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Four successful cases of expanded free latissimus dorsi myocutaneous flaps are reported. Expansion of free latissimus dorsi flaps has 2 distinct advantages: moulding of the flap prior to its transfer to a convex surface (cranium); primary closure of the donor site. The latissimus dorsi myocutaneous flap seems to be the flap of choice for pre-transfer expansion.

Since 1978 (Lauritzen), several experimental and clinical procedures of end-in-end vascular microanastomosis have been described, including that proposed by Wang (1986) in which the tubulisation is accompanied by a counter-incision of the recipient vessel. Our experimental study was designed to assess the reliability of this procedure, to quantify it in relation to the diameter of the artery and direction of flow and to verify the existence of absence of any particular intraluminal histological phenomena. 42 Wistar rats were operated under general anaesthesia. 42 microanastomoses were performed: 15 carotid and 15 femoral in the direction of arterial blood flow, and 15 carotid anastomoses in the opposite direction to flow. The 15 carotid anastomoses performed in the direction of flow were all patent at each of the postoperative examinations (D0, D + 15, D + 90). Patency decreased in the anastomoses performed in the opposite direction to blood flow (10 out of 15 carotid anastomoses were patent) and as a function of the arterial diamenter (5 out of 12 femoral anastomoses were patent). Horizontal and transverse histological sections performed on the 15th and 90th days demonstrated continuity of the intimal endothelial lining and thickening of the adventitia of the two internalised and recipient walls in every case. In practice, although this experimental study demonstrates the clinical reliability of this internalised microanastomosis procedure in rat carotid arteries, the other results and the anatomo-clinical discrepancy do not justify its clinical use in all circumstances, particularly in the opposite direction to blood flow and in arteries with a diameter less than or equal to 1 mm.

The authors present the use of semi-free parascapular flap for coverage of defects on the distal part of the leg and the foot. 3 cases illustrate this technic. This is a microsurgical cross-leg flap. The flap is temporarily anastomosed on vessels on the opposite leg when local and free flaps are not suitable on the ipsilateral limb. This procedure needs one or two separating operations. The cross-leg fasciocutaneous flap must be discussed.

The purpose of this study is to demonstrate the development of angiogenesis spreading from a vascular pedicle stretched by an expander, and to determine its potential to supply blood to an adjacent skin area. In the pig model (9 animals), we inserted an expander under the saphenous vessels after interrupting all the connections between the pedicle and the related inguinal skin. The opposite side was used as a control with a non-expanded silicone sheet, 1 mm (2 animals) and 3 mm (7 animals) thick. After 6 weeks of expansion, vascular island skin flaps were elevated on the saphenous vessels. 6 out of 7 expanded flaps were totally successful. Of the 5 flaps elevated above the 3 mm silicone sheet, 1 flap was successful and 4 partially failed. The 2 flaps elevated above the 1 mm silicone sheet failed. An anatomical arteriovenous pedicle stretched by an expander can supply a skin area located distal to it. Angiogenesis also occurs in contact with a thick silicone sheet but the blood supply of the skin is less effective. The newly formed vascular network is visualized on the angiograms.

The authors present the use of a free latissimus dorsi myocutaneous flap for closure of large orbital exenterations. Five cases illustrate different tumor involvements and coverage possibilities. Several technical details are studied. The vascular anastomoses are performed on cervical vessels: external carotid artery internal jugular vein. The latissimus dorsi myocutaneous flap is particularly suited for reconstruction of large facial soft tissue defects around the orbit when obliteration of the orbital cavity and restoration of deficient facial skin are necessary with correct morphological results.

The authors have studied 48 chinese forearm free flaps operated since 1982 at St-Louis, Hospital Paris. Analysis of early complications and failures shows that the few problems that occurred seem to involve hemodynamics more than technical problems. The results support the hemodynamic theory about radial forearm free flaps: low-flow flap which contrasts with the wide diameter of the radial artery. This kind of free flap may not support interpositional vein graft for arterial bridging (stasis, distension of the graft then thrombosis), which must be taken into account in the operating procedure. When the radial artery needs to be lengthened, we therefore systematically reduce the risk of thrombosis by re-establishing radial artery outflow for safety: either by distal radial artery anastomosis, or with an arteriovenous shunt.

Over a period of ten years the authors have performed 176 elective free tissue transfers. Flaps used were 99 latissimus dorsi, 46 chinese forearm flaps, 12 fibula, 6 toes, 5 omentum, 4 parascapular, and 4 others flaps. Recipient sites were lower limbs in 106 cases, head and neck in 50 cases, forearm and hand in 13 cases, thorax, abdomen, and buttocks in 7 cases. The overall failure rate was 5.7 per cent. Analysis of these failures taught us some original principles. Among these principles, the risk of vascular thrombosis is very important when a venous graft is performed on one end of the artery of a low blood flow flap such as chinese forearm or fibular flaps when the other end of this artery is ligated. When such a graft is done we think that the best way to avoid thrombosis is to suture the other end of the flap artery to a recipient vessel which can be even the distal end of the flap vein itself. Pretransfer expansion of a latissimus dorsi flap was successfully performed in 4 cases. Migrating semi-free flap method, in which the vascular pedicle of a flap is temporarily sutured to recipient vessels located far from the defect, was performed in 12 cases, in most cases on lower limbs where this method constitutes a modern variant of the cross-leg. Folded free-flap method, in which a flap is folded on itself during some days before excision of the recipient site, was performed in 14 cases. Analysis of this series also allowed us to review in detail our usual strategic principles for vascular anastomoses in the head and lower limbs.

The authors report a case of double island forearm flap for a double defect on the inferior part of the leg. The chinese flap is the only flap which has a segmental and staged vascularisation allowing multiple island skin flaps to be performed separated only by the vascular pedicle.