We reviewed the clinical results and anastomosed veins in cases of head and neck reconstruction at our institution. Fifty-four patients with malignant tumors of the head and neck that were reconstructed using free flaps were included (39 males and 15 females, with a mean age of 60.7 years) . Two veins were anastomosed in 30 of 54 patients and one vein was anastomosed in the remaining 24.　
Complete survival of the flaps was achieved in 50 of the 54 patients, but partial and total necrosis occurred in 3 and 1, respectively. Partial necrosis was due to congestion of the external jugular venous system in all cases, and total necrosis was caused by obstruction of the artery. Of the 24 patients with one venous anastomosis, partial necrosis occurred in 2 of the 7 patients with external jugular venous system anastomosis.　
Nearly half of anastomosis were to a single vein and cases of anastomosis to the external jugular venous system had a higher incidence of necrosis. When using the external jugular venous system, it is necessary to avoid excessive dissection and to pay attention to vessel placement.

We report a case of arteriovenous malformation of the forearm that was treated with reconstruction of the radial artery by vein grafting.　
A 71-year-old man had an elastic soft mass of 2 cm in diameter under the middle radial side of the forearm, which had no tenderness or radiating pain, but arterial pulsation was palpable. No color changes, superficial blood vessel distension, or impaired peripheral blood flow was observed. CT angiography confirmed an abnormal vascular mass that continued from the branch of the radial artery and returned to the comitant vein. A diagnosis of arteriovenous malformation was made and resection was performed. The nidus that spread to the deep layer of the brachioradialis was resected together with a part of the radial arteries and veins. The radial artery was reconstructed with a cephalic vein graft.　
Surgical treatment of arteriovenous malformations requires complete resection of abnormal vessels, and insufficient resection can lead to recurrence and further spread of the lesion. As we performed treatment at a relatively early stage, we were able to remove the nidus without sacrificing surrounding tissue. In addition, the radial artery, one of the main arteries of the forearm, was reconstructed by vein grafting and the physiological hemodynamics were maintained.

Infected pseudoarthrosis of the wrist after open radial fracture is difficult to treat and bone grafts are often necessary. We report the use of a scapula tip and latissimus dorsi free flap to treat infected pseudoarthrosis of the wrist. A 55-year-old male presented with a left open radial fracture (Gustilo typeⅢB) sustained while working with a forklift. Persistent deep infection developed after fracture fixation. A large skin and soft tissue defect remained on the left wrist. Split-thickness skin grafting was performed after controlling the infection. However, the patient developed pseudoarthrosis of the wrist and presented with pain, reduced hand function, and contracture of the hand and forearm. Parts of the proximal carpal bones and distal radius were removed, and the defect was reconstructed using a scapula tip and latissimus dorsi free flap.
Postoperatively, stabilization of the wrist joint, pain reduction, and improved hand function were observed. This case suggested that a scapula tip and latissimus dorsi free flap is an option for the treatment of carpal and radial bone defects involving skin and soft tissue defects.

As the possession of guns is strictly regulated in Japan, gunshot wounds are rare in daily medical practice. However, gunshot wounds, especially those sustained at high speeds, such as by rifles, can cause extensive tissue damage and be difficult to treat. We report the case of an extensive hand tissue defect due to the miss-shot of a rifle. Gunshot wounds on the limbs have been reported to have a higher infection rate than those at other sites. Initial treatment for gunshot wounds requires foreign body removal and debridement to prevent infection and lead poisoning. Fractures due to high speeds require a longer time for bone fusion than normal fractures. Due to the high risk of infection, tissue filling and internal fixation in fractures should be performed during a secondary surgery. We reconstructed an extensive hand tissue defect using a free fibula flap. The patient can pinch with the thumb and index finger, and is satisfied with the outcome.

Although an end-to-side anastomosis (ETS) is an essential method for free flaps in severe extremity injuries, the ETS has not been established in orthoplastic surgeons compared to an end-to-end anastomosis. We have adopted a microscopic parachute end-to-side (MPETS) technique which is modified from the ETS technique commonly used by cardiovascular surgeons. The MPETS technique consists of the two simple steps with microscope. First, the flap vessel is cut and widened and a large slit window is made into the recipient vessel. Second, the heel of the vessel is sutured using the parachute technique, followed by suturing both posterior and anterior walls with a continuous suture. In addition to the conventional ETS procedure, the MPETS technique has many advantages for free flaps, including easy slit-shaped vesselotomy, making a large window to avoid anastomotic narrowing, and easy anastomosis using the parachute technique at the heel of vessel which is a high-risk site of blood leakage. This technique can be applied to various sizes of arteries and veins. We believe that the microscopic parachute end-to-side technique might make free flaps easier and improve their clinical outcomes in severe extremity injuries.