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Perforator flaps have recently become ubiquitous in the field of plastic surgery. To understand and appreciate their unique nature, it is necessary to compare and contrast them with the development of other types of flaps. A complete yet abridged version of the history of flap surgery is presented in this article. Beginning with Sushruta's Indian cheek flap method for nasal reconstruction, a trip through time and space is taken to highlight the milestones leading to the evolution of the perforator flap. Random pattern skin flaps, axial pattern skin flaps, and musculocutaneous flaps are all discussed. Finally, the future of perforator flaps is presented.
Although many credit the horrific injuries of World War I and II with providing the stimulus for the beginning of plastic and reconstructive surgery, the roots of flap surgery can be traced back to an especially humiliating form of punishment rampant in India more than 30 centuries ago. In 1500 bce, Prince Lakshmana amputated the nose of Lady Surpunakha as punishment and consequently, King Ravana ordered its reconstruction.1 Although this is the first historical account of nasal mutilation, the first written description of the pedicled flap for the repair of amputated noses is found in the Sushruta Samhita.2 In Sushruta's landmark treatise, he described over 120 surgical instruments and 300 surgical procedures that were supposedly passed on from Lord Dhanwantri, physician to the gods.3 Describing a pedicled cheek flap for a nasal reconstruction, Sushruta wrote:
I now narrate the proper method of constructing a nose of one whose nose is mutilated. A careful physician having taken a plant leaf of the size of the nose of that person, and having cut adjoining cheek according to that measurement, and having scarified the nose tip should attach it to the nose tip and quickly join it with perfect sutures…When the healing is complete and the parts united, remove the excess skin. If the nose is smaller than required, try to increase it; if it is in excess, trim it. And thus was born the Indian cheek flap.
Though the Indians closely guarded this secret, medical knowledge was often shared with the Greeks, and both Hellenistic and Roman physicians later described reconstructive procedures mirroring the Indian methods. The Arabs later disseminated this knowledge to all of Europe with the occupation of Sicily during the 9th to 12th centuries. Unfortunately, the Church specifically condemned surgical procedures and brought a halt to surgical advances during the Middle Ages. With the birth of the Renaissance, however, the Branca and Boiani families of Italy revisited the Indian method and modified it by using a delayed skin flap from the forearm instead.iii A description of the procedure is as follows:
A flap is detached from the arm and cut in the form of a nose to be applied to the stump of a nose. They detach the skin from the arm with a bistoury, scarifying the nose, and attach the arm to the head, in such a manner that the two wounds are applied to one another. When union is perfect, they cut off with admirable skill, as much skin off the arm as necessary to form a nose.4
This method, popularized by Tagliacozzi's 1597 book De Curtorum Chirurgia per Insitionem (Surgery of the Mutilated by Grafting), came to be known as the “Italian method” for nasal reconstruction. Despite its early popularity, however, several misconceptions surrounding the nature of flap surgery prevented the Italian method from gaining wider acceptance.5
Two centuries passed before the reemergence of skin grafts and flaps in Europe. British Army surgeon Cully Lyon Lucas is credited with providing the stimulus for the revitalized interest in 1794. With a simple letter addressed to a Mr. Urban in the Gentleman's Magazine of London, Lucas described how an Indian bullock driver had his nose reconstructed with a forehead flap by a member of the brick maker caste after it was cut off by the sultan.4,6 English surgeon Joseph Carpue immediately took advantage of this technique and applied it to two British army officers who had undergone nasal mutilation. In 1816, he published “Account of Two Successful Operations for Restoring a Lost Nose” and subsequently renewed European interest in reconstructive flap surgery.1,3
More surgical advances were made with the development of anesthesia and aseptic technique. Reverdin was the first to describe his use of epidermal skin grafts to assist wound healing in 1869.4,7 As split-thickness and full-thickness skin grafts gained popularity, flap surgery continued to progress with the French using advancement flaps during this time period.8 Their knowledge was limited, however, because random flaps were raised without consideration of any known blood supply. Manchot published his pioneering work describing the arteries of the skin in 1889 and Salmon (1935) expanded these observations using radiopaque injection studies but unfortunately, both contributions went unrecognized in much of the English-speaking world.9,10 This led to the development of rigid length-to-width ratios for flaps to help ensure viability. A general rule was that the length of skin flaps was not supposed to be greater than 1.5 times the width.11 Even Captain Gino Pieri's design of new and more reliable flaps, based upon methylene blue dye injection studies of source and perforator arteries, did little to demonstrate the futility of such length-to-width ratios.12 It was not until Stuart Milton's work in the 1960s that this concept was properly challenged. Working on porcine skin flaps, Milton demonstrated that the reliability of a skin flap depended upon its vascularization.13,14 Long and narrow skin flaps could be safely raised as long as they were based on a known vessel.13 This led to McGregor and Morgan's classification of “axial” and random pattern skin flaps in the early 1970s.15
Axial pattern skin flaps, such as the groin flap, were based on large and distinct subcutaneous vessels with a predictable orientation.12,16 Just as these cutaneous flaps started gaining acceptance, however, attention shifted to the introduction of muscle and musculocutaneous flaps. Ger17 demonstrated the value of using muscle flaps for the treatment of leg ulcers and soon after, the first free muscle transfer was performed.18 With muscle and musculocutaneous flaps gaining such rapid momentum, it seemed as if any reconstructive problem could be addressed with these types of flaps. Unfortunately, these flaps were not without their own disadvantages and ways of reducing donor-site morbidity and unnecessary bulk were revisited.
