Coming to description of modern methods in reconstructive surgery of the face, we would like to analyze historical aspect of development of this direction in plastic surgery. Amazing responsibility and scrupulousness in research of certain elements of reconstructive surgery is evidenced by reports of scientists who lived more than one century ago.

Analyzing the literature, we were pleasantly surprised that many innovative methods were discovered several centuries ago. On the other hand, we were disappointed that their use was delayed for many centuries. Obviously, medicine in those days was of a semi-official nature and could not fully develop due to many restrictions. We learned about various anatomists and surgeons who continued their researches during the Renaissance under threat of punishment and laid the foundations for the study of anatomy, topography and facial reconstruction.

Facial reconstructive surgery has a long history dating back to BC.

The earliest description of skin flap grafting is dated back to 1000 BC (Sushruta-Samhita manuscript) [1]. In ancient India, doctors became adepts in flap grafting for facial reconstruction (most often, middle zone). The technique was based on a principle similar to the modern principle of skin grafting. A rectangular cutaneous flap was excised along 3 sides, while the 4^th side was preserved for blood supplying. Mobilization of the flap was followed by its transplantation for defect closure.

The Roman scientist and physician Aulus Cornelius Celsus (25 BC–50 AD) described similar skin flaps. According to the German physician and surgeon Edward Zeiss [2, 3], Aulus Cornelius Celsus can be considered the founder of plastic surgery in the West. His methods of lip and ear defect closure after injuries are described in detail (De medicina) [4, 5]. As the Roman physician correctly noted, “if a patient presents with a defect de novo, tissue will not grow spontaneously on its own, so surrounding tissue transplantation is necessary”. Skin grafting technique described by Celsus, in fact, does not differ from that described by Sushruta. At the same time, Celsus emphasized one very important aspect regarding defect transformation into a geometric shape for easier closure.

After Celsus, skin flaps were not described for a long time until Oribasius (325-403) in Alexandria suggested this technique for ear, nose, lip and forehead defect closure [6-9]. Geometric shapes were similar to those proposed by Celsus. It is assumed that Oribasius described these approaches for the Arabs and the last ones transferred their knowledge to Europe.

The Greek surgeon Pavel Eginsky (VII century) made a great contribution to the technique of skin grafting [10]. He did not use skin flaps in modern sense. Nevertheless, he described mobilization of the wound edges. For the first time, the necessity of full-thickness mobilization of the wound edges with subsequent layer-by-layer sutures was considered. This maneuver greatly improved the later variations of flap surgery.

We would like to quote the words of the great surgeon Henri de Mondeville (1260–1320) [11, 12]. He was a personal physician of Louis X and his father Philippe le Bel. This surgeon said that “no master should work with a subject without knowing about this subject. Since the human body is an object of all medical art with surgery as one of the tools, it is obvious that surgeon performing incisions in various parts of the body and limbs will never work well without realizing their anatomy”.

Manuscripts of Claudius Galen are also very important for reconstructive surgeons (131-217) [13]. He was a researcher and anatomist, personal physician of Emperor Marcus Aurelius. Claudius Galen believed that “nothing was created by Mother Nature without a reason, and therefore every organ should be designed to best fulfill its function” [14, 15]. His idea was completely realized only by the end of the 20^th century — the beginning of the 21^st century when microsurgical tissue autotransplantation was applied for optimal reconstruction of facial and cervical defects. Modern reconstructive surgeon seeks to recreate all anatomical features that correspond to normal functioning and aesthetic perception. By the way, Galen was the author of the first anatomical manuals — “Anatomy of muscles”, “Description of bones”. He is also creator of cranial nerve classification.

