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On August 4th, 2020, at 6:07pm local time, an explosion took place in Beirut's port near the central district. This tragic event reportedly left more than 204 victims dead, more than 6,500 wounded, and displaced around 300,000 from their homes. Patients were transported to several hospitals, which became quickly overwhelmed within minutes by the large number of patient admissions. This is a retrospective chart review conducted on 292 patients, who presented to the American University of Beirut Medical Center (AUBMC) after sustaining blast-related injuries during the Beirut port explosion on August 4th, 2020. Measures including age, gender, location of the injury, mechanism of blast injury (primary, secondary, tertiary, and quaternary) and outcomes were collected. Time of arrival of the first victim was 10 minutes after the explosion. Patients across all ages presented to the medical center (age range from 3 months to 86 years) and the majority of injuries were in the upper extremity (45.6%), and head and neck region (43.2%). Most blast-related injuries were due to secondary and tertiary types, 78.4% and 24.1% respectively. This study aims to expand the literature and widen the knowledge regarding the mechanism of injury associated with the Beirut port explosion. Moreover, it could be helpful in preparing medical staff, healthcare centers and other communities to work under difficult conditions in similar disasters and improve the global response to devastating events.

Le 4 août 2020 à 18 h 07 locales, une explosion s'est produite dans le port de Beyrouth, à proximité du centre- ville. Cette explosion a tué 204 personnes, en a blessé plus de 6 500 et en a laissé environ 300 000 sans abri. Les blessés ont été acheminés dans plusieurs hôpitaux, vite débordés par cet afflux massif. Cet article est une revue sur dossier de 292 cas de patients blastés lors de cette catastrophe pris en charge à l'Hôpital Universitaire Américain de Beyrouth, la première étant arrivée 10 mn après l'explosion. Nous avons répertorié l'âge, le sexe, la localisation des blessure et le type de lésions de blast (primaire, secondaire, tertiaire ou quaternaire), les plus fréquents étant les blasts secondaires (78,4%) et tertiaires (24,1%) et l'évolution. Les patients étaient âgés de 3 mois à 86 ans et leurs blessures se situaient plus fréquemment au niveau de la partie supérieure du corps (45,6%) ou de la région cervico- céphalique (43,2%). Cette étude permet d'abonder la littérature sur les mécanismes lésionnels après une explosion comme celle du port de Beyrouth. Elle pourrait en outre permettre d'améliorer les réponses médicale, hospitalière et générale après une catastrophe.

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Pigmented onychomatricoma (OM) is a very rare benign fibroepithelial tumor of the nail matrix. We report the case of a 23-year-old Lebanese man with 15-year history of nail plate dystrophy with longitudinal ridging, yellowish discoloration, excessive transverse curvature and late-onset melanonychia along the medial third of the right thumb nail. Excisional biopsy was performed and confirmed OM. We outline the clinical history, radiological and histopathological findings as well as the surgical and reconstructive technique of this unusual case of OM. The age group, history of crush injury, and pigmentation of the nail plate make of this rare form of ungual tumor an interesting case report.

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Modern warfare has seen advances in both weaponry and personnel protective material, thus allowing for better survival of injured individuals. As a result, the medical system is faced with an increasing number and diversity of non-life threatening wounds, to the extremities especially, sustained by multiple mechanisms. These wounds have a thermal injury component regardless of the mechanism, and there is often a delay in them being definitively treated, thus affecting final cosmetic and functional outcomes. Fourteen patients presented to our institution after sustaining blast injuries of different etiologies. Time of admission was between 0-10 days, and time of microvascular reconstruction after initial serial debridement was between 5-28 days. All patients were found to be infected with multiple organisms upon admission. Five patients were reconstructed with free vascularized skin flaps, three with osseous and osseocutaneous free flaps, four with free latissimus dorsi muscle flaps and two by toe-to-hand transfer. The follow-up period ranged from 4 to 52 weeks (mean, 26.7 weeks). Eleven free flaps survived completely. Two patients presented with minor dehiscence and were treated with secondary closure. Two patients developed a hematoma under the flap that required evacuation. One flap failed due to arterial thrombosis. Early free flap reconstruction proves to be a good option for the early reconstruction of blast injuries with thermal components after serial debridement and tangential excision of the wound beds.

