The Anatomical Basis for Reverse First to Fifth Dorsal Metacarpal Arterial Flaps

Applications and Reliability of Dorsal Metacarpal Artery Perforator Flap

Dorsal metacarpal artery perforator flap (DMAP), first described by Quaba and Davison, is a useful tool in the armamentarium of plastic surgeons. It provides like for like tissue for the reconstruction of dorsal finger defects. It is a simple and relatively easy flap to harvest with minimal donor site morbidity. In this case series, we present our experience, applications, and surgical technique of flap harvesting.

Cutaneous vascularization of the proximal two-thirds of the dorsal aspect of the hand: descriptive anatomical study of a perforating arterial arch

PURPOSE

Several reports have suggested that transverse arches between the radial and ulnar sides of dorsal hand skin supply the proximal part of the skin. The main objective of the study was to provide an anatomical and radiological description of a superficial vascular arch in the proximal third of the metacarpals of the long fingers.

METHODS

We dissected 11 hands after injection with a mixture of lead and resin. A CT scan was performed before dissection. All vessels supplying the skin were individualized on the back of the hand and measured.

RESULTS

A superficial perforating dorsal arch of the hand was present in all cases in this study. It was supplied by a dorsal radial perforating artery arising from the radial artery and by a dorsal ulnar perforating artery arising from the dorsal carpal arch. The distal recurrences of the intermetacarpal spaces communicated with this arch. This arch was the only source of vascularization of thess proximal third of the third space and presented a dominant ulnar side in the majority of cases. It presented numerous anatomical variations. The source vessels had mean diameters of 0.5 mm. There was an excellent radiological-anatomical correlation on CT scan.

CONCLUSION

Given the constancy of this arch in the study, perforating flaps not yet described could be considered, having as pivot points the ulnar or radial origin of this arch.

The anatomic relationship of dorsal arterial perforators of the distal forearm, wrist, and dorsum of the hand with conclusions for the clinic

BACKGROUND

Extended soft tissue defects of the fingers are often challenging to treat, and therefore, we performed cadaver dissections to elucidate the anatomic relationship between dorsal arterial perforators of the distal upper extremities to support the development of new local flaps.

METHODS

Ten fixated cadaveric distal dorsal lower forearms were dissected to their arterial perforators down to 0.1 mm diameter in size with identification of their relationship.

RESULTS

Dorsal distal fascia piercing perforators of the lower forearm come in two distinct rows, radial and ulnar, of the fourth extensor compartment. These were interconnected by subfascial axial arteries in line. The most proximal perforator is usually located 8-10 cm from the dorsal wrist, the most distal about 1-2 cm, and on average, only three subcutaneous bridging vessels connect both axial systems. The number of less reliable subcutaneous arterial connecting vessels between the dorsal wrist and forearm is also fairly limited to only one or two. More constant bridging arteries interconnect at the level of the dorsal retinaculum between the axial systems of the hand and lower forearm. At the level of the dorsum of the hand perforators reaching the skin, they interconnect in an arcuate fashion. This unique distribution pattern could be used for freestyle perforator propellor flaps of the hand, as we demonstrated in a case directly derived from our recent research.

CONCLUSION

In our opinion, a super-extended perforator flap should be possible with the inclusion of the bridging arteries in flap design at the level of the dorsal retinaculum.

Reappraisal of arterial anatomy of thumb

The nomenclature of arteries supplying the thumb and its sources arteries differs between the studies. This makes difficulty in understanding the irrigation pattern to the thumb. The main purpose of this study was to identify the proper digital arteries supplying the thumb on its radial and ulnar side from both the palmar and dorsal aspect. Also this study aimed to trace its source and classify with proper definition with the review of blood supply to thumb. Dissection was carried out in 55 hands form 28 freshly embalmed adult human cadavers of both genders. The proper digital arteries to the thumb and its source arteries were carefully traced and defined. Thumb receives its dominant blood supply mostly from its palmar side. The ulnar palmar digital artery was seen in all the dissected hand (100.0%) whereas; the radial palmar digital artery was present in 53 hands (96.4%). The radial dorsal digital artery and ulnar dorsal digital artery were observed in only 10.0% and 7.3%. The most common source of both the palmar digital arteries to thumb was from first palmar metacarpal artery (FPMA). In majority of the hands, in addition to the radial or ulnar palmar digital arteries from the FPMA, there were also additional palmar digital arteries arising from the superficial palmar arterial system. The universal naming of the proper digital arteries to the thumb as well as its source arteries is mandatory for the proper understanding of normal as well as variant arterial anatomy of thumb.

