The evolution of head and neck reconstruction

Introduction Like most areas of plastic surgery, head and neck reconstruction has evolved considerably over the past half century, incorporating new techniques and innovations. In many parts of the world it has become part of the specialty of head and neck surgery, which itself evolved from general surgery, plastic surgery and otolaryngology, such that it is no longer thought of as part of plastic surgery alone. This discipline now includes new techniques, new flaps and new approaches. In addition, we have seen the blending of hitherto unrelated subspecialties, so that microsurgery and craniofacial surgery are now often practiced by a new breed of practitioners who are trained in both techniques. We have also seen a blending of resection and reconstruction, often by the same surgeon, which though it may seem like a new approach, is how it was done originally. The sheer scope of the subject prevents this paper from being exhaustive, so we attempt to give a broad overview of the changes and to give some background on how and why these advances happened. Such an overview is considered timely and useful for an early issue of this journal. Key references are cited to provide further reading.


Introduction
Like most areas of plastic surgery, head and neck reconstruction has evolved considerably over the past half century, incorporating new techniques and innovations. In many parts of the world it has become part of the specialty of head and neck surgery, which itself evolved from general surgery, plastic surgery and otolaryngology, such that it is no longer thought of as part of plastic surgery alone. This discipline now includes new techniques, new flaps and new approaches. In addition, we have seen the blending of hitherto unrelated subspecialties, so that microsurgery and craniofacial surgery are now often practiced by a new breed of practitioners who are trained in both techniques. We have also seen a blending of resection and reconstruction, often by the same surgeon, which though it may seem like a new approach, is how it was done originally. The sheer scope of the subject prevents this paper from being exhaustive, so we attempt to give a broad overview of the changes and to give some background on how and why these advances happened. Such an overview is considered timely and useful for an early issue of this journal. Key references are cited to provide further reading.
Russian literature in 1961. 3 The pectoralis major flap is still used today and the deltopectoral flap, while still occasionally used, has morphed into the internal mammary artery perforator (IMAP) flap. 4 The introduction of microsurgical techniques to the head and neck revolutionised this area of surgery and made possible many procedures that were hitherto fraught with major complications or impossible to perform safely. This saw the end of the tubed pedicle flap and significantly reduced the morbidity seen with these procedures. 5 The groin flap was one of the initial common flaps in microsurgery as it was the first flap recognised to have an axial blood flow. 6,7 Many microvascular free flaps of every region of the body were then described in quick succession, although not all are suitable for head and neck reconstruction.
Flap surgery has undergone an evolution as our anatomical knowledge increased over the years.
Mathes and Nahai opened the door to the rapid evolution of flaps in the 1980s by classifying muscle blood supply. 8 What was originally known as the 'Chinese flap' and more commonly known now as the radial forearm flap was introduced by Song in 1982. 9 This flap was revolutionary in that it brought us for the first time a thin pliable flap, with a long vascular pedicle and the potential for innervation. Despite its suboptimal donor site, it is ideal for many applications in the head and neck, Distraction can also be applied to other situations and has simplified our approach to many difficult situations.
In some respects, less has become more in

Stereolithography and 3D printing
Computers have improved our precision, particularly in designing osteotomies and placing implants. With the aid of stereolithography 43

Conclusion
Head and neck reconstruction is a complex area of practice that seems to become more complex as surgical techniques evolve. However, it must be remembered that evolution and development is not just happening in surgery but also in fields such as radiation and medical oncology, both of which have a major impact on what reconstructive surgeons do and how the field will change with time.
The history of plastic surgery has been one of innovation regardless of the area of reconstruction.
As a specialty, we tend to develop novel techniques for addressing difficult problems, and not infrequently new approaches are adopted and sometimes taken over by other specialties to the exclusion of plastic surgery. We are vulnerable to this because of the fact that this specialty is often not the 'gatekeeper' for patients with the particular problem being addressed. Head and neck surgery is one such area. Continuing to innovate, adapt and introduce new techniques and approaches is our best protection in ensuring that head and neck reconstruction remains in our domain.