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An ideal flap for fingertip injuries should cover a significant loss of substance and avoid joint flexion to prevent later contracture and joint stiffness. In this study, the authors describe a modified homodigital island flap-the homodigital propeller flap-to better meet these requirements.An anatomical model of fingertip loss is used to analyze the advancement achieved without flexion of the finger. Twenty-four fresh-frozen fingers were dissected. Wires were inserted to maintain joints in extension. The skin paddle was similar in location to a homodigital island flap. The neurovascular bundle was dissected without exceeding the proximal interphalangeal joint and was released from the proximal half of the paddle. Then, the homodigital propeller flap was rotated 180 degrees to cover the defect. A mixture of India ink and barium sulfate was injected into the pedicle artery after the release of the proximal half of the flap from the neurovascular pedicle to assess residual flap vascularization. India ink highlights the residual subcutaneous vascularization network of the cutaneous paddle. A radiographic study of the flap was then performed to visualize the subcutaneous vascular network of the cutaneous paddle.The homodigital propeller flap achieved an average cutaneous advancement of 18 mm (range, 15 to 22 mm) and allowed full coverage of cutaneous defects for all fingers while maintaining the proximal interphalangeal joint in strict extension.The homodigital propeller flap is a refinement of the classic homodigital island flap. It allows efficient coverage of fingertip defects because of a large advancement without flexion of the finger, reducing the risk of stiffness.

The purpose of this study was to evaluate the results of the medial adipofascial flap (MAF) in infected tibia fractures reconstruction and to identify criteria for success or failure.Fifty-nine patients treated with a MAF were enrolled. Age, BMI, tobacco use and bone status were recorded. Early and late postoperative complications were assessed. Bone healing and flap success were systematically evaluated at 12 months.Tibia fractures were initially open in 48 cases (81%) and closed in 11 cases (19%). Infection was acute (30 days) in 9 cases (15%) and chronic in 50 (85%). Thirty-one patients (53%) experienced no early postoperative complications (30 days). There were 10 (17%) cases of necrosis of the skin graft, 2 (3%) cases of necrosis and 4 (7%) haematomas in the harvesting area, 7 (12%) cases of partial flap necrosis at its tip and 4 (7%) flap failures. None of the criteria was statistically correlated with the occurrence of a complication. At 12 months, 53 flaps (90%) were successful. Immediate skin graft were significantly correlated with flap success (P=0.05). Forty-six patients (78%) had complete bone healing documented by CT scan.The MAF provides a reliable alternative for lower leg reconstruction. Its major advantages are sparing of the major leg vessels, no donor site morbidity and relatively easy and rapid dissection.

Rib-sternal osteoradionecrosis is a rare but serious complication of chest radiotherapy. No consensus-based method of managing deep sternal wounds that develop after radiotherapy is available. Usually patients require long-term antibiotics. The surgical placement of a muscle, an omental flap, or a prosthesis is described. We report, in pictures, four successful omental flap placements. Between March 2015 and July 2018, four women with deep sternal wound injuries that developed after radiation therapy to treat breast cancer underwent rib-sternal reconstruction with omental flap placement. The first signs of infected radionecrosis developed 28.5 years after radiotherapy. Despite prolonged antibiotic treatment, surgery was necessary. The mean age at surgery was 76 years (range: 62–86 years). All necrotic tissue was excised and debridement was performed before the placement of a pedicled omental flap dissected along the transverse colon and raised through a subcutaneous tunnel. No skin graft or osteosynthesis was required. After surgery, lubricated bandages were applied daily, and antibiotics were prescribed for a few weeks. Complete healing was obtained after surgery without clinical complication. Our experience suggests that a pedicled omental flap is an affordable, simple, and very useful option for reconstructing deep rib-sternal wounds caused by radiation.

Dorsal digital soft tissue defects are considered among the most challenging to reconstruct. Numerous treatment options are proposed, including advancement flaps, antegrade, retrograde flow flaps, adipofascial flaps, and digital artery perforator flaps. However, the optimal treatment remains controversial. The concept of the "bridge principle," consisting of the indirect transfer of the flap to the defect area through a muscular bridge, has recently introduced by authors for medial canthal reconstruction. The aim of the study was to examine the feasibility of its application in digital reconstruction for dorsal defects and the development of a new flap. The utilization of the dorsal subcutaneous adipofascial digital or toe tissue as a "bridge" led to description and development of bridged digital artery perforator flaps as an alternative treatment of such defects.From November 2017 to September 2019, a series of 14 patients (mean age of 57.1 years) suffered from dorsal digital or toe soft tissue defects of different dimensions and sustained reconstruction with this new technique.Twelve digits and 2 toes have been concerned. The mean size of the defects was 1.3 × 1.1 cm. All flaps survived without a sign of venous congestion. No functional digital or toe problems were observed during the follow-up period (mean of 11.6 months). Minor wound dehiscence presented in 2 cases (2 of 14 [14.3%]) and a transient skin swelling around the flap in 1.A new concept was introduced to resolve a challenging problem. Initial outcomes are very encouraging. These flaps could be a valuable and reliable reconstructive option.

Introduction: In this study, we present a prospective series of medial triceps free flaps for ankle and foot complex defects coverage and discuss its numerous advantages. Materials and methods: Between January 2011 and December 2012, eight patients, two women and six men underwent medial triceps brachii (MTB) free flap procedure to cover defects localized at the ankle and foot in our department. Patient mean age was 37.3±15.2years at the time of surgery (range of 13-53years). Mean defect size to be covered was 21.8±9.9cm2. The bone was exposed at the level of the calcaneum in six cases, at the level of the forefoot in one case, and at the level of the lateral malleolus in one case. Special attention was accorded to intra-operative findings. Flap survival and complications on both the donor and recipient site were prospectively evaluated. Results: Mean MTB flap raising time was 51.3±6.0min. All the flaps survived and there was no partial flap necrosis. A skin graft was performed after a mean time of 11.8±2.1days post-operative. The mean follow-up was 18.1±3.8months. Complications at the donor site level included one hematoma and a case of hypertrophic scar. Complete healing of both the donor and recipient sites was achieved in all cases. Conclusions: MTB free flap appears to be a useful option for covering small to medium defects in lower limb extremities. Due to the constant anatomy of the MTB nerve, we suggest that the flap could also be used as an innervated free flap for small or medium muscular reanimation such as sequelae of forearm and hand muscle impairment, or facial palsy.