The First Dorsal Metacarpal Artery Perforator Free Flap: The Comet Flap

BACKGROUND

Distal extremity defects pose a particular challenge to the reconstructive surgeon, however, advances in perforator flaps have expanded the armamentarium of potential reconstructive options. Herein, we present our experience in reconstructing distal extremity defects using a thin, cutaneous free flap based on the perforator of the first dorsal metacarpal artery - "the Comet flap."

METHODS

A retrospective review was performed on all patients who presented with a distal extremity defect and underwent reconstruction using a Comet flap between 2015 and 2019. Patient demographics, flap anatomy and harvest, and postoperative course were reviewed and analyzed.

RESULTS

A total of sixteen patients were included. The mean patient age was 36.5 years old. Trauma was the most common etiology. The average defect size was 5.4x3.2cm. The average pedicle length of the Comet flap ranged from 3.5 to 30cm, depending on involvement of the radial vessels. All donor sites underwent uncomplicated closure with local rhomboid flaps. One flap was complicated by an acute venous thrombosis that was successfully treated operatively. Flap survival rate was 95%. All patients were able to maintain their preoperative range of motion and were satisfied with their final outcome. Follow-up time ranged from 6 to 50 months.

CONCLUSION

Local flaps remain an important reconstructive approach for distal extremity defects; however, in complex soft tissue injuries, free tissue transfers become necessary. The Comet flap is a safe, versatile, and reliable flap for reconstructing upper and lower extremity defects that can be performed in a single procedure under regional anesthesia.

Cutaneous Perforators and Their Clinical Implications on Intrinsic Hand Flaps: A Systematic Review

Background:

Most hand flaps are local intrinsic flaps because hand perforators are small and fragile. The purpose of this review was to gather anatomical data on cutaneous perforators of the hand and their implications on intrinsic hand flaps.

Methods:

An electronic search was performed through PubMed, Scopus, ScienceDirect, ProQuest, and CINAHL in April 2021. The search terms included “hand,” “palm,” “manus,” “cutaneous artery,” “angiosome,” and “perforasome.” Studies were filtered according to the PRISMA flow chart, and critically appraised using the Quality Appraisal for Cadaveric Studies (QUAC) and Appraisal Tool for Cross-sectional Studies (AXIS).

Results:

A total of 33 studies were included, of which 20 were pure anatomical studies, 10 combined anatomical and clinical studies, and three imaging-based clinical studies. A total of 643 hands and 406 fingers were included. The dorsal aspect of the hand, the dorsal digits, hypothenar, midpalm, thenar, and dorsal wrist consistently have adequate, closely distributed perforators of small diameters and short pedicle lengths. A series of clinical studies proved the success of elevating local perforator flaps on each of these areas.

Conclusions:

The hand contained densely interlinked cutaneous perforators of varying sizes and pedicle lengths. Although some areas of the hand are still unexplored, knowledge on cutaneous perforators of the hand allows the creation of a variety of possibilities for intrinsic hand flap designs.

First dorsal metacarpal artery perforator-based propeller flap: functional anatomy and clinical application in soft-tissue defects of the dorsal hand and digits

BACKGROUND

Many approaches have been reported to repair soft-tissue defects of the hand using dorsal metacarpal artery flaps. Use of a perforator-based propeller flap from the first intermetacarpal space to the dorsum of the hand has been described. The aim of this study was to confirm the functional anatomy of a first dorsal metacarpal artery (FDMA) perforator flap.

METHODS

Twenty-nine fixed cadaveric hands were dissected to determine the origin, course, and branches of the FDMA. Clinically, five cases of soft tissue defects of the hand underwent reconstructive surgery using an FDMA perforator-based propeller flap.

RESULTS

The FDMA was found in 27 specimens (93%). The ulnar branch of the FDMA always supplied the cutaneous perforator (mean ± SD, 4.3 ± 1.6), and the most distal cutaneous perforating branch was found along the metacarpal long axis within 25 mm of the tip of the metacarpal head with high frequency (28/29, 97%). In the two hands that had aplasia of the FDMA, well-developed perforators arose directly from the radial artery and advanced to the metacarpal head. Seven hands (24%) had perforators arising from the palmar arterial system, penetrating through or passing close by the second metacarpal bone. In clinical application, all the flaps survived completely without major complications.