La guerre moderne a fait des progrès à la fois dans le domaine de l'armement et également au niveau du matériel de protection. La médecine se trouve ainsi confrontée à un nombre croissant de plaies diverses, ne mettant pas en jeu le pronostic vital; elles siègent notamment au niveau des extrémités et sont secondaires à de multiples mécanismes. Ces plaies, quelque soit la cause, ont une composante thermique, et il existe souvent un retard au traitement définitif à la fois sur le plan esthétique et fonctionnel. 14 patients ont été traités dans notre service après avoir été victimes d'explosions de différentes étiologies. L'admission s'est faite entre 0 et 10 jours, et le moment de reconstruction micro chirurgicale, après un débridement itératif entre le 5e et le 28e jour. Tous les patients présentaient des infections par de multiples germes lors de l'admission. Cinq patients furent reconstruits avec des lambeaux libres cutanés, trois avec des lambeaux libres osseux et osteo cutanés, quatre avec un lambeau libre de grand dorsal, et deux avec un transfert d'orteil. La période de suivi s'étendait de 4 à 52 semaines (moyenne 26,7 semaines). 11 lambeaux libres ont survécus complètement. Deux patients ont présenté une petite désunion et ont nécessité une suture secondaire. Deux patients ont développé un hématome sous le lambeau exigeant une évacuation. Un lambeau fut suivi d'échec, à cause d'une thrombose artérielle. La reconstruction précoce par lambeau libre est donc une bonne option pour la reconstruction précoce des traumatismes par explosion avec composante thermique, après un débridement itératif et une excision tangentielle des plaies.

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The reconstruction of digital pulp defects is still a challenge in hand surgery. Several reconstructive techniques are available, but in some cases, their advancement capacities are not sufficient for the flap to cover the whole defect. The Gigogne flap is a new, very simple and safe technique. It consists of harvesting two cutaneous flaps successively on the same neurovascular digital palmar bundle. The first plasty may be chosen among the well-known flaps usually applied in pulp reconstruction. The second plasty, the Gigogne flap, is an advancement VY plasty done on the main cutaneous paddle of the first proximal flap. We performed 15 Gigogne flaps in 13 patients, who suffered zone II and III digital pulp amputations. The Gigogne flap increased the advancement capacity of the proximal flap as well as restoring the physiological pulp fatty pad, thus reconstructing a functional and aesthetic fingertip.

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This paper reports our experience with temporary ectopic digital implantation. Four patients suffered 12 digital amputations with large defect over the proximal stumps. Only 8 digits were suitable for microsurgical salvage but the local conditions made direct replantation impossible. In our first patient, the two digits were ectopically implanted onto the foot, while in the second patient the four amputated digits were implanted onto the opposite forearm. After stump reconstruction, the digits were microsurgically transferred to the hand, restoring a functional pinch. One digit suffered a venous congestion and necrosis in the ectopic site caused by a haematoma and another experienced a no-reflow phenomenon. In conclusion, temporary ectopic implantation remains a procedure that can be used to salvage amputated digits.

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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.

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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.

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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.

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The authors present the results of their surgical experience based on an original approach in secondary reconstructing 71 flexor tendons of the hand. For 20 years, they have been using vascularized tendon transfers either islanded or as free transfers. Their techniques are based on extensive knowledge of the sliding mechanisms involved around the flexor tendons, for which the authors have developed new scientific explanations resulting from their observations and the fine analysis of movements. This sliding system has a multimicrovacuolar, multifibrillar architecture that is able to accommodate every request for movement. By performing vascularized transfers, the authors also transfer the sliding capability together with the tendon itself, thereby avoiding the two traditional stages of tendon reconstruction. Results are better than with the traditional techniques and the gain in time is considerable. Moreover, the biological and physical advantages of transferring living structures are such that the functional outcome in secondary interventions is much better. Furthermore, the wide variety of transfers available offers possibilities for reconstruction that are better suited to the range of presentations encountered in this challenging area of surgery. This new approach to reconstruction is reserved for complex clinical cases and experienced surgeons.

