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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.

The author is neither anthropologist nor invested in social activities. He has learned some reviews of anthropology and some social and philosophical books since seven years. He describe not a general review but an analysis of these lectures according to the composite tissues allotransplantations (CTA). The discussion concerns anthropology and symbols, philosophical and social aspects. There is a natural umbilicus between the anthropological science and the surgical art according to CTA.

Resume La Societe francaise de chirurgie plastique reconstructrice et esthetique (SOF.CPRE) est nee le 3 decembre 1952. Initialement labellisee sans le mot esthetique, elle a accepte celui-ci en 1983 et les « logos » ont evolue au fil du temps : SFCPR, SFCPRE, SOF.CPRE. Son organe officiel d'expression a aussi evolue au cours du temps et des hommes : tributaire des Annales de chirurgie en 1954 et 1955, revue autonome Annales de chirurgie plastique en 1956, devenue Annales de chirurgie plastique et esthetique en 1983 puis Annales de chirurgie plastique esthetique (ACPE) en 1992. Depuis l'origine, cinq redacteurs en chef des « Annales » se sont succede : Claude Dufourmentel, Raymond Vilain, Jean-Pierre Lalardrie, Claude Le-Quang, Jean-Luc Cariou. Quatre d'entre eux sont encore vivants a ce jour. L'auteur, par connaissance et interviews, retrace ici l'histoire naturelle de ces cinq redacteurs en chef des ACPE qui ont tous eu un triple parcours : personnel, chirurgical et editorial.

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.

Resume Depuis 1975, le lambeau libre de perone n'a cesse d'evoluer et il represente actuellement pour nous le lambeau de choix en reconstruction mandibulaire, mais certaines circonstances postoperatoires rendent difficile ou impossible la surveillance de la vitalite osseuse. Par ailleurs, la vascularisation osseuse peut etre apprehendee par l'imagerie par resonance magnetique (IRM) dynamique, cela ayant ete valide experimentalement et chez l'homme dans le diagnostic precoce de l'osteonecrose. L'objet de cette etude etait de valider la surveillance postoperatoire des lambeaux libres osseux fibulaires en reconstruction mandibulaire chez l'homme par IRM dynamique. L'IRM dynamique, avec injection de gadolinium, consiste a etudier la variation de prise de contraste en fonction du temps au niveau du canal centromedullaire du transplant osseux fibulaire. Cette variation d'intensite de signal est materialisee sous la forme d'une courbe, veritable courbe de perfusion de la region centromedullaire. Cet examen a ete realise chez trois patients a des dates et dans des circonstances differentes. Il a permis dans un cas de confirmer le caractere vascularise du transplant de perone malgre la necrose de la palette fasciograisseuse adjointe. Sont exposees les difficultes de methodologie, notamment dans l'exploitation des donnees par l'outil informatique, et compares nos resultats avec ceux de la litterature. L'IRM dynamique est un examen simple, fiable, non invasif et son utilisation dans la surveillance postoperatoire des lambeaux libres osseux en chirurgie reconstructrice parait tres seduisante, permettant de confirmer le caractere vascularise ou non du transplant osseux.

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 author proves conclusions of that report on composite tissues allotransplantation (CTA). Cadaveric, functionnal and surgical anatomy has allowed the progress of reconstructive surgery since 30 years. It is an inventive, but always altruistic and emotional, reconstructive surgery which has allowed the progressiveness and expansion of CTA which is no more illusion but reality. The indications are and will remain exceptional. CTA's expansion remain dependent on progress of immunosuppressive drugs, and the actual research is turning towards immunologic allowance, induced chimerism and genetic mosaicism. In French, CTA is also Ethics and it is the only one case in the world, according to the lawful activity of the Ethics' advisory board.

