75 Years of Excellence: The Story of Reconstructive Surgery

Abstract

On December 11, 1940, Dr. John Staige Davis presented “The Story of Plastic Surgery” during his presidential address at the Southern Surgical Association meeting, highlighting lessons learned during the First World War in the management of traumatic injuries.1 He also proposed chronicling advances in plastic surgery, and in response to his call, the Plastic and Reconstructive Surgery journal was established in July of 1946. Since then, the Journal has become the most established communication method for advances in our field and has played a pivotal role in enabling subsequent generations of surgeons to continue to innovate and improve the field. It would be impossible to describe the immense progress in the field of plastic surgery over the last 75 years in detail here, so instead we highlight changes in our understanding of biology, improved techniques, and new technologies that have spawned advances in reconstructive surgery (Fig. 1).Fig. 1.: The current state of reconstructive surgery, brought about by the imagination, dedication, and hard work of our colleagues over the past 75 years, has surpassed the vision and goals for plastic surgery set forth by Dr. Davis in 1941. In parallel with these advances in reconstructive surgery, dramatic, accelerating advances in publishing, led by Plastic and Reconstructive Surgery, have allowed us to better communicate our ideas.The first major advancement in plastic surgery was the development of microsurgery, which was made possible by the triangulation method of microvascular anastomosis, discovery of heparin, and invention and refinement of the operating microscope.2–7 Microsurgical techniques were used initially by surgeons to replant amputated digits and limbs. Success with experimental microvascular tissue transplantation in animals prompted the application of microsurgical free tissue transfer in humans, starting with the first free tissue transfer of a temporal scalp flap by Harii et al.8 and a free groin flap by Daniel and Taylor9 in 1972. [See Figure, Supplemental Digital Content 1, which shows a line drawing of important anatomic landmarks for a groin flap (reprinted with permission from Daniel RK, Taylor GI. Distant transfer of an island flap by microvascular anastomoses. Plast Reconstr Surg. 1973;52(2):111–117), https://links.lww.com/PRS/E733.] Over the ensuing decades, multiple new free flaps were described, and free tissue transfer became an integral component of the reconstructive armamentarium.10 No aspect of reconstructive surgery was affected more by this development than head and neck reconstruction. For the three decades following the Second World War, reconstructive options were limited to rotational or pedicled flaps. Due to the lack of adequate available local tissue and the limitations of pedicle length, these options were insufficient to reconstruct many head and neck defects. The advent of microsurgical free tissue transfer opened a plethora of options for these patients. The description of the fibula flap and elucidation of peroneal perforator anatomy permitted the use of these flaps in reconstructing mandibular and other osseous defects.11,12 Use of the anterolateral thigh flap redefined soft-tissue reconstruction following glossectomies and laryngopharyngeal and other soft-tissue resections.13–16 Today, free tissue transfer is routinely used as the primary option for many skull base and craniofacial defects and for the reconstruction of the numerous components of the aerodigestive tract. The development of synthetic and biologic mesh material enabled surgeons to address the structural component of composite defects.17,18 Successful reconstruction of thoracic and abdominal wall defects is now achieved with the use of mesh for structural support and pedicled or free flaps for soft-tissue coverage.19,20 The capacity of biologic mesh materials to tolerate significant contamination has radically changed the face of complex abdominal wall reconstruction. Definitive closure can now be achieved with fewer surgeries without the need for staged operations.21,22 The use of mesh and the refinement of techniques to reduce fascial tension, such as component separation, have also significantly reduced hernia recurrence in abdominal wall reconstruction.23 Computer-aided design/computer-aided model ing and three-dimensional printing technology have further advanced the ability of plastic surgeons to customize their reconstruction plans and restore defects closer to their premorbid state. The use of this technology has allowed osseous flaps to be more accurately shaped and plated, leading to improved outcomes and the restoration of premorbid occlusion following radical maxillectomies and mandibulectomies.24–26 The ability of plastic surgeons to reconstruct larger and more complex defects has enabled oncologists to treat previously unresectable disease. Orthopedic surgeons and neurosurgeons now perform hemipelvectomies, total sacrectomies, and multilevel vertebrectomies in collaboration with plastic surgeons (Fig. 2). The innovative use of tissue and osseous flaps enhanced with the application of computer-aided design/computer-aided modeling technology has reduced short- and long-term complication rates and enabled patients to remain ambulatory.27–31Fig. 2.: Color photograph showing reconstruction of a pelvic defect with free fibula flaps.Reprinted with permission from Agrawal N, DeFazio MV, Bird JE, Mericli AF. Computer-aided design and computer-aided manufacturing for pelvic tumor resection and free fibula flap reconstruction. Plast Reconstr Surg. 2020;145:889e–8990e.The invention of negative-pressure wound therapy in 1997 provided plastic surgeons the option of temporizing wounds and revolutionized the management of lower extremity trauma.32 One of the earliest pioneers of lower extremity reconstruction, Marco Godina, described the importance of addressing bone and soft-tissue components within 72 hours after trauma. With the use of negative-pressure wound therapy, definitive reconstruction can be delayed for 7 days or more to allow for the systematic coordination of multidisciplinary care.33,34 In recent years, effective multidisciplinary collaboration to achieve revascularization, rigid