We have come this far in Plastic, Reconstructive surgery only by standing upon the shoulders of these giants: the “Firsts” who paved the way for us.
Only by knowing the history and evolution of a field can we derive inspiration and develop the perspective required to push the boundaries in future. Here, we have made a small attempt in chronological listing the important milestones about flap surgery (pedicled to free, and have included replantation and transplantation).
Study the past if you would define the future
Confucius
Disclaimer: Though we have made extra efforts— gone through each of the index papers (>400), apart from the history-based articles (the most useful of which are mentioned under references below), flap textbooks— to make sure that we have got the facts, full-names and countries right— please feel free to comment if you don’t agree with any. We are always open to discussion and correcting information.
Use the ‘Search’ option below to find a particular flap or surgeon and to ‘Bookmark’ this page for future reference, press: Ctrl+D —or— ⌘Cmd+D.
| Year(s) | Surgeon(s) | First Described/ Performed/ Rediscovered/ Popularized |
|---|---|---|
| ~1000–600 BC | Maharshi Sushruta (India) | First- Cheek flap for nose reconstruction in "Sushruta Samhita" (? evolved into forehead flap- "Indian method"). |
| 1400s | Gustavo Branca (Sicily, Italy) | Rediscovered the above "Indian method" for nose. (? when 'Sushruta Samhita' translated to Arabic, ultimately travelled to Italy and reached the Brancas). |
| 1400s | Antonio Branca (Gustavo Branca's son) | First- described Distant flap from the arm for nose, lip, ear "Italian method". |
| 1597 | Gaspare Tagliacozzi (Bologna, Italy) | Popularized the above "Italian method" for nose through "De Curtorum Chirurgia per Insitionem". |
| 1700s | Francois Chopart (France) | Advancement flaps for lip reconstruction. |
| 1800s | Johann Carl Georg Fricke, Léon Tripier, Karl August von Burow, Jakob August Estlander, Robert Abbe, Johann Friedrich Dieffenbach | Various Facial flaps (named after the Surgeons). |
| 1854 | Frank Hastings Hamilton (USA) | First- Cross-leg flap (for a chronic ulcer in the lower limb of a 15-year-old boy). First- recognized and described the benefits of flap delay. |
| 1862 | John Wood (UK) | First- Hypogastric pedicled flap (for burn scar contracture on the wrist and forearm of an 8-year-old girl). It's mentioned as 1st groin flap in some places but wasn't- as it was based on SIEA. - Rediscovered and used as tubed pedicled flap by Darrel T Shaw, Robert L Payne (USA)- 1946. |
| 1889 | Carl Manchot (Germany) | First- studied cutaneous circulation and innervation by injecting ?dyes- was the foundation of Angiosome concept a decade later. |
| 1894 | Dauriac (France) | First- Muscle flap- Rectus abdominis muscle flap (for abdominal hernias). In 1895, Wolkowicz (Poland) also described it independantly. |
| 1896 | William Halsted, G Shrady | First- to use the concept of Walking ('Wanderlappentransplantation’/ 'Waltzing’)- skin flap from the side and back of the neck to the front of the neck [or, Jumping flap- eg. transfer of a toe to the face with the wrist as an intermediate carrier] - Concept 1st proposed by Victor von Hacker. - Popularized by Harold Gillies. |
| 1896 | Iginio Tansini (Italy) [Spelled as Tanzini in many places] | First- musculocutaneous flap- Latissimus dorsi- for breast defects. |
| 1897 | Carl Nicoladoni (Austria) | First- pedicled Thoracoepigastric flap to cover a degloved thumb (1897). - also in 1900- First- pedicled Second toe to thumb transfer. |
| 1898 | George H Monks (USA); | First- used Temporoparietal fascia flap (TPFF)- for Eyelid. - First- free TPFF flap was described by: Robert Allen Smith (USA). |