Human skin melanin pigmentation is regulated by systemic and local factors. According to the type of melanin produced by melanocytes, the transfer and degradation of melanosomes differ, thus accounting for most variations between ethnicities. We made the surprising observation that in a drastically changed environment, white and black phenotypes are reversible since Caucasian skin grafted onto nude mice can become black with all black phenotypic characteristics. Black xenografts differed essentially from other grafts by the levels of epidermal FGF-2 and keratin 5. In vitro analysis confirmed that FGF-2 directly regulates keratin 5. Interestingly, this phenomenon may be involved in human pathology. Keratin 5 mutations in Dowling-Degos Disease (DDD) have already been associated with the pheomelanosome-eumelanosome transition. In a DDD patient, keratin 5 was expressed in the basal and spinous layers, as observed in black xenografts. Furthermore, in a common age-related hyperpigmentation disorder like senile lentigo (SL), keratin 5 distribution is also altered. In conclusion, modulation of keratin 5 expression and distribution either due to mutations or factors may account for the development of pigmentary disorders.

Objective: To evaluate the tolerance and healing rate of a collagen regeneration template in covering full-thickness wounds, including rate of adverse events. Method: In this prospective, multicentre study, patients with a full-thickness wound underwent two-stage surgery consisting of implantation of a collagen regeneration template followed by a split-thickness skin graft (STSG). Patients were followed-up for 12 months. Adverse events arising from either the implantation or STSG were evaluated. Results: Of the 33 patients included in the study, 29 completed the full follow-up period. During the study, 13 adverse events occurred at the treated wound site, as reported by 11 patients during follow-up. These included local infection (n=5), a diffuse infection (n=1) and non-infectious seroma under the silicon layer (n=1). The mean percentage of take of the collagen template at 21±7 days after implantation was 81.2% of the treated surface. The mean percentage of take of STSG at 28 days after grafting was 84.4% of grafted surface. STSG was successful in 28 patients, but was completely rejected at 12 months for one patient. Mean functional score at 12 months, as evaluated by the treating surgeons, was 76.8/100 and mean aesthetic score was 62.7/100. Conclusion: This study found use of a collagen regeneration template to be a safe procedure for the coverage of full thickness-wounds.

BACKGROUND: Treating chronic osteomyelitis of the lower extremities is challenging. The treatment of acute lower limb trauma by orthoplastic teams has shown good results over the past few decades. This study aimed to characterize surgical outcomes of leg and heel chronic osteomyelitis by an orthoplastic team. METHODS: The cases of 113 consecutive leg and heel chronic osteomyelitis patients undergoing soft-tissue reconstruction with an orthopedic procedure were reviewed in this retrospective single-center observational study. The main objective was to assess surgical outcomes of skin healing and gait recovery at the 1-year follow-up. The secondary objective was to evaluate the global success rate at the last follow-up. RESULTS: The median follow-up was 19.7 months. A free flap was performed for 33 patients (29.2 percent) and a locoregional flap was used in 79 patients (69.9 percent). Seventy-two patients (63.7 percent) had chronic osteomyelitis on continuous bone. The others had a septic pseudarthrosis with a mean bone defect length of 42.9 mm. Forty-four patients (38.9 percent) underwent curettage only, eight (7.1 percent) underwent curettage and cement, 20 (17.7 percent) underwent curettage and bone fixation, and 39 (34.5 percent) underwent the Masquelet technique. At the 1-year follow-up, 72 patients (63.7 percent) had achieved skin healing and had recovered their gait. The success rate at all follow-up time points was 82.3 percent. The median time to achieve skin healing was 6.5 months and that to bone union in cases of septic pseudarthrosis was 7.9 months. CONCLUSION: Orthoplastic management of leg and heel chronic osteomyelitis patients with combined soft-tissue reconstruction using an orthopedic procedure was a viable strategy that offered good results even though the time to complete healing was long. CLINICAL QUESTION/LEVEL OF EVIDENCE: Risk, III.

Summary Background In recent years, the progress of anatomical knowledge and microsurgical techniques, in particular the development of perforator flaps, has risen the number of flaps available for lower leg reconstruction. The esthetic consequences of flap choice and harvest do have an impact on patients’ quality of life. Nowadays, more researchers evaluate the esthetic changes following lower limb reconstruction. Objectives This review aims to summarize the available evidence on the esthetic outcome of lower limb reconstruction. Data sources A systematic review was planned to identify the most relevant indexed articles on this subject. The search was performed on Pubmed database without date of publication limits. Study eligibility criteria All papers about reporting information about the esthetic outcome of lower limb reconstruction were selected. Case reports and the articles not including specific information about complications, secondary procedures, and outcomes were excluded. The articles were categorized according to their topic and date of publication. The full texts of all the articles were obtained and read thoroughly. The references for each article were screened to identify articles that were eventually left outside our database search. Participants, and interventions One hundred and eight articles were retained for the definitive review. Eleven review articles were kept because they represented a good source of information. Thirty-three articles were added after reading the full texts. The articles appear highly heterogeneous and at, this stage, only a critical and qualitative analysis could be performed. Results We found information about 7895 lower reconstructions, 1295 local flaps, 6546 free flaps. Limitations The esthetic evaluation is intrinsic subjective. Many psychological and cultural factors influence both the patient and the surgeon. There is not a validated assessment tool for the esthetic outcome of lower leg reconstruction. Therefore, no quantitative analysis was performed. Conclusions Some ancient techniques are today obsolete, like the rectus abdominis free muscle flaps and perhaps free forearm flap, others are always useful, like gracilis and latissimus dorsi free flap. ALT flap is the most versatile perforator flap today available, but the SCIP flap is gaining the favor of a growing number of surgeons. Local flaps will be always performed with success but their indications should not be pushed beyond the medium-size defects. The best cosmetic outcome for each patient cannot necessarily be obtained neither with the easiest techniques nor with the most technically demanding ones. It is necessary to develop validated tools to assess the cosmetic outcome of lower limb reconstruction.

