MILLENIUM PAPER
The History of Dermatologic Surgical Reconstruction
Daniel E. Zelac, MD,* Neil Swanson, MD,^† Michael Simpson,* and Hubert T. Greenway JR, MD*

  Dermatologic Surgery 26  (11), 983-990
 

Over the last 40–50 years, reconstructive surgery in dermatology has undergone expansive growth and development. As dermatologists began to provide a greater array of surgical services during this period, it became apparent that new skills and techniques in the area of reconstruction would be required. Initially many of the procedures and concepts were adopted from other specialties, however, in the years since, significant contributions have been made by dermatologists which in turn have benefited other specialties as well. This review attempts to summarize some of the significant historical events and innovations that have established and supported dermatologic surgical reconstruction.

THE DEVELOPMENT of reconstruction spans several millennia and has been addressed more extensively elsewhere.^1–3 Early efforts were chronicled in ancient India where nasal reconstruction was practiced using procedures including flaps and grafts. (See Table 1.) Ancient Rome was the home for Celsus and Galen who each explored a variety of flaps as well as surgical principles that serve as the basis of some techniques utilized today.^4–6 During the 1500s, local and distant pedicle flaps were employed by the Braca family of Sicily and Gaspare Tagliacozzi of Italy. Following that period, progress in the field became stagnant due to political and religious pressures. Interest in surgical reconstruction was revitalized in the late 1700s when an English journal documented methodology practiced in India for nasal reconstruction using a forehead flap.⁷ Progress continued slowly until the early 1900s when the modern age of reconstructive surgery is felt to have begun with Sir Harold Gillies, Varztad Kazanjian, and Vilmay Blair popularizing facial reconstruction during World War I.

Prior to the 1950s it was relatively uncommon for a dermatologist to be engaged in surgical reconstruction. Efforts had been principally performed by general and plastic surgeons who were at that time also responsible for many of the cutaneous excisions being performed. Initially many of the early dermatologists in the United States had a strong interest in the surgical treatment of disease. For some, their formal training had been in Europe where dermatology was associated with urology and shared in urologic surgical procedures. This tradition was initially continued in the United States as reflected in journal titles such as The Journal of Cutaneous and Genito-Urinary Diseases, first published in 1882. Gradually the focus in dermatology shifted to medical treatments when a greater emphasis was placed on syphilis in the early 1900s. Surgical and reconstructive procedures however, were not completely abandoned during this period as demonstrated by the inclusion of topics such as grafting and excisional design in L. A. Durhing's textbook, Cutaneous Medicine, published in 1905.⁸ During this era, dermatologic surgery was dominated by destructive rather than reparative techniques and reconstruction was not emphasized. This trend continued until the 1950s when a change in the general scope of dermatologic surgery was noted by several authors, including L.A. Lewis.⁹ This change has been partially attributed to the growing popularity among dermatologists for Mohs chemosurgery, dermabrasion, and hair transplantation. These evolving techniques sparked the imagination and interest among dermatologists to expand their surgical practices beyond acne, ablative, and minor excisional surgery. Of these three influences, the expansion of Mohs chemosurgery may have been the most influential to the growth of reconstructive surgery by dermatologists. Envisioned and pioneered by Fredric Mohs in the 1930s, chemosurgery required a strong understanding of histopathology and was embraced by a number of dermatologists. Initially this technique did not directly stimulate the use of reconstructive procedures by dermatologists because tissue treated with the fixative preparation was not suitable for immediate surgical repair.