The 15^th century was marked by a significant phenomenon (use of distant flaps for facial reconstruction). Gustavo Branca, father of the Sicilian plastic surgeon Antonio Branca, did an excellent job in defect closure using local flaps. However, Antonio decided to master new techniques. Perhaps, influence of the Renaissance was essential. Indeed, disfiguring facial scars after local plastic surgery was considered unacceptable due to a particularly refined perception of beauty. Moreover, invaders of Sicily (the Greeks, Romans, Arabs) with higher cultural development had a significant influence. Antonio Branca predominantly used the flaps from the inner surface of the shoulder for nose reconstruction. He considered these flaps more adequate compared to facial flaps. This technology required much time due to adaptation of the flap and its pedicle. Later, these flaps were used by other surgeons (the Vianeo brothers in Calabria). Other flaps were also subsequently used, for example, by Alessandro Benedetti [16, 17] and Heinrich von Pfolfprundt from Germany [18]. Distant pedicled flap technique was predominant in plastic surgery in post-Renaissance Europe.

Unfortunately, Branca and Vianeo had no certificate for professional surgical activity according to modern concepts. So, they hid their work. Instead of these surgeons, professor of anatomy and enthusiast from the University of Bologna Gaspare Tagliacozzi (1546–1599) described this technique although he did not perform a single surgery.

Jacques Guillemeau (1550–1613) made a great contribution to development of reconstructive surgery. He closed extensive defects in patients with congenital clefts of the face. He proposed bilateral incisions. This technique was subsequently recreated by Le Dran [19, 20].

A new round of the use of flaps in reconstructive surgery occurred in the 18^th century. A group of surgeons returned from India, where they were shaken by techniques nose reconstruction with forehead skin flaps. The English surgeon Joseph Carpue described this technique and successfully performed this operation in 2 patients. The monograph was published in 1816 under the title “An account of restoring a lost nose” and became a sensation in the 19^th century [21].

Subsequently, flap surgery was being developed rapidly due to changing approach to the management of skin cancer and need for facial defect closure following the wars of the 19^th century. The book of the German surgeon Johann Friedrich Dieffenbach “Regeneration and Transplantation” was the most notable report devoted to this issue. The foundations laid by Dieffenbach are still used by oncologists and plastic surgeons for facial defect closure.

The book by Paolo Baroni (1857) was dedicated to facial defect closure with pedicled flaps after previous surgery for cancer [22]. For the first time, clinical guidelines for flap surgery were established (Fig. 1).

Fig. 1. Closure of buccal defect from the book by Paolo Baroni.

Up to the present day an important addition is Burow’s triangles for correction of “dog ears”. This method was described by Karl Burow in 1855 [23].

Prototype of submental flap was introduced in 1824 by Charles Lallemand and later modified by Bernhard Rudolf von Langenbeck in 1839 [24].

Nasolabial flaps were independently proposed by Ernst Blasius [25, 26], I.F. Dieffenbach [27, 28–30] and V. Bruns [31]. Common lower eyelid flap was described by Carl Johan Fricke in 1829. In 1855, pedicled upper eyelid flap was developed by Louis de Wecker and Edmund Landolt [32].

For the first time, O. Berger described Z-plasty of the face in 1887 [33].

Rotational preauricular flap is often used in facial surgery. T. Delpech in France first applied this approach in 1820. First clinical application was half-successful [34, 35].

H. Fritze and O. Reich described all above-mentioned methods in the book “Plastic Surgery” in 1845 [36].

In Russia, the first edition devoted to plastic surgery appeared under the editorship of Yu.K. Shimanovsky (part I — Kiev, 1864; part II — 1865; Part III, issues 1 and 2 — St. Petersburg, 1869). The authors described all nuances of local plastic surgery known at that time, especially lip repair after previous surgery for cancer.

To this day, we use an upper lip flap for closure of extensive defects of the lower lip. This technique is known as Shimanovsky’s method.

Considering the above-mentioned literature data, we can conclude that local facial flap is a limited zone of tissue with various components including skin, subcutaneous tissue, fascia and muscle with blood supply through the axial and perforator vessels. Displacement of this flap under 30–180° is possible.

Honored scientist of the RSFSR, doctor of medicine, professor A.A. Limberg (1894–1974) may be considered a real virtuoso of plastic surgery. In addition to new solutions in odontology and dentistry, A.A. Limberg created a fundamentally new theory of local plastic maxillofacial surgery. If earlier students could focus exclusively on the literature and clinical examples, now they were provided with an algorithm of actions and specific planning of surgeries. A.A. Limberg wrote the monograph “Mathematical foundations of local plasty on the human body surface” in the besieged Leningrad (published in 1946). This book made him famous. In the USSR, Alexander Anatolyevich Limberg was awarded the State Prize (Fig. 2).