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At the end of the seventy, we saw the reconstructive microsurgery developed to such an extent that it became a new and an independent surgical specialty. The development of the microsurgical instrumentation and the description of the surgical anatomy allowed the application of this technology to the most complex plastic reconstructions and particularly to the replantation of the amputated digits, especially the very distal digital amputations. Nowadays, the indications of digital replantation are well-defined according to numerous parameters conditioning the anatomical result and the functional outcome. It is well-known that the replantation of the amputated digit should be realized as soon as possible with optimal conditions of digital hibernation during the patient transport. In spite of that technical progress, the failure rate is still relatively important. The causes are sometimes recognizable and connected to technical defection, such as a non permeable vascular anastomosis, bad hemodynamics conditions or an insufficient anticoagulation, while in certain cases, the digital ischemia occurs in spite of permeable and technically successful arterial anastomosis. We then consider a "no reflow phenomenon". It corresponds to the constitution of vascular microthrombi which will block the arteriolar network. Those microthrombi are inaccessible to the microsurgical techniques and their treatment remains medical by intra-arterial infusion of antithrombotic agents. Through our series of fifteen digital replantations, having suffered a "no reflow phenomenon", we are going to present the fibrinolytic protocol we used and the promising results we obtained. All our patients were victims of traumatisms associating avulsions and crush injuries mechanisms. The conditions of preservation of the amputated digits were all quite unfavourable: 1) the amputated digit soaked in water in 5 cases; 2) the amputated fingers underwent a long-term "warm ischemia" in three cases, going up to 13 hours for one of them; 3) the amputated digits were completely frozen in six cases; 4) and one amputated finger was correctly hibernated but for too long a period (8 hours). The signs of ischemia appeared very prematurely in the first minutes after the microvascular revascularisation in ten cases, and in average within three hours postoperatively in the other five cases, with extreme cases going from 2 up to 6 hours. As soon as the diagnosis of "no reflow phenomenon" was confirmed, an intra-arterial catheter was fixed. The radial axis was chosen as the arterial infusion way and approached at the level of the pulse groove. The antithrombotic protocol included a flash of 50,000 UI of urokinase, 36 ml of lidocaïne 1% and 40 mg of enoxaparine, followed by an electric syringe infusion the first six hours with 150,000 UI of urokinase, 36 ml of lidocaïne 1% and 40 mg of enoxaparine at 6 cc/h speed. The urokinase was then interrupted but the intra-arterial infusion maintained with 72 ml of lidocaïne 1% and 80 mg of enoxaparine for 24 hours, at a 3 cc/h speed, and this for ten days. In 12 cases, the "no reflow phenomenon" was able to be raised and the digital vascularization restored. The success rate is very encouraging (80%) and it turns this protocol into a precious ally of the digit replantation microsurgery and an effective therapeutic means way against the "no reflow phenomenon".

