General introduction HISTORY The introduction of the microscope for surgery of the middle ear in 1925 by Nylen1, and the first microsurgical anastomoses in a 3 mm vessel in 1960 performed by Jacobson and Suarez2 gave birth to a new discipline: microsurgery. Subsequently the first digit replantation was performed in 1965 by Tamai3 and later, actually unsuccessful, a free flap was done by Antia and Buch in 19714. Ian McGregor and Ian Jackson performed the first successful transfer of a groin flap with microsurgery in 1973 using the term “free flap”5. From then on, numerous different free flaps were planned and successfully done. The flaps were initially divided in fasciocutaneous and musculocutaneous types. The fasciocutaneous flaps were nourished by direct cutaneous perforators reaching directly the skin after piercing the fascia: the musculocutaneous flaps were vascularized by indirect perforators derived from vessels supplying the deep structures. The musculocutaneous flaps showed a higher morbidity of the donor site as the deep structures had to be included in the flap to ensure the vascularization to the skin5. In order to reduce the donor site morbidity in 1989 Koshima and Soeda6 reported the first clinical application of the inferior epigastric perforator flap. It was demonstrated that it was possible to harvest the same amount of lower abdominal skin and fat as in the TRAM (transverse rectus abdominis myocutaneous) flap, without sacrificing the rectus abdominis muscle. In 1994 Allen and Treece7 reported the first series of 22 successful breast reconstruction with the DIEP (deep inferior epigastric perforator) free flap. Since that moment the transfer of tissue based on perforators became the workhorse for microsurgery. The vascular anatomy and the physiology of perforator flaps have been studied intensively since then and different perforator flaps are described. VASCULAR ANATOMY OF THE SKIN The first publication about vascular supply of the skin was in 1628 by William Harvey8. He was the first who described completely and in detail the systemic circulation and properties of blood being pumped to the body by the heart. Harvey initially studied serpents and fish to prove how the blood circulated in a circle: he stated that the heart propelled the blood in a circular course through the body noticing that if he tied the veins, the heart would become empty, while as he did the same to the arteries, the organ would swell up. Spalteholz18 in his work in 1873 divided the arteries to the skin into direct 8
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