1.3 Pedicled Flaps

For a long time, head neck defects have been repaired with local rotation flaps or with free skin grafts, not considering rehabilitation or esthetic result important.

The first step in the development of reconstructive technique could be recognized in the use of pedicled flaps (fasciocutaneous or fascio-myocutaneous).

The first report about a pedicled flap was described by Tansini in 1886: he used a pedicled latissimus dorsi flap for a thoracic reconstruction. Time has to pass by to see the first application of the same latissimus dorsi flap for reconstruction in the head and neck area, as described by Quillen in 1978 [2].

Another pedicled flap, among the first that have appeared in the history of reconstructive head and neck techniques, is the temporalis muscle flap. Described by Golovire in 1898 [3], it was subsequently taken up by several authors in the 1970s with various applications, from facial paralysis rehabilitation to reconstruction of skull base defects.

In 1963, McGregor [4] first introduced a forehead flap for reconstruction of oral defects and in 1965, Bakamjian first described the deltopectoral flap [5]. These last two flaps had been the gold standard for most head and neck reconstructions in the 1960s and 1970s, before the introduction of myocutaneous flaps, which carried the great advantage of the immediate reconstruction since autonomization of the flap was not needed. This technical achievement avoided long hospitalization and multiple surgeries on the same patient.

Conley was the first to report use of the trapezius pedicled flap incorporating the muscle and bone in 1972 [6]. Ariyan (1979) [7] and McCraw and Dibbell (1976) [8] popularized the flap design that we now refer to as the superior trapezius flap, which is an extension of Conley’s original work.

Design and successful application of other pedicled cutaneous and myocutaneous flaps arose, such as the pectoralis flap. The discovery that each vessel nourishing the skin comes from arteries within the muscle led to the intuition that the transfer of the muscle and its vascular pedicle could include the overlying skin, creating a myocutaneous flap. The first uses are reported in 1947 when Pickerel [9] et al. used the pectoralis myocutaneous flap for the reconstruction of thoracic defects. Subsequently, in 1979, Ariyan recognized the tremendous potential of the musculocutaneous unit based on the pectoralis major for the reconstruction of a high number of wide head and neck defects. The pectoralis myocutaneous flap was considered the “workhorse” flap of head and neck reconstruction during the 1970s.

Pedicled flaps shortly became the first-choice reconstructive flaps being easy and quick to harvest, as they do not require a multi-team for the preparation or dedicated instrumentation. Moreover, they provide a good volume of reconstruction with overall low morbidity.

1.4 From Pedicled to Free Flaps

On the other hand, some limits of the pedicled flaps, such as the limited length of the vascular pedicle and the need of a pliable and thin flap in some cases, contributed to the search of new reconstructive strategies.

From the late 1960s to the early 1980s, the need for a more “tailored” surgery, the study of new body segments that can be used for the transfer of even composite flaps, as well as the increasing confidence with vascular mapping in different anatomic sites (especially thanks to Nahai and Mathes during the 1970s), were the major factors that led to a new era in reconstructive surgery: the introduction of free flaps.

1.5 Microsurgery

The spread of free flaps is necessarily intertwined with the development of the modern microsurgery. This surgical branch, which embraces more specialties, has its roots on three fundamental pillars.

We find the first, and perhaps the most important one, in 1902 when Alexis Carrel reported the triangulation method of the end-to-end anastomosis that is still routinely used today and for which he was later awarded the Nobel Prize in 1912 (Fig. 1.3) [10].

The second pillar is the introduction of anticoagulation. Heparin was discovered in 1916 by Jay McLean [11], a medical student at Johns Hopkins University, together with Howell and Holt. The ability to control blood clotting was an essential step forward in the development of microvascular surgery.

The third one concerns the introduction of visual magnification systems in the medical field. In 1876, Saemich first used binocular glasses with magnifying power in clinical practice.

The first surgeon to operate with the aid of a microscope was the Norwegian otolaryngologist Carl-Olof Siggram Nylén (1892–1978) who adapted a monocular Leitz-Brinell microscope (designed to be used for hardness testing and having a low magnification and long working distance) for inner ear surgery in 1921. In 1922, Gunnar Holmgren was among the first otolaryngologists who immediately recognized the benefits of the microscope, and he developed new surgical techniques, including stapedectomy and resection of acoustic neuromas.

In 1952, Dr. Hans Littmann (1908–1991), head of Med-Lab at Zeiss Opton Oberkochen, West Germany (now Carl Zeiss AG), and his team of technicians designed their first operating microscope. They started a new era by inventing a microscope capable of changing magnification without changing the focal length. His design, the Zeiss-Opton, provided 200 mm of working distance and magnifications of 4, 6, 10, 16, 25, 40, or 63 selectable through a rotary Galilean system.

In 1953, exploiting the intuition of Horst L. Wullstein, an otolaryngologist from Gottingen, who designed a moving arm on which mount the microscope to improve its mechanical flexibility, Littmann manufactured the “Zeiss OPMI 1” (Zeiss Operating Microscope 1), the first “modern” microscope, as the ones in use nowadays.

1.6 Applied Microsurgery

During the 1960s, we find the pioneers of microsurgery and their first attempts to apply it to clinical practice. The use of the microscope to perform the first microvascular anastomoses is attributed to Jules Jacobson, a Vermont vascular surgeon, who performed an anastomosis on less than 1.4 mm vessels in 1960. The term microsurgery was born (Fig. 1.4). In 1963, Jacobson designed the microsurgical instrumentation that is being used still today, even if modified in some details (Fig. 1.5).