The introduction of the frozen-tissue Mohs technique, or fresh-tissue technique, as it came to be known, made immediate reconstruction following Mohs surgery possible. This approach did not require the use of the zinc chloride paste employed in the fixed tissue technique and did not result in the tissue damage associated with this fixative. Originally reported by F. Mohs in 1958 for use at specific sites such as the eyelid, the application of the fresh tissue technique to other anatomic sites was introduced by S. Stegman and T. Tromovitch at the American College of Chemosurgery meeting in 1970. Greater acceptance of this technique followed in 1974 when S. Stegman and T. Tromovitch demonstrated cure rates that were similar to those associated with the fixed tissue method.¹⁰ P. Robins and M. Albom and other groups also confirmed these cure rates in the next few years.¹¹ The fresh-tissue technique offered a number of distinct advantages over the fixed-tissue technique, including the completion of the procedure in a single day, removal of the tumor with less discomfort, and most importantly, production of a defect that could be immediately repaired. The opportunity for a Mohs surgeon to serve as both the primary surgeon as well as the reconstructive surgeon was very appealing to some. Initially the argument for delayed repair was made, but this opinion did not prevail and immediate repairs began to be performed by dermatologists with greater regularity. The techniques and knowledge of reconstructive surgery were incorporated into the growing skills of many Mohs surgeons. As a greater number of these surgeons began to provide their patients with surgical reconstruction, it became apparent that many of the defects produced by Mohs surgery differed in shape, depth, and size from defects produced by other forms of excisional surgery. Innovative approaches to address these differences began to be described in the dermatologic literature.^12–15 While reconstructive surgery was gaining popularity among Mohs surgeons, dermatologists in general were also becoming more active in surgical procedures including reconstructive procedures.

In 1975, Perry Robins developed the Journal of Dermatologic Surgery to address the growing need for a dedicated cutaneous surgery journal.² The inclusion within the inaugural issue of an article reviewing the history of reconstructive surgery reflected the escalating interest among dermatologists for reconstructive surgical procedures and foreshadowed the future growth that would follow. Topics such as anatomy, instrumentation, closure design, and methodology dominated the articles during first few years. Although a number of articles were presented in the early issues of the Journal of Dermatologic Surgery that addressed wound closures, S. Stegman's “Fifteen Ways to Close Surgical Wounds” caught the attention of many readers in its concise and thorough explanation of some of the available techniques¹⁶ (see Figure 1). This initial article has been followed by numerous reviews in the years since which have each also examined repair options in terms of optimal technique of execution, site of use, biomechanics, and tissue requirements.¹⁷ L. Dzubow examined these issues of design and potential complications in an article entitled “Flap dynamics”.¹⁸

The goal of dermatologic reconstructive surgery is not only to restore anatomic form and function, but also to provide an optimal cosmetic result. With respect to this, dermatologic surgeons have learned to consider a variety of factors including tissue availability, anatomic structure and function, tumor surveillance, and the patient's overall health and expectations while planning a surgical repair.¹⁹ Consideration of repair options takes into account the use of delayed repair as well as the use of second intention healing. Historically, most defects created by the Mohs fixed-tissue technique were allowed to heal by secondary intention. This provided the opportunity for dermatologic surgeons to gain the confidence that cosmetically acceptable results are possible by secondary intention in some cases. Wound closure may, however, be deemed a superior choice due to characteristics and possible complications of second intention healing such as scar retraction, webbing, free margin distortion, and a possible lengthy healing period.

Wound closures other than primary closures can be categorized based on tissue movement and may be subdivided into the following types of flaps and grafts: advancement, rotation, transposition, island flaps and pinch, split thickness, or full-thickness grafts. Numerous reviews have appeared which describe the characteristics of each including the mechanics of these closures and their individual advantages and disadvantages. Decision making when planning a closure is an integral component to the repair process. D. Brodland in 1994 proposed a stepwise approach to aid in evaluating options using the mnemonic “STARS”[Simple primary closure, Transposition flap, Advancement flap, Rotation flap, and Skin graft].²⁰ Other systems use an hierarchy approach to evaluating closure options based on a number of variables as mentioned above (see Figure 2). Although some closures are preferentially utilized at specific sites, the choice of a closure for a particular defect relies on an evaluation at the time of repair that takes into account many of the other considerations already mentioned. The lines of least skin tension, Langer's lines, have been considered for years in the design and placement of closures.^21,22 S. Stegman addressed this issue as well and introduced the simplistic yet effective concept of pinching the skin to determine skin laxity in his 1976 guidelines for placement of elective incisions.²³ Use of this technique provides a simple method for judging skin laxity at the time of the execution of the repair. Another concept that contributed greatly to optimizing cosmetic outcomes was that of cosmetic boundaries or cosmetic units. R. Webster, R. Smith, L. Dzubow, and L. Zack among others have explored these boundaries and stressed their value in reconstruction design.^24,25 Emphasis on utilizing these lines and units has enabled dermatologic surgeons to achieve superior cosmetic results in reconstruction.