Assessment of patient satisfaction following an aesthetic surgery has shown an increasing trend over the past years. To date, there is no prospective and comprehensive study evaluating this aspect after surgical facial and neck rejuvenation. The aim of the current work was to address patient satisfaction after face and neck lift surgery using a validated questionnaire.We present a prospective and multicenter study (five regional centers) involving all patients undergoing face and neck lift surgery between April 2015 and April 2017 in several French centers for aesthetic surgery. All subjects assessed the FACE-Q scales before the procedure, and furtherly at 3-month, 6-month and 12-month follow-ups.Thirty-six patients were included with a median age of 58.5 years old [IQR 54.0-66.0]. The FACE-Q outcomes were significantly higher at 3-month follow-up (p 0.001). Seventy-five percent of the patients underwent an additional surgical procedure associated with face and neck lift. Particularly, a combined blepharoplasty led to a significant increase in the score of global facial appearance. The patients considered themselves a mean of 6 years younger in the third month after surgery. These results remained constant at six and twelve postoperative months.A statistically significant improvement of the FACE-Q scores could be highlighted on every scale, with permanent results at 6 and 12 months postsurgery. We hereby present the first study with evidence that appearance and quality of life outcomes can be reliably assessed after rhytidectomy.This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

Epithelioid sarcoma is an uncommon soft tissue tumor of the hand characterized by high frequency misdiagnosis and high potential for local recurrence and regional lymph node metastasis. The recommended treatment is wide excision, which leaves complex tissue defects with tendon or neurovascular structure exposure requiring coverage. We present two patients who had tumor excision followed by wound coverage with dermal regeneration template and split-thickness skin graft. Integra® template represents a different approach, which provides a safe, reliable and effective means of soft tissue coverage of the hand.

Introduction Medial canthus is a common area of skin cancer prevalence. Defects in this region represent a challenging reconstructive task. The nasal version of keystone perforator island flap (KPIF) has proven its versatility. The aim of the present study was to expand its utilization in the neighbor medial canthus area. A modified croissant-like KPIF (CKPIF) was used resolving inner convexity-related problems. The presence of procerus in the glabella area, bridging a surface from nasalis up to the frontalis, changed the traditional dissecting flap technique. Thus, the authors introduce the bridge principle, which consists of the indirect transfer of the flap to the defect site through a muscular "bridge" (the procerus). The authors report their experience in medial canthal reconstruction combining a modified KPIF with a new dissecting "principle." Methods From November 2016 to July 2017, a series of patients presenting soft tissue defects of various dimensions in the medial canthus, secondary to tumor extirpation, sustained reconstruction with a CKPIF dissected with the bridge principle. Results A total of 15 patients were treated with this new technique. Their mean age was 75.3 years. The mean size of the defect was 2.08 cm (length) × 1.5 cm (width). All flaps survived without any sign of venous congestion. A transient epiphora presented in 4 patients (4/15 or 26.6%), which was subsided 2 months later. Conclusion A new approach following a novel paradigm was introduced to resolve an old problem. Initial outcomes are encouraging. However, longer series are needed to extract definitive and safer conclusion.

Resume Objectif La chirurgie de feminisation faciale fait partie integrante du processus de transformation des patientes transsexuelles male to female. Une evaluation globale de la satisfaction de ces patientes par un questionnaire specifique est fondamentale afin de confirmer le benefice de cette chirurgie et d’optimiser les pratiques cliniques. L’objectif de cette etude est de developper un outil fiable et valide permettant de mesurer la satisfaction de ces patientes. Methodes Une revue de la litterature, l’avis d’une commission d’experts et des entretiens avec des patientes issues de la population cible ont permis de mettre en place le Conceptual Framework du questionnaire. Il regroupe l’ensemble des domaines majeurs du questionnaire et a permis la creation des differents items. Resultats Aucun questionnaire n’existe a ce jour pour mesurer de maniere specifique la satisfaction de ces patientes. Dix experts et 18 patientes ont participe a l’etude. Le Conceptual Framework se compose des domaines suivants : satisfaction concernant l’apparence feminine du visage ; les sequelles postoperatoires ; qualite de vie. Le questionnaire comprend quatorze echelles de Likert independantes entre elles, utilisables en preoperatoire et postoperatoire. La fiabilite du questionnaire est excellente avec un score Alpha de Cronbach moyen de 0,85. La satisfaction mesuree apres chirurgie de feminisation faciale dans cet etude est tres bonne avec une moyenne de 83,7 ± 7,41. Conclusion Le QESFF1 est un questionnaire fiable dont la creation respecte les etapes du patients reported outcomes process. La demonstration de sa validite necessite une etude pluricentrique ulterieure. Il permet aux praticiens de mesurer objectivement l’impact de la chirurgie de feminisation faciale chez les patientes transsexuelles male to female et peut egalement etre utilise en recherche clinique.

Introduction The goal of lower extremity reconstruction after trauma is the coverage of defects to give patients a healed wound and to let them resume their life, ambulate and return to work, while preventing amputation. In this article, we describe an innovative use of Integra® for free flap pedicle coverage in lower extremity reconstruction. Materials and methods Between January 2011 and December 2015, ten patients, four women and six men, underwent a lower limb reconstruction with an association of free flap and Integra® to cover the flap pedicle. The mean age of the patients was 38.8±15.6 years at the time of surgery (range of 14-59 years). The mean defect size was 102±54 cm2 (range of 40-160 cm2). The bone and/or tendons were exposed at the level of the middle third of the leg in 2 cases, at the level of the distal leg in 5 cases and at the level of the foot in 3 cases. Results There were no intra-operative complications. Mean size of Integra® needed for flap pedicle coverage was 12.8±2.3 cm2 (range 10-15 cm2). The mean follow-up was 41±19 months (range 21-70 months). Revision surgery was necessary in three cases due to haematoma of the pedicle. In these cases, the dermal substitute was easily removed while awaiting revision. This allowed flap survival in all cases. A skin graft was performed after a mean time of 3.4±0.8 weeks post-operatively. Complications at the donor site level included one seroma and a case of hypertrophic scar. Complete healing of both the donor and recipient sites was achieved in all cases. Conclusions The combination of free flap and Integra® appears to be a useful option in covering complex defects in the lower limb. The dermal substitute avoids skin tension and compression of the pedicle. Haematomas of the pedicle, if they occur, are highly visible and thus easy to manage. We hypothesize that the use of dermal substitute for this specific indication of pedicle coverage will expand in the near future.