CONCLUSIONS

The FDMA perforator-based propeller flap is minimally invasive and technically simple. It is expected to be a new option for hand reconstruction.

A vascularized bone graft harvested from the dorsal base of the third metacarpal bone for the treatment of scaphoid nonunion

The purpose of this retrospective study was to introduce the use of an alternative vascularized bone graft for treating scaphoid non-union. The vascularized bone graft was harvested from the dorsal base of the third metacarpal bone. From May 2014 to September 2017, 29 patients with scaphoid non-union were treated. Grip and pinch strengths were compared to the contralateral side. The patients rated wrist joint pain on a visual analogue scale. Wrist function was assessed on Mayo Wrist Score. p < 0.05 was considered statistically significant. 18 scaphoids healed at 6 weeks and the other 11 at 16 weeks. Follow-up ranged from 28 to 73 months, for a mean 48 months. At final follow-up, mean wrist flexion had improved from 65° (range, 51°-81°) preoperatively to 72° (range, 61-78°) (p > 0.05), for a contralateral value of 74° (range, 65°-86°). Mean extension had improved from 56° (range, 44°-72°) to 60° (range, 47°-76°) (p > 0.05) for a contralateral value of 66° (range, 52°-80°). Mean wrist pain improved from 4 (range, 3-8) to 2 (range, 0-4) (p < 0.05). Mean pinch strength improved from 6.4 kg (range, 5.2-7.3 kg) to 8.6 kg (6.1-9.9 kg) (p < 0.05). Mayo Wrist Score improved from 49 (range, 10-65) to 92 (range, 70-100) (p < 0.05). Transferring a vascularized bone graft harvested from the base of the third metacarpal bone was an effective alternative for the treatment of scaphoid non-union, achieving bone healing and normal wrist function without significant donor-site morbidity. TYPE OF STUDY/LEVEL OF EVIDENCE: Therapeutic IV.

The retrograde approach to the reverse dorsal metacarpal artery flap

We present a short communication on the use of a retrograde approach in the DMCA Perforator flap in cases of reconstruction post SCC excision of the hand. We illustrate the anatomy, and present intra- and post-operative findings.

Multi-dorsal metacarpal artery perforator adipofascial turnover flap for index to little finger reconstruction: Anatomical study and clinical application

Reconstruction of the dorsum of the hand and fingers is one of the main challenges in hand surgery. Regional flaps from the forearm, free flaps, or pocket procedures are options when multiple digits are injured with tendon damage and bone exposure. These procedures can be technically demanding and are often plagued by a texture mismatch. We conducted an anatomical study of 20 fresh frozen hands. The second, third and fourth intermetacarpal spaces were analyzed with the aim of defining the vascular foundation of dorsal hand adipofascial-turnover flaps based on dorsal metacarpal artery (DMA) perforators, analyzing their potential for reconstruction procedures on the dorsum of the hand. In three cases, the 4th intermetacarpal space lacked the DMA. A mean of 3.5 arterial communications were found between the DMA and palmar arterial system. Each hand had 11 ± 2 dorsal skin perforators, which were equally distributed among different intermetacarpal spaces. At least one perforator was present in each one-third of the space. The most distal perforators were the largest in all spaces but missing in two hands. A clinical case of multiple index finger to little finger reconstruction with this new multi-dorsal metacarpal artery perforator (mDMAP) adipofascial turnover flap is presented. Our anatomical study confirmed previous descriptions of the anatomy of the dorsum of the hand. It supports the safety of the mDMAP adipofascial turnover flap based on all distal arterial perforator for the simultaneous reconstruction of index to little finger injuries. Similarly, adipofascial turnover flaps can be raised from more proximal perforators arising from DMAs if more than one intermetacarpal space is included.

The first dorsal metacarpal propeller perforator (FDMP) flap for finger reconstruction

We describe here the first dorsal metacarpal artery propeller perforator flap, used to cover a full thickness, radiopalmar defect of the index finger after tumour excision. By associating a propeller design to the dissection of the first metacarpal pedicle, this flap can be effective in coverage of proximal index and web space defects, with primary closure and pleasant aesthetic outcomes. Harvested together with a superficial sensory branch from the radial nerve, this flap can provide effective coverage and sensory recovery.

