We describe the indications and preoperative precautions, intraoperative tips, and pitfalls of elevation of vascularized fibula graft, including some case examples. The indications for the vascularized fibula graft are diverse including reconstruction after resection of tumor, congenital pseudoarthrosis of tibia, and trauma. Pre-operative planning and evaluation are important for a successful result. The key to the operation is to identify the running pattern of the perforator in the preoperative evaluation using ultrasonography and find it between the soleus and peroneal muscles, so that the flap can be safely elevated. If the perforator is difficult to dissect, the flap can be abandoned, or other vascularized bone grafts can be considered. Vascularized fibula graft, especially when performed as free flap, is a technically demanding procedure that requires microsurgical techniques. It should be mastered by surgeons performing reconstructive surgery.

  Conventionally, autologous nerve transplantation has been used to treat peripheral nerve defects. Since the 1890s, studies on peripheral nerve reconstruction by tubulization have been performed because of sensory disturbance at the donor site and limited supply of donors. This study introduces the history of the development of artificial nerves in Japan and worldwide and the clinical results of Japanese-made artificial nerves (Nerbridge and Renerve) , which are used in Japan. Nerbridge and Renerve are excellent artificial nerves that are used according to the operator’s ease of use, site to be transplanted, and defect size. Artificial nerve transplantation is a good indication if the nerve ends cannot be connected without tension due to peripheral nerve injury. The finger is the most susceptible site for peripheral nerve injury. If the gap between the peripheral nerve stumps is ≥ 1 mm in the extended finger position, artificial nerve grafting should be performed.

  Arterialized venous flap (AVF) has become the most commonly used technique among the four venous flap techniques. AVF harvested from the volar forearm is suitable for digital defect reconstruction, as the color, texture, pliability, and thinness are similar. Moreover, AVF can be performed using a simple technique, provide various flap designs for the defects, and be attached to additional tissues such as cutaneous nerves and tendons. Thus, AVF is often used as an alternative to conventional flaps for digital defects. In our hospital, 14 AVFs were used for digital reconstruction. All the flaps survived even though partial congestion was initially detected in 10 AVFs (71.4%) . Recently, shunt restriction and retrograde anastomosis have been performed to reduce congestion; however, we did not perform these techniques in the present study. Further studies are needed to elucidate the reasons why the AVFs survived without congestion-reduction techniques. Our findings and a review of the literature suggest that AVF for digital reconstructions is safe in cases where countermeasures to reduce congestion were not performed.

  Osteonecrosis of the femoral head (ONFH) is a devastating disease that affects young adults. Joint-preserving surgery is important. Free vascularized fibular grafting (FVFG) is a joint-preserving surgery that has been reported to be successful for patients with early stages of osteonecrosis. We retrospectively reviewed the results in seven patients (ten hips) who had undergone FVFG for the treatment of ONFH between 2011 and 2020 in our institution. The average duration of follow-up was 5.2 years (range, 3-12 years). The Japanese Orthopaedic Association Score improved from 63 to 82 points at the time of the final follow-up evaluation. One hip was converted to total hip arthroplasty after 3 years; however, all other hips survived and pain-free good range of motion was restored. Complications were: five patients had flexion contracture of flexor hallucis longus, one had undisplaced proximal femoral fracture, and one had lateral femoral skin nerve palsy. FVFG is an essential salvage procedure of ONFH, especially in younger patients in the early precollapse stages of osteonecrosis.

  Glomus tumors are relatively rare soft tissue skin tumors with a relatively high recurrence rate. Studies on the usefulness of microscopic resection are limited.　
  We collected information from the medical records of 245 patients, including cases of reoperation for recurrence, with pathologically diagnosed glomus tumor after subungual excision or finger abdominal soft tissue tumors at our hospital between April 2010 and December 2021. In this study, “recurrence” was defined as the presence of certain symptoms, such as pain and nail deformity on the same finger postoperatively, and presence of tumor confirmed by imaging or surgery.　
  Of 245 patients, 134 underwent microscopic excision and 111 underwent a procedure that did not use a microscope. The recurrence rate was 7.35% in all cases, 3.73% in cases with microscopic excision, and 11.7% in cases without the use of a microscope.　
  In this study, microscopy significantly reduced the incidence of recurrence. Using a microscope enabled more detailed tumor dissection and resection, which may have allowed detection of all the tumor. Our findings suggest that using a microscope for glomus tumor resection under the fingernail or in the finger abdomen is an effective technique.