| 1906 | Louis Ombredanne (France) | First- Pectoralis muscle flap for Breast. |
| 1916 | Vladimir Petrovich Filatov (Ukraine) | 1st- Tubed pedicled flaps. In 1917, during World War 1, it was again independently described by Ganzer (Germany) and then Harold Gillies (UK)- who popularized it through "Plastic Surgery of facial burns" (1920). |
| 1917 | James Leonard Joyce (UK) | First- Cross-hand flap (Opposite ring finger to thumb transfer). |
| 1919 | Fred H. Albee (USA) | First- Osteoplastic finger reconstruction-a bone graft with a distant flap. |
| 1926 | Gatewood (USA) | First- Thenar flap for index fingertip. (First- regional flap for hand). - Popularized by Adrian Ede Flatt (UK). |
| 1934 | Owen Harding Wangensteen (USA) | First- pedicled Tensor fascia lata (TFL) flap- as 'muscle' flap for Abdominal hernia. - First described as 'musculocutaneous' flap by: B N Bailey (UK)- in 1967- for filling in the gap in the acetabulum after excising the hip joint. Popularized for ischial and trochanteric pressure sores by H Louis Hill, Foad Nahai, Luis O Vasconez (USA) in 1978. - First described as a 'perforator-based' flap by: Stephan Deiler (Germany)- later in 2000. |
| 1935 | Tranquilli Leali (Italy) | First- V-Y advancement flap for volar fingertip. - Refined and popularized decades later (1970) by Erdogan Atasoy (USA). |
| 1939 | Michel Salmon (French) | First- showed the detail of much smaller vessels (than by Manchot) by intra-arterial injection of radio-opaque liquid and radiography. |
| 1945 | Thomas D Cronin (USA) | First- performed Cross-finger flap |
| 1946 | Alexander A Limberg (Russia) | First described Rhomboid (Limberg) flap. Modified by Claude Dufourmentel (France) in 1962 and Richard C Webster (USA) in 1978. |
| 1946 | W J Stark (Canada) | First- described Pedicled muscle flaps ( for limbs- chronic osteomyelitis). Popularized by Ralph Ger (South Africa→USA)- 1960s. |
| 1947 | William Kuttler (USA) | First- Bilateral V-Y fingertip advancement for fingertip. |
| 1950 | Otto Hilgenfeldt (Germany) | First- described dorsal metacarpal artery (FDMA) flap (in German- inaccessible to others then). Independantly rediscovered by: J William Littler (USA) and Erik Moberg (Sweden) in 1960. |
| 1952 | R Vilain (France) | First- Flag flap (analogous to FDMA for other digits). |
| 1960 | J William Littler (USA) | First- introduced the Neurovascular island flap principle. (was for the thumb). |
| 1960s | John Wesley Snow, Bernard O'Brien, Erik Moberg | First- Axial-pattern advancement flaps for fingertips or thumb tip (named after the Surgeons). |
| 1962 | Ronald A Malt, Charles F McKhann (USA) | First- successful Replantation in human (Arm of a 12-year old boy)- performed in 1962, published in 1964. |
| 1963 | Harold Kleinert, Morton Kasdan (USA) | First- Thumb revascularization (under loupe magnification). Note: It was revascularization not replantation. |
| 1964 | Yoshio Nakayama (Japan) | First- Free flap- Segments of intestine to head and neck. Popularized by |
| 1965 | Chinese surgeons (details were not available due to political isolation) | ?First- Microvascular Toe to thumb transfer (Technically, this is the ?first free flap in human but not much details are available and hence the ?mark remains). |
| 1965 | Vahram Bakamjian (USA) | First- Deltopectoral (DP) flap. Extended Deltopectoral flap was introduced by: Ian A McGregor, Ian T Jackson (UK)- 1970- for hand, head and neck. |
| 1965 | Susumu Tamai, Shigeo Komatsu (Japan) | First- successful Digit (finger) Replantation- Thumb at the metacarpophalangeal joint in a 28-yr old man. |
| 1966 | Ralph Ger (USA) | First- Medial gastrocnemius flap, Brachioradialis flap, Soleus flap. Also, popularized pedicled muscle flaps for limbs (first described by W J Stark). |
