In 2012, we reported on the clinical observation method following 544 free flap transfers for head and neck reconstruction. After 10 years, we reviewed the postoperative outcomes using the similar monitoring approach. The success rates of free flap transfer were 97.8% for 495 head and neck defects and 80.8% for 26 lower extremities defects. Compromised flaps were observed in 21 patients. Flap color change was identified as the first clinical sign of flap compromise in 14 out of 21 patients. Of the 14 head and neck cases, emergency salvage surgeries were performed in six cases, and three flaps were salvaged. The other eight flaps were observed conservatively, however, all of them suffered total necrosis. In the five cases of lower extremity reconstruction with flap compromise, one patient underwent salvage surgery; however, the flap could not be salvaged. The other four flaps that did not undergo salvage surgery developed total necrosis. The flap salvage rate using the clinical observation method was comparable to previously reported rates. To further improve the salvage rate, it is essential to inspect the anastomosis site directly and perform salvage surgery promptly upon recognizing subtle and characteristic color changes in the flap.

　We evaluated the clinical outcomes of the microscopic lateral subperiosteal approach for subungual soft tissue tumors in seven patients. Symptom duration ranged from 6 months to 30 years (median 6 years) . Preoperatively, all patients presented with spontaneous pain and tenderness. Four had cold sensitivity, two had blue spots, and two had nail deformities. Ultrasonography and MRI detected subungual tumors in six cases. The surgical procedure was performed under a microscope from skin incision to closure. Dissection of the tumor was performed under maximum magnification. The tumor size ranged from 0.8 to 6.5 mm. The histopathological diagnoses were glomus tumor for six cases and angioleiomyoma for one case. The postoperative follow-up period ranged from 1 to 5 years (median 2 years) . At the final follow-up, all patients had no tenderness. No recurrence of the tumor was observed, and no new nail deformities occurred during follow-up. Our findings suggest that this technique is a minimally invasive and effective treatment option for small subungual soft tissue tumors.

　Perforator and musculocutaneous flaps are reliable options for the successful reconstruction of back defects. We present three cases of successful dorsal intercostal artery perforator (DICAP) flap coverage for back defects after sarcoma resection. This study included two women and one man, with ages ranging from 62 to 69 years (mean: 65 years) . Four DICAP flaps were elevated using the dorsal branch of the posterior intercostal artery. The flap size ranged from 15×8 to 30×11 (mean: 23.8×9.8) cm. No flap loss was observed. When the skin defect is localized to mid-back, the DICAP flap is minimally invasive because of the short distance between the vascular pedicles and the skin defect. DICAP coverage is especially useful for patients with recurrent tumors who have previously undergone latissimus dorsi flap coverage. Based on these advantages, the DICAP flap should be considered as a viable option for the repair of back defects.

　Cranial reconstruction ranges from skin-only reconstruction to reconstruction of skin-soft tissue and bone complexes. Reconstruction goals include protection of brain tissue, prevention of lethal complications, and cosmetic appearance. We retrospectively reviewed the functional and cosmetic results of our two-stage reconstruction cases using free vascularized tissue grafts and artificial bone substitutes for extensive cranial and skin defects due to infection after post-craniotomy cranioplasty. We enrolled three patients, ranging in age from 37 to 79 years. The patients underwent hard tissue reconstruction with artificial bone substitutes after a certain period following debridement of infected tissue and free anterolateral thigh flap transfer between May 2017 and May 2022. All patients had no postoperative complications such as infection and sinking skin flap syndrome. The hydroxyapatite implants used for hard tissue reconstruction have been reported as highly resistant to infection, and we found no infections in our reconstruction cases. From the previous studies and our own experiences, we believe that our two-stage reconstruction strategy is suitable for post-cranioplasty infection in terms of the low risk of infection recurrence, availability of well-tailored artificial bone substitutes, and possibly a better cosmetic result.

　We treated two patients with skin defects of the phalanges using folded venous flaps. The size of the skin defect was measured, and a skin flap half as wide and twice as long as the defect was designed as an A-V type venous flap. In Case 1, a 23-year-old man with fingertip amputation of his little finger, the flap was used to wrap the distal phalanx. In Case 2, a 62-year-old man with a radial skin defect of the distal phalanx of his middle finger, the defect was covered after osteosynthesis of the distal phalanx. Both cases were successful. The advantages of this technique include: the ability to secure both the inflow arterial and outflow venous vessels at the same site, similar to a free arterial flap; the narrow width of the skin flap stabilizes blood flow, facilitating closure on the donor side; and the skin flap can be harvested from the same operative field.

　Axillary nerve palsy is commonly associated with shoulder dislocations or fractures; however, cases of axillary nerve injury without these conditions have also been reported. Herein, we report a case of combined injuries of the axillary and suprascapular nerves due to a nondislocating rugby injury. A 21-year-old male was tackled on his left shoulder and experienced persistent limitations in shoulder elevation. Neurolysis of the subclavicular brachial plexus and nerve transfer were performed three months after the injury. The axillary nerve was damaged over a length of 10 cm and intraoperative nerve stimulation confirmed the absence of compound muscle action potentials in the deltoid muscle. Consequently, the radial nerve motor branch to the long head was transferred to the anterior branch of the axillary nerve. Thirty-one weeks post-surgery, the patient regained deltoid muscle strength (grade MMT5) and improved shoulder function, allowing him to return to playing rugby. A systematic review of axillary nerve injury suggested that there were not significant differences in functional outcomes between nerve grafts and nerve transfers; however, nerve transfer is simpler and faster, with no donor-site morbidity and quicker reinnervation. Nerve transfer may be considered a viable treatment option for axillary nerve injury resulting from nondislocating shoulder injuries in contact sports.

　In severe extremity trauma, selecting the recipient vessel for a free flap is critical. The popliteal artery is often chosen to avoid the zone of injury. In this study, we reviewed nine cases where the popliteal artery was used as the recipient vessel via a medial approach in the supine position. A medial midline incision from the distal thigh to the proximal leg in the supine position allowed adequate exposure of the popliteal artery, and anastomosis with the vascular pedicle of the flap. Compared to the common posterior approach in the prone position, this approach was more efficient because it did not require repositioning of the patient. Flap elevation and recipient vessel preparation could be performed simultaneously. Our findings suggest the effectiveness of the medial approach to the popliteal artery in the supine position.

　We report a case involving the pedicle of a previously transferred omental flap that was used as a recipient vessel in the microsurgical reconstruction of a right orbital sebaceous adenocarcinoma. A 65-year-old male with right maxillary sinus squamous cell carcinoma underwent extended total maxillectomy and anterolateral skull base reconstruction using a free rectus abdominis musculocutaneous flap after chemotherapy and radiation therapy. Postoperative cranial osteomyelitis developed and was treated with a free omental flap. Fifteen years later, he developed a right sebaceous carcinoma in the eyelid and underwent eyelid resection, oophorectomy, and a meshed skin graft. Three years later, local recurrence involving the skull base was observed. Because of the difficulty in reconstruction with a local flap, the defect was reconstructed using a free radial forearm flap. The pedicle of the omental flap was used for the recipient vessel because there was almost no scarring around the vessels, especially the veins. The postoperative course was uneventful.　Unlike the “Tsugiki” method, the pedicle of the previously transferred omental flap, especially its vein, showed almost no scarring. This suggests its usefulness as a recipient vessel for multiple free-flap transfers.