The author proves conclusions of that report on composite tissues allotransplantation (CTA). Cadaveric, functionnal and surgical anatomy has allowed the progress of reconstructive surgery since 30 years. It is an inventive, but always altruistic and emotional, reconstructive surgery which has allowed the progressiveness and expansion of CTA which is no more illusion but reality. The indications are and will remain exceptional. CTA's expansion remain dependent on progress of immunosuppressive drugs, and the actual research is turning towards immunologic allowance, induced chimerism and genetic mosaicism. In French, CTA is also Ethics and it is the only one case in the world, according to the lawful activity of the Ethics' advisory board.

The author is neither anthropologist nor invested in social activities. He has learned some reviews of anthropology and some social and philosophical books since seven years. He describe not a general review but an analysis of these lectures according to the composite tissues allotransplantations (CTA). The discussion concerns anthropology and symbols, philosophical and social aspects. There is a natural umbilicus between the anthropological science and the surgical art according to CTA.

The french Society of Plastic Reconstructive and Aesthetic Surgery (SOF.CPRE) is born December 3th 1952. Initially without "aesthetic", this "key-word" is agreed in 1983 and the symbols are advanced since: SFCPR, SFCPRE, SOF.CPRE. Its official organ, formerly included in Annales de chirurgie (1954-1955), become Annales de chirurgie plastique in 1956, Annales de chirurgie plastique et esthétique in 1983 and finally Annales de chirurgie plastique esthétique (ACPE) in 1992. Since the origin, five Editors-in-chief succeded: Claude Dufourmentel, Raymond Vilain, Jean-Pierre Lalardrie, Claude Lê-Quang, Jean-Luc Cariou. Four of them are alive, Raymond Vilain is dead. The author relate here the natural story of these five editors who had all a triple route: personnal, surgical and editorial.

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.

The vascularized free fibular graft has been used in mandibular reconstructive surgery since 1975. This technique has been progressively developed, and it is now the procedure of choice for mandibular reconstruction although in certain postoperative circumstances it can be difficult if not impossible to monitor bone vitality. However, bone vascularization can be detected by dynamic magnetic resonance imaging (MRI), as this technique has been experimentally and clinically validated in the early diagnosis of osteonecrosis. The aim of this study was to evaluate the efficacy of MRI for the postoperative monitoring of vascularized free fibular grafts in human mandibular reconstruction. Dynamic contrast-enhanced MRI was used to study the variation in contrast over time following injection of gadolinium contrast medium, and to evaluate the degree of bone marrow perfusion of the fibular graft. This variation in signal intensity was visualized in the form of a curve, i.e., a perfusion curve for the bone marrow region. An examination was performed in three patients at different postoperative times and under different conditions. In one case, MRI confirmed the presence of fibula blood supply in spite of the necrosis of the adjacent fascio-adipose layer. In this article, the methodological difficulties have been discussed, particularly as regards data processing, and the present results have been compared with the findings in the literature. Dynamic MRI is a simple, reliable, non-invasive technique and its use in the postoperative monitoring of bone marrow perfusion and vascularized free fibular grafts permits a determination of the status of the latter following surgery, i.e., whether there is an adequate blood supply or not.

After a summary of the embryology and anatomy of the arterial blood supply of the face, the authors present the descriptive anatomy of the facial artery and its eight most frequent branches. Variations of the origin, course and division of the artery are then described. The literature contains 3 to 5 different descriptions of the course of the artery. The authors considered 4 of these descriptions to be relevant: I (angular), II (nasal), III (superior labial), IV (hypoplastic). Seventeen different branches have been described, many of which are inconstant. The superficial and deep anastomotic network is described, with emphasis on the subdermal network and that of the transverse facial artery. The various vascular regions of the face, first described by Mitz and Whetzel, are described. Based on these observations, and on Lasjaunias'theory of the triple hemodynamic balance, the authors propose a functional analysis of the arterial blood supply of the face. According to this analysis, the anatomic variations observed are determined by regional hemodynamic balances. These observations influence the design and creation of certain local facial flaps, such as the submental, nasolabial and buccinator flap. They may also influence present concepts concerning the hemodynamics of arteriovenous malformations of the face.