As greater numbers of reconstructive cases were performed, new and unique defects were encountered which required approaches not previously utilized by dermatologic surgeons. Numerous articles were published within the dermatologic literature that introduced techniques and approaches utilized by other specialties. When these approaches were applied in a dermatologic setting, specific deficits were noted with some of these methods. Dermatologists recognized that additional understanding of anatomy, wound healing, and closure methodology was required for their growing needs and began to address these areas. L. Field has for many years advocated a strong interaction with physicians of other specialties and with other dermatologic surgeons worldwide. From these interactions, he has been able to introduce numerous flap designs and techniques, such as the hinged mucosal flap, the square-to-Z flap, the “banner” flap, and the subcutaneously bipedicled island flap, some of which represent new approaches.^26–28 Numerous other dermatologic surgeons have also proposed new flap designs and novel surgical techniques over the years. A. Arnold and R. Bennett, for example, described an innovative approach to closing wide primary defects with the “bilateral dog-ear transposition flap.^29,30 Not only were new flaps required, but modification to earlier flap designs were also necessary for their application to new sites and anatomical needs. The M-plasty, for example, described by R. Webster, T. Davidson et al., D. Gormley and others, allowed closures to be modified to local anatomic constraints.^31,32 Dog-ear deformities and their correction have been addressed in a number of articles including a review in 1977 by D.E. Gormley and most recently by N. Weisberg et al. in this past April's issue of Dermatologic Surgery.^33–36

Although modifications and new approaches have been required and developed for many anatomic sites, in this article we will concentrate on some of the novel approaches that have been developed by dermatologists for the repair of the nose. The nose has been the focus of much attention because of its cosmetic prominence, functional requirements, and frequency of involvement with cutaneous tumors. Surgical defects resulting from the removal of cutaneous tumors can be quite variable and numerous reviews have appeared which examine the available techniques for repair of this challenging structure.^37,38 The nose can be divided into distinct zones based on cosmetic boundaries and tissue differences between these areas. An excellent examination of many of the anatomical considerations and possible solutions for nasal reconstruction appears in Aesthetic Reconstruction of the Nose by G. Burget and F. Menick.³⁹ Because of tissue availability, texture, anatomic function, and topography, defects affecting some subunits are associated with greater difficulty. The nasal tip and the ala are both sites of significant challenge and potential complication, particularly when affected by full thickness defects. Many methods for reconstruction of these areas have been described.^40–44 J. Zitelli provided a significant contribution to the repair of the nasal tip when in 1989 he published his design of the bilobed flap. This new design greatly improved on the earlier design of Esser, introduced in 1918, an earlier standard, which had several inherent problems including the formation of a prominent dog-ear protrusion at the angle of rotation.⁴⁵ In order to address this effect, Zitelli modified the design to allow more acute tissue movement angles and to limit the anticipated tissue redundancy with early removal of a burow's triangle⁴⁶ (see Figure 3a, 3b). These changes adequately addressed the problems of the previous design and virtually eliminated the need for a possible secondary procedure to correct this tissue redundancy. The Peng flap, which was introduced in 1987, provided another solution for the repair of the nasal tip.^47,48 This novel approach combined aspects of a linear advancement flap with those of a bilateral rotation repair. The resulting flap provides excellent symmetric coverage of the nasal tip with superior survival rate (see Figure 4). D. Papadopoulos and F.A. Trinei additionally described a new approach to nasal tip reconstruction based on a myocutaneous island pedicle flap with bilevel undermining.⁴⁹ Not only did these last authors provide an additional new method for tip reconstruction, but also they clearly demonstrated in a scientific manner, the vascular pattern on which this flap is based that contributes to its survival (see Figure 5). The bilevel approach to flap mobilization is an innovative approach that builds on prior methodology such as the nasalis myocutaneous sliding flap by V. Constantine and S.S. Wee.^50,51 Addressing the reconstruction of specific subunits may be adequate and appropriate in some cases, however, total nasal reconstruction may be required in some instances due to the extent of the defect or in an attempt to provide a superior cosmetic result. R. Kotler and J.R. Mellette Jr. each provides an excellent review on the use of the paramedian forehead pedicle flap for this purpose.^52,53