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The authors report a new cutaneous flap harvested from the dorsal and distal quarter of the forearm: the dorsoradial flap. The vascularisation type of the cutaneous paddle belongs this flap to the anterograde and axial family flaps. The anatomical study carried out on thirty six fresh cadaver upper arms showed a constant and a consistent cutaneous collateral branch of the radial artery which arises at the apex of the first intermetacarpal space. Two anatomical types were recorded according to the origin of the dorsoradial artery: type I (84% of cases), the vessel arises directly from the radial artery; type II (16% of cases), it arises from a common trunk with the first dorsal intermetacarpal artery. Those anatomical findings does not influence the flap operative technique, the flap design and the location of the pedicle pivot point. The dorsoradial artery emerges vertically from the apex of the first intermetacarpal space, crosses the angle between the extensor pollicis longus tendon laterally and the extensor carpi radialis longus tendon medially and turns proximally towards the distal radio-ulnar joint. Over the dorsal aspect of the wrist, the dorsoradial artery enters the subcutaneous tissue, runs parallel to the extensor pollicis longus tendon at three millimeters in a medial position, passes over the medial collateral branch of the superficial radial nerve and irrigates all the distal and dorsal quarter of the forearm. The artery is consistently accompanied by two comitantes veins, which assume the venous drainage of the cutaneous territory. The flap paddle is designed over the distal dorsal forearm quarter, between the dorsal crease of the wrist distally, the ulnar crest medially and the radial crest laterally. All this skin territory can be harvested and supplied by the dorsoradial pedicle, but we always should deal with the needs of the defects reconstruction and the morbidity of the donor site. The vascular pedicle is outlined between the distal radio-ulnar joint and the apex of the first intermetacarpal space with a minimum of one centimeter width. The surgical procedure is carried out under a tourniquet without an upper arm exsanguination. The skin is firstly dissected over the vascular pedicle through an S shape incision; it is lifted on the dermo-hypodermis plan preserving all the superficial venous network with the pedicle. The flap is elevated from proximal to distal including the dorsal forearm fascia. Over the dorsal extensor retinaculum, the dissection is underwent close to it elevating all the subcutaneous tissues. The medial collateral branch of the superficial radial nerve should be identified and respected. At the distal border of the dorsal retinaculum, the extensor pollicis longus and the extensor carpi radialis longus tendons are identified and retracted. The pedicle dissection goes deeper between this two tendons towards the first web space. It takes all the areolar tissue around the pedicle in order to preserve the venous network of the cutaneous paddle. The donor site is closed primarily if the skin width does not exceed 3 cm or grafted secondarily. Its large rotational arc allows the cutaneous paddle to cover the dorsal hand and metacarpo-phalangeal long fingers defects, the dorsal aspect of the thumb and the first intermetacarpal space. It can also safely reach the palmar aspect of the wrist. We report four clinical cases where the dorsoradial flap was successfully applied. This preliminary clinical experience exhibits the vascular network reliability and the operative technique simplicity of this new cutaneous flap. We believe that it should be added to the armamentarium of the reconstructive hand surgeon and considered as a useful tool for soft tissue hand and thumb reconstruction defects.

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The Omega "Omega" pulley plasty: a new technique for the surgical management of the De Quervain's disease. The De Quervain tenosynovitis is an inadequacy into the first extensor compartment between the osteo-fibrous tunnel and the tendons. This mechanical conflict generates a tenosynovitis of the extensor pollicis brevis and the abductor pollicis longus tendons. This is generally expressed by a tenderness on the radial side of the wrist over the radial styloid process. The medical management consists on corticoids infiltrations of the first extensor compartment, the avoidance of repetitive and stress movements of the first ray with the use of a rest splint. The surgical approach is considered with the recurrence of the painful symptoms. This well-known pathology is reputated to require a simple section of the pulley. Our post-operative complications have been reported in the literature of this classical surgical solution. These complications concern an incomplete release of the extensor pollicis brevis and the abductor pollicis longus tendons particularly when an extensor sub-compartment exists and was overlooked, an irritation of the collateral branches of the sensitive radial nerve or the occurrence of a nevroma after a nerve injury and the most serious complication is a palmar subluxation of the extensor tendons which can occur with the thumb extended and the wrist flexed. In rare cases, this subluxation can be really painful and requires a surgical management with secondary reconstruction of the pulley. This reconstruction necessitates distal pedicle flaps from the dorsal retinaculum or the brachioradialis tendon. To prevent these complications, Codega and Kapandji described techniques of reconstruction of the pulley after its release. More recently, Le Viet reported a procedure using the anterior flap of the pulley; fixed to the dermis it will work as a barrier and maintain the tendons sliding on the radial styloid groove. These techniques require to divide the pulley and to reconstruct it suturing the different flaps. It can generate adherences between the extensor tendons, the overlying skin and the collateral branches of the radial nerve. The authors present a new and original plasty procedure of the first extensor compartment pulley, the "Omega" Omega plasty. It consists to liberate the anterior attachment of the pulley over the anterior lip of the styloïd process respecting its continuity with the periosteum flap. This conservative procedure is very interesting; it permits enough expansion of the tunnel volume decompressing the extensor tendons as a treatment of the De Quervain disease and respecting the anatomy and the continuity of the osteo-fibrous tunnel. This technique is simple, reliable and respects the first ray extensor tendons gliding physiology and biodynamic. In spite of our short clinical experience with only ten cases, all the patients retrieve a normal function of the thumb with complete disappearance of the first ray tenderness and pain without any complications. These preliminary results are encouraging and push us to consider the "Omega" plasty as a first choice for the surgical treatment of the De Quervain tenosynovitis.

