We report the replantation of amputated fingertips (Zone I) in six children. The children were 0 years 4 months to 12 years 10 months of age. The fractures were fixed with steel wire. All patients had one arterial anastomosis, two had venous anastomosis, and one had nerve suture. For infants who were unable to maintain rest, cast immobilization was used to elevate the affected limb for rest. To prevent congestion, pinprick was performed in two cases, and fish mouth was performed in two cases. In two cases, only an arterial anastomosis was performed without stasis measures. All cases were viable. Although only arterial anastomosis could be performed for replantation of the fingertips in children, the survival rate was good; however, the need for inpatient general anesthesia and management was a problem.

  Microsurgery is an essential technique in reconstructive surgery, and off-the-job training is recommended to master the technique. We have held a microsurgical training seminar annually since 2007. We report the results of a post-attendance survey of participants.　
  The seminar was a two-day program, consisting of dry lab to wet lab training, coached by supervising physicians. A Google Form survey was conducted of seminar participants (n = 65) in the spring of 2021.　
  Responses were received from 44 participants (68%) . Sixty-six percent of the respondents were under 30 years old. Seventy-eight percent were in a fellowship program. Nearly 90% were working in secondary or higher-level emergency hospitals. Ninety percent of the participants successfully performed a vascular anastomosis during the seminar. Before the program, more than 60% of the participants replied that they “could not” perform a vascular anastomosis, but after participation, more than 80% reported they “could”. After the program, most participants reported that they had an opportunity to use a surgical microscope and that they would recommend other physicians participate in the seminar.　
  Our findings suggest that the microsurgery seminar changed young physicians’ attitudes toward microsurgery and encouraged them to perform microsurgery in clinical practice.

  Reports of clinical features and clinical results of great toe replantation are rare in Japan. Herein, we report replantation for incomplete amputation of great toe in six patients between 2010 and 2020. The patients were five males and one female ranging in age from 27 to 79 years and mean age was 52 years. Five toes were crushed by something heavy at work and one was crushed in a traffic accident. Five of six were accompanied by lateral toe injuries or degloving injuries of dorsal foot. Three cases had arterial anastomosis with vein graft, and two cases had vein anastomosis. In one case, the toe was attached only with flexor hallucis longus tendon and we performed stump plasty because revascularization of the medial plantar digital artery failed. In the five successful cases, the proximal first dorsal metatarsal artery was used for arterial anastomosis. In conclusion, the incomplete amputation of great toe often accompanied lateral toe injuries, but the survival rate was high. Therefore, replantation of incomplete amputation of the great toe should be considered.

  For deep mediastinal reconstruction, surgical options should be considered and selected according to the patient’s primary disease, the area of the defect, and the exposed critical organs such as trachea, aorta, and esophagus. In particular, during posterior mediastinal reconstruction cases, the bronchial stump or exposed stents used for esophagus and aorta coverage is used in order to prevent serious complications, such as bronchopleural or aortoesophageal fistula, associated with high morbidity and mortality. Reinforcement of critical structures is often achieved through the use of various flaps. For example, thoracic surgeons prefer to use the intercostal muscle, pericardial fat pad, pleura, and diaphragm. On the other hand, in some circumstances, plastic surgeons need to carefully repair complicated defects by performing local flaps or microvascular free tissue transfers. Although microsurgical reconstruction is versatile and can be used in challenging cases, appropriate selection of recipient vessels is critical for successful free tissue transfer in intra-thoracic lesions. In this report, we present our experience using the latissimus dorsi free flap via intra-thoracic microvascular anastomoses for coverage of a bronchial stump and for endovascular aortic stent-graft exposure.

  Fix and flap surgery for severe open limb fractures is already a standard treatment. In cases where the fracture is complicated or accompanied by bone defects, secondary surgery is required for fracture sites covered with a myocutaneous flap after the soft tissue condition has stabilized. We applied the delayed procedure concept used for distant flaps and attempted to prevent postoperative myocutaneous flap necrosis by performing a provisional incision prior to the longitudinal incision of the flap. We report the course of five cases of the longitudinal division of the myocutaneous flap using “provisional incision” after free-flap surgery for severe open fracture. The types of flaps used for soft tissue reconstruction were latissimus dorsi myocutaneous flap in four cases and anterolateral thigh flap in one case. Secondary surgery consisted of osteosynthesis in one case, plate removal in one case, and bone cement removal and autologous bone grafting in three cases. In all cases, the wound healed without necrosis of the myocutaneous flap. Longitudinal division of the myocutaneous flap using “provisional incision” is a safer approach to the necessary secondary surgery and reduces the possibility of necrosis of the flap.