stabilization, and stable soft-tissue coverage has increased limb salvage rates to 90 percent in many level 1 trauma centers.35 The advances in reconstructive surgery that took place in the 1960s and 1970s bore fruit over the following decades. Similarly, ongoing development in the fields of supermicrosurgery, robotic surgery, and vascularized composite tissue allotransplantation may change the face of reconstructive surgery over the course of the next century. A more thorough understanding of microvascular anatomy and perforator physiology, coupled with advances in instruments, microscopes, and techniques, has fueled the development of supermicrosurgery, a technique that enables surgeons to perform anastomoses in vessels with diameters as small as 0.3 mm.36,37 Using supermicrosurgery techniques, plastic surgeons have redefined the treatment of lymphedema by offering patients physiologic surgical treatments such as vascularized lymph node transfer and lymphovenous bypass (Fig. 3).38,39 Supermicrosurgery, coupled with more detailed descriptions of the perforator angiosome, has enabled surgeons to perform perforator-only flap reconstructions.40–42 While limiting donor-site morbidity, perforator-only flaps can be highly customized with respect to volume and tissue type to restore defects with much higher fidelity.43Fig. 3.: Advances in supermicrosurgery show great potential for the treatment of lymphedema, as shown in these photographs demonstrating substantial improvement following lymphatic bypass. Reprinted with permission from Mihara M, Hara H, Tange S, et al. Multisite lymphaticovenular bypass using supermicrosurgery technique for lymphedema management in lower lymphedema cases. Plast Reconstr Surg. 2016;138:262–272.The continued desire to push the boundaries of reconstruction has led to the adoption of robotic technology. Plastic surgeons have used surgical robots, such as the DaVinci (Intuitive Surgical, Sunnyvale, Calif.) to harvest pedicled and free flaps, such as latissimus dorsi and rectus abdominis flaps, with minimal donor-site morbidity.44,45 As we continue to test the limits of supermicrosurgery in even smaller dimensions, we approach the limits of human ability and open the door for the use of microsurgery-specific robots in clinical practice. With the elimination of tremor and advances in motion scaling, this technology will usher in a new era of innovation and further expand the scope of reconstructive surgery.46 The ultimate goal of reconstructive surgery is to restore both form and function. While the many advances in reconstructive surgery discussed above have brought us closer to this goal, we still fall short of truly replacing “like with like.” Advances in vascularized composite tissue allotransplantation, driven in a large part by plastic surgeons, have made the achievement of this holy grail a possibility.47,48 Since the first successful hand transplant in 1998, more than 45 face and 120 hand transplants have been performed to date. Other regions of the body, including the abdominal wall, larynx, lower extremity, uterus, and penis, have also been successfully transplanted.49 Despite significant progress in surgical technique, complications associated with immunosuppression have prevented the routine inclusion of this option in our reconstructive armamentarium.50,51 The application of reconstructive principles to the needs of transgender patients also dates back to the Second World War, with surgeries quietly performed for adults with intersex conditions.52 Surgical care has always been accompanied by hormonal and other treatments, with the nature of multidisciplinary care provision evolving over time. We now recognize that there is not one pathway for medical transition but many procedures that can be used to meet an individual’s needs. Though not all transgender patients require reconstructive surgery to affirm their gender identity, the plastic surgeon is at the forefront of surgical expertise and innovation. The patient perspective, particularly with regard to aesthetic and somatic experiences of the reconstructed anatomy, is beginning to be operationalized across surgery in the form of validated patient-reported outcome measures, which are crucial to defining the success of these reconstructive operations.53 The current state of reconstructive surgery, brought about by the imagination, dedication, and hard work of our colleagues over the past 75 years, has surpassed the vision and goals for plastic surgery set forth by Dr. Davis in 1941. In parallel with these advances in reconstructive surgery, dramatic, accelerating advances in publishing, led by Plastic and Reconstructive Surgery, have allowed us to better communicate our ideas (Fig. 4). Early in the Journal’s history, most articles were focused on case reports and small case series. Illustrations were line drawings, and photographs were few and in black and white (Fig. 5).54 Today, the Journal prioritizes high-quality, evidence-based research published along with high-definition pictures and videos. Electronic digital submissions to the Journal have revolutionized the ability to efficiently submit manuscripts and revisions. Electronic communications have simplified multi-institutional collaborations, including those that cross borders. Improvements in the review and publication processes should further shorten the time between submission and publication. As we look forward to the next 75 years, we cannot help but feel optimistic and excited by new biological advances, technological developments, and innovations by surgeons to improve techniques. We hope to see a continued acceleration in the science and practice of reconstructive surgery.Fig. 4.: Advances in reconstructive surgery were paralleled by advances in publication, as seen in Plastic and Reconstructive Surgery. Electronic communication has accelerated advances in both areas. NPWT; negative-pressure wound therapy; CAD-CAM, computer-aided design and computer-aided modeling.Fig. 5.: This figure is from an article published by Kazanjian in the second issue of Plastic and Reconstructive Surgery showing how to reconstruct scalp avulsions using burr holes. Reprinted with permission from Kazanjian VH, Webster RC. The treatment of extensive losses of the scalp. Plast Reconstr Surg. 1946;1:360–385.