Fig. 2. Preoperative planning proposed by A.A. Limberg (1946). Dissection of triangular flaps.

In 1967, he wrote the next monograph “Planning of local plastic surgery” based on more than 40-year clinical and scientific experience. This book was published in the German Democratic Republic in German and later in English. Thus, A.A. Limberg had an opportunity to become the most cited Russian surgeon.

For the first time, P. Sabattini used a vascular flap on the face for lip reconstruction in 1838. However, his clinical experience was not widely used [39]. Only 60 years later, the American surgeon Robert Abbe proposed a similar technique. The last one is called by his name and actively used today.

Further development of facial plastic surgery was associated with a round pedicled flap proposed by an ophthalmologist from Odessa V.P. Filatov. He used this flap for eyelid defect repair. The author recommended this method for other facial zones in the manuscript published in 1917 in the “Bulletin of Ophthalmology” [37]. V.P. Filatov believed that a round flap effectively resists to infection.

Abroad, round pedicled flap is called Gillies flap. Military surgeon Harold Gillies from England proposed this method a year later regardless the discoverer and popularized this technique in Europe. His report first occurred in the literature in 2 years after the manuscript by V.P. Filatov in 1919 [38]. The British are very careful about the legacy of their compatriot. The drawings by Gillies’s assistant Henry Tonks with various techniques of pedicle flap dissection are still kept at the Royal College of Surgeons in London (Fig. 3).

Fig. 3. Clinical example of the use of a round stem in the Gillis clinic.

In Russia, pedicled flap was widely used in the 30s–40s of the last century thanks to the works of A.E. Rauer (1871–1948) and N.M. Mikhelson (1883–1963) (Fig. 4).

Fig. 4. A consultation led by A.R. Rauer.

Filatov’s round flap was actively used in the war years when the department of maxillofacial surgery was opened at the CITO hospital. This hospital was created in 1921 for the treatment of invalids of the First World War and the Civil War and research of urgent problems of orthopedics and replacement. A.E. Rauer headed this department (Fig. 5).

Fig. 5. Guided facial Injury analysis by N.M. Michelson.

Various techniques of dissection of Filatov’s round flap for closure of the defects of pharynx, esophagus, face, cheeks, lips and nose were developed throughout the war and early post-war period.

By the 1940s, more than 20-year experience in reconstructive maxillofacial surgery was summarized and published in the book “Plastic surgery on the face” (1943). A.E. Rauer and his student and co-author N.M. Mikhelson subsequently received the State Prize for this monograph.

Professor F.M. Khitrov had an extraordinary stereoscopic vision and developed own recommendations on facial plastic surgery. He headed the maxillofacial surgery department of the CITO hospital since 1946.

Rhinoplasty by F.M. Khitrov was an essential aspect of round pedicled flap surgery. All nuances of formation of the tip of the nose are still considered by surgeons, although Filatov’s flap is replaced by other tissue autografts (Fig. 6).

Fig. 6. Outer nose formation with the tissues of Filatov stem by F.M. Khitrov.

F.M. Khitrov believed that Filatov’s flap is the most suitable for facial plastic surgery. F.M. Khitrov was awarded the highest government award (the Lenin Prize) for reconstruction of the pharynx and upper parts of the esophagus.

A gunshot wound and facial defect closure using Filatov’s flap are shown in Fig. 7. We can emphasize that many years and even generations were required to resolve this issue. However, the technique for effective facial reconstruction was developed (Fig. 8). This method remained the only one for closure of extensive defects of the face and neck for a long time (almost about half a century).

Fig. 7. A clinical example of a gunshot wound of average the faces and transposition of the Filatov stem into the defect zone are shown.

Fig. 8. The result before and after using the Filatov stem by the method of F.M. Khitrova.

We should mention another virtuoso surgeon of the last century — David Ralph Millard (June 4, 1919 – June 19, 2011). He developed and improved many methods of local plastic surgery, in particular those related to closure of facial clefts. Moreover, this surgeon developed certain surgical principles in addition to multiple techniques of local plastic surgery. These principles are still actual.