Surgical texts specifically geared toward the needs of a cutaneous surgeon have evolved over the years. Skin Surgery by Epstein, first published in 1956, was one of the earliest textbooks specifically dedicated to dermatologic surgery. This text which has grown significantly during the five editions that followed, ushered in the new era of surgery's greater presence in dermatology. A comprehensive listing of dermatologic surgery texts has been prepared by Hanke and Krull that lists many of the significant dermatologic surgical books.⁵⁴ The following titles are included in the above mentioned lists and have been very helpful in developing an understanding of reconstructive surgery for one of the authors (DZ): Fundamentals of Cutaneous Surgery by Bennett; Techniques in Skin Surgery by Epstein editions 1–6; Basics of Dermatologic Surgery by Stegman, Tromovitch, and Glogau; Atlas of Cutaneous Surgery by Swanson; Advanced Dermatologic Surgery by Bailin; Cosmetic Dermatologic Surgery by Stegman and Tromovitch; Basics of Dermatologic Surgery by Stegman, Tromovitch, and Glogau; Surgical Dermatology by Roenigk and Roenigk; Dermatologic Surgery: Principles and Practice Atlas of Cutaneous Facial Flaps and Grafts by Moy; Cutaneous Surgery by Wheeland; Flaps and Grafts in Dermatologic Surgery by Tromovitch and Stegman; and Outpatient Surgery of the Skin by W. P. Coleman III.^55–67 Publications such as Fundamentals of Dermatologic Surgery for the Dermatologist by Geronemus and Hanke and Skin flap manuals by Davidson have also aided in the education of numerous dermatologists.^68,69 The Yearbook of Dermatologic Surgery, recently renamed The Yearbook of Dermatology and Surgery, series originally edited by N. Swanson, and later by H.T. Greenway and B.H. Thiers, has provided excellent reviews of current dermatologic surgical developments and has routinely provided a section on advancements in reconstructive surgery.

A thorough understanding of cutaneous anatomy is absolutely necessary for the proper and safe execution of dermatologic surgery and for optimal cosmetic and functional reconstruction. Initially, when dermatologists began to perform a greater number of these surgeries, references were limited to general anatomy texts that were oriented toward other specialties. A number of anatomy books and surgical atlases were subsequently written by dermatologists in order to address the need for specialized texts that addressed issues concerned with dermatologic reconstruction. Included in this group are the following: Atlas of Cutaneous Surgery by Robinson, Arndt, LeBoit, and Wintroub; Surgical Anatomy of the Skin by Salasche et al.; and Cutaneous Surgical Anatomy of the Head and Neck by Breisch and Greenway.^70–72

By the 1970s, it was evident that the practice of surgical procedures including reconstructive procedures by dermatologists was rapidly expanding and that an organization would be required to adequately address the specialized interests of those dermatologists who were involved in this movement. Leonard A. Lewis, MD and Sorrel S. Resnik, MD, in 1970 organized a meeting of a core group of 29 dermatologists that would form the American Society for Dermatologic Surgery (ASDS). The goal of this new society was “to promote excellence in the care of patients through education in dermatologic surgery.”⁹ The ASDS joined the already existing Mohs College for micrographic surgery (originally titled The American College of Chemosurgery) which was founded in 1967 by Fredric Mohs to provide opportunity to educate the growing numbers of dermatologists who were becoming interested in surgical and reconstructive endeavors. In 1977, Dr. Perry Robins founded the International Society for Dermatologic Surgery (ISDS) which expanded the horizons of dermatologic surgery and allowed the exchange of ideas at an international level. A number of dermatologic societies developed and their members actively shared their thoughts and methods of surgical reconstruction. The Association of Surgical Faculty was founded by L. Field and S. Mandy in 1985 and has allowed many dermatologic surgeons to exchange their ideas and personal experiences related to dermatologic surgery and reconstruction in an open discussion. Edward Krull founded the Association of Academic Dermatologic Surgeons in 1989. Neil Swanson served as the first president of this organization whose membership is composed of surgical directors in residency programs and whose purpose is to assist in the education of residents and medical students in surgical modalities including reconstructive procedures. The American Academy of Dermatology, founded in 1938 has also through the years been instrumental to the growth and expansion of reconstructive surgery in dermatology through its sponsorship of educational and developmental efforts. A great number of dermatologic and dermatologic surgical societies have been greatly supportive and have encouraged the exchange of ideas and experiences of dermatologists at a local, state, national and international level.

