromised hosts, because local infections may spread to other tissues. Saucerization and debridement are the first choice to reduce the number of bacteria. Flap surgeries should be considered under aseptic conditions to reconstruct the tissue defects. A few antibiotics should be used at a high dose for a short period to prevent the evolution of antibiotic-resistant bacteria. An ALT flap with the vascularized fascia lata and vastus lateralis was suggested to be effective to reconstruct the Achilles tendon and to control infection.

Central mandibular defects require reconstruction considering the shape and function. In younger patients with many residual teeth, vascularized bone grafts should be selected to maintain mandibular function using dentures and implants. The double-barrel method with a fibula flap can achieve high-quality mandibular reconstruction; however, most reports describe its application for unilateral mandibular defects because of its technical difficulty. We report a 52-year-old woman who underwent reconstruction of a central mandibular defect using the double-barrel method with osteoseptocutaneous fibula flap surgery. Four pieces of the fibula were built into the shape of the mandible at the donor site. We describe our design and strategies, including the semi-open-wedge technique.

In recent years, advancements in surgical procedures and perioperative management have improved cancer treatments, thereby expanding surgical indications for pancreatic cancer treatment. In distal pancreatectomy with celiac axis resection (DP-CAR) for pancreatic cancer, the left gastric artery (LGA) , which is the main feeding vessel of the stomach, may be dissected with the celiac artery. As a result, there is a high possibility of ischemic gastropathy due to decreased blood flow in the stomach. In order to avoid ischemic gastropathy after DP-CAR, a retrospective study was conducted on three cases in which the LGA was reconstructed with the middle colic artery (MCA) . In all cases, intraoperative indocyanine green angiography revealed sufficient blood flow to the stomach wall. Postoperative contrast-enhanced computed tomography did not demonstrate stenosis or occlusion of the vascular anastomosis, and ischemic gastropathy was not observed. In DP-CAR, reconstruction of the LGA with the MCA may prevent postoperative ischemic gastropathy.

If arterial thrombosis develops after a free flap operation, we need to remove the thrombosis and surgically re-anastomose the arteries. For this, the entire arterial thrombosis area is surgically removed and we may have to use a vein graft. The vein used for grafting must be selected according to factors such as the difference in diameter from the artery, time required for collection, state, and sacrifice of the donor site. We hypothesized that these problems can be solved using a comitant vein of the flap that was transplanted. We were able to achieve good results using this method in two cases of arterial thrombosis after transplantation of a free rectus abdominis myocutaneous flap during head and neck reconstruction. We consider this method useful for feeding arteries shortened by arterial thrombosis in cases with two comitant veins.

Various techniques for nail reconstruction have been reported until now; however, a simple one providing good esthetic results was difficult to find. Arterialized venous toenail flap is a free flap that includes the nail bed and matrix with a pedicle formed solely by the subcutaneous vein of the toe. The use of this flap is minimally invasive, easy, and the flap has a high survival rate. The mechanism of graft survival remains unknown given the non-physiological circulation. To the best of our knowledge, no studies have explained this mechanism with reference to detailed postoperative course. We herein present two cases of nail reconstruction performed using arterialized venous toenail flap. We analyzed the postoperative course in detail, which enabled us to postulate on the mechanism of graft survival.