In the reconstruction of skin and soft tissue defects caused by tumor excision and trauma, it can be difficult to decide whether to use a suture closing or a local flap.
Judgment should be based on the skin properties of the defect and the surrounding anatomical landmarks.
We have applied the unit principles for facial reconstruction with satisfactory results. These principles are also extremely beneficial for obtaining natural contour and symmetry in the face. It is important not only to understand the configuration of the unit for reconstruction, but also to select the most suitable donor site and reconstructive procedure, since these also affect the aesthetic results.

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Local skin flaps are useful for reconstruction of small-to-medium-sized cutaneous defects. Recent studies of the vascular anatomy of the skin have contributed to the invention of new flaps such as perforator flaps. However, conventional random pattern flaps (e.g., advancement flap, transposition flap, and Limberg flap) are still useful, especially in the face because of its rich vascular supply. Here, we describe how to use conventional random pattern flaps.

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For the treatment of skin defects after removal of facial tumors, we often use local flaps to preserve the three-dimensional structure of the face. For this purpose, we prefer to use oblique sigmoid subcutaneous island (OSS flaps) to obtain good aesthetic results. The facial skin defects of 11 patients with malignant skin tumors (including 6 cases of basal cell carcinoma, 1 squamous cell carcinoma, 2 Bowen's disease, and 2 solar keratosis) were reconstructed using OSS flaps. Two of the skin defects were located in the medial canthal region, 2 were in the nasal root, 5 were in the cheek, 1 was in the lateral canthal region and 1 was in the nasolabial fold. Good aesthetic results were obtained and maintained in all patients, without any signs of complications. Facial reconstruction with a local flap is superior to other methods based on two points : minimal resection of normal skin is required and curved surface reconstruction is feasible without damaging the three-dimensional structure of the face. The OSS flap was originally reported by Ono, et al. in 1993. Although it has been frequently used for defects less than 15mm after excision of small facial tumors, we have obtained good aesthetic results in patients with large defects using this technique. We conclude that reconstruction with an OSS flap is a superior technique for various sizes of facial skin defects.

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There are two main options for radiotherapy after keloidectomy : external radiotherapy (ERT) using electron-beam and high-dose-rate interstitial brachytherapy (HDR-ISBT).
In our institute, we determine the method according to the conditions of each keloid. We usually apply radiotherapy only for keloids on the anterior chest wall, shoulder, and pubic area. We apply radiotherapy for spontaneously formed keloids, recurrent keloids, and when the patient strongly wants radiotherapy. ERT is most suitable for flat areas with bone just beneath the surface and areas reconstructed with flaps or skin grafts. HDR-ISBT is suitable for keloids on curved surfaces, keloids that recur after radiotherapy, and when the patient prefers a shorter period of radiotherapy.
We treated 51 patients (64 keloids) with surgery and followed them for more than one year. Adjuvant radiotherapy was administered to 13 patients (19 keloids). The total dose of ERT was 15 Gy (3 fractions), and that of HDR-ISBT was 12 to 24 Gy (2 to 4 fractions). Only two of 19 keloids recurred after radiotherapy (10.5%), and in both cases, the patients had multiple spontaneously formed keloids and they were treated with only 12 Gy (2 fractions) of HDR-ISBT.
In conclusion, our study demonstrated the effectiveness of radiotherapy after keloidectomy.

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Keloids and hypertrophic scars are fibroproliferative disorders of the skin caused by abnormal wound healing and are characterized by chronic inflammation. Local risk factors for keloids and hypertrophic scars include 1. cyclical tension, 2. inadequate moist condition, 3. foreign body and allergic reaction, and 4. infection. It has been suggested that these factors cause persistence of inflammation. It is important for both the physician and patient to understand treatments for the reduction of mechanical forces and inflammation. In this paper, we discuss therapies for reduction of mechanical forces including 1. improvement of tension reduction sutures, 2. Z-plasty, 3. small wave incision, 4. core excision method, 5. reconstruction using flaps, and 6. stabilization using gel sheet or tape as therapies. We also discuss therapies for reduction of inflammation including 1. postoperative radiation therapy, 2. radiation monotherapy, 3. laser treatment, and 4. corticosteroid injection tips.

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The availability of reliable recipient vessels for free flap transfers in head and neck reconstruction may be limited in case of prior neck dissection or radiation therapy. To solve these problems, we use the internal mammary vessels as recipients for free omental flaps.
From 2001 to 2010, four patients who presented with pharyngocutaneous fistulas were treated with free omental flap and free jejunal flap transfer using the internal mammary vessels as recipient vessels. All free flaps took entirely.
The combined free omental flap and free jejunal flap transfer is a good option for patients with pharyngocutaneous fistula in whom previous surgery or radiation therapy has compromised local recipient vessels.

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