In 1981, Ponten presented his experience with lower-limb “superflaps.” These flaps, which included the deep fascia, demonstrated that inclusion of the fascia conferred a survival advantage over random flaps of similar size.19 Known as the fasciocutaneous flap, subsequent studies led Cormack and Lamberty to state that “the fasciocutaneous flap specifically is supplied by arteries which pass along intermuscular and inter-compartmental fascial septa to reach the overlying deep fascia and in turn the superficial fascia and skin.”20 Such arteries, known as “perforators,” were focused upon by Koshima and Soeda in hopes of addressing the donor-site morbidity and bulk inherent with musculocutaneous flaps.
With a landmark publication in 1989, Koshima and Soeda21 described their use of a skin flap based upon a single paraumbilical perforator from the deep inferior epigastric artery. The subsequent skin flap was thin and left the rectus abdominis muscle intact. Allen and Treece22 followed suit and demonstrated the use of the deep inferior epigastric perforator flap for autologous breast reconstruction. Soon, perforator vessels throughout the body were being mapped out to design potential flaps. Confusion, however, set in as to the correct nomenclature for perforator flaps because such a vast number of flaps were being described simultaneously within the international literature. The deep inferior epigastric perforator flap alone was referred to by many names, including paraumbilical perforator flap, paraumbilical perforator-based flap, deep inferior epigastric perforator flap, deep inferior epigastric artery perforator flap, inferior epigastric artery skin flap without rectus abominis muscle, and deep inferior epigastric artery skin flap.23 Further controversy arose when some authors proposed to define perforator flaps as those based upon musculocutaneous perforators only.24 Although initial classification and nomenclature varied from author to author, there is now general agreement that three different perforator flap types exist: direct cutaneous, septocutaneous, and musculocutaneous.25
Further advances and controversies in perforator flap surgery will undoubtedly be influenced by the growth of supramicrosurgery, as described by Koshima and colleagues.26 Suprafascial free flaps, based upon the anastomosis of cutaneous vessels less than 0.8 mm in diameter, are harvested above the fascial plane and eliminate the need for lengthy, intramuscular dissections. Offering a decrease in operating time and virtual elimination of trauma to the muscle, the advantages of such flaps are enticing, but currently few surgeons possess the meticulous skill and technique necessary to use such flaps. Wei and Mardini27 described harvesting flaps based upon a perforator vessel being picked up preoperatively by a handheld Doppler probe. Such “freestyle free flaps” will undoubtedly expand our repertoire of donor sites because we will be able to dissect a flap from any region of the body as long as a preoperative Doppler signal is present. Matching texture, color, and density should not be an issue when we have such a wide range of donor sites available to us. Of course, none of this would be possible without the technological advances that allow us to perform microvascular anastomoses between vessels 1.0 mm, or less, in diameter. Finer instrumentation and suture material, better pharmacological agents, and more sophisticated flap monitoring devices have been the key to perforator flap success. But the success will not end here. Newer applications for perforator flaps are being developed as this issue of Seminars in Plastic Surgery is being published. The recent introduction of chimeric sentinel muscle perforator flaps for free-flap monitoring, local perforator flaps for lower extremity reconstruction, and perforator-to-perforator free flaps is simply the beginning. Based upon our past experiences, it is a safe bet to assume that we have simply scratched the surface when it comes to the use of perforator flaps.