Until the beginning of the 1980s, reconstruction of major post-traumatic diaphyseal bone loss as an alternative to amputation was possible only by massive autologous bone grafts. Such a technique was limited by the amount of available bone required for grafting. Ilizarov explained the distraction osteogenesis principle and designed a circular external fixation material that was suitable for compression-extension. He described the concept of segmental bone transfer, which allows bone regeneration to take place within the actual injured limb. Our present experience is based on the literature and the study of 12 cases. All patients presented with significant post-traumatic tibial bone loss ranging from 45 to 145 mm. In this article, we discuss the indications, benefits and risks of such a technique compared to classic methods. Mainly indicated in patients who have sustained significant bone loss, bone transfer is the method of choice for preserving bone stock and correcting limb discrepancy, although it does not reduce consolidation time. Moreover, circular external fixations are often poorly tolerated and may be replaced by unilateral devices that are easier to install.

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.

The authors report some general considerations concerning the bony anatomy and the bone blood flow. They describe the vascularization of the long bones involving arteries, veins, capillaries and lymphatic vessels. The double systemic and local control of the bone blood flow is evaluated. The local factors are numerous: autoregulation, nervous regulation as well as humoral, metabolic and cellular factors. Some surgical deductions are then discussed concerning osteosynthesis procedures and biomechanical properties of vascularized bone grafts.

One case of repeated incisional hernia is reported. This hernia was initially repaired but repeated infection occurred. This hernia was then successfully treated with a fasciocutaneous tensor fasciae latae island flap. The patient was reexamined two years after surgery and presented a functional abdominal wall. Other different reconstructive possibilities of regional myocutaneous flaps are described.

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.

A madreporic coral graft was used for orbital floor reconstruction following facial trauma. This report presents a multicentric study of 83 patients with a follow-up period of 15 to 24 months. The results of this study indicate no significant rejection or infection opposed to so many synthetic implants outcome. The radiological follow-up demonstrates a partially resorption of the implant within about 2 years and its replacements by new bone. Coral implant was used to correct enophthalmos or diplopia due to enlarged orbital dimensions. It was technically easy to insert and its anatomic shape does not require to be fashioned before use. Its inflexibility allows to bridge large bone defects and this implant should be considered as an attractive alternative to autogenous grafts, avoiding a second surgical site, in reconstructing orbital floor fractures.

The reconstruction of extensive femoral defects, particularly septic, by revascularized free fibula flap has become part of routine practice for many years. Following the demonstration of secondary stress fractures, splitting of the fibula into two vascularized barrels was proposed in 1987 to avoid this complication. The authors conducted an anatomical study on 100 dry bones in order to define the situation of the fibular foramen which is usually found at about 1.45 cm from the midpoint of the fibula. This foramen must be spared during the intermediate splitting osteotomy in order to obtain two bone barrels: one with a double centromedullary and periosteal blood supply which will be used like a contromedullary pin, and the other with only a periosteal blood supply, which will be used as a medial or lateral splint. The deductions concerning the preoperative strategy and splitting technique are explained as a function of the length of the defect. From 1989 to 1993, 6 male patients underwent extensive femoral reconstruction (average length of 9.8 cm). Four free revascularized transfers were performed, including one osteocutaneous flap. In two cases, the osteocutaneous transfer was a proximally based island pedicle flap. Apart from one patient who was subsequently amputated, five patients underwent a secondary autologous bone graft after an average of three months. Consolidation was achieved after a mean of 12.6 months. A secondary stress fracture was observed in one case. With a minimum follow-up of two years, all patients are able to walk with a mean shortening of 2 cm of the reconstructed limb and without any donor site sequelae.

