A Brief Historical Review of Flaps and Burn Reconstruction

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Author(s): 
Mayer Tenenhaus, MD, FACS;1 Linda A. Lukacs, BS, DDS;1 Rei Ogawa, MD, PhD;2 Hans-Oliver Rennekampff, MD3

“We are like dwarfs sitting on the shoulders of giants. We see more, and things that are more distant, than they did, not because our sight is superior or because we are taller than they, but because they raise us up, and by their great stature add to ours.”

                         —John of Salisbury, 1159 AD

Classic Examples of Flap and Burn Reconstruction

Perhaps one of the earliest and most notable flap reconstructive descriptions can be found in the Sushruta Samhita. Thought to have been written around 600 BC, it contains an excellent description of the reconstruction of a nose using a series of flaps, which were derived from the face and cheek.1,2 The subsequent evolution of this nasal reconstruction methodology ultimately developed into a routinely employed series of well defined stages based on the ascending axial supratrochlear vessels, now generally referred to as the median forehead flap (Figure 1).

Antonius Branca, and later Gaspare Taglicozzi (1546–1599), formulated and developed the concept of tubed and pedicled flaps.2 These flaps utilized defined patterns of delay to improve vascularity and reliability of transfer, enabling the transfer of tissue from the upper arm to reconstruct the nose (Figure 2).

Further development of these staged transfers allowed tissue to be transferred to ever more distant sites by “waltzing” the flap from recipient site to recipient site. An appreciation for flap contracture, vascular pedicle kinking, and prefabrication is described well in the description of these procedures. Examples of modern helical rim (ear) reconstructions continue to employ this methodology (Figure 3).

References: 

1.     Bhishagratna KK. The Sushruta Samhita: An English Translation Based on the Original Sanskrit Text, vol 1. PX1 Varanasai India: Chowkhamba Sanskrit Series; 1963.
2.     Brain DJ. The early history of rhinoplasty. Facial Plast Surg. 1993;9(2):81–88.
3.     Hallock GG. A history of the development of muscle perforator flaps and their specific use in burn reconstruction. J Burn Care Rehabil. 2004;25(4):366–371.
4.    Gabka J, Vaubel E. Plastic Surgery Past and Present: Origin and History of Modern Lines of Incision. New York, NY: Karger, 1983:106.
5.     Heslop J. The Murray Clarke Oration: A brief history of burn treatment and the contribution of four New Zealand pioneers of plastic surgery. ANZ J Surg. 1998;68(10):746–751.
6.     Mills SM. Burns down under: lessons lost, lessons learned. J Burn Care Rehabil. 2005;26(1):42–52.
7.     McGregor IA, Jackson IT. The groin flap. Br J Plast Surg. 1972;25(1):3–16
8.     McCraw JB, Dibbell DG, Carraway JH. Clinical definition of independent myocutaneous vascular territories. Plast Reconstr Surg. 1977;60(3):341–352.
9.     Pontén B. The fasciocutaneous flap: its use in soft tissue defects of the lower leg. Br J Plast Surg. 1981;34(2):215–220.
10.    Germain MA, Legagneux J. Vascular microsurgery and progress of free flap surgery. Ann Chir. 2001;126(10):960–968.
11.    Seidenberg B, Rosenak SS, Hurwitt ES, Som ML. Immediate reconstruction of the cervical esophagus by a revascularized isolated jejunal segment. Ann Surg. 1959;149(2):162–171.
12.    Al-Shammari S, Gupta A. Revascularization of the digits and palm. Hand Clin. 2001;17(3):411–417.
13.    McLean DH, Buncke HJ Jr. Autotransplant of omentum to a large scalp defect, with microsurgical revascularization. Plast Reconstr Surg. 1972;49(3):268–274.
14.    Daniel RK, Taylor GI. Distant transfer of an island flap by microvascular anastomoses: a clinical technique. Plast Reconstr Surg. 1973; 52:111–117.
15.     Nakajima H, Fujino T, Adachi S. A new concept of vascular supply to the skin and classification of skin flaps according to their vascularization. Ann Plast Surg. 1986;16(1):1–19.
16.     Song YG, Chen GZ, Song YL. The free thigh flap: A new free flap concept based on the septocutaneous artery. Br J Plast Surg. 1984;37(2):149–159.
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18.     Morris SF, Taylor GI. Predicting the survival of experimental skin flaps with a knowledge of the vascular architecture. Plast Reconstr Surg. 1993;92(7):1352–1361.
19.    Neuman CG. The expansion of an area of the skin by progressive distention of subcutaneous balloon. Plast Reconstr Surg. 1957;19:124.
20.    Radovan C. Tissue expansion in soft-tissue reconstruction. Plast Reconstr Surg. 1984;74:482.
21.     Cherry GW, Austad E, Pasyk K, McClatchey K, Rohrich RJ. Increased survival and vascularity of random-pattern skin flaps elevated in controlled, expanded skin. Plast Reconstr Surg.1983;72(5):680–687.
22.     Sasaki GH, Pang CY. Pathophysiology of skin flaps raised on expanded pig skin. Plast Reconstr Surg. 1984;74(1):59–67.
23.     Foyatier JL, Comparin JP, Boulos JP, Bichet JC, Jacquin F. [Reconstruction of facial burn sequelae]. Ann Chir Plast Esthet. 2001;46(3):210–226.
24.     Spence RJ. An algorithm for total and subtotal facial reconstruction using an expanded transposition flap: a 20 year experience. Plast Reconstr Surg. 2008;121(3):795–805.
25.     Tsai FC. A new method: perforator-based tissue expansion for a preexpanded free cutaneous perforator flap. Burns. 2003;29(8):845–848.
26.     Masser MR. The preexpanded radial free flap. Plast Reconstr Surg. 1990;86(2):295–301.
27.     Kenney JG, DiMercurio S, Angel M. Tissue-expanded radial forearm free flap in neck burn contracture. J Burn Care Rehabil. 1990;11(5):443–445.
28.     Laitung JK, Batchelor AG. Successful preexpansion of a free scapular flap. Ann Plast Surg. 1990;25(3):205–207.
29.     Balakrishnan C. The preexpanded radial free flap. Plast Reconstr Surg. 1991;88(1):171.

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