| 1967 | Miguel Orticochea (Colombia) | First described- Four-flap Scalp reconstruction technique. In 1971- he refined it to Three-flap Scalp reconstruction technique. |
| 1967 | Toyomi Fujino (Japan) | First- demonstrated the importance of Perforators in the circulation of skin flaps. |
| 1968 | J R Cobette (UK) | First- publicized Toe to hand transfer- So, this is the First (reported) Free flap in human. First- Vascularized joint transfer (1976) eventually. |
| 1970 | Bent Barfod, Damee Michael (Denmark) | First- described Lateral gastrocnemius flap (for knee). |
| 1971 | Noshir Hormasji Antia, V I Buch (India) | First- Free soft tissue flap in human- SIEA based dermo-lipomatous tissue for post-hemimaxillectomy (with orbital floor intact) contour deformity. "Considerable absorption of the graft especially in the upper half of the face"- was reported: ?due to distal ischemia. |
| 1971 | Harry J Buncke, Donald H McLean (USA) | First- Free (Omental) flap (Large volume free flap to skull). |
| 1972 | Ian A McGregor, Ian T Jackson (UK) | First described Groin flap. |
| 1972 | Miguel Orticochea (Colombia) | First- pedicled Gracilis myocutaneous flap (It is the First- Myocutaneous flap described). |
| 1973 | Ian A McGregor, Gwyn Morgan (UK) | Classified skin flaps into Axial and Random pattern. |
| 1973 | Rollin K Daniel, G Ian Taylor (Australia) | First- Free flap (skin, subcutaneous tissue)- groin (aka- iliofemoral) flap to foot. - also in 1975, First- described intra-muscular dissection of perforators of the gastrocnemius musculocutaneous flap to the sural vessels- later popularized as "Free-style" technique by Fu-Chan Wei (Taiwan) & Samir Mardini (USA) in 2003. |
| 1974 | Kiyonori Harii (Japan) | First- free Scalp flap (for hair replacement) |
| 1975 | G Ian Taylor et al. (Australia) | First- Free osseous Fibular flap. (without cutaneous component). |
| 1975 | Toyomi Fujino et al. (Japan) | First- Superior gluteal myocutaneous free flap for Breast. (Note: this is not perforator-based). |
| 1976 | Susumu Tamai (Japan) | First- Free iliac osteocutaneous flap. |
| 1976 | Kiyonori Harii, Kitaro Ohmori et al. (Japan) | First- Free Gracilis musculocutaneous flap. First- Free Functioning Muscle transfer (FFMT) in human- Gracilis for facial reanimation for Bell's palsy (in a separate publication). The motor nerve of gracilis was anastomosed to a deep temporal nerve. - Independently, surgeons in China (1976- published in Chinese) performed Free Pectoralis major (lateral part) muscle flap to the forearm for finger flexion after VIC. The same was repeated by Y Ikuta, T Kubo, K Tsuge (Japan). |
| 1978 | C LeQuang (France) | First- Inferior gluteal myocutaneous free flap for Breast. (Note: this is not perforator-based). |
| 1978 | Louis H Hill et al. (USA) | First Transverse Lumbosacral flap (pedicled, not perforator-based) for lumbosacral defects. |
| 1979 | Stephan Ariyan (USA) | First- Pectoralis major myocutaneous (PMMC) flap. |
| 1978 | Goufan F Yang (China) | First- performed free Radial artery forearm flap (FRAFF)- "Chinese flap"- initially introduced as a free flap. (Reported in 1981). |
| 1979 | G Ian Taylor et al. (Australia) | First- deep circumflex iliac artery (DCIA) perforator flap. |
| 1980 | Robert A Chase et al. (USA) | First- Functioning myocutaneous flap transfer (pedicled Abductor digiti minimi flap for thumb- opposition). |
| 1980 | Bernard O’Brien, Wayne Morrison (Australia) | First- Wrap-around Toe flap to the Thumb. |
| 1980 | Bernard McC O'Brien (Australia) | First- Gracilis FFMT for facial reanimation (2 staged- innervated by cross facial graft). Popularized by Julia K Terzis (USA)- 1997. |
| 1981 | Bengt Pontén (Sweden) | First- described Fasciocutaneous Flap (for lower limb, with length-to-width ratios as great as 3:1 as compared to 1:1 without fascia) |
