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Composite tissue allotransplantation (CTA) is a new concept in reconstructive surgery to improve major physical defects with no current solution. Although not a life-saving procedure, tissue replacement by CTA offers great potential for improving quality of life but relies on lifelong immunotherapy. This new practice has become achievable with the refinement of microsurgical techniques, with experience gained from limb and scalp replantations, with the development of organ transplantation and the release of new immunosuppressive drugs. Experimental and clinical research made it possible. The first human cases of CTA proved the reality and the feasibility of the concept. While the early functional results of these allografts are encouraging, they will need to be assessed in the long-term, and development of less toxic - more efficient immonu-suppressive drugs will be a permanent requisite to the broadening of CTA. Although long-term outcome and potential adverse effects of chronic immunosuppression remain uncertain, as for organ transplantation, CTA is already a potential solution for some highly selected patients carrying physical disabilities such as large facial defects and bilateral hand amputation.

One century, after Carrel in 1906, technics of vascular surgery are the same. After two world wars, peace surgery has been improved by war surgery. Microscopy surgery gave a new way for vascular surgery which became microsurgery with specific instrumentation. We have move from the developing period of microsurgery in the 1970s, to the fully matured period of microsurgery in the 1980s and the the development of clinical free flaps. The 1990s must be the turning point from autogenous tissue transplantation to allogenic transplantation. Ethic comity keeps keys of future! About microvascular anastomoses, many instrumental technics are explored but no-one is better than the classic manual suture. For us, the best instrumental technic is the anastomose with titanium clips VCS((R)) but we only use it in good situation without difficulties.

A systematic and theoretic review is performed on the vascularised bone donor sites that may be useful in the case of hemifacial microsomia. A review of the literature reveals that the iliac crest and the scapula are the most commonly used vascularised bone grafts. A case study is included in the paper, showing an hemifacial microsomia reconstruction using a composite fibular vascularised bone graft. They highlight the criterias they think fundamental for choosing the vascularised bone graft donor site regarding the aims of the reconstruction of a Pruzansky grade II or III.

One century, after Carrel in 1906, technics of vascular surgery are the same. After two world wars, peace surgery has been improved by war surgery. Microscopy surgery gave a new way for vascular surgery which became microsurgery with specific instrumentation. We have move from the developing period of microsurgery in the 1970s, to the fully matured period of microsurgery in the 1980s and the the development of clinical free flaps. The 1990s must be the turning point from autogenous tissue transplantation to allogenic transplantation. Ethic comity keeps keys of future! About microvascular anastomoses, many instrumental technics are explored but no-one is better than the classic manual suture. For us, the best instrumental technic is the anastomose with titanium clips VCS((R)) but we only use it in good situation without difficulties.

A systematic and theoretic review is performed on the vascularised bone donor sites that may be useful in the case of hemifacial microsomia. A review of the literature reveals that the iliac crest and the scapula are the most commonly used vascularised bone grafts. A case study is included in the paper, showing an hemifacial microsomia reconstruction using a composite fibular vascularised bone graft. They highlight the criterias they think fundamental for choosing the vascularised bone graft donor site regarding the aims of the reconstruction of a Pruzansky grade II or III.

The microsurgical story of the fibula began 25 years ago. The author reports on the vascular anatomy of the fibular free flaps, particularly the osseous, cutaneous and muscular branches of the fibular artery and their variations. This surgical anatomy explains the various osseous and composite flaps that can be harvested on the fibular vessels. The fibular flaps harvested on the anterior tibial vessels are used less often. The surgical procedure is explained about the typical osteocutaneous peroneal flap and the many other variations. The indications and results are discussed according to the international literature and the author's experience: 42 mandibular, 12 tibial, ten femoral, three radial, two humeral and one nasomaxillary reconstructions. The aetiological and topographical particularities, various abilities of the fibular donor site, preoperative strategy, bone implantation and contention, vascular anastomosis and delays of consolidation are analysed for each recipient site. The advantages and disadvantages of these fibular flaps are then discussed. Finally, the present and future associated procedures are evoked.

From October 1995 through March 1997, we performed 30 microsurgical reconstructions and achieved microvascular anastomoses in 16 with an automatic stapler (VCS) which allows insertion of titanium clips in the everted vessel walls. The mean age of the patients (15 men, 1 woman) was 42 years. Mean vessel diameter of the donor and recipient sites was 2 mm for the arteries and 3 mm for the veins. Recipient vessels had suffered radiation damage in 3 cases. Micro-anastomoses were performed in 26 cases, with end-to-end sutures in 24 and end-to side sutures in 2. There were 11 arterial procedures including 3 bypasses and 15 venous procedures with 1 bypass. Peroperative thrombosis occurred in 2 cases and were treated by undoing the anastomoses and resuturing manually. There were no early or late postoperative vascular complications. This clinical experience confirms the advantages of this mechanical approach to microanastomotic procedures for small vessels as previously demonstrated in experimental work: a system avoiding transfixation, rapid procedure, reliability.

