An Evolutionary Perspective on the History of Flap Reconstruction in the Upper Extremity

Frank Fang, MD and Kevin C. Chung, MD, MS∗kecchung@med.umich.edu,     Section of Plastic Surgery, Department of Surgery, The University of Michigan Health System, 2130 Taubman Center, SPC 5340, 1500 East Medical Center Drive, Ann Arbor, MI 48109-5340, USA

∗Corresponding author.

Examining the evolution of flap reconstruction of the upper extremity is similar to studying the evolution of biological species. This analogy provides a perspective to appreciate the contributing factors that led to the development of the current arsenal of techniques. It shows the trajectory for the future and provides a glimpse of the factors that that will be influential in the future.

Keywords

Upper extremity

Flap reconstruction

History

Key points

• The evolution of flap reconstruction of the upper extremity can be summarized in the format of a phylogenetic tree.

• The history of upper extremity flap reconstruction can be organized into 5 major eras.

• In the nineteenth and early twentieth centuries, progress in upper extremity flap reconstruction followed the breakthroughs in head and neck reconstruction.

• From the 1990s to the present time, flap reconstructive techniques have been developed that are unique to the upper extremity.

Introduction

Studying the development of flap reconstructive modalities of the upper extremity is similar to tracking the evolution of a species from its precursors. Similar to how a species evolves a niche because of environmental factors and resources that are present, the techniques of upper extremity flap reconstruction have developed primarily in response to 3 factors: trauma generated by the maiming insults of war and industry, knowledge exchange, and technology. This article presents this story from an evolutionary perspective that guides the reader through the development of each class of upper extremity flap reconstruction from the roots in ancient time to the distal branches of recent time. Readers should note the consistent theme of derivation from head and neck reconstructive methods that characterizes the early years of upper extremity flap reconstruction. This story organizes into 5 eras of time (Fig. 1). The period from antiquity to the Industrial Revolution (∼1760–1820) is notable for bringing core anatomic knowledge, early principles of plastic surgery, and improvements in trauma care. The next time period spans the 1800s through the end of World War I and is most notable for key scientific breakthroughs and the propagation of plastic surgery. The following time period that is discussed is the interwar period through the end of World War II. The first Great War had generated a huge reconstructive case volume that catalyzed the maturation of plastic surgical reconstruction of the head and neck. The first applications of these plastic surgical principles to the hand after World War I marked the arrival of a new specialty: hand surgery. The next time period, the post–World War II era, is most notable for trauma from modern tools. This time period continues with an evolution upper extremity flap reconstruction that lags slightly behind that of head and neck reconstruction. Microvascular surgery also arrives during this era. It is not until the fifth time period (1990s–2010s) when flap reconstruction in the upper extremity takes a unique course of development by combining reconstructive principles in a way not yet seen before on other parts of the body. This most recent time is also notable for the impact of evidence-based medicine in guiding the implementation of techniques that are available.

Antiquity to the Industrial Revolution

Early Antiquity: Accumulation of Core Anatomic Knowledge and the Initial Principles of Plastic Surgery

The evolution of the specialty of plastic surgery and basis for upper extremity flap reconstruction begins in antiquity. Early Indian and Greek cultures showed enormous potential for advancing plastic surgery. Susruta of India (∼1000–800 bc) described a regional pedicled flap for the nose in Samahita. Significant anatomic discoveries occurred in ancient Greek and Roman civilizations. Herophilus of Chalcedon (c. 250 bc) performed the first scientifically documented human cadaver dissections in Alexandria, Egypt (the only academic arena in ancient Greece where cadaver dissections were legal). Galen (131–221 ad) of the subsequent Roman culture described muscular anatomy from a perspective that was based on both his interpretation of Herophilus’ records and also his dissections of animals. During Roman times, Celsus (25 ad) and Oribasius (325–403 ad) described random circulation pedicled flaps and local tissue rearrangements for the lips, nose, ears, and forehead. This era had all of the critical factors that would drive the accelerated course of evolution of upper extremity flap reconstruction seen during the early twentieth century (anatomic investigation, surgical technique innovations, and trauma from war). However, because of the language and communication barriers of this time period, the early techniques of plastic surgery during Indian and Greek cultures developed in parallel and never combined to yield an even greater advancement. The collapse of the Roman Empire ushered in the Dark Ages of Europe. This period of time is marked by frequent warfare and a virtual disappearance of urban life, bringing plastic surgery development to a standstill. Henceforth, no similar skin flap work was recorded for many centuries.

Antiquity (After the Dark Age): Rediscovery and Progress in Anatomy and Plastic Surgical Technique

The early medieval period of Europe is marked by retracing and building on the discoveries of early antiquity. Anatomic discovery, which had remained stagnant from the time of Galen’s reports until exploration resumed in the twelfth to thirteenth centuries, resumed with the University of Bologna (Italy) group of anatomists. Ugo Borgognoni of Lucca and his son Theodoric of Cervia conducted human cadaver dissections on executed criminals. This practice was acceptable at the University of Bologna because it was not affiliated with the Catholic Church. Guglielmo da Saliceto (1210–1277 ad) described motor nerves for the first time. Mondino de Liuzzi (1270–1326 ad) was the first anatomist to inject colored liquids into blood vessels, a method that made study of the circulatory system possible; investigators used variants of this technique in the nineteenth and twentieth centuries to define the vascular supply of flaps elevated for reconstructive surgery. In the 1400s, European surgeons rediscovered the flap techniques of ancient India. Gustavo Branca of Italy began using the locoregional forehead flap technique of Susruta for the nose. There is speculation that the original Indian texts of Susruta had been translated to Arabic, which ultimately traveled to Italy and the Brancas. This development marked what was likely the first international exchange of technical knowledge; one of the major factors affecting the evolution of upper extremity flap reconstruction. The exact details and dates are uncertain because the Brancas were very secretive.1 Gustavo Branca’s son Antonio began using a distant flap reconstruction for the nose as harvested from the arm, which is the first documented use of the upper extremity as a donor site for flap reconstruction. The Vianeo brothers of Calabria and Heinrich von Pfolsprundt (c. 1450) of Germany also used this technique for distant flap reconstruction of the nose. Gaspare Tagliacozzi (1545–1599), a professor of anatomy and surgery at the University of Bologna, finally published the technique with hopes of distributing it widely. However, the surgical community of that era did not embrace his technique, and the use of skin flaps died away again in the Western world. However, despite another stagnation in evolution of plastic surgical technique, anatomic knowledge relevant to flap reconstruction advanced steadily. The use of the printing press during the fifteenth to sixteenth centuries allowed wide distribution of this knowledge. Upper extremity anatomic depictions made significant advances in accuracy with the work of the Renaissance scientist-artists Michelangelo Buonarroti (1475–1564) and Leonardo da Vinci (1452–1519). Berengario da Carpi (1460–1530) of the University of Bologna produced detailed depictions of both the abdominal musculature and upper extremity vasculature. Giovanni Battista Canano of Ferrara (1515–1579) produced excellent illustrations of muscles of the upper extremity in his Muscolorum Humani Corporis Picturata Dissectio.2 During this period, the Belgian anatomist Andreas Vesalius working in Padua published Humana Corporis Fabrica (1543), the accuracy and detail of which led him to become known as the...