Flaps, Flaps, Flaps: The Evolution Continues

Reconstruction in plastic surgery is almost synonymous with flap design. Flaps (a section of tissue supplied by its own vessel) are used all over the body—from lip and palate surgery to bone reconstruction. As early as 1500 BC, when King Ravana ordered the reconstruction of an amputated nose,[1] there was an idea that tissue could be redistributed to cover soft tissue defects with a better aesthetic outcome. The Greeks and Romans, then the Arabs shared these foundations of reconstruction with the whole European continent. Through World War I and II, reconstruction improved alongside modern science with better understanding of anesthesiology, antibiotics, and improved equipment. Over the past century, the description of flaps used in plastic surgery also evolved from random pattern flaps where vascular anatomy was vague, to axial pattern flaps where vascular anatomy was identified entering the muscle and musculocutaneous flaps.[2] With microsurgical techniques, these flaps provide reliable coverage for difficult wounds. However, the challenge continues to be a restoration of function while achieving the best possible normal. We also aim to provide the optimal result with a minimum number of operations, with attention to cost, and with shorter hospital stays. The reconstructive ladder has evolved into the reconstructive elevator to achieve these goals.[3] Concepts such as perforator flaps, propeller flaps, free style flaps, and perforasomes are components of this paradigm shift. This trend toward new flap design to achieve better solutions to difficult reconstructive challenges led to a discussion at the 2013 World Society for Reconstructive Microsurgery meeting “Achieving normal: The ultimate paradigm in reconstructive surgery.”

We are not only faced with extensive and complex defects, but also wounds that require small, delicate repair. The panel on “Flaps, flaps, flaps, fifteen new flaps” presented new ideas to reconstruct the defects and wounds of today. To cover large, extensive defects, a chimeric flap—where multiple tissues are combined by a single artery—was presented to maximize efficient use of recipient and donor pedicles.[4] Better understanding of the anatomy for an alternative flap to the anterolateral thigh, the anteromedial thigh flap, may help a surgeon shift to a quick Plan B.[5] A medial femoral condyle flap is a reasonable alternative to other, known bone flaps; this newly described flap provides a reconstructive solution to recalcitrant scaphoid nonunions.[6] To provide a flap with adequate volume for breast reconstruction, the profunda artery perforator flap and superior epigastric perforator flap have been described.[7] [8] To achieve the “best normal” without multiple revisions, especially in small wounds and defects, can be very challenging. Perforator flaps based on digital arteries, or small perforator flaps such as the medial plantar perforator flap, can provide ideal contours to the fingertip and other small wounds of the hand and foot.[9] Finally, a new plane of elevation was introduced to eliminate the need for debulking large flaps: the superficial fascia plane can be used safely in many perforator flaps.[10] In the future, using capillary-based perforator flaps may be a common reality.[11]

This panel, discovering and discussing new flaps to solve difficult reconstructive problems, will stand out in my memory as one of the most exciting. Our efforts to address long-standing problems in a more efficient and creative way are part of the ongoing evolution of microsurgical reconstruction. Pure creation is unusual to find in any field in modern times, but the evolution of flap design based on past wisdom is the Future of Flaps.

I personally thank Robert Walton for hosting an inspiring meeting and providing the forum to share our ideas and experience. I also thank Bernard Lee and his editing team for their efforts to communicate new ideas about flap design in this special edition of Journal of Reconstructive Microsurgery. Most of all, I thank the authors for their valuable contribution to the meeting, the field of reconstructive microsurgery, and their patients. It has been a privilege to edit this issue, and I look forward seeing new ideas, new flaps, new techniques—always stepping closer to the ideal reconstruction and the best possible normal.

• References

• 1 Nichter LS, Morgan RF, Nichter MA. The impact of Indian methods for total nasal reconstruction. Clin Plast Surg 1983; 10 (4) 635-647
• 2 Morris S. Perforator flaps: a microsurgical innovation. Medscape J Med 2008; 10 (11) 266
• 3 Gottlieb LJ, Krieger LM. From the reconstructive ladder to the reconstructive elevator. Plast Reconstr Surg 1994; 93 (7) 1503-1504
• 4 Kim SW, Youn S, Kim JD, Kim JT, Hwang KT, Kim YH. Reconstruction of extensive lower limb defects with thoracodorsal axis chimeric flaps. Plast Reconstr Surg 2013; 132 (2) 470-479
• 5 Yu P, Selber J, Liu J. Reciprocal dominance of the anterolateral and anteromedial thigh flap perforator anatomy. Ann Plast Surg 2013; 70 (6) 714-716
• 6 Higgins JP, Burger HK. Proximal scaphoid arthroplasty using the medial femoral trochlea flap. J Wrist Surg 2013; 2 (3) 228-233
• 7 Saad A, Sadeghi A, Allen RJ. The anatomic basis of the profunda femoris artery perforator flap: a new option for autologous breast reconstruction—a cadaveric and computer tomography angiogram study. J Reconstr Microsurg 2012; 28 (6) 381-386
• 8 Hamdi M. Oncoplastic and reconstructive surgery of the breast. Breast 2013; 22 (2, Suppl 2): S100-S105
• 9 Koshima I, Nanba Y, Tsutsui T, Takahashi Y. Medial plantar perforator flaps with supermicrosurgery. Clin Plast Surg 2003; 30 (3) 447-455 , vii
• 10 Hong JP, Chung IW. The superficial fascia as a new plane of elevation for anterolateral thigh flaps. Ann Plast Surg 2013; 70 (2) 192-195
• 11 Koshima I, Narushima M, Mihara M , et al. New thoracodorsal artery perforator (TAPcp) flap with capillary perforators for reconstruction of upper limb. J Plast Reconstr Aesthet Surg 2010; 63 (1) 140-145