Background Most authors have evaluated the location of lower leg arterial perforators, but little is still known about the relationship between the arterial network and great saphenous vein (GSV) and saphenous nerve (SN). The aim of this study is to evaluate the relationship between the arterial network of the posterior tibial artery perforators, the cutaneous nerves, and the superficial venous system in the lower one third of the leg. Methods Eighteen lower limbs from cadavers were used for this study. The arterial and venous compartment were selectively injected with a mixture of barium sulfate and epoxy. The specimen were CT scanned and the superficial veins, nerves, and the arterial perforators were dissected. Results A large perforator of the posterior tibial artery was found at a mean distance of 6.23 cm ± 0.88, with a 95% CI: 5.79-6.67, from the medial malleolus. The average diameter was 0.9 mm ± 0.17, with a 95% CI: 0.81-0.99. In 67% the connection of the venae comitantes to the superficial venous system was established with the GSV, in the other cases, with Leonardo's vein. Both dissection and imaging studies showed perineural interperforator connections along the branches of SN in all the specimens examined. Conclusions The distribution pattern of posterior tibial artery perforators followed the superficial nerves in this region. There is an interperforator anastomotic network along the SN. The various patterns of the venous drainage system, in relationship to the distribution of the branches of posterior tibial artery perforators, have been clarified.

The medial head of the triceps brachii muscle (MTB)-free flap is an attractive solution to cover small-to-medium defects of the lower limb. This muscular head has no well-identified function, suggesting minimal impact of its removal on elbow mobility. The aim of this study was to evaluate the safety and reliability of the harvest procedure and the functional and cosmetic morbidity of this donor site. Twenty-four consecutive MTB-free flaps were performed for reconstructive surgery of the lower limb between 2011 and 2015. Patients and their records were retrospectively examined. Functional results were evaluated by assessing elbow extension strength using a dynamometer and with a QuickDASH questionnaire. Cosmetic results were assessed using the POSAS observer and patient scales. Twenty-four patients were followed up postoperatively for an average of 33.9 [min 12–max 59] months. No major complication (in particular, no ulnar or radial nerve injury) occurred during harvest. No patient complained of elbow pain or reduction in strength. Elbow extension was complete in all patients and the mean strength was calculated at 89 [61.1–112.5] % of the opposite arm. The POSAS scale scored an average 8.6 [7–21] for the observer and 10 [7–26] for the patient. Cosmetic results using the POSAS scale were satisfactory in all patients. Objective evaluation of patients who underwent an MTB-free flap for limb reconstruction shows no impact of the harvesting procedure on elbow extension. Patient satisfaction with the donor site was high. From this retrospective study, it appears that this surgery is safe, aesthetically acceptable, and has minimal impact on donor site elbow function.

A vast array of tumors can occur on the skin. Recent data demonstrated that more than two million of new cases of skin cancer are diagnosed annually [1]. Areas of sun exposure are more prone to develop numerous nonmelanoma skin cancers. The skin of the upper extremity and the hand is not an exception. It is known that the hand represents 1–2% of the total body surface. However, skin cancers involving this area account for 10–15% of all cases of skin malignancies [2, 3]. Unfortunately, there is a poor documentation of their natural history [4–6]. An explanation could be that either heterogeneous groups of soft tissue and cutaneous hand tumors or only specific skin cancers (e.g., squamous cell carcinomas) have been considered in the published series [7–12]. It is important to notice that the skin of the hand disposes a unique structure and is highly specialized allowing mobility for complex motor skills along with fine sensibility and resistance to withstand tearing and wearing forces. In addition the subcutaneous tissue is thin covering and protecting functionally important deeper structures. Subsequently, any therapeutic attempt necessitates a special consideration in this area counterbalancing sometimes two contradictory issues: tumor eradication and preservation or function restoration.

Background Upper arm deformities secondary to weight loss or senile elastosis have led to an increased demand for aesthetic contouring procedures. Objective To objectively assess whether, in Teimourian high-grade upper arm remodelling, laser-assisted lypolysis (LAL) alone could result in patient satisfaction. Methods Between 2012 and 2013, 22 patients were treated for excessive upper arm fat (Teimourian grade III and IV) solely with LAL. The laser used in the present study was a 1470 nm diode laser (Alma Lasers, Israel) with the following parameters: continuous mode, 15 W power and transmission through a 600 μm optical fibre. Previous mathematical modelling suggested that 0.1 kJ was required to destroy 1 mL of fat. Patients were asked to complete a satisfaction questionnaire. The arm circumference was measured pre- and postoperatively. Treatment parameters, adverse effects and outcomes were recorded. Results Pain during the anesthesia and discomfort after the procedure were minimal. Complications included ecchymoses and prolonged edema. The mean (± SD) arm circumference decreased 5.5±1.0 cm in the right arm (PConclusion LAL for upper arm remodelling is not sufficient to ensure full skin tightening for patients with Teimourian grades III and IV upper arm deformities. A complementary surgery is mandatory for grades III and IV.

INTRODUCTION Multiplication of incisions and/or radiotherapy on the scalp, lead to skin necrosis and chronic osteitis. In this situation, reconstructive surgery can be useful to cover complex lack of tissue. MATERIALS AND METHODS The 5 patients were treated with the neurosurgery department of our hospital. The procedure included debridement of the infected calvarian bone and tissues and coverage by free antebrachial flap. A 2 stages skin graft, using a dermal regeneration template, or direct closure was used for the donor site. Evaluation of flap quality and donor site morbidity was done during hospitalization and 3 months after the procedure. RESULTS The procedure was achieved on 5 patients. All the patients were healed 3 months after surgery. For 1 patient, a second procedure was done in emergency for anastomosis revision. There was non-complication concerning the donor site. All the patients healed with a good coverage. CONCLUSION Treatment of calvarian bone necrosis needs a very good and reliable coverage, such as free flap can provide. In our opinion, the antebrachial free flap is an interesting option, despite the fact that it is still underused for scalp coverage.

Introduction Learning a new technique, even for an established surgeon, requires a learning curve; however, in transsexual surgery especially, there is a lack of professional and public tolerance for suboptimal aesthetic and functional results due to a learning curve. Aims In this context, we have tried to build a learning concept for vaginoplasty that includes four steps: (i) formal identification of the surgical steps in order to provide both measure of surgical process and measures of outcomes; (ii) training on cadavers with expert assistance; (iii) performing the live surgery with assistance from expert; and (iv) performing the surgery alone. Herein, we emphasize the second step of our learning concept. Material and Methods Between September 2013 and December 2013, 15 cadavers were operated on by an established surgeon learning vaginoplasty under assistance from two expert practitioners. Mean global time and mean time necessary to perform each step of the operation were recorded by the experts. Intraoperative complications were systematically registered. The final depth and diameter of the neaovaginal cavity were precisely measured. For each cadaver, the aesthetic results were assessed by one of the experts. Results Mean total operating time was 179 ± 34 minutes and decreased from 262 minutes for the first training attempt to 141 minutes for the last one. Intraoperative expert correction included modification of the scrotal triangular flap design and change of position of the urethra: This happened during the first training. No lesion of the urethra or of the anus occurred. The two experts judged the outcomes as excellent in seven cases, very good in four cases, good in two cases, and fair in two cases. Conclusion Despite the numerous reports on vaginoplasty in the literature, there is a real lack of published information on the learning curve of this operation. We make the hypothesis that introducing a learning concept with assistance from expert practitioners at the beginning of the surgeon's experience can optimize both the duration of his learning curve and reduce the risk of major complications.