As dermatologic surgical reconstruction grew, it was evident that there was a need to educate both practicing dermatologists and dermatology residents. Courses began to be offered with greater frequency and number at the annual American Academy of Dermatology (AAD) meetings in the 1960s.⁷³ The first educational course sponsored by the ASDS, “Basic Surgical Techniques for Dermatologists” was then presented at the AAD's meeting in Miami, Florida in 1972. Subsequent years yielded additional courses in a variety of topics of dermatologic surgery including reconstruction. Additionally other surgical conferences and workshops were created to provide exposure to surgical principles and techniques. Among the early courses, the Schering-sponsored soft tissue workshops under the direction of Perry Robins provided practicing dermatologists, many of whom had received no training while in residency, with their initial introduction to skin flaps and grafts. The annual Hugh T. Greenway, Jr. co nference on Superficial Anatomy and Cutaneous Surgery held in San Diego was developed in 1983 to provide hands-on experience using fresh cadaver laboratories both in cutaneous anatomy and reconstructive surgical techniques. One of the highlights of this course in particular is that the faculty has been composed of surgeons from a variety of specialties, thus allowing exposure to the perspective and expertise that each of these fields offers (see Figure 6).

Residency training now reflects the integral role for reconstructive surgery in dermatology today. Initially introduced while Edward Krull was president of the American Society of Dermatologic Surgery in 1982, the training program requirements set the minimum requirements for surgical exposure and competence that every resident shall demonstrate during their residency. The Residency Review Committee for Dermatology, sponsored by the Accreditation Council for Graduate Medical Education, expanded the residency requirements in 1990 to include a more significant component that included reconstructive techniques such as “complex closures, flaps, and grafts”. Additionally this committee mandated that each program have a surgical program director who would be responsible for ensuring that the residents receive adequate training and exposure to surgical procedures during their residency.

During the last 40–50 years, reconstructive surgery has earned its place among the many activities performed by dermatologists and its growth has paralleled that of dermatologic surgery. This past era has been highlighted by numerous activities including the formation of several dermatologic surgical societies, the creation of a journal dedicated to cutaneous surgery, the publication of numerous surgical texts, and the refinement and development of new and novel surgical techniques. The future is bright and will most definitely bring additional refinements in techniques and as our technology continues to evolve, further advancements in areas such as tissue engineering and wound healing will help shape dermatologic surgical reconstruction in years to come.

Acknowledgments

References 

Thanks to Drs. Lawrence Field, Perry Robins, Stuart Salasche, Ramsey Mellette, Richard Bennett, Stephen Mandy, Ed Lack, Roger Ceilley, and others who have contributed to this review through their conversations and insight. A special thanks to John Zitelli, MD for his assistance in the review and preparation of this paper.Additionally throughout the years, select physicians from other fields have provided articles in the dermatology literature, spoken at the national meetings and have participated in workshops and conferences to the betterment of dermatologic surgical reconstruction. Gary Burget MD, Richard Webster MD, and Terry Davidson MD, Stephen Pratt MD, and Edward Hockstein, DPM are just a few of the individuals that have contributed to the education of dermatologists in reconstructive surgery and we would like to thank the efforts of these and other individuals in other specialties who have extended their talents and knowledge to advance the reconstructive surgical field in dermatology.

 

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