In the light of previous studies, the authors conducted an anatomical study on 21 cadaveric dissections with injection in order to define the characteristics of the distally based fasciocutaneous flap of the posterior surface of the thigh, described for the first time in 1988 by Maruyama. This leaf-shaped flap extends from the popliteal region to the gluteal sulcus. It possesses an axial arterial network derived from the popliteal artery, reinforced by the perforating arteries derived from the vessel or the profunda femoris artery. The venous return is ensured by venae comitantes and the communicating saphenous vein. The flap raising technique is described. From 1991 to 1994, 3 patients were operated in order to cover a defect of the knee (1 case) and amputation stumps (2 cases). The postoperative course was uneventful and the results were considered to be stable and of excellent quality with a follow-up of 2 to 4 years.

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 authors propose an elaborate variant of the classical saphenous or lateral leg fascio-cutaneous flap with a proximal pedicle for the cover of post-traumatic skin defects of the knee. The original feature of this flap resides in the purely aponeurotic or adipo-fascial pedicle which increases the arc of rotation, while minimizing cutaneous sequelae of the donor site. Twenty four injected cadaveric dissections were used to define the neurovascular content of the lateral sural fascia: the lateral and medial superficial sural arteries and their territory of perfusion, accompanying veins and the short saphenous vein, as well as the lateral and medial sural cutaneous nerves. The technique of harvesting of the island flap is described. Nine patients were operated between 1991 and 1994, with an uncomplicated postoperative course in terms of flap vitality and donor site. The skin cover of the knee was considered to be of excellent quality, stable and sensitive, with a follow-up ranging from 6 months to 3 years four months.

This experimental study performed in rats examined the possible vascular extensions of a periprosthetic membrane neoflap with an axial vascular pedicle towards an adjacent cutaneous angiotome. 22 Wistar rats were operated. After tattooing the superficial iliac circumflex angiotome, the adjacent epigastric pedicle was expanded. After expansion and a two-month rest period, clinical and microangiographic studies were performed. In 50% of cases, the iliac island skin flap raised on the periprosthetic membrane created by the epigastric pedicle was considered to be viable. The microangiographic results were identical. The pathophysiological mechanism is analysed in the light of the literature.

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.

The fascia superficialis temporalis (FST), one of the planes of cranial cover, can be raised to form an axial pedicle flap or a vascular island flap on superficial temporal vessels. Its fibrovascular structure, the area able to be raised and the possible addition of other superficial tissues (scalp, forehead skin) and deep tissues (calvarial bone) mean that this flap can be used in surgery of the external and intracavitary facial contours and shapes. The authors report their experience of 35 facial reconstructions: 7 ear reconstructions, 5 suspensions of a paralysed labial commissure, 10 conjuctivo-palpebral revisions, repair of 5 subcutaneous defects, 3 haired resurfacings, 1 inferior labial, 1 cheela, 1 orbitomalar reconstruction, 1 malo-commissuro-labial repair, 1 prefabricated free flap. The donor site sequelae were considered to be negligible: 1 case of temporal anaesthesia with dysaesthesiae, 4 cases of band alopecia. The analysis of these 35 reconstructions reveals the quality of all cases of defect repair, especially palpebral; the ease and persistence of suspensions of the labial commissure; the value of FST as a conjunctival and buccal mucosal substitute; the density of the hair contribution. However, total or partial ear reconstruction using this technique constitutes a more limited indication.

Management of full thickness defects of cheek and lips area is a challenge with both aesthetic and functional aims. Many surgical procedures can be proposed. A composite island temporal flap gathering fascia superficialis temporalis, an heary portion and a beardless skin paddle is a very interesting alternative. Surgical procedure and results are explained, concerning a gun shot injury clinical case.

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.

A 19 year old girl presented with a dedifferentiated chondrosarcoma of maxilla. The recurring tumor, diagnosed initially from the provoked pain, appeared on the scan image as a heterogeneous mass containing numerous calcifications. Histology showed, within a well differentiated chondrosarcoma, an anaplastic sarcomatous zone of the malignant fibrous histiocytoma (MFH) type. This histologic appearance is consistent with a poorer clinical prognosis. Radical surgery of the 4th tumor recurrence was combined with maxillofacial prosthetic rehabilitation. This appears to be first reported case of a dedifferentiated chondrosarcoma of the MFH type located in the maxilla.