The aim of this study was to present our experience with the use of the Keystone Perforator Island Flap (KPIF) in a case series of patients with small size (diameter ≤ 2 cm) nasal defects which will be useful prospectively to assist plastic surgeons in planning a reconstructive strategy that will work. The KPIF was utilized in 30 patients with nasal defects post tumor extirpation. More than one type of KPIF (type I or type III) was used following the nasal subunit principle or a modified version of it. The mean follow-up period was 10.5 months. Overall good outcomes were achieved, with no major complications encountered, except minor wound dehiscence in 3 cases. It is the first time that the utilization of this flap is reported in nasal reconstruction. The versatility of the KPIF makes it a safe technique even in the hands of inexperienced surgeons under guidance for nasal defects up to 2 cm in diameter.

Objectives/Hypothesis In 2006, our institute reported the first clinical use of laser-assisted cartilage reshaping (LACR) for protruding ears. Since then, the technique has been developed and refined. This article reviews the literature on the clinical application of LACR. Study Design Literature review. Methods A MEDLINE literature search was performed on LACR combined with cross-referencing. The period of search was 1993 to 2014. Search terms used were: laser, cartilage reshaping, protruding ears, LACR. Results Only seven clinical studies using three different wavelengths were found in the literature: 1,064 nm (Nd:YAG), 10,600 nm (CO2), and 1540 nm (Er:Glass). Clinical outcomes, laser wavelength and parameters, and patient satisfaction are discussed in each case. Conclusions The success rate for ear reshaping achieved with LACR appears promising. The use of this noninvasive technique will increase in the near future. Level of Evidence Laryngoscope, 125:2067–2071, 2015

Lower extremity defects may account for 14.6% of the approximately 117 million visits to emergency departments in the U. S. in 2007. In this article, we present a reconstruction of a traumatic plantar foot defect with a medial triceps brachii (MTB) free flap.A 53-year-old man sustained an accidental gunshot wound to the right foot. The patient was admitted after the failure of a sural flap procedure performed in another hospital. He presented with a soft-tissue defect with calcaneal exposition and osteomyelitis. The defect was reconstructed with a MTB free flap anastomosed to his dorsalis pedis vessels.Flap raising time was 52 min. There were no intraoperative complications. The total flap surface was 38.5 cm². The pedicle length was 3 cm. The diameters of the artery and vein of the flap pedicle were 1.1 mm and 1.4 mm, respectively. Ischemia time was 28 min. His donor site healed uneventfully without any morbidity, and the scar was well concealed. The flaps survived and there was no partial flap necrosis. A split-thickness skin graft was performed 12 days postoperatively. Two months later, he had a completely healed wound with no contour abnormality. The total follow-up was 24 months. The patient was able to walk normally.MTB free flap appears to be an excellent option for plantar foot defects in patients with preserved vascularization of the foot. Due to the anatomical shape of the flap, the position of its pedicle, and the moldability of the muscle, we predict that the use of the MTB free flap will grow and develop rapidly for reconstruction of ankle and foot defects.

Introduction Hyperhidrosis is a debilitating problem that is not only uncomfortable and inconvenient, but also embarrassing in work and social situations. In spite of the availability of several options for the treatment of axillary hyperhidrosis, recently, there has been an increasing interest in the use of laser therapy. This study aims to evaluate the efficacy of a laser diode device emitting at wavelengths of 924 and 975 nm and classical curettage either alone, simultaneously or in combination. Material and methods A randomized prospective controlled trial was carried out on 100 patients divided into four groups, each with a different protocol: Laser alone at 975 nm (group 1), laser alone at 924/975 nm simultaneously (group 2), curettage alone (group 3), and finally laser at 924/975 nm followed by curettage (group 4). HDSS, starch test and GAIS were used to assess treatment efficacy. The follow-up extended to one year. Statistical analysis (SPSS) was used to determine the accuracy of the results. Result Two patients of group 1 experienced burns during treatment, which took over a month to heal. This group of patients achieved the worst results: The starch test scale results after treatment were 2.48 ± 0.51 and 2.76 ± 0.44 (at 1 and 12 months). The GAIS results were 1.04 ± 0.35 and 0.92 ± 0.28 (1 and 12 months). In group 2 the starch test scale results after treatment were 1.36 ± 0.49 and 1.48 ± 0.51 (at 1 and 12 months). The GAIS results were 2.36 ± 0.49 and 2.72 ± 0.46 (at 1 and 12 months). In group 3, the starch test scale results after treatment were 1.56 ± 0.51 and 1.76 ± 0.60 (at 1 and 12 months), which corresponds to small to substantially smaller dark areas. The GAIS results were 2.28 ± 0.46 and 2.64 ± 0.49 (at 1 and 12 months). The best results were obtained in group 4: HDSS scores were reduced from 3.88 ± 0.33 before treatment to 1.24 ± 0.44 and 0.48 ± 0.51 at the 1 and 12 months controls. The starch test scale results after treatment were 0.40 ± 0.50 and 0.44 ± 0.51 (at 1 and 12 months). The GAIS results were 3.72 ± 0.54 and 3.76 ± 0.44 (at 1 and 12 months). Conclusion In this study, the laser at 924/975 nm combined with curettage was determined to be the optimal treatment option of those tested for axillary hyperhidrosis. This treatment was safe, with few side effects and improvement that persisted to one year follow-up. Lasers Surg. Med. 47:173–179, 2015. © 2015 Wiley Periodicals, Inc.