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The authors report a new technique of pulley plasty of the flexor digital system. It is not an operative procedure to reconstruct a damaged pulley but an original way to expand the volume of an intact pulley in order to adapt its volume to the diameter of the repaired flexor tendon. The flexor tendons ruptures in Verdan zone II and particularly in Tang zones IIA and IIB are often accompanied by an osteofibrous tunnel injury. Initially, the tendon sheath closure was advised after tendons repair. This sheath recovery had to have an effect on tendons nutrition by establishing the synovial cavity continuity and particularly to protect the tendons from adhesions formation. The closure of the digital tube was rapidly shown to be unnecessary creating an obstacle to the tendons movements without any effect on tendons healing. In primary tendon management, the tendon repair is associated with an increase of the tendon diameter. An incongruence appears with the surrounding digital tube with gliding resistance complicating the tendon injury recovery. In secondary tendon injury management, the flexor digital tube is subject to healing and inflammatory process. This situation with the absence of the flexor tendon generates a retraction with a collapse of the digital tunnel over the injured area. This incongruence between the repaired flexor tendons and the narrowed digital tube required a release of the retracted zone to restore an adequate volume. The only way reported is the "Venting" of a part or the total length of the pulley. This procedure even if it resolves the tendon gliding resistance, is still unacceptable. Indeed it destroys an important anatomical structure of the flexor tendon dynamic system. The flexor pulley Omega plasty "Omega" consists in releasing the lateral palmar attachment of the pulley enhancing its internal volume and increasing the flexor tendon gliding area. The digital tube is composed by the succession of five annular and three cruciform pulleys. The cruciform pulleys are thin and flexible. They retract during the digital flexion assuring the continuity of the digital tube, while the annular pulleys are thicker and fill a biomechanical function. There are two types of annular pulleys: the joint pulleys as A1, A3 and A5; they are attached to the palmar plates of the MP, PIP and DIP joints respectively. During the digital movement, they retract approximately 50% of their length. The osseous pulleys as A2 and A4 are fixed over the lateral and palmar borders of the first and the second phalanx respectively. It is on these pulleys that the Omega plasty is practised. The operative procedure is simple. It consists on a periosteal dissection over the one lateral border of the phalanx. The liberation is undergone palmarly releasing the lateral attachment of the pulley. It respects the anatomical continuity of the pulley and its mechanical properties. Indeed, the continuity of the pulley is fully respected with the periosteal flap of the digital tube floor maintaining sufficient attachment to the pulley to resist to the flexor tendon forces. The level of the flexor tendon injury and the digit position during the initial trauma will determine the level of tendon resistance and where the pulley plasty must be made. If the flexor zone II injury occurred with the digit in an extension position, the tendon conflict appears with the A2 pulley, while it arises with the A4 pulley if the digit was in flexed position. The Omega plasty creates the ideal conditions for an optimal flexor tendon movement recovery. It is a simple and a reproducible procedure. It doesn't distort the mechanical properties of the pulley and the digital tube. We used this pulley Omega plasty fifteen times in twelve patients. In 60% of the cases, the injury concerned the dominant hand, and in 67% of the cases, it was a work accident. In eight of our cases, the omega plasty was done in emergency at the same time of flexor tendon repair, while in the other seven cases, the pulley Omega plasty accompanied the late flexor tendon repair forgotten during the initial trauma management. In ten cases, the plasty concerned the A4 annular pulleys, while in the other five cases, it concerns the A2 annular pulleys. Four cases necessitate a secondary tenolysis three months after the tendon repair. Two patients moved out and cannot be included in our results. On the thirteen-remainder cases, nine retrieved a full digital flexion particularly those who underwent digital tenolysis, while the other four cases retrieved a satisfying digital function in spite of the partial DIP flexion. In our hand, the pulley Omega plasty "Omega" becomes almost a systematic procedure in conjunction with the flexor tendon repair. It offers the ideal conditions for a tendon healing and a physiological flexor tendons motion recovery.