The next stage in development of facial reconstructive surgery was associated with pedicled flaps. In 1887, the Viennese surgeon R. Gersuny first used a submental flap for cheek defect closure [40]. In 1893, the American surgeon Theodore Dunham reported a pedicled frontal flap on superficial temporal artery [41].

In 1980, J. McCraw et al. [42, 43] theoretically substantiated blood supply of the musculocutaneous flaps in their monograph “The recent history of myocutaneous flaps”.

In 1909, J. F.S. Esser first used transposition of an extensive pedicled flap with two vascular pedicles for jaw defect closure [44]. This technique is still relevant for correction of lower facial defects. Later, Kazanjian V.Kh. confirmed an adequate blood supply of the flap with one vascular pedicle [45].

In 1917, D.L. Aimard first used musculocutaneous flap with inclusion of pectoralis major muscle. However, his technique was described by V.Ya. Bakamjian only 50 years later [46].

In 1972–1973, Smith, Foley and McGregor described clinical use of axial, in particular inguinal, flaps. In 1973, J. Morgan and I. McGregor substantiated successful use of other axial flaps (deltopectoral flap and trapezius flap with inclusion of sternocleidomastoid muscle). These methods came into practice for many decades and replaced Filatov’s flap [47].

Transplantation of vascularized distant flaps towards a defect gave a powerful impetus to the use of vascularized autografts in maxillofacial surgery. This approach reduced hospital-stay, increased resistance to infection and ensured favorable aesthetic effect and functional result.

Vascularized autograft is a complex of autologous tissues with axial blood supply system and perspective recovery of circulation through the vessels in the recipient zone.

Strauch B. et al. [48] first described microvascular reconstruction of the jaw in 1971. The authors performed free autotransplantation of the vascularized rib into the area of mandibular defect.

In 1978, Arian S. and Finseth F.J. proposed a free osteocutaneous rib graft. Application of this autograft was important for understanding the processes of vascularized bone regeneration [49].

The first successful experiments on vascularized bone transplantation into mandibular region were carried out on rib autografts in 1975–1977 [50]. D. Lalonde et al. (1984) [51] argued that histological structure of vascularized autografts does not differ from intact bone. The advantage of vascularized bone transplantation has become obvious. This is especially true for patients with extensive combined facial defects, cicatricial soft tissue bed and impaired perfusion of bone and soft tissues after previous radiotherapy. Microsurgical autotransplantation is the only option for these patients.

Vascularized autografts were introduced into clinical practice over 50 years ago. The main milestones in development of microsurgical autotransplantation in maxillofacial surgery are associated with creators of vascularized autografts (flaps). McKee D.M. [52] proposed a rib autograft with anterior intercostal vessels (1978), D. Serafin et al. [53] — rib with posterior intercostal vessels (1980), J. Taylor et al. [54] — fibula (1975), iliac crest (1977) [55], J.F. Yang — radial flap (1981) [56], A. Gilbert and Teot A. [57] — scapular flap (1982).

Significant advances in microsurgical knowledge and surgical techniques ensured simultaneous reconstruction of the most difficult/complex defects with a free flap. In the past, this reconstruction was difficult without multiple stages. Microsurgery underwent several historical stages. The beginning of this history was laid by Murphy J.B., who performed the first vascular anastomosis in 1897 [58]. Almost 2 decades later (in 1912), Alexis Carrel was awarded the Nobel Prize for vascular triangular anastomosis [59]. In the 1960s, Jacobson J.H. and Suarez E.L. succeeded in vascular anastomoses with a diameter of 0.25 mm. They used a microscope and created the concept of “microvascular surgery” [60]. In 1973, Daniel R.K. and Taylor G.I. used the term “free flap”, and the era of reconstructive microsurgery was started with introduction of a free inguinal flap [61].

Free flap transplantation revolutionized tissue reconstruction. Surgical microvascular techniques of free flap transplantation ensure accurate closure of various defects and deformities. Various types of flaps for different tissue compositions are available. Muscular, musculocutaneous, fasciocutaneous and musculocutaneous bone flaps are classically distinguished.