Upper arm deformities secondary to weight loss or senile elastosis have led to an increased demand for aesthetic contouring procedures. We conducted this study to objectively assess if, in Teimourian low-grade upper arm remodelling, one session of laser-assisted lypolisis (LAL) could result in full patient satisfaction. Between 2011 and 2013, 45 patients were treated for unsightly fat arm Teimourian grade I (15 patients), grade IIa (15 patients) and grade IIb (15 patients) with one session of LAL. The laser used in this study was a 1470-nm diode laser (Alma Lasers, Cesarea, Israel) with the following parameters: continuous mode, 15 W power and transmission through a 600-μm optical fibre. Previous mathematical modelling suggested that 0.1 kJ was required in order to destroy 1 ml of fat. Treatment parameters and adverse effects were recorded.The arm circumference and skin pinch measurements were assessed pre and postoperatively. Patients were asked to file a satisfaction questionnaire. Pain during the anaesthesia and discomfort after the procedure were minimal. Complications included prolonged oedema in 11 patients. The average arm circumference decreased by 4.9 ± 0.4 cm in the right arm (p

Background: The proper digital arteries as any other axial vessel give rise to multiple cutaneous perforators either volar or dorsal along their course. Their identification is performed with Doppler flowmetry. The vasculo-cutano-tendino-osseous complex (VCTOC), which was described by the senior authors, was responsible for the vascularization of all digital anatomic structures (extensor apparatus, skin, periosteum). Their consistent appearance to well measured distances from the digital joints led the way to the present clinical study for highlighting this described anatomy in-vivo and demonstrating the predictability in digital artery perforator (DAP) flap harvest. Methods: From November 2012 to March 2014, fifteen patients underwent reconstruction with a predictable pattern digital artery perforator flap (PPDAP), based on the previously described VCTOC mapping, for digital lesions secondary to tumor extirpation. Flaps were designed as V-Y advancement or propeller type. Postoperative control concerned flap viability and digital function. Results: Seven males and 8 females underwent elective surgery using PPDAP flaps for digital defects following tumor extirpation. The diameter of the defect ranged from 0.5 to 1.5 cm. The vast majority of the lesions were identified on the right hand, the index, the ring finger and the distal phalanx. All flaps survived without signs of venous congestion. No functional digital problems were observed during follow up (mean of 77 months). A minor wound dehiscence presented in one patient. Conclusions: Authors introduced the concept of a “predictable pattern” in the surgery of perforator flaps in the digits. These flaps are reliable and could be a valuable reconstructive option.

Background The medial triceps brachii is vascularized by the middle collateral artery and the arterial circle of the elbow. This vascularization allows a distal pedicled use to cover soft tissue defects of the elbow. We report our experience using this flap to cover traumatic and postsurgical wounds. Methods Patients who underwent a pedicled medial triceps brachii flap procedure between 2008 and 2015 were included. Data concerning characteristics of the patients, wound size, surgical technique, and complications were retrospectively reviewed. An independent observer examined patients and assessed outcome of the coverage procedure: wound healing, scar length, range of elbow motion, and patient satisfaction. Results Eight patients were included (70.6 ± 17.7 years old at the time of surgery). All patients had serious comorbidities and risk factors of poor wound healing. Defects were due to postoperative healing complications (5 patients), skin necrosis secondary to an underlying olecranon fracture (1 patient), and direct open fractures (2 patients). Soft tissue defects had a median surface of 17 (14-22) cm2. The olecranon was exposed in 7 cases and the medial humeral epicondyle in 1 case. Mean procedure duration was 83 ± 14 minutes. There was no intraoperative or postoperative complication. All patients healed properly at 3 weeks of follow-up. No wound recurrence or surgery-related complication was reported after a median follow-up of 40.5 (21.5-69.5) months. Conclusion Favorable outcomes in all of our 8 patients make this flap an interesting option to cover small to medium-sized defects of the posterior aspect of the elbow.

Resume L’etude anatomique des muscles du poignet par la dissection permet de mettre en evidence la morphologie differenciee des muscles du poignet et leurs rapports avec les muscles intrinseques de la main et les structures fibreuses de cohesion. A partir de l’organisation anatomique ainsi presentee et des donnees de la litterature sur l’architecture musculaire, les auteurs proposent de justifier l’aspect qualitatif des techniques de renforcement musculaire dans la reeducation du poignet. Niveau de preuve V.

Resume Un foyer septique peripherique peut etre le mode de revelation d’une fistule aortodigestive chez un patient porteur d’une prothese endovasculaire aortique. Nous avons pris en charge un patient de 69 ans pour un abces de la face anterolaterale de la jambe gauche. Le patient avait beneficie quatre annees auparavant d’un pontage prothetique aortobifemoral secondaire a la cure d’un anevrisme de l’aorte abdominale. Le bilan initial de recherche de fistule aortodigestive justifie par la presence de germes anaerobies retrouves lors du parage et de la mise a plat de l’abces, etait reste negatif. Le traitement de l’abces associait un parage et une mise a plat, un pansement a pression negative et une couverture de la perte de substance cutanee par un substitut dermique et une greffe dermoepidermique. Quelques mois plus tard, devant un retard de cicatrisation inexplique et l’apparition de signes generaux, un nouveau bilan a permis de mettre en evidence une fistule aortodigestive. De plus, les prelevements locaux au niveau de la plaie et les hemocultures retrouvaient tous deux de nombreuses colonies d’ Escherichia Coli . Le changement de la prothese aortobifemorale et la cure de la fistule aortodigestive ont permis la cicatrisation complete de la perte de substance cutanee de la jambe. Les fistules aortodigestives sont des complications des protheses endovasculaires aortiques au pronostic tres defavorable. De diagnostic difficile, leur suspicion clinique doit engager un bilan paraclinique complet. Toutes les plaies septiques chez un patient porteur d’une prothese vasculaire doivent faire evoquer le diagnostic de fistule aortodigestive.

Perforator flaps have become very popular in reconstructive surgery. The thoracodorsal and lateral thoracic artery perforator flaps are highly studied, and successful clinical series have been reported, whereas the literature concerning the lateral intercostal and serratus anterior artery perforator flaps is quite poor and their vascular anatomy needs yet to be clarified. We describe a case of free serratus anterior artery perforator flap for the reconstruction of a dorsal defect of the foot, followed by an anatomic and radiological study. A 17-year-old boy reported a fracture of the first and second metatarsal bone of the left foot, with a dorsal skin defect, due to a motorcycle accident. After the osteosynthesis treatment, a perforator was identified through a handheld Doppler in the lateral chest area and a cutaneous paddle was designed. Retrograde dissection revealed the perforator's direct link to the serratus anterior pedicle. In our knowledge, an elucidated method to preoperatively visualize the perforating vessel of the serratus anterior artery has not yet been described. Thus, an anatomic study on 8 hemithorax and a radiological study on 33 computed tomographic angiographies of the chest were carried out to clarify the vascular anatomy of the serratus anterior artery perforators and to verify the possibility of their preoperative visualization. The authors believe that the serratus anterior artery perforator could be preoperatively investigated, thus making this flap a valuable option when harvesting a perforator flap in the lateral chest area.