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The mobility of our body structures is so intrinsic and natural to us that we tend to take it for granted. The very fact of being able to pinch your skin and lift it, then let it go and see it return to its initial shape and texture in just a few seconds may seem banal enough until you begin to think of all the elements involved. The same is true when you bend your fingers and think of the movement of the flexor tendon across the palm without external translation. For decades, scientists thought that the skin was simply an elastic structure with loose connective tissue and a more or less virtual space. However, in biomechanical terms, this explanation is very vague. These old concepts developed more than 50 years ago have evolved thanks to the impact of research at the microscopic level, and the global, mesospheric concept has been abandoned. And yet, surgical dissection in vivo demonstrates that there are only tissue connections, simply a histological continuum without any clear separation between skin and hypodermis, the vessels, the aponeurosis and the muscles. In fact, visible everywhere are structures, which ensure a gliding movement between the aponeurosis, the fat structures and the dermis. As they studied this system of gliding between the various organs, in particular at the level of the tendons, the authors noted the existence of a type of system composed of cables and veil-like structures that they term the Multimicrovacuolar Collagen Dynamic Absorption System (MCDAS). This system looks totally chaotic in organization and seems to function in a manner far removed from traditional mechanical structures. The functional unity of this sliding system is dependent upon a polyhedral three-dimensional crisscrossing in space of the microvacuoles, whose collagen envelope is type 1 or type 4 and whose content is made up of proteoglycoaminoglycans. The dynamic of this multimicrovacuolar system allows all of the subtle movements that occur within the body, thanks to its pre-stressed nature and the molecular fusion-scission-dilacerations that it is capable of. In this way, the system is mobile, can move quickly and interdependently, and is able to adapt is plasticity. This notion of microvacuoles is a fascinating one because it provides an explanation for the system's space-filling ability. The matter is composed of elements. However, although they seem to be arranged in a haphazard manner, this is not the case. In fact, they occupy space in an optimal manner. If we accept this notion of microvacuoles, then it becomes possible to explain certain pathologies occurring with age, such as edema, obesity, aging and inflammation. This sliding system is to be found everywhere in the body and would seem to be the basic network of tissue organization. For this reason, it should be thought of in global terms. Since it constitutes the inseparable link and occurs in all living structures and at many levels, could it be that it the basic architectural design of Life?

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We present two clinical cases with complete amputation of multiple digits that were salvaged after having been successfully implanted on ectopic sites. The first case concerns a 73-year-old patient, who suffered a severe crush injury of his right hand that resulted in amputation of all four long fingers and an extensive tissue loss of the palm and the dorsum of the hand. Two of the amputated digits, that were considered to be replantable, were implanted on the dorsum of the left foot. The hand defect was covered with a pedicle groin flap. After six weeks, the two ectopically implanted fingers were transferred to their proper anatomical site. Several reconstructive procedures were performed later, in order to lengthen the first ray of the injured hand, and to deepen the first web space. Satisfactory functional results were recorded after eighteen months of follow-up. The second patient concerns a 45-year-old male patient, who had a gun shot accident of his right hand. The injury resulted in a composite tissue loss of the hand with complete amputation of his four long fingers. All fingers were implanted on the left forearm, while the hand defect was reconstructed using an osteocutaneous free flap of the iliac crest. Six weeks after the initial procedure, the ectopically implanted digits were transferred - as a single free flap - to the hand. We described with details the local conditions of the injured hands in both cases, and discuss the reasons we decided to perform this sophisticated method in order to preserve the viability and function of those totally amputated fingers. The recipient sites were selected in a distance from the injured area, always considering the availability and size of appropriate recipient vessels, and the safety of the surgical procedure. We agree that the whole concept of this procedure is very demanding, and requires several microsurgical operations with high risk of complications. However, it does deserve special consideration in reconstructive microsurgery, since it offers the possibility to salvage multiple amputated digits, by preserving the anatomy and restoring the function of severely injured hands.