  Several nerve conduits have become available for repairing peripheral nerve defects. However, nerve regeneration using these nerve conduits is less efficacious than using autografts. At our facility, we cover the nerve conduit with a well-vascularized adipose flap, which effectively blocks scarring and prevents adhesion-related damage. Herein, we reviewed the outcomes of 12 patients with peripheral nerve injury in upper extremities, treated with nerve conduit wrapping with pedicled perforator adipose flaps. The average follow-up was 18 months. The nerve conduits were wrapped with digital artery perforator adipose flaps in six digital nerves, radial artery or digital artery perforator adipose flaps in four radial nerve sensory branches, and ulnar artery perforator adipose flaps in two ulnar nerve sensory branches. The average size of the perforator adipose flap was 308 mm², which was enough to cover the nerve conduit. The VAS score of neuropathic pain was improved from a preoperative mean of 70 to a postoperative mean of 17. The mean scores of Quick DASH and Hand20 were 9.3 and 12 at the last follow up, respectively. Our findings suggest that nerve conduit wrapping with pedicled perforator adipose flap is an effective method for repairing peripheral nerve defects in the upper extremity.

  There are several perforator flaps that use pedicles from branches of the lateral circumflex femoral artery. Among them, the anterolateral thigh flap is frequently used in head and neck reconstruction; however, it often has anatomical variations in the vessels. We report a case with anatomical variation of the lateral circumflex femoral artery during elevation of the anterolateral thigh flap. The patient was a 77-year-old man. He was scheduled for a subtotal maxillary resection and reconstruction for supragingival carcinoma. We found a perforator at the midpoint of the straight line connecting the anterior iliac crest and the lateral patella, and confirmed that it was an oblique branch of the lateral circumflex femoral artery. It is necessary to select an appropriate perforator so as not to impair blood flow when elevating the anterolateral thigh flap. Preoperative CT angiography and ultrasonography are recommended to ensure safe and reliable elevation.

  In radiotherapy, the tolerable dose of radiation for normal tissues is defined, and irradiating beyond this limit can cause serious complications such as tissue necrosis and ulceration. Herein, we report a case of left oropharyngeal cancer treated with a total of 120 Gy of radiotherapy. In the post-irradiation course, osteomyelitis of the mandible, mucosal necrosis of the oropharynx, and osteomyelitis of the cervical vertebrae occurred at different times, and reconstructive surgery was performed for each. Although reconstructive surgery has been reported for tissue damage caused by conventional radiation therapy, few studies have reported reconstruction for adverse events caused by radiation exposure far in excess of tolerable doses. Re-irradiation is a curative treatment for recurrent head and neck cancer, although the potential for prolonged survival comes with an increased risk of serious adverse events. Although reconstructive surgery for adverse events after re-irradiation is extremely challenging, it should be administered at the appropriate time to help patients maintain their activities of daily living.

  During soft tissue reconstruction for open fractures using free flaps, surgical manipulation during vessel anastomosis can lead to increased scarring around the blood vessels, thereby expanding the zone of injury. Consequently, the occurrence of partial necrosis in the free flap after surgery often necessitates more complex treatment, involving the anastomosis of additional free flaps farther away. We report two cases of open fractures in the lower leg with soft tissue defects in the middle third of the leg, resulting from partial necrosis following free flap reconstruction. We used an extended pedicled gastrocnemius flap obtained by fasciotomy. In both scenarios, the defect location rendered conventional gastrocnemius flaps impractical; however, by performing pie-crusting on the deep fascia of the gastrocnemius muscle and extending the flap, successful coverage was achieved. We consider the extended pedicled gastrocnemius flap obtained by fasciotomy to be a valuable alternative for the reconstruction of soft tissue defects beyond the conventional indications such as those found in the proximal third of the lower leg.

  I am currently working for the National Center for Child Health and Development as a pediatric hand surgeon, focusing on congenital anomalies of the extremities, pediatric fractures, and deformities. I had the opportunity to talk about the episodes that have had a strong impact on me so far under the theme of the symposium at the 49th annual meeting of the Japanese Society for Reconstructive Microsurgery (December 1-2, 2022, Hamamatsu) . In order to learn microsurgery, I studied at Ogori Daiichi General Hospital and then abroad at Christine M. Kleinert Institute for Hand and Microsurgery (Kleinert Kutz Hand Care Center, Louisville, KY, USA) . I would like to look back on what I have done so far and talk about the present and future.