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

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.