Use of the First Dorsal Metacarpal Artery-Based Fascial Flap for Reconstruction of Small Defects on the Dorsum of the Hands

PURPOSE

To describe the reconstruction of small defects on the dorsum of the hands using a first dorsal metacarpal artery-based fascial flap harvested through the borders of the defect.

METHODS

From January, 2015 to May, 2017, 29 patients (29 hands) with soft tissue defects on the dorsum of the hand were treated using a first dorsal metacarpal artery-based fascial flap. At final follow-up, we measured range of motion of the metacarpophalangeal joints and the first web span.

RESULTS

Average size of the defects was 2.7 × 2.5 cm. Average size of the flaps was 2.9 × 2.7 cm. Average length of the pedicle was 2.9 cm. All flaps survived. Range of motion of the second to fourth metacarpophalangeal joints reached 93% to 98% of the opposite hand. The span of the first web reached 98% of the opposite hand.

CONCLUSIONS

A first dorsal metacarpal artery-based fascial flap can be an alternative for reconstruction of small defects on the dorsum of the hands. Flap harvesting through the border of the defect avoided an additional scar at the donor site.

TYPE OF STUDY/LEVEL OF EVIDENCE

Therapeutic IV.

The reverse dorsal metacarpal artery flap in finger reconstruction: A reliable choice

Background:

The finger skin and soft-tissue defects are reconstructive challenges due to their nature and the intricate extensor apparatus and flexors it protects. The reverse dorsal metacarpal artery (RDMA) is a time-tested option for the reconstruction of the same.

Materials and Methods:

A total of 14 cases of RDMA flap for finger defects involving proximal to distal phalanx were performed. Thirteen of these patients were male and one patient female and the most common mode of injury was occupational in nature followed by road traffic accident. The overall appearance was assessed for the flap and the donor site. The associated injuries and the range of motion were noted.

Results:

All but one flap survived completely. One patient had partial distal flap loss, which was tackled with split-thickness skin grafting. The flap size varied from 3.5 cm × 1.5 cm to 9 cm × 2 cm with mean of 6.64 cm × 1.72 cm. The mean age of the patients was 33.4 years. All the patients had acceptable aesthesis. The donor site had no complications and healed with linear scar.

Conclusions:

RDMA flap is a reliable flap for finger defects reconstruction. The range of movement mainly depends on the associated injury rather than flap transfer alone and to prove this we require doing analysis of range of movement in patients with flap done alone or with associated injuries.

The double-pedicled dorsal-metacarpal-artery (dpDMCA) flap of the hand: a novel DMCA-derived flap

The dorsal-metacarpal-artery (DMCA) flap in its standard or extended version is considered as the working horse to cover dorsal soft tissue finger defects with exposed extensor tendon or bone. We hereby present a clinical case of an 80-year-old male patient who is right-handed and sustained a soft tissue defect of the proximal dorsal aspect of his left 5th finger and the postoperative outcome employing a modified transposition flap. The double-pedicled DMCA flap (dpDMCA flap) of the hand poses in adequate clinical scenarios a comparably fast and safe solution to cover dorsal finger defects extending just distal to the PIP joint. To the best of our knowledge, this is the first report of a DMCA-based flap with a double pedicle to cover soft tissue defects at the dorsum of the hand.

Level of Evidence: Level V, therapeutic study.

Color Doppler ultrasound assessment for identifying perforator arteries of the second dorsal metacarpal flap

PURPOSE

The second dorsal metacarpal (SDMC) perforator flap has been widely used for the soft tissue reconstruction of the hand. However, it is difficult to identify the depth and branches of the perforators of the second dorsal metacarpal artery (SDMA) using only handheld acoustic Doppler flowmetry (HADF), which is the most common method. The purpose of this study was to compare the results of examination by color Doppler ultrasonography (CDU) with those of HADF and to evaluate the efficacy of CDU for detection of the perforators to be used in the design of the SDMC flap.

METHODS

Twenty-two healthy volunteers (42 hands) were examined using both CDU and HADF. All locations identified as the perforators of the SDMA by the two examinations were mapped respectively.

RESULTS

The total perforator arteries detected with CDU in all hands were 111 branches, 49 branches of which could not be identified with HADF. The average number of perforators of the SDMA per hand found with CDU was 2.8 branches, while that for HADF was only 1.8 branches. The detection rates of the cutaneous perforators of the SDMA by CDU were 100% in the proximal one-third of the second metacarpal and 95% in the distal one-fourth of the second metacarpal.

