EDITORIAL
When Our Vocabulary Changed Leonard T. Furlow, Jr, MD
B
efore the 1970s, the language we plastic surgeons used when we talked about flaps was geometric: length-width ratio, advancement flaps, transposition flaps, rotation flaps, z-plasties, diamond (Limberg) flaps, tube flaps, V-Y f laps; or geographic: wrist carriers, cross-leg f laps, abdominal f laps, Dr Millard’s ‘‘crane’’ f lap, island f laps, random f laps, distant f laps; or temporal: delayed f laps, staged f laps (not to mention symphonic: waltzed f laps, or mortal: ‘‘black-flag dead f laps’’). Those terms let us describe the mechanism for creating and moving f laps. Flap surgery consisted in elevating the tissue to be moved on a random network of vessels, often in stages to permit survival despite the sublethal ischemia which induced the vessels to become more robust, so that transfer of tissue in stages, such as tube pedicle flaps, and made possible remarkable reconstructive efforts. The few flaps with defined axial vessels were mostly in the head or hand, considered to be unusual or unique fortunate arrangements of local anatomy, such as index finger pollicization to create a thumb and the Abbe flap for creating a philtrum. Free flaps were almost in view just over the horizon. During the decade of the 1970s, the entire conceptual framework of f laps changed. No one trained in plastic surgery after 1980 is familiar with that older vocabulary, is likely to have delayed a f lap, or ever to have seen a tube pedicle f lap, because the concept of supplying the blood for tissue transfer changed quickly from training random vessels to feed the f lap, to finding the axial vessels supplying the tissue to be moved. The most commonly used version of the axial f lap became the myocutaneous f lap, in which the axial vessels feed a muscle, which is moved carrying its overlying skin, fed by smaller vessels from the muscle. The surgeon most responsible for this design change that changed our vocabulary and our practice is John McCraw. Orticochea constructed a penis from a muscle carried on its axial vessels with skin supplied by branches of the muscle’s axial vessels, an ingenious f lap to solve a specific problem. In this specific solution, John McCraw saw a general myocutaneous pattern for solving many reconstructive problems, an insight that quickly changed reconstructive plastic surgery. John had become very familiar with muscle anatomy and physiology as an orthopedic resident under the tutelage of Dr Leonard Goldner at Duke. When he decided to switch to plastic surgery, he came to the University of Florida, intending to train there under Dr Jurkiewicz, who promptly moved to Emory, leaving John at UF. A year later, when John arrived at Emory for his second year, he began dissecting a variety of myocutaneous f laps, and shared the idea with his cohorts at Emory who joined in their development. McCraw and PG Arnold recorded their dissections, published them in their remarkable 2 editions of McCraw and Arnold’s Atlas of Muscle and Musculocutaneous Flaps, and taught the f laps in their annual Flap Course for 19 years, 1977 to 1995, in Norfolk, Va. Mathes and Nahai classified the muscles’ vascular patterns. As others became expert in the new f laps, they were added to the f lap course faculty of clinical surgeons using the new reconstruction methods. Development of fasciocutaneous, septocutaneous, and perforator f laps soon followed McCraw’s seminal recognition of the wide array of myocutaneous f laps as a pattern for f lap surgery rather than a series of specific f laps. McCraw’s practice-changing insight, the prodigious amount of work he put into teaching it to us, and the profound effect his myocutaneous f laps have had on reconstructive plastic surgery should certainly rank him high among the most important plastic surgeons of the 20th century.