We can proudly emphasize parallel microsurgical experimental studies performed at the Petrovsky National Research Centre of Surgery in the 1970s. These studies were performed by V.S. Krylov and colleagues. This author developed and implemented vascularized autografts in clinical practice simultaneously with Western surgeons and performed the first microsurgical procedure in 1978. This surgery was unsuccessful. Nevertheless, the second successful transplantation of vascularized inguinal flap onto the temporal region was performed in 1979 for closure of the defect after excision of extensive basal cell carcinoma. The surgeons were V.S. Krylov, G.S. Stepanov, and A.I. Nerobeev. History of national reconstructive microsurgery of the face and neck was started from this period. The manuscript “Free transplantation of composite skin grafts” comprised scientific and practical understanding of the first microsurgical tissue autotransplantation. This report was published in the journal “Surgery” (No. 2, 1981) by B.V. Petrovsky, V.S. Krylov, G.S. Stepanov and A.I. Nerobeev [62].

Professor Nerobeev A.I. made a revolution in maxillofacial reconstructive surgery in our country. He analyzed topographic and anatomical data and confirmed the feasibility of vascularized flaps in face reconstruction. These data were also substantiated by numerous surgeries.

Later, Nerobeev A.I. created a school of facial reconstructive surgery, whose representatives are still introducing the new flaps and methods of reconstruction of the face and neck. His book “Restoration of Head and Neck Tissues”, published in 1988 [63], became a unique publication that accumulated all the latest achievements of facial reconstructive surgery at that time. This handbook is rightfully a desktop guide for modern reconstructive surgeons.

Significant factors influencing the choice of the vascularized flap are large defect, texture of surrounding skin, composition of tissue comprising the defect, available recipient vessels, quality of blood supply of surrounding tissues, as well as functional damage and condition of recipient vessels. Musculocutaneous flap is ideal for closure of a large defect with a dead space. Active perfusion of muscle grafts is valuable for repair of inflammatory and necrotic wounds without complications. Nerobeev A.I. introduced these musculocutaneous flaps for vascular malformations, when tamponade of the defect cavity is required.

Professor L.A. Brusov developed the personalized silicone implants for facial repair in patients with various congenital and acquired deformities. It is an important achievement of national plastic surgery. Development of these implants was initiated in the 60s of the last century. The first operation was performed in 1965. The result of these developments was a gold medal received at the 44^th World Salon of Inventions “Brussels-Eureka-95”. These developments were an impetus for foreign analogues (Medpor and others). The priority of national development is obvious because each implant is modeled by an artist and made for a certain patient with an individual problem.

The next stage in development of reconstructive facial surgery was tissue autotransplantation in the treatment of cancer patients. Reconstruction methods developed by Reshetov I.V. [64], Sobolevsky V.A. [65] and Polyakov A.P. [66] expanded the boundaries of resections and improved the quality of life of these patients. These researches became extremely important at the intersection of two specialties and made it possible to expand the boundaries of resections. The book “Tumors of the head and neck organs” by Reshetov I.V. is fundamental manuscript devoted to defect closure in patients with cancer.

The book by Verbo E.V. and Nerobeev A.I. “Reconstruction of the face with vascularized autografts” is essential in maxillofacial surgery. The authors described the essence of microsurgical flaps for optimal facial reconstruction in terms of functional and aesthetic rehabilitation. Modeling of vascularized flaps in accordance with face shape and initial experience of computer modeling are reported. Verbo E.V. first scientifically substantiated topographic-anatomical approach in choosing a safe formation of bone vascularized autografts according to facial bends [67]. Subsequently, Butsan S.B. and Nazaryan D.N. significantly improved these developments.

Transplantation of femoral flap for small defects is an important direction in recent years (Gileva K.S. “Vascularized periosteal-cortical femoral flap for local maxillofacial defects”) [68]. Currently, K.S. Gileva has accumulated the world’s largest experience in the use of femoral flap in maxillofacial surgery.

Petrosyan A.A. reported ulnar artery forearm flap. This flap ensures less damage to the donor zone compared to radial flap [69].