| 1981 | Stephen J Mathes, Foad Nahai (USA) | First- classified- Muscle and myocutaneous flaps. |
| 1982 | Ruyao Song, Ye-guang Song, Yuseng Yu, Ye-liang Song (China) | First- free Lateral arm flap. |
| 1982 | C R Hartrampf, Michael Scheflan, Paul W Black (USA) | First- pedicled Transverse rectus abdominis muscle (TRAM) flap. |
| 1983 | Zhong‐Wei Chen, Wang Yan (China) | First- free Fibular osteocutaneous flap. - Popularized by: Fu-Chan Wei et al. (Taiwan)- 1986- convinced surgeons of the reliability of the skin paddle of the osteo(septo)cutaneous fibular flap. First described for Mandibular reconstruction by David A Hidalgo (USA)- 1989. |
| 1984 | Ye-guang Song, Guo-zhang Chen, Ye-liang Song (China) | First- Anterolateral thigh (ALT) flap. |
| 1985 | Eduardo A Zancolli, Claudio Angrigiani (Argentina) | First- described pedicled Posterior Interosseous Artery (PIA) flap [at 6th European Hand Surgery Course in Umea, Sweden- but published in 1988] The anatomic basis of PIA flap was first published by Alain Charles Masquelet (France) with C V Penteado (Brazil) in 1986. Osteocutaneous PIA flap for thumb reconstruction- first described by Horacio Costa (UK)- 1988. |
| 1987 | G Ian Taylor, J H Palmer (Australia) | Introduced- "Angiosomes" concept (vascular territories) and choke vessels. |
| 1989 | Julian T K Wee, V T Joseph (Singapore) | First- Pudendal thigh fasciocutaneous flap- "Singapore flap"- for Vaginal reconstruction. |
| 1989 | Franklyn L Elliott et al. (USA) | First- Free lateral transverse Thigh flap for Breast. |
| 1989 | Koshima I, Soeda S (Japan) | First- first perforator flap in human- DIEA Perforator flaps (without Rectus muscle) for Groin and Tongue. Was popularized for Breast by: Hans Holmström (Sweden)- 1979; James Grotting et al. (USA)- 1991. |
| 1990 | Ke Liu et al. (China) | First- described Posterior tibial artery (PTA) island flap- reverse flow. 1992- Isao Koshima (Japan) described PTA perforator-based flap. |
| 1990 | Awf Quaba (UK) | First- described distally based dorsal hand flap (now called Quaba flap). |
| 1991 | Geoffrey G Hallock (USA) | Introduced- Chimeric flap (multiple flap components from the same pedicle). |
| 1991 | Kazuhiro Sakai, Kazuteru Doi, Shinya Kawai (Japan) | First- Free Medial femoral condyle flap. |
| 1992 | Julian Pribaz (USA) | First- Facial artery musculo-mucosal (FAMM) flap. |
| 1992 | John N Yousif et al. (USA) | First- Transverse upper gracilis (TUG) flap (for Breast). |
| 1993 | Isao Koshima (Japan) | First- Superior gluteal perforator-based flap (S-GAP)- It was for a sacral defect. Note: For breast- it was first described by: Robert J Allen Sr (USA)- 1995. |
| 1994 | Abraham Thomas (India) | First- successful full Face and Scalp replantation (on a 9-year-old girl whose hair got caught in a threshing machine and avulsed her scalp and face). |
| 1994 | Robert J Allen Sr, Penny Treece (USA); | First: Free Deep inferior epigastric perforator (DIEP) flap for Breast. Note: The same year Phillip N Blondeel et al. (Gent, Belgium) also described it. |
| 1995 | Günter Germann (Germany) | First- Free FDMA flap. |
| 1997 | Robert J Allen Sr et al. (USA) | First- Inferior gluteal perforator-based flap (I-GAP) for Breast. |
| 1998 | Jean-Michel Dubernard & team (France) + Earl Owen (Australia) | First- ?successful human hand transplantation. (Unilateral)- on a 48-year-old Australian man, with amputation due to assault in a New Zealand prison. After 2 years, the patient became non-compliant and stopped the immunosuppression, developed acute tissue rejection and underwent explantation- 2001. |
| 1998 | Isao Koshima (Japan) et al. | Introduced the "supramicrosurgery" surgical technique. |