Received April 5, 2014, and accepted for publication, after revision, April 5, 2014. From the Gainesville, FL. Conflicts of interest and sources of funding: none declared. Reprints: Leonard T. Furlow Jr, MD. E-mail: [email protected]. Copyright * 2014 by Lippincott Williams & Wilkins ISSN: 0148-7043/14/7301-0001 DOI: 10.1097/SAP.0000000000000254
Annals of Plastic Surgery
& Volume 73, Number 1, July 2014
www.annalsplasticsurgery.com
Copyright © 2014 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
1
When Our Vocabulary Changed Leonard T. Furlow, Jr, MD
B
efore the 1970s, the language we plastic surgeons used when we talked about flaps was geometric: length-width ratio, advancement flaps, transposition flaps, rotation flaps, z-plasties, diamond (Limberg) flaps, tube flaps, V-Y f laps; or geographic: wrist carriers, cross-leg f laps, abdominal f laps, Dr Millard’s ‘‘crane’’ f lap, island f laps, random f laps, distant f laps; or temporal: delayed f laps, staged f laps (not to mention symphonic: waltzed f laps, or mortal: ‘‘black-flag dead f laps’’). Those terms let us describe the mechanism for creating and moving f laps. Flap surgery consisted in elevating the tissue to be moved on a random network of vessels, often in stages to permit survival despite the sublethal ischemia which induced the vessels to become more robust, so that transfer of tissue in stages, such as tube pedicle flaps, and made possible remarkable reconstructive efforts. The few flaps with defined axial vessels were mostly in the head or hand, considered to be unusual or unique fortunate arrangements of local anatomy, such as index finger pollicization to create a thumb and the Abbe flap for creating a philtrum. Free flaps were almost in view just over the horizon. During the decade of the 1970s, the entire conceptual framework of f laps changed. No one trained in plastic surgery after 1980 is familiar with that older vocabulary, is likely to have delayed a f lap, or ever to have seen a tube pedicle f lap, because the concept of supplying the blood for tissue transfer changed quickly from training random vessels to feed the f lap, to finding the axial vessels supplying the tissue to be moved. The most commonly used version of the axial f lap became the myocutaneous f lap, in which the axial vessels feed a muscle, which is moved carrying its overlying skin, fed by smaller vessels from the muscle. The surgeon most responsible for this design change that changed our vocabulary and our practice is John McCraw. Orticochea constructed a penis from a muscle carried on its axial vessels with skin supplied by branches of the muscle’s axial vessels, an ingenious f lap to solve a specific problem. In this specific solution, John McCraw saw a general myocutaneous pattern for solving many reconstructive problems, an insight that quickly changed reconstructive plastic surgery. John had become very familiar with muscle anatomy and physiology as an orthopedic resident under the tutelage of Dr Leonard Goldner at Duke. When he decided to switch to plastic surgery, he came to the University of Florida, intending to train there under Dr Jurkiewicz, who promptly moved to Emory, leaving John at UF. A year later, when John arrived at Emory for his second year, he began dissecting a variety of myocutaneous f laps, and shared the idea with his cohorts at Emory who joined in their development. McCraw and PG Arnold recorded their dissections, published them in their remarkable 2 editions of McCraw and Arnold’s Atlas of Muscle and Musculocutaneous Flaps, and taught the f laps in their annual Flap Course for 19 years, 1977 to 1995, in Norfolk, Va. Mathes and Nahai classified the muscles’ vascular patterns. As others became expert in the new f laps, they were added to the f lap course faculty of clinical surgeons using the new reconstruction methods. Development of fasciocutaneous, septocutaneous, and perforator f laps soon followed McCraw’s seminal recognition of the wide array of myocutaneous f laps as a pattern for f lap surgery rather than a series of specific f laps. McCraw’s practice-changing insight, the prodigious amount of work he put into teaching it to us, and the profound effect his myocutaneous f laps have had on reconstructive plastic surgery should certainly rank him high among the most important plastic surgeons of the 20th century.
Received April 5, 2014, and accepted for publication, after revision, April 5, 2014. From the Gainesville, FL. Conflicts of interest and sources of funding: none declared. Reprints: Leonard T. Furlow Jr, MD. E-mail: [email protected]. Copyright * 2014 by Lippincott Williams & Wilkins ISSN: 0148-7043/14/7301-0001 DOI: 10.1097/SAP.0000000000000254
Annals of Plastic Surgery
& Volume 73, Number 1, July 2014
www.annalsplasticsurgery.com
Copyright © 2014 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
1
