It is interesting to note, at least from what can be gleaned from recorded history (2), that the first successful transfer of human tissues to heterotopic sites was done by what we now call pedicle techniques. Such transfers are never even transiently, deprived of blood supply. Thus, on a trial-and-error basis, it should not be a surprise that the success of the Hindu Sushruta (1) during the pre-Christian era depended on the use of pedicle flaps of tissue in the face and forehead.

The designation of “Indian flap” for nasal reconstruction has survived, and its use in contemporary surgery testifies to its practicality. It appears to have taken centuries for the principle and procedure itself to travel from its origin in India to Europe—first to the Brancas in Italy, who became known in the fifteenth century for use of the technique and the principle to develop new and imaginative reconstructive procedures. Tagliacozzi in the sixteenth century made use of the printing press to disseminate knowledge of the techniques abroad through his celebrated De Curtorum Chirurgia (3) published in 1597.

Nonetheless, the procedures lay dormant for about 200 years until a newspaper, the Madras Gazette, and the Gentleman’s Magazine (4) reported the Indian method for nose reconstruction in 1794. Among others, Carpue (5) in England and von Graefe (6) in Germany further developed the technique in Europe. Zeis, in his 1830 description of the procedure (7), displayed illustrations suggesting the dusky appearance of the flap early after surgery. Warren was the first in the United States to publish this technique in 1837 (8). It appeared in the Boston Medical and Surgical Journal (now the New England Journal of Medicine).

The pedicle flap principle, initiated by trial and error in pre-Christian history, was established and refined in the nineteenth century and formed the fundamental basis for the spectacular developments in the modern decades of surgery.

I shall mention a few landmarks in the development of tissue transfers during the nineteenth and twentieth centuries. In 1829, Fricke of Hamburg published a book describing many alternate facial flaps (9). Shortly thereafter, Tripier, Malgaigne (10), Burrow, Estlander, von Graefe (6), Abby, Denonvilliere, Rosenthal, Dieffenbach, and Zeis (2)—to name the principals— added further innovations in the shift of tissues to adjacent areas within the face for reconstruction.

Hamilton of Buffalo reported the first successful cross-leg flap in 1854 (12). He also was the first to apply the principle of delay to flap transfer. In 1868, Prince published A New Classification and a Brief Exposition of Plastic Surgery (12) with examples of applications of pedicle-flap techniques in plastic surgery. At the Practitioner’s Society of New York in 1891, Shrady used an open jump flap cut from one arm and carried after vascularization by the contralateral index finger to fill a cheek contour defect (13). Shortly thereafter, in 1896, the renowned William Stewart Halsted (14) first “waltzed,” by end-over-end transfer, a flap from the abdomen up to the neck of a burn victim. He was the first to use the term waltzed.

In pedicle-transfer surgery, aside from studies of the delay phenomenon (11, 15, 16), effects of drugs and radiation (17), and thinning of the flap (18), the refinements during this era were confined largely to the carrying pedicle itself. In 1849, Jobert of Paris, in his two-volume textbook Chirurgie Plastique (19), described “the temperature changes in skin flaps and the reinnervation of flaps” and noted that “the size of the pedicle should be proportional to the size of the flap.”

The renowned Sir Harold Gillies stated, “In general, a flap should not be larger than the width of its carrying pedicle.” In 1920, he added a rider: “A longer flap could be raised if the flap contained in its base a larger vascular pedicle such as the superficial temporal artery” (20).

Gillies’ book, Plastic Surgery of the Face (21), is a classic in the field and, together with that of John Staige Davis, ushered in the modern era of plastic surgery. Both were based on lessons learned from current works and publications early in the
twentieth century, such as those of Vilray Blair (22), and experiences during World War I. Gillies himself had been stimulated and influenced by Morestin, whom he had visited in France. The war experience was very influential on many great contributors to plastic surgery—V. H. Kazanjian, Ferris Smith, R. H. Ivy, Eastman Sheehan, and Sterling Bunnell, to name a few.

As noted by Khoo Boo-Chai (23), John Wood in 1863 had described a flap that, in 1869 (24), he called a “groin flap.” He commented on the importance of incorporating known vessels— in his patients, the superficial epigastric vessels.

John Staige Davis, reporting World War I experiences, expanded the uses of pedicle flaps (2, 25) and later with William German et al. (26) explored the vascular anatomy of the skin and subcutaneous tissues important in designing such flaps.

John Roberts of Philadelphia pointed to lessons learned in the war and applicable to reparative surgery using pedicle flaps on the hand (27). In 1919, Albee described the surgical construction of an osteoplastic finger substitute using a pedicle flap and a bone graft (28). Also in 1919, at the clinic day of the American Orthopaedic Association at Jefferson Hospital in Philadelphia, P. G. Skillern presented a patient from Polyclinic Hospital in whom a double-pedicle “strap” flap was used for coverage of the dorsum of the right hand (29). Steinler’s books appeared in 1923 and 1925 (30, 31), at the same time Allen Kanavel’s book (32) was published, and later Marc Iselin’s Atlas (33, 34) and Cutler’s The Hand (35).