| 1998 | Masakazu Ao (Japan) | First- Free Lumbar artery perforator (LAP) flap- was for lumbosacral defects. First- LAP for Breast was by: Louis de Weerd et al.(Norway)- 2003; and popularied by: D Opsomer, F Stillaert, Philip N Blondeel- 2018. |
| 1999 | Warren C. Breidenbach (USA) | First- successful hand transplant (Unilateral)- with long-term success- on a 37-year-old man- amputation (left hand) after a firecracker accident. |
| 2000 | Jean-Michel Dubernard & team (France) + Earl Owen (Australia) | First successful double-hand transplantation (reported in 2003)- on a 33-year-old man with B/L hand amputations after a blast injury. |
| 2000 | Claudio Angrigiani, Daniel Grilli (Argentina), Charles H Thorne (USA) | First- Profunda artery perforator (PAP) flap (then called: Adductor flap). PAP flap used first for breast by: Robert J Allen Sr et al. (USA) Its precursor was the pedicled Posterior thigh myocutaneous flap (then called: Gluteal Thigh Flap)- first introduced by: Dennis J Hurwitz, Robert L Walton (USA) for perineal, sacral defects- 1980. |
| 2003 | Fu-Chan Wei (Taiwan), Samir Mardini (USA) | Introduced the term and popularized "Free-style" technique of retrograde perforator dissection until the appropriate size and length are reached- initially performed for Soleus perforators during free fibula harvest. The technique was first described by Rollin K Daniel, G Ian Taylor (Australia) in 1975. |
| 2004 | Isao Koshima (Japan) et al. | First- described superficial circumflex iliac perforator (SCIP) flap. |
| 2005 | Jean-Michel Dubernard, Bernard Devauchelle & team (France) | First- successful human partial Face transplant. |
| 2006 | Isao Koshima (Japan) | First- Digital artery perforator flaps. |
| 2009 | Michel Saint-Cyr (USA) | First- introduces the term 'Perforasome"- the vascular territory of a single perforator. |
| 2013 | Joseph H Dayan (USA) | First- Diagonal upper gracilis (DUG) flap (for Breast). |
| 2015 | L Scott Levin (USA) & team. | First- pediatric B/L hand transplantation- on 8-year old who underwent amputation of all 4 limbs due to life-threatening sepsis. |
| 2020 | Eduardo Rodriguez & team (USA) | First- Face and double-hand transplantation- on a 22-year-old man with flame burn deformities. |
| 2021 | Aram Gazarian & team (France) | First- Double shoulder and arm transplantation- on a 48-year-old man- with B/L shoulder-level traumatic amputations. |
It’s interesting to note how some flaps were lost in time and rediscovered decades later and popularised then to become mainstream. Moreover, on fact-checking attempts by going through the original papers, we found few of the names mentioned under “firsts” in some of the popular textbooks to be not entirely correct (the person who popularized a flap were listed, while the one who discovered it found no mention).
It’s a long list that we would want to grow further with time. Please feel free to add to it or edit it by giving your views in the comments section below.
Use the ‘Search’ option above the table to find a particular flap or surgeon. If you found it useful, you may want to ‘Bookmark’ this page (Ctrl+D —or— ⌘Cmd+D) for future reference and Subscribe for similar posts and meetings related to Plastic Surgery.
References for Further Reading:
- Fang F, Chung KC. An evolutionary perspective on the history of flap reconstruction in the upper extremity. Hand Clin. 2014;30(2):109-v.
- Griffin JR, MD, Thornton JF. Microsurgery: Free Tissue Transfer and Replantation. Selected Reading Past Surg. 2005; 10(5.2).
- Marck KW, Palyvoda R, Bamji A, van Wingerden JJ. The tubed pedicle flap centennial: its concept, origin, rise and fall. Eur J Plast Surg. 2017;40(5):473-478.
- Antia NH, Buch VI. Transfer of an abdominal dermo-fat graft by direct anastomosis of blood vessels. British Journal of Plastic Surgery. 1971;24:15-19
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