Buncke [12] gains the reputation of founding father of microsurgery as he first performed numerous experiments involving replanting or transplanting tissues in laboratory animals.

The first attempts in applied microsurgery are related not to head and neck reconstructive surgery but to limbs reimplantation trying to reduce the percentage of post-traumatic amputation.

One of the first historically reported attempts came in 1958, when Tamai and Onji tried to reimplant an incompletely amputated thigh on a 12-year-old girl at Nara Medical University Hospital, but the limb was lost after four weeks due to infectious thrombotic problems [13].

The first successful limb reimplantation was performed in 1962 by Malt and McKhann who reimplanted an amputated arm in a 12-year-old boy in Boston (the paper was published in 1964) [14].

The first publications concerning the use of free revascularized flaps for reconstruction of distant sites are sporadic: in 1959 by Seidenberg [15] who reconstructs a cervical esophagus with a flap of jejunum, while in 1965 the first reported experimental free skin flap transplantation of abdominal skin flap based on the superficial epigastric vascular pedicle was performed in a dog by Krizek and associates.

In 1965, Tamai reworked the vascular clamps used for the microsurgical treatment of intracranial aneurysms, transforming them into the vascular clamps used today for microsurgical vascular anastomoses [13].

During the 1960s, we find such a constant increase in microsurgical procedures that in 1967 the world’s first panel on microsurgery was held at the Annual Meeting of the American Society of Plastic and Reconstructive Surgeons in New York City.

However, the most substantial development of microsurgery applied to reconstructive techniques began in the following decade, with the use of composite free flaps. In 1971, Strauch et al. [16] first reported a pedicled vascularized rib transfer to the mandible in dogs, demonstrating the possibility of a vascularized bone transfer.

McLean and Buncke used omentum pedicled on the gastroepiploic vessels to cover a cranial defect in 1972 [17]. In 1973, Daniel and Taylor [18] described the first cutaneous free flap, and in the same year, Ueba and Fujikawa described a case of congenital ulnar pseudarthrosis treated with a fibula free flap. They published this report after nine years of follow-up in 1983 [19].

In 1976, Baker and Panje were the first to publish the use of cutaneous free flaps for the reconstruction of head and neck defects. In the same year, Harii described gracilis muscle flap as one of the first musculocutaneous flaps to be transferred by microvascular technique and popularized it for dynamic facial reanimation [20].

In 1979, Watson et al. [21] reported the first successful microvascular transfer of a free latissimus flap; in the same year, Taylor and colleagues described iliac crest composite flap based on the deep circumflex iliac artery (DCIA).

In 1978, a fasciocutaneous free flap from the volar aspect of the forearm and pedicled on the radial artery was first used in China. When this so-called Chinese flap was originally described by.

Yang et al. in 1981 [22] and Song et al. in 1982 [23], both groups already had performed more than 100 successful flap transfers.

In 1980, dos Santos [24] published the dissection study on the cadaver of the scapula limb and the connected circle. In 1982, Gilbert and Teot [25] published the first clinical transfer of a free scapular flap. The studies on the subscapular circle conducted by Toet will lead to the use of osteocutaneous composite flaps as a variant of the scapular flap popularized in 1986 by Swartz [26]. While in 1982, Nassif and coworkers proposed to use the descending septocutaneous branch of the circumflex scapular artery as the nourishing skin vessel defined as parascapular skin flap [27].

In 1983, Chen and Yan were the first to report about an osteocutaneous fibula flap [28]. This extension of flap raising became possible following the proposal of Gilbert to use a lateral approach for harvesting the bone flap in 1979, which was easier to perform and allowed for visualization of the cutaneous branches of the peroneal artery. This approach is the most used today [29].

In 1980, Pennington and Pelly [30] first reported a free rectus abdominis musculocutaneous flap based on the deep inferior epigastric artery and vein.

One of the most recent revolutionary concepts in the free flap era was introduced in the 1980s, and it is design of free flaps based on cutaneous perforators. This technique is based on the fact that it is not always necessary to include the underlying muscle in the flap, but it is technically possible to isolate the perforating vessel, excluding the unnecessary tissues.

The anterolateral thigh (ALT) free flap was first described by Song et al. in 1984 [31] as a soft tissue flap that is perfused by septocutaneous branches of the lateral circumflex femoral artery. The ALT flap was popularized for the head and neck reconstruction in the 1990s by Koshima et al. [32] and Kimata et al. [33]

Koshima and Soeda in 1989 [34] introduced the deep inferior epigastric perforator flap. In 1998 again, Koshima introduces the concept of “supermicrosurgery” which will later pave the way to the free-style flaps described by Wei in 2004. Wei should also be mentioned as the first to approach the vascular pedicle of the flap in a retrograde way, from the perforating vessel toward the main one [35].

The history of reconstructive surgery, as described in this chapter, was born in ancient times and has arrived at our recent past. The variety of reconstructive options available nowadays promises to meet almost any reconstructive need in such an anatomically and functionally complicated area as the head and neck. However, in an attempt to obtain the best functional and esthetic outcome for each specific patient, reconstructive surgery in the head and neck district is a developing field of research. Taking advantage of the brilliant ideas of the surgeons in their everyday practice history of reconstructive surgery is fortunately still in progress.