CONCLUSION

This study demonstrated the superiority of CDU compared with HADF for detection of the perforators of the SDMA. The CDU examination could easily identify the locations of the cutaneous perforators and help in the useful assessment of vascularity for the SDMC flap.

Scar contractures of the hand

This article discusses scar contracture of the hand. It contains a brief outline of the anatomy of the hand and upper extremities and the types of injuries involved. Hand reconstruction, including examination, nonoperative treatment, surgery, excision and skin grafting, flaps, postoperative management, and complications, are covered.

Unipedicled laterodigital transposition flap for covering dorsal longitudinal skin defects in multi-digit injuries

A variety of flaps have been described to treat longitudinal soft tissue defects located on the dorsal aspect of the fingers. We report 13 dorsal soft tissue defects in four patients in which unipedicle laterodigital transposition flaps were used for reconstruction. This flap is especially useful for the reconstruction of long and narrow defects located on the dorsal region of the fingers in multi-digit injuries.

The dorsal metacarpal artery perforator flap: a case report utilizing a quaba flap harvested from a previously skin-grafted area for dorsal 5th digit coverage

Burns to the hand are common in burn victims. These burns often leave complex wounds that require local flaps for coverage. Local flaps are often excluded because they lie within the zone of thermal injury. The purpose of this case report is to report the successful use of a Quaba flap harvested from a previously burned and skin-grafted area. The patient's medical record including pre-operative, intra-operative, and post-operative photographs were reviewed and utilized as sources of data. The patient tolerated the procedure well and was able to return to his previous hand therapy regimen without adverse event and with an acceptable cosmetic result. The Quaba flap can be a safe and effective option for local hand coverage even in previously burned and skin-grafted areas.

New trends in arthroscopic management of type 1-B TFCC injuries with DRUJ instability

Advances in radiocarpal and distal radioulnar joint (DRUJ) diagnostic arthroscopy permits a treatment-oriented classification of triangular fibrocartilage complex (TFCC) peripheral tears: 1) repairable distal tears; 2) repairable complete tears; 3) repairable proximal tears; 4) non-repairable tears; and 5) tears associated with DRUJ arthritis. Class 1 tears should be sutured; Class 2 and 3 are associated with DRUJ instability and require TFCC reattachment to the fovea; Class 4 tears need reconstruction using a tendon graft and Class 5 tears require an arthroplasty. Arthroscopic assisted TFCC foveal reattachment is possible through the direct foveal portal, a dedicated DRUJ working portal. Arthroscopic TFCC reconstruction using a tendon graft showed promising results.

Sagittal rotational malunions of the distal radius: the role of pure derotational osteotomy

Sagittal rotational malunion after distal radius fractures was identified in eight patients by the presence of a "hinge" point on the volar cortex on the lateral radiograph, and the ulnar head being shorter than the anterior lip of the radius on the posterior-anterior radiograph. The surgical correction consisted of preplating the distal fragment with a volar locking plate before an osteotomy through the "hinge" point, and correcting the dorsal tilt of the distal fragment. Any dorsal defect was filled with cancellous bone graft from the olecranon. Pain, range of motion and grip all improved. Disabilities of arm, shoulder and hand score changed from 54 to six. Dorsal sagittal tilt improved by 26 degrees , from -23 degrees to +3 degrees . Ulnar variance improved by 3 mm, from +1.5 to -1.5 mm, becoming identical to the opposite side. A pure derotational osteotomy corrected the apparent shortening of the radius and restored the volar tilt.

Multislice computed tomography angiography of the fourth dorsal interosseous space in cadavers

PURPOSE

To study computed tomography angiography (CTA) findings and compare anatomic correlation of the 4th dorsal metacarpal spaces and to determine the role of this technique for anatomic studies and flap design.

METHODS

Hands from 17 cadavers were injected with a radiopaque mixture. The specimens were imaged using 16-detector-row computed tomography. Each image was analyzed by a radiologist, a plastic surgeon, and an anatomist. The following data were recorded: the presence of the 4th dorsal metacarpal artery, proximal and distal communicating branches and distal recurrent branch, and the number of cutaneous perforators. Afterwards, a meticulous dissection was carried out. A correlation between the radiologic findings and the gross anatomy was established.

