Objectives: Loss of smile and inability of eye closure are coexisting features of complete facial paralysis. Both reconstructions are commonly performed separately. In this study, we present an option of using one gracilis functioning free muscle transplantation for the simultaneous and combined reconstruction of smile and lagophthalmos.

Methods: A retrospective review was performed from an institutional database for facial paralysis. The gracilis for functioning free muscle transplantation was split into three portions, namely the upper gracilis was used for smile, the lower gracilis was used for eye closure, and the central gracilis was used for maintenance of vasculature. Intramuscular dissection of the obturator nerve was performed to create two motor neurotizers. The design was to adopt one muscle with two functioning free muscle transplantations for two functions, i.e., smile and eye closure.

Results: A total of five patients with unilaterally complete facial palsy, which resulted from acoustic neuroma resection, were enrolled. All patients had a follow-up of at least 1 year. The smile score improved from 0 (no tooth visible) up to 3+ (at least three teeth visible). The eye closure improved from 9-11 mm to 0-6 mm in interpalpebral distance.

Conclusions: Based on the technique of intramuscular nerve dissection and division, one gracilis functioning free muscle transplantation can be split into upper and lower gracilis for two functioning free muscle transplantations with the preservation of the central part of the vasculature. The surgical strategy proves that it is theoretically and clinically applicable for simultaneous and combined reconstruction of smile and eye closure with only one nutrient vessel anastomosis.

Level of Evidence: IV

Objectives: Fingertip injuries are common, and there are many techniques used for reconstruction. The authors reviewed the outcomes of fingertip reconstruction, including sensation and shape, using the combined technique of the adipofascial cross-finger flap and glabrous skin graft and defined the optimal dimensions of fingertip defect that is applicable to this technique.

Methods: Between 2006 and 2016, 10 cases, aged 3-60 years (mean, 28.1 years), who had undergone fingertip reconstruction using a combination of the adipofascial cross-finger flap and glabrous skin graft were reviewed. The presence of fingertip and nail deformity and the results of the Semmes-Weinstein monofilament and static two-point discrimination tests were analyzed.

Results: Fingertip deformity was noted in three cases where the defect was more than 50% of the Tamai zone I or extended to zone II. Mild nail plate deformity was found in three cases with more than 40% of the nail bed defect. Two of these three cases presented with partial phalangeal tuft defects. Eight fingers were examined using the Semmes-Weinstein test, and their scores were between 2.83 and 4.31 in five fingers and 4.56 in three fingers. Six were examined for static two-point discrimination, with 5 mm in three, 6 mm in one, and 10 mm in two. The color and contour of all donor fingers were almost typical.

Conclusions: The combination of the adipofascial cross-finger flap and full-thickness glabrous skin graft is applicable to around 50% of fingertip defect within the Tamai zone I, achieving a satisfactory shape and regaining more than protective sensation.

In some cases of free flap transfer, two comitant veins must be anastomosed to a single suitable recipient vein to avoid congestion due to the lack of network between the two comitant veins. In this situation, both veins are mostly anastomosed to the recipient vein in an end-to-side fashion. However, the distal end of the recipient vein sometimes has to be cut to reach the comitant veins that are short in length. In such cases, we anastomose both of the comitant veins to a single recipient vein in an end-to-end fashion with a twin tower shape. The twin tower-shaped anastomosis technique involves two comitant veins in parallel anastomosed to a single recipient vein in an end-to-end fashion, and the gap of the two comitant veins is closed directly via an interrupted suture method. With this technique, two comitant veins and the recipient vein can be successfully anastomosed in an end-to-end fashion.

Scrotal defects requiring reconstruction may occur after trauma, cancer, or infection. To maintain good testicular function, the ideal scrotal temperature should be slightly lower than the abdominal temperature. However, large local flaps that are enough to cover the testes cannot be used in all patients. A 74-year-old man presented with scrotal and perineal tissue defects after undergoing debridement for Fournier's gangrene due to rectal carcinoma-induced perforation. The scrotal skin defect was reconstructed using a 22 × 10-cm-free ulnar forearm flap. The postoperative course was uneventful, and at the 14-month follow-up examination, the scrotal skin was found to be thin and pliable. Moreover, the donor site on the left forearm was in an acceptable state and no hand dysfunction due to contracture was observed. Based on our observations, we recommend that the free ulnar forearm flap might be an effective option for scrotal reconstruction, causing little donor site morbidity.

Supermicrosurgery, a technique involving the dissection and anastomosis of small vessels, has revolutionized the field of lymphedema treatment. However, in a lymphatic venous anastomosis, an arduous technique is required to manipulate the 0.1-0.8-mm lymphatic channels, whereas conventional microsurgery deals with 0.8-2.0-mm vessels. Although several practice models in lymph supermicrosurgery are available, the upgradation of lymph supermicrosurgical skills in human lymphatic venous anastomosis has not been reported. In this study, we suggest the efficacy steps of the lymph supermicrosurgical technique for surgeons who are not accustomed to microsurgery. After acquiring 1 year of experience in lymph microsurgery, using the line production system and intravascular stenting method, the author along with experienced supermicrosurgeons concludes that accurate anastomosis of the small lymph channel is possible in a safe and rapid manner. In this study, tips for lymphatic venous anastomosis are described in the text and video.