In 1931, Jacques Joseph, using illustrations of Manchot from 1889, justified and published illustrations of deltopectoral flaps as vascular-pattern flaps (36, 37). The deltopectoral flap was later popularized and used imaginatively by V. Y. Bakamjian, as described in his papers starting in 1965 (38, 39). McGregor and Jackson showed its use in hand surgery (40).

A debate between S. H. Milton (41) and P. M. Stell (42) raged in the early seventies on the appropriate base for random flaps. By then, the classification of flaps according to the nature of the pedicle had begun to crystallize. McGregor and Morgan had hinted at it in 1960 (43). Ten years later, McGregor and Jackson proposed that one could outline self-contained vascular territories (44). They referred to work by Shaw, who, together with Payne, had described such a flap based on the superficial epigastric arterial and venous system (45). The technique was developed for care of the wounded during World War II. Other developments in tissue transfer in hand surgery were described in the volumes on hand surgery in World War II (see below).

General plastic surgery as a discipline made enormous strides during this war. For example, at the beginning of the war, there were only four fully experienced plastic surgeons in Great Britain: Gillies, McIndoe, Mowlem, and Kilner. This nucleus of surgeons and their trainees established plastic surgical centers throughout Great Britain, and each made major contributions to the field.

In the United States, Fomon’s 1939 The Surgery of Injury and Plastic Repair (46) and Barsky’s Principles and Practice of Plastic Surgery (47) appeared at the beginning of World War II. During the war, Ivy and a group of plastic surgical luminaries wrote two manuals on plastic and maxillofacial surgery for use by military surgeons (48). Plastic surgical centers such as the one at Valley Forge General Hospital were spawning grounds for consolidation of reconstructive strategies. James Barrett Brown, Sheehan, McDowell, Tanzer, Littler, and Cannon exemplify what could be an enormous list of contributors. Books by Sheehan (49), Ivy (50), Kazanjian and Converse (51), May (52), New and Erich (53), Padgett and Stephenson (54), Pick (55), and Smith (56), among others, were published after experiences during the war.

McGregor et al. described the anatomic basis for a flap based on the superficial circumflex iliac vessels (57), the classic McGregor or groin flap. The groin flap has been a mainstay in reconstructive hand surgery (58, 59). The terms random and axial were applied to flaps in McGregor and Morgan’s paper in 1973 (60, 61).

Early in the twentieth century, the carrying pedicle for random or chance axial pedicle flaps was large and flat. It was refined to a closed tube independently by the Russian Filatov in 1917 (62) and by Gillies at about the same time (20, 63, 64). Pedicle flaps with identifiable blood vessels had become the rule wherever possible.

Sterling Bunnell’s second edition of Surgery of the Hand (65) drew heavily from experiences in hand centers during World War II. It was filled with a variety of types of pedicle flaps, as well as his additional technical modifications of the tubed-pedicle flap technique.

William L. White put together an organized review of flap grafts (66) for a meeting that he organized and chaired in Pittsburgh in 1959.

With waltzing, jumping, and tubing, the transfer of tissues from place to place in endless combinations (67), including composites of skin, fascia, muscle (68), and bone, was firmly established (69).

Since the turn of this century, further refinement of the carrying pedicle had reached the point where flaps are transferred regularly on vascular and neurovascular bundles. The principle of transfer without an intact epithelialized skin pedicle was initiated by Robert Gersuny, of Vienna. In 1887, he published a description of the transfer of a composite flap of soft tissue from the neck to the oral lining of the cheeks (70) carried on a very narrow pedicle of dermis and subdermal vessels from the periosteum of the mandible. This was a one-stage transfer of a pedicle flap without an intact skin pedicle and without specifically identifiable blood vessels.

In August of 1882, Theodore Dunham, of New York, excised a large epidermoid cancer of the cheek and eyelid. He raised a flap from the forehead, and in his publication (71) said, “This flap was so cut as to contain traversing its pedicle and ramifying in it, the anterior temporal artery.” Three days after the first procedure, Dunham dissected out the vascular pedicle and buried it beneath the skin of the cheek. The skin pedicle was returned to its donor site. This was the first recorded two-stage island pedicle flap preserving the transferred blood supply intact.

However, it was Monks in 1898 who repaired the defect resulting from an excision of a lower eyelid epithelioma and who first reported a one-stage island pedicle flap (72). He illustrated the procedure that same year in the Boston Medical and Surgical Journal. Shelton Horsely beautifully illustrated the use of a forehead flap carried on temporal vessels in a paper in the Journal of the American Medical Association in 1915 (73).

J. F. S. Esser, publishing in the New York Journal of Medicine in 1917 (74), pointed out that during his care of wounded soldiers in Austria, he often used flaps from the neck directly under the jawline near the external maxillary artery. These flaps had no skin pedicle, but a carrying arm consisting of soft tissue that contained the external maxillary artery. Said Esser, “I called them ‘island flaps’ because after being placed in the facial defect resulting when scars are removed, they give the effect of a free transplantation.”

There was renewed interest in the island pedicle flap for a variety of uses in the sixties (75, 76, 77, 78, 79, 80). For example, temporal arterial island flaps found a place in eyebrow reconstruction and for coverage of difficult areas requiring a permanently transferred blood supply.