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In the present article, the authors describe a new chondrocutaneous island flap from the ear helix for nose reconstruction. Anatomic studies showed that helix vascularization depends mainly on the superficial temporal vessels. The presence of vascular communications between the anterior frontal branch of the superficial temporal system and the supraorbital and supratrochlear arterial systems allows this flap to be used in a reverse vascular flow fashion. This new flap has been used successfully in seven cases for reconstructing composite defects of the nasal tip and ala. The donor-site defect is repaired with an advancement and rotation flap from the helical rim, leaving an inconspicuous scar and giving an acceptable cosmetic result of the donor area.

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The authors describe a new chondrocutaneous reverse island flap from the ear helix for nose and eyelid reconstruction. Anatomic studies showed that the blood supply of the helix is derived from the superficial temporal system. The presence of vascular communications between the anterior frontal branch of the superficial temporal artery and the supra-orbital and supra-trochlear arterial systems allows this flap to be used in a reverse vascular flow fashion. Three flaps have been successfully used for reconstruction of alar and nose tip defects and in one case for total lower eyelid reconstruction. The donor site is repaired with an advancement and rotation flap from the helical rim giving an acceptable result. In this paper, the authors propose a new pedicle flap for reconstruction of complex nose and eyelid defects.

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The dorsal digitometacarpal flap or extended distal pedicled dorsal metacarpal flap is a new skin flap, useful in reconstructing large distal defects on the dorsal aspect of the digits. It is raised on the dorsum of the hand, over an intermetacarpal space. Its vascularisation is provided by proximal dorsal cutaneous branches of the digital collateral arteries through the rich, anastomotic arterial network of the webspace. This flap is a useful flap compared to others flaps harvested from the dorsum of the hand, such as the reverse metacarpal flaps. The operative procedure preserves the dorsal interosseous muscles aponeurosis, the junctura tendinum and the dorsal metacarpal artery. Its vascularisation depends on the webspace arterial network; it is constant contrary to the dorsal metacarpal arteries of the ulnar spaces. This flap is indicated to cover distal defects on the dorsum of the digits because of its large rotation arc. The anatomical basis and operative technique of the flap are described. Two out of 22 clinical cases were selected to illustrate the ability of this flap for reconstruction of digital defects.

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Reverse dorsal digital and metacarpal flaps use the dorsal skin of the digital or metacarpal areas, and they are based on the arterial branches anastomosing the volar and dorsal arterial networks of the fingers. These flaps are transposed as reverse island flaps. Dissection of the flap is easy, fast, and preserves the collateral nerve and artery to the fingertip. A series of 27 flaps is reviewed, with more than 6 months of follow-up. Skin defects in all patients were located over or beyond the proximal interphalangeal joint as far as the fingertip and were combined with bone, joint, or tendon exposure. The flaps we used were reliable, and a joint or extensor tendon reconstruction could be performed at the same time. Patients were discharged the day after surgery and allowed to mobilize the finger early. No flap necrosis was observed, and donor site morbidity was minimal; primary closure or a skin graft was used in all patients. These flaps combine the advantages of an extended skin paddle and a versatile pivot point on the phalanx, and they allow coverage of wide and distal defects. When conventional local flaps are inadequate, this fast and simple procedure should be considered for its reliability and low associated morbidity.

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The author describes an original and new method to lengthen the fingernail plate in distal digital amputation. After digital amputation, the loss of substance concerns the pulp tissue and fingernail apparatus. Generally, most palmar falp techniques can restore functional and aesthetic pulp. The fingernail defect is obviously not tolerated by the patient and needs to be corrected. The eponychial flap is a backward cutaneous translation flap. This flap lengthens the nail plate and restores normal dimensions of the nail apparatus. Two clinical cases are reported. This technique should be reserved for reconstruction of stage I and II distal digital amputations.

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