ObjectiveTo describe the surgical technique of the V-Y cutaneous supra-fascial (modified) gluteal advancement flaps for reconstruction after radical vulvectomy and to assess the outcome of patients according to their clinical characteristics.MethodsBetween January 2006 and July 2012, 36 V-Y flaps were performed in 21 patients to cover the defect after radical surgery of primary vulvar cancers. Surgery duration, blood loss, hospital stay, and wound healing were assessed according to patient age, body mass index (BMI), American Society of Anesthesiologists (ASA) score, and the initial defect size.ResultsMedian patient age, BMI, and ASA score were 80 (range, 31–91), 28 (range, 18–36), 3 (range, 1–3), respectively. Median surgery duration and blood loss were 180 minutes (range, 60–275) and 400 mL (range, 100–1000), respectively. Median operating time was higher in patients ASA3 than ASA less than 3, 200 versus 120 minutes (P = 0.038). Median initial defect size was higher in patients with BMI greater than 28 than 28 or less, 92 versus 55 cm2 (P = 0.004). Local scar defect was observed in 16 patients (76%), mild, less than 10 cm2 in 10 patients. Median wound healing duration was higher in patients with bilateral than unilateral flap, 16 versus 9.5 days (P = 0.034).ConclusionsThe V-Y cutaneous suprafascial gluteal advancement flap for vulvar reconstruction after vulvectomy is an easy, safe, and reliable procedure. However, even mild local scar defect after bilateral flap may impact on wound healing and hospital stay, in elderly and ASA3 patients.

The ala is a unique landmark of the nose disposing aesthetic and functional properties. The head and neck area is the main site of appearance of nonmelanoma skin cancer. One third of them are located in the nose with an alar preponderance compared with other nasal subunits. Correction of alar defects is a challenging reconstructive task. The keystone perforator island flap (KPIF) was introduced as an alternative in nasal reconstruction by senior authors. In the present case series, KPIFs' application is introduced into the alar subunit as an alternative, versatile, and reproducible reconstructive option, even for the novice plastic surgeon.From April 2014 to September 2015, patients presenting with partial thickness alar defects (≤1.5 cm) secondary to tumor extirpation sustained reconstruction with different types of KPIF.A total of 31 patients (mean age of 72 years) were treated with various types of KPIF. The mean diameter of the defect was 1.14 cm. The vast majority of reconstructions concerned a type IV KPIF (18/31 or 58.1%). Sometimes an upward alar retraction was noted. A minimal rim wedge excision was performed (≤0.3 mm) using counterbalancing correcting sutures. All flaps survived without any sign of venous congestion, whereas the rim healed uneventfully. The mean follow-up period was 6.5 months.KPIF was introduced as a single-stage alternative reconstructive option for partial thickness alar defects, completing author's experience with this flap into such a challenging and aesthetically critical anatomic area.

A letter in response to: Seavey JG, Masters ZA, Balazs GC, Tintle SM, Sabino J, Fleming ME & Valerio IL. Use of bioartificial dermal regeneration template for skin restoration in combat casualty injuries. Regen. Med. 11(1), 81–90 (2016).

Resume Les substituts collageniques representent une alternative therapeutique pour la couverture cutanee dans la chirurgie des sequelles de brulure lorsque le sous-sol est bien vascularise. Dans le cas contraire, le recours a l’utilisation d’un lambeau s’impose. Les auteurs proposent une nouvelle technique chirurgicale utilisant les lambeaux prefabriques vecteurs de neo-collagene. Celle-ci est illustree par un cas de retraction cutanee dorsale du poignet chez l’enfant corrigee par l’utilisation d’un lambeau pedicule axial et d’un substitut collagenique. Ce lambeau prefabrique de neo-collagene constitue un degre de sophistication supplementaire dans la chirurgie des lambeaux, par la possibilite de creer par les propres cellules du patient, des lambeaux neoformes pedicules ou libres, encore plus adaptes au site receveur tout en limitant le plus possible les sequelles sur le site donneur.

Resume But de l’etude Le lambeau perforant gluteal inferieur, vascularise par les branches perforantes de l’artere gluteale inferieure (anciennement « ischiatique »), est preleve en regard du pli gluteal. Le but de cette etude anatomique etait de preciser les caracteristiques anatomiques de ce lambeau et de localiser les perforantes qui lui sont destinees, dans la perspective de faciliter son prelevement chirurgical, notamment comme lambeau libre pour la reconstruction mammaire. Materiel et methode Nous avons realise une serie de 12 dissections sur cadavres frais, injectes au prealable par une solution gelifiee coloree et radio-opaque par voie selective au niveau de l’artere gluteale inferieure. Lors du prelevement de la palette, nous avons localise les perforantes issues de l’artere gluteale inferieure et destinees a la palette cutanee du lambeau. Resultats Nous avons pu distinguer quatre zones, definies par rapport aux reperes anatomiques de la region, en fonction de la frequence des perforantes. Conclusion Cette etude anatomique permet d’orienter le prelevement chirurgical de ce lambeau dans sa forme libre en vue de son utilisation en reconstruction mammaire. Il represente une alternative interessante de reconstruction autologue, d’autant plus qu’il a de nombreux avantages : un volume graisseux constant meme chez les patientes minces et des sequelles minimes au niveau du site donneur.

We report our experience with the use of Integra® for the management of severe traumatic wounds of the hand. Fifteen patients were treated with follow-up ranging from 10 to 37 months. Wounds were associated with an osseous and/or joint and/or tendon exposure. Following Integra® placement, patients were managed with dressings and subsequent split-thickness skin grafting an average of 26 days later. Integra® was successful in achieving durable, functional and aesthetic definitive coverage in 13 of 15 applications while allowing a satisfying pollicidigital prehension. Regarding our clinical experience, Integra® is an effective technique to deal with severe wounds of the hand with exposed tendon and/or bone and/or joint, even in the absence of paratenon or periosteum. This can potentially lessen the need for local rotational or free flap coverage and should be taken into consideration as a viable alternative in traumatic reconstruction of the hand.

