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A free vascularized rectus abdominis muscle graft with a long motor nerve was used for reconstruction of unilateral established facial paralysis in one stage. Regarding the procedure, the pedicle vessels were anastomosed to the recipient vessels in the ipsilateral face, and the motor nerve of the muscle was sutured to the contralateral facial nerve. The advantages of using the rectus abdominis muscle are as follows: (1) the muscle is very thin, not bulky, (2) the muscle can be split easily to reduce the volume, (3) the intercostal nerve is long enough (more than 20 cm) to reach the contralateral facial nerve for suturing, (4) the pedicle vessels are large and long, (5) it is possible to carry out simultaneous operations with two teams, and (6) the donor-site morbidity is minimal. The disadvantages of this method are that complicated surgical dissection is required to obtain a motor nerve and that a postoperative abdominal hernia may occur.

The free vascularized rectus femoris muscle graft with a long motor nerve was used for reconstruction of unilateral established facial paralysis in one stage. The pedicle vessels were anastomosed to the recipient vessels in the ipsilateral face, and the motor nerve of the muscle, which was led through the upper lip, was sutured to the contralateral facial nerve. The advantages of this one-stage reconstruction as compared with surgery involving second-stage reconstruction are that the reconstruction can be completed in one stage and that the period required for muscle refunctioning after surgery is short. The vascular supply of the rectus femoris muscle can emanate mainly from the lateral circumflex femoral artery. In our cadaveric study, five types of variation were found for origination of a nutrient artery of the muscle. The most common type was one in which the artery derived from the descending branch of the lateral circumflex femoral artery (39 percent). The motor nerve of the rectus femoris muscle is derived from the femoral nerve under the inguinal ligament and runs downward through the intermuscular space between the sartorius muscle and the iliopsoas muscle before entering the posteromedial part of the upper third of the rectus muscle. The advantages of using the rectus muscle are as follows: (1) safety and simplicity exist with one main large arterial supply for arterial anastomosis; (2) the length of the femoral nerve (more than 20 cm) is adequate for reaching the contralateral facial nerve for suturing; (3) a simultaneous operation by two teams is possible with the patient in the supine position; (4) the force and distance of contraction are appropriate to reanimate the face; (5) the rectus muscle can be separated as a segment with appropriate lengths, size, and power for replacing lost muscles in the face; (6) the tendinous fascia in both ends provides a reliable point for anchoring sutures, which provides firmer attachment; and (7) no loss of donor leg function occurs.

Use of the posterior tibial flap pedicled on the posterior tibial vessels has been described by several authors, but with it there is the major disadvantage of an unavoidable transection of the posterior tibial artery. To overcome this disadvantage, we anatomically studied the perforators from the posterior tibial artery and used posterior tibial perforator-based flaps clinically. Based on our anatomic study of 25 cadaveric legs, the cutaneous perforators were considered to be distributed from the distal to the proximal sides of the lower leg through the medial border of the tibia, and they were classified into three types: septocutaneous perforators mainly located in the distal third of the leg, muscle perforators located in the proximal half, and periosteal perforators in the proximal third of the leg. The average size and number of perforators was 0.8 mm and 3.1 in one leg, respectively. A considerable number were located at sites from 70 to 140 mm superior to the medial malleolus. Based on our clinical cases repaired with flaps, we consider this flap to be useful as a free flap for the repair of defects of the extremities and as an island flap for reconstruction of defects on the anteromedial aspect of the lower leg. The territory of the flap is relatively wide, being 19 x 13 cm. The long saphenous vein can be used safely as the venous drainage system in the case of free-flap transfer.

An island connected "Siamese" deep femoral and gluteal perforator-based flap with double vascular pedicles, the perforators from the deep femoral and superior gluteal arteries, was transferred successfully to repair an extensively large posterior thigh defect in an 84-year-old man. For reconstruction of large, massive defects of the posterior thigh region, this connected "Siamese" flap has the following advantages: (1) the flap and the pedicles are nearest to the defect, (2) the skin territory of the flap is extremely long, (3) the flap elevation is easy, because there are several perforators that can be considered as pedicle candidates in both the deep femoral and the gluteal perforator-based flaps, (4) there is no necessity for positional change to elevate the flap, and (5) no sacrifice of muscles implies little postoperative functional limitation of the donor leg.

A triple combined anterolateral thigh flap, anteromedial thigh flap, and vascularized iliac bone graft was used for reconstruction of a full-thickness defect of the mental region after wide resection of advanced tongue cancer. The distal end of the pedicle vessels of these double skin flaps, i.e., the lateral circumflex femoral system, was directly anastomosed in tandem to the pedicle of the iliac bone graft, which was enveloped by these flaps. The advantages of this iliac osteocutaneous flap are as follows: It can be transferred within a shorter surgical time because the flaps can be obtained in the supine position simultaneously with tumor resectioning; and its skin components can be separated from the bone because each component has its own pedicle vessels, has a longer vascular pedicle (10 cm), and has a thicker crest of the bone graft. This flap is believed to be suitable for reconstruction of large full-thickness defects in various sizes of the mandibular and maxillary regions of the face.

Free transfers of the distal parts of the second toe for reconstruction of distal phalangeal losses of the fingers were successfully carried out. This method is believed to be the best for functional and cosmetic reasons, but major postoperative vascular problems exist. To overcome these problems, multiple vascular anastomoses were employed at operation. The indications for this method are limited in Japanese patients, and its use depends on the patient's age, sex, religious beliefs and the shape of the second toe.

Fibrin glue was clinically applied to the excised wound in 10 extensively burned patients, and its haemostatic and fixation effects on the isolated skin transplants were investigated. The following advantages resulted from the application of the fibrin glue: The haemostatic procedures and fixation of the isolated skin transplants were simplified. The quick and efficient haemostatic procedures considerably reduced the blood transfusion volume during and after the surgical procedures, by achieving a notable reduction in blood loss. Based on the above merits, the operation time was reduced and, eventually, the surgical stress might be alleviated. Satisfactory haemostatic effects were attained particularly in the limbs without supplemental haemostatic aids, leading us to conclude that the application of fibrin glue to the excised wound in burns is very useful.

Fibrin glue was clinically applied to the excised wound in 10 extensively burned patients, and its haemostatic and fixation effects on the isolated skin transplants were investigated. The following advantages resulted from the application of the fibrin glue: The haemostatic procedures and fixation of the isolated skin transplants were simplified. The quick and efficient haemostatic procedures considerably reduced the blood transfusion volume during and after the surgical procedures, by achieving a notable reduction in blood loss. Based on the above merits, the operation time was reduced and, eventually, the surgical stress might be alleviated. Satisfactory haemostatic effects were attained particularly in the limbs without supplemental haemostatic aids, leading us to conclude that the application of fibrin glue to the excised wound in burns is very useful.