To date, development of vascularized tissue autotransplantation for facial reconstruction has entered a qualitatively new stage. Previously, effective closure of the defect with vascularized autograft was enough. Currently, surgeons are striving for a full-fledged anatomical and functional restoration of the lost area and minimal donor zone damage.

Salmon M. (1936) was a forerunner of the era of perforator flaps and perforator blood supply of the facial zones. He studied contrast enhancement data on cadaveric material, compared these results X-ray data and revealed the dominant vessel in each zone [70, 71].

Unfortunately, these rare scientific data have not been used in further clinical application. Later (in 1987), Taylor G.I. and Palmer J.M. first described this idea in their book considering the Salmon’s data and introduced the concept of “angiosome” [72].

The concept of angiosome ensured multicomponent reconstruction with less damage to the donor area. Microvascular surgery with a great success and popularization of perforator flaps is currently essential in all structural and functional reconstructions. Successful reconstruction should imply functional recovery rather closure of tissue defect only. Therefore, the choice of flaps, as well as functional and aesthetic result in recipient and donor areas depend on characteristics of recipient area.

Comprehensive understanding of the flaps was associated with evolution of surgical techniques and characteristics of autografts. Conventional flaps on the arteries were replaced by the flaps on arterial branches. Recently, the concept of perforator flaps on these branches was presented. In the past, axial musculocutaneous flaps were popular for reconstruction. However, the problems associated with these reconstructive techniques (excessive volume and cumbersomeness of the flap, donor area damage) caused the changes in this direction. The authors described fasciocutaneous flaps. The last ones were preferentially formed on arterial branches rather the main arteries. This technique ensures dissection of a thinner flap (including the fascia) and no damage to the underlying muscle. In 1989, Koshima I. and Soeda S. described the technique of dissection of perforator flaps with preservation of the underlying muscle [73]. We found no national and foreign data on cervical perforator vessels. However, flaps from a region adjacent to the face are very significant due to identical texture and color of these tissues to facial tissues. Nerobeev A.I., Balkizova V.V. and Verbo E.V. (2002) first used perforator vascularized autografts in maxillofacial region in Russia [74]. Further development of perforator flaps of the neck was associated with their clinical application by Verbo E.V. and Filippov I.K. (2016) [75]. Later, Abdullaev K.F. and Gileva K.S. improved mobilization of femoral perforator flap that made it possible to form a flap of various thicknesses depending on trajectory of perforator vessel [76]. Then, computer modeling of soft tissue perforator grafts (DIEP flap) was widely developed by Gileva K.S. [77].

Extensive research of vascular anatomy and physiology of the flaps was followed by delineation of architecture of angiosomes. These processes ensured the choice of various donor zones of perforator flaps. As a result, today we can selectively harvest only those tissues that are necessary for reconstruction. This contributes to minimum damage to the donor area, controlled flap thickness and precise approaches to reconstruction [78].

In the last decade, the so-called propeller flaps have become widespread [79]. These so-called “free style” flaps can be transplanted to the defect that compensates the lack of tissue texture and ensures the opportunity to replace the defect with homogeneous tissue components.

Also, a movable V-Y flap can be attributed to these flaps, although its foundations were described by Dieffenbach in the 19^th century [28].

Perforator flaps are essential in face reconstruction for hemifacial macrosomia because these flaps ensure planning a certain thickness of the defect for correction of contour deficit. Moreover, modeling of the flap with different volume in various parts is possible due to perforator blood supply.

Lateral circumflex femoral artery perforator flap and deep inferior epigastric artery perforator flap are the most common in reconstructive surgery. The last one is usually used in breast reconstruction. Nevertheless, Gileva K.S. et al. [77] used this flap in face reconstruction.

Thoracodorsal artery perforator flap is widely used abroad. However, this flap is not common in our country due to the previously described wide possibilities of modeling a classical flap.

Thus, we can observe a historical spiral in introduction of new surgical techniques based on previous approaches. Importantly, each of the proposed techniques was essential in development of reconstructive facial surgery. Moreover, all these procedures should be currently considered in choosing the optimal management.

The authors declare no conflicts of interest.