Dorsal adipofascial flaps have been used in the surgical reconstruction of complex injuries distal to the eponychial fold. Such injuries produce nail matrix devascularization/necrosis so that nail bed reconstruction can be a challenging technical problem. Irregular scarring of the nail bed and regrowth anomalies of the nail lamina can result, with both functional and cosmetic impairment of the finger. This study aimed to define the precise vascular anatomy of the dorsal adipofascial flap that has previously been used to reconstruct such complex soft tissue defects. Specifically, the purpose was to identify the key points of safe dissection for these flaps. Anatomical dissections were performed on 32 long fingers. The vascular tree was injected with suitable contrast and the distal dorsal region of the long fingers was studied.

HIV-related facial atrophy is a common complication due to antiretroviral treatment. The social handicap due to this lipodystrophy increase the demand of surgical correction. The usual treatment is the Lipostructure described by Coleman. The hypertrophy is one of the complications which can occur after a correction by Lipostructure. This complication is different from the overcorrection by the free time before his appearance. The treatment by liposuction is possible but there is a high risk of recurrence. The best treatment, after the literature review, seems to be the direct excision.

Scrotal elephantiasis is a pathology of often unknown etiology. Symptomatology is characterized by an oedematius infiltration of skin and subcutaneous tissue, hard-bound aspect and purplished color. The scrotum, the penis and the perineal area are gradually affected. This pathology is very invalidating for the patient, on functional, sexual and aesthetic aspects. The authors present the case of a 58-year-old man with an enormous scrotal mass invading the penis and drowning the testicular elements, which were impossible to palpate. The aetiology was determined by exclusion and an iatrogenic origin following the cure of bilateral inguinal hernia was retained. Resection of the scrotal mass was performed. The reconstruction of the scrotal purse and the cutaneous sleeve of the penis were carried out using local flaps of the remaining healthy skin.

The inferior gluteal artery perforator flap, which is vascularized by perforator branches of the inferior gluteal artery (formerly ischiatic artery) is harvested in the gluteal crease. The purpose of this anatomical study was to clarify the anatomical features of this flap and locate the perforators of the inferior gluteal artery destined to the flap, in view to facilitate its surgical removal, as free flap for breast reconstruction.. The authors performed 12 dissections on fresh cadavers, after selective injection of the inferior gluteal artery with a gelled solution. During harvesting the perforators were located which arise from the inferior gluteal artery and perfuse the flap. There are four zones, defined relatively to anatomical landmarks of the region, according to the frequency of perforators. This anatomical study enables to steer the surgical harvesting of this flap in its free shape for breast autologous reconstruction especially given its numerous advantages: a constant volume of fat even in thin patients and minimal donor site morbidity.

Reconstruction surgery requires imagination, inventiveness, and creation-a quest that entails overcoming obstacles never before encountered. Over the past 25 years, with the advent in microsurgery of free revascularized transfers, it was believed that this fundamental breakthrough would be sufficient to resolve difficulties of whatever nature, and that little else would be necessary. Undoubtedly, the results obtained by using free autotransfers have been so remarkable that it is no longer possible to undertake reconstruction in plastic surgery without fully mastering these techniques. Nevertheless, limitations remain, especially with regard to form and shape, as there are areas where form and function merge. As a result, some clinical cases today continue to induce a sense of powerlessness, as was the case 25 years ago when surgeons were presented with large skin defects that are nowadays treated routinely and with a sense of confidence. The sense of powerlessness today clearly signals that another milepost needs to be reached; we believe this milepost should be allotransplantation. Yet allotransplantation should not remain within the realm of the exceptional; on the contrary, it should become routinely accessible. But in order for it to become so, cryopreservation, a pathway that has so far received little attention, and about which much remains to be learned, should be explored. Accordingly, in this article, we report our experience with xenotransplantation, a mainly clinical procedure in the area of hand surgery.

Two cases of a human vascularized allotransplant of a complete digital flexion system are reported with detailed descriptions of the dissection technique and postoperative treatment. Satisfactory functional results open new prospects for this type of transplantation surgery.

Microsurgery and human allotransplantation progress as well as the improvement of immunosuppressive drugs actually allow the development of the composite tissue allotransplantation. One of the latest challenges in plastic surgery is to restore the anatomic and functional structures using similar tissues. Composite tissue allotransplantation will probably reach this goal. Our work is to find new surgical techniques for the reconstruction of the osteotendinous apparatus of the long digits. In this paper, we will demonstrate the surgical technique to harvest the allotransplant and its modulation in the reconstruction of various digital defects.

The cryopreservation of cells and human tissues has generated a great interest from the scientific community since 1949 when the cryoprotective activity of glycerol was discovered. For a homogeneous cellular group or a one-layer cellular tissue it is easy to define the optimal technique conditions of its cryopreservation (cryoprotective agents, speed and steps of freezing, speed of warming). It is considered successful when a high recovery of the cellular structures and tissue components after warming is achieved. The cryopreservation of a whole composite tissue is less easy to obtain. Each tissue presents its own parameters and its own reactivity during the cryopreservation process. The challenge consists in, on the one hand, the selection of the ideal cryoprotective agents'combination which can fit the needs of the different tissues and on the other hand, the definition of adequate technical parameters. The aim of this work is to demonstrate the feasability to cryopreserve a composite tissue in order to carry out surgical reconstructive procedures of particular anatomical and functionnal units (metacarpo-phalangeal and proximal interphalangeal joints, flexor system apparatus, extensor system, median nerve, etc.) with complete revitalization of the allograft using vascular microsurgical procedures. To do so, our present work is divided into three different parts. The first chapter deals with the fundamental principles of the cryobiology of biological structures with special interest in the liquid transfer process between the extracellular and intracellular compartments and ice initiation and agregation during the freezing process. The different physical and chemical reactions and their consequences on the biological tissues are described according to the different cryoprotective agents used, should they belong to the extracellular or intracellular cryoprotective groups. The second chapter makes a review of the litterature concerning the results of all experiments made on the cryopreservation of the different tissue structures as skin, vessels, bones, cartilage, periosteum, nerves, cornea, on the one hand, and the different organs as kidneys, liver, heart, trachea, lung, parathyroid glands and ovaries, on the other hand. We are reporting the results of these experiments focusing on the immunomodulation effect of cryopreservation on the antigenic response of biological structures. These experiments were made either on organs or on the cells involved in the immunogenic process. In the third chapter, we are reporting the results of our experiments carried out in the Aquitaine Hand Institute in the field of the cryopreservation of the xenografts of digital segments on the rabbit. These digital segments were cryopreserved, then warmed and revitalized through vascular microsurgical techniques. The preliminary results are very encouraging and pave the way to the allotransplantation of cryopreserved composite organs in our common surgical activity.