RESULTS

In all specimens, the 4th dorsal metacarpal artery and distal recurrent branch were identified. In 15 cases, at least 1 perforator was identified within the 4th space. In 2 cases, no perforator was identified. In all cases, the radiologic findings correlated with the anatomic findings in the dissection.

CONCLUSIONS

Multislice CTA provides good-quality information about the vascular anatomy of the dorsal aspect of the hand, including perforator vessels less than 0.5 mm in diameter. Multislice CTA allows for observation of the axis, trajectory, and branching pattern of the blood vessels and, most importantly, demonstrates the anatomic relationships among blood vessels, bones, and soft tissue.

The evolution and refinements of the distally based dorsal metacarpal artery (DMCA) flaps

Distally based DMCA flaps are well established in reconstructive hand surgery. They comprise the dorsal flap described by Quaba and the DMCA flaps described by Earley, Milner and others. The most frequent indications for these flaps are soft tissue defects of the dorsum of the proximal phalanx and the total length of the finger. Since its introduction several modifications have been developed to match specific defect requirements; these include: the development of pure fascial DMCA flaps, the use of DMCA flaps in dorsally grafted burned hands and modifications in design to avoid 'tunnelling' and to permit skin-skin defect closure. The purpose of this article is to provide an overview of the evolution and refinements of the DMCA flaps based on the experience of a single centre. The DMCA flaps provide one stage coverage of excellent quality with independent vascularisation and permit primary closure of the recipient site without sacrificing relevant arteries (e.g. proper digital artery). However, the DMCA flaps also possess drawbacks, for example, apart from the fact that this technique is quite demanding, possible hair growth and a visible scar on the exposed dorsal part of the hand present aesthetic problems for some patients. Despite these limitations, DMCA flaps are considered to be extremely useful.

Extended reverse dorsal metacarpal artery flap: clinical experience and donor site morbidity

Extended reverse dorsal metacarpal artery (RDMA) flaps use the skin from the dorsum of the hand to cover defects of the long fingers up to the distal phalanx. The authors present a series of 12 patients who underwent closure of defects of the long fingers with these flaps. As relevant literature is scarce, special emphasis was put on donor site morbidity. Active and passive total range of motion (TRM) and pinch grip strength of the finger neighbouring the reconstructed one were evaluated and compared to the corresponding finger of the contralateral hand. The donor site was furthermore evaluated for cosmetic appearance and pain. There was no statistically significant difference for active and passive TRM. The difference for pinch grip reached statistical significance (p=0.04). Subjective evaluation of pain and cosmetic appearance by the patients revealed a mean pain value of 1.25 on a visual analogue scale (0=no pain, 10=maximal imaginable pain) and a mean estimation of cosmetic appearance of 8 (visual analogue scale, 0=worst cosmetic result, 10=best cosmetic result). In conclusion, compared to other flaps, the extended RDMA flap is a fast, secure and single-stage procedure for defect coverage on the long fingers with low donor site morbidity.

Cutaneous perforators of the fourth dorsal interosseous space: anatomic study

PURPOSE

Many investigators have studied the vascular anatomy of the dorsal metacarpal arteries but little attention has been paid to the exact distribution of the cutaneous perforators of the dorsum of the hand. We present an anatomic study of the cutaneous perforators within the fourth dorsal interosseous space, which was supposed to have the most inconsistent vascular anatomy.

METHODS

Twenty hands were dissected after black latex injection. A skin paddle was outlined along the fourth dorsal metacarpal space. Suprafascial dissection was performed, preserving any vessel piercing the fascia and reaching the skin. Each perforator was traced back to its origin. The location and origin of each perforator was recorded by digital pictures and measured from a reference point.

RESULTS

In 17 of the cases (85%) at least 1 perforator was identified within the fourth space piercing the dorsal interosseous muscle fascia and reaching the skin. In 10 hands, a perforator branching off the proximal communicating branch was identified, located a mean distance of 11 mm from the carpometacarpal joint line.

CONCLUSIONS

A dissectable perforator was found consistently (17 of 20; 85%) in the proximal third of the fourth dorsal interosseous space branching off the proximal communicating branch. Few perforators branch off the middle third of the dorsal metacarpal artery. The perforator described herein shows the connection between the superficial and deep vascular systems of the ring and small metacarpal spaces, and establishes the anatomic basis for reconstructive flaps.