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.

This experimental study, conducted in the rat, assessed the influence the volume of expansion and time after expansion on the vascularised area of a periprosthetic membrane axial pedicle (epigastric) expanded island flap. 15 Wistar rats were operated on and divided into 3 series according to the expanded volume (20 cc, 40 cc) and the time (1, 2 months). The membrane vascularisation derived from the pedicle was study by microradiography based on geometric parameters. At equal times, the volume essentially increased the length of the pedicle and had little effect on the vascularised area. For equal expanded volumes, increasing latency time increased the length and especially the width of opacification derived from the pedicle. The periprosthetic membrane axial pedicle island flap is an experimental entity whose vascularised area, obtained after a certain amount of expansion, is influenced more by time than by the volume of expansion.

This study was designed to demonstrate that progressive inflation of an expansion prosthesis placed under the epigastric pedicle of the rat induced the formation of vascular connections between this vessel and the periprosthetic membrane. 17 Wistar rats were operated under general anaesthesia. The 7 cc prosthesis was implanted into the inguinal fold and the valve was placed in a dorsal position via limited incisions. 11 rats were studied, divided into 3 series: 3 control rats (non-inflated prosthesis), a series in which the prosthesis was inflated up to 20 cc (at a rate of 5 cc per week) and a series in which the fate of the capsular flap isolated as a vascular island flap in a prefabricated silicone block was studied. The assessment was threefold: clinical, microradiographic after injection of lipiodol into the epigastric artery and histological. The clinical and microradiographic studies demonstrated the reality of the blood supply of part of the periprosthetic membrane and its connections with the epigastric axial pedicle. This membrane surface, constituting a real biological flap prefabricated by expansion, corresponds to the peripedicular zone (2 x 1 cm). The viability of the island flaps was confirmed after 8, 14 and 21 days. Histological studies confirmed the hypervascularisation and richness of the collagen fibres as a result of expansion.

Clinical applications of fasciocutaneous peroneal island flaps are important. 25 patients with cutaneous or composite defects of the lower extremity have been investigated by preoperative Doppler flowmeter and angiography. This before and after reviewed study allow the authors to establish a clinically useful peroneal arterial map which particularly concern the number and distribution of the postero-lateral septocutaneous arteries. The false positive and negative results of these two examinations are presented and explain differences with anatomic findings. Two anatomic variations are revealed by arteriography and are important for the surgical procedure. The first is the inconstant "circumflex peroneal artery" (12 cases on 22) which is the uppermost posterolateral cutaneous vessel which arises from the posterior tibial artery. The second is the angiographic view of a proximal bifurcation of the peroneal artery (9 cases). Regarding these findings, the authors classify the indications of preoperative angiography: absolute, useful, useless according to each case.

A peroneal fasciocutaneous flap supplied by the peroneal septocutaneous vessels and raised from the lateral side of the lower leg was reported by Yoshimura in 1983. This flap which can be used as a proximally or distally pedicled or free flap is very useful for leg skin coverage. This flap has a great potential for skin cover and composite reconstruction of the lower limb due to its multiple structural facets (cutaneo-aponevrotic or composite flap), its possible extensions to other vascular territories and the variable geometry of its mode of transfer. 8 reconstructions have been performed. Their indications are described: 4 proximally pedicled flaps (3 with the fibula), 4 reverse-flow island flaps (1 with Soleus and Peroneus longus muscles). The authors stress the importance of preoperative assessment of the feasibility of a given flap which may be limited by post-traumatic, surgical or anatomic modifications. In particular, the uppermost septocutaneous artery which corresponds inconstantly to the "circumflex peroneal artery" can only be visualized by preoperative arteriography. This artery supplies a proximal peroneal flap which can be used as an island or a free flap. We have used this new variety as a free flap in 2 cases and were satisfied with the results. These various clinical applications without any significant complication or flap failure confirm the biological performance and the safe procedure of peroneal flaps.