Projectile trauma of the lower face causes major functional damage and disfigurement. Reconstruction with tissue flaps, after microsurgical revascularization to guarantee tissue vitality, can restore satisfactory mental function. We report 26 mental reconstructions, including 20 using free fibular flaps which, due to its vascular pedicle and length of the available bone, appears to be the best adapted for reconstruction of the lower face. When used with cutaneo-aponevrotic flaps, only one operation is needed.

After a brief review of definitions and semantics, the author recalls the state of the art before 1984 concerning arterial and venous cutaneous blood supply. Studies and concepts published since 1984 include those of Nakajima, who distinguished six types of cutaneous arteries, Gumener, who emphasized the vascular entity represented by the subcutaneous connective tissue, and Taylor. This author, after many studies on the whole body, defined forty arterial and venous cutaneous territories, border-arteries and veins oscillating at the borders of these territories, as well as a number of neurovascular entities (neurocutaneous arteries and veins). In terms of haemodynamics, the concepts of anatomical, haemodynamic and potential arterial cutaneous territories, the concepts of arteriosome and venotome and the concept of low venous pressure zones are analysed. These anatomical and concepts haemodynamic are the basis for the feasibility and reliability of the various cutaneous, musculocutaneous and fasciocutaneous flaps. A number of classifications for these various flaps have been proposed since 1984: a theoretical classification (Kunert's), classifications according to vascular systematization, including Nakajima's classification, and many others. The author proposes a practical classification which should allow a better understanding and better national and international exchange. In parallel, the design and indications of various types of flaps have also advanced since 1984. Skin flaps without a systematized blood supply do not correspond to random flaps. Musculocutaneous flaps have advanced in three directions: partial muscular harvesting when the objective of the flap is essentially cover, an increase of the skin flap surface area; substitution, in certain anatomical regions, of the concept of fasciocutaneous flap for that of musculocutaneous flap, particularly in thoracolumbar and anterior thoracic regions. The author notes the progress in fasciocutaneous flaps: distal pedicle leg flaps, development of decreased cutaneous morbidity resulting in fasciosubcutaneous flaps and proximal or distal fascial (or fascio-adipose) pedicle fasciocutaneous island flaps, progress of normal flow or reverse flow island septocutaneous flaps on the main vessels of the limbs towards to similar types of island flaps on secondary vessels, especially in peri-articular sites. The other clinical concepts analysed include grafted fascial flaps, grafted adipose and fascioadipose flaps, neurocutaneous flaps, "tailormade" flaps and chimeric flaps. This progress in vascular and clinical concepts of skin cover flaps over the last ten years is illustrated by many examples of skin cover, particularly involving the posterior aspect of the heel.

The retrospective analysis of 56 mandibular defects, 28 of which were reconstructed by free revascularised bone flaps, and the difficulties of their reconstruction led the authors to propose a new anatomosurgical bony classification of mandibular defects. This classification, a theoretical transcription of traumatic and oncological realities, distinguishes more or less extensive anterior defects (Aa and Ab), lateral defects (La), lateroterminal defects (Lb) and defects exceeding the hemimandible (T). These bony imperatives, either alone or associated with skin lesions, depending on the traumatic or neoplastic aetiology, influence the indication for microsurgical reconstruction and the choice of particular bone and integument combined or composite flaps. The authors have deliberately adopted the option of one-stage multiple tissue reconstruction by the same composite flap and propose a justification for this microsurgical choice based on the proposed classification as well as the the theoretical and practical advantages and disadvantages of the various composite free revascularised bone flaps. Two donor sites appear to be particularly suitable: iliac and fibular.

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.

Although revascularized fibula bone transfers have been used in reconstructive surgery of long bones for about fifteen years, the first reported cases of mandibular reconstruction were only published in 1989 by Hidalgo. The mandible and the fibula actually have very few points in common apart from their respective length and a certain similarity of cross-section. However, free composite flaps including the fibula are adapted to reconstruction of the mandible for several reasons: the length of the bone which can be raised (25 cm) and osteotomized into several fragments; the addition of other components (skin, aponeurosis, muscle, etc.) for skin and/or mucosal repair; the spatial independence of these various elements; the microsurgical qualities of the peroneal artery. This possibility of multidirectional and multiple tissue bony mandibular reconstruction is analysed on the basis of 9 clinical cases: 5 cases of traumatic sequelae of the lower third of the face following gunshot injuries, 2 cases of radiation osteonecrosis, 2 benign bone diseases. The triple bone, integument and vascular adaptation between the fibular donor site and the recipient site must be assessed preoperatively. Due to the quality of the morphological and functional results compared with the limitations of other free composite bone transplants, the authors propose free composite fibular flaps as adapted and adaptable solutions for one-stage reconstruction of extensive mandibular defects (10 cm) associated with small or large mucocutaneous lesions.