SRPS PS - Plastic Surgery Internal

Figure 15. Design of reverse dorsal metacarpal flap and
cross-section at distal flap (Reprinted with permission from
Maruyama. 432 )
interconnections between terminal branches of the
dorsal metacarpal arteries and the deep digital and
palmar arterial systems. 434–436 Maruyama raised flaps on
all five dorsal metacarpal arteries and reported a
largely successful experience in eight cases.
Figure 16. Arterial basis of distally based dorsal hand flap is
direct branch from dorsal metacarpal artery that enters skin
0.5 to 1 cm proximal to adjacent metacarpophalangeal joint.
(Reprinted with permission from Quaba and Davison. 433 )
SRPS Volume 10, Issue 25, 2009
In contrast, several authors 433,437 reported that the
flaps are nourished by a direct cutaneous branch of the
dorsal metacarpal artery that enters the skin 0.5 to 1
cm proximal to the adjacent metacarpophalangeal joint
(Fig. 16). The authors raised reverse dorsal metacarpal
artery flaps on the second, third, and fourth
intermetacarpal spaces in 21 patients and reported one
partial loss and one failure. 433 Donor sites up to 2 cm
wide can be closed primarily.
Large Defects of the Hands or Digits
Regional Flaps
The regional flaps applicable for resurfacing the hand
are based on the three major arteries of the forearm:
the radial, ulnar, and posterior interosseous arteries. 438
Yang et al. 439 described the territory of the radial
forearm flap in 1981. The skin on the flexor surface of
the forearm is relatively hairless, thin, and pliable,
which makes it ideal for resurfacing the dorsum of the
hand. The radial forearm unit can be raised as a
composite of fascia-skin, 440–442 fascia, 443,444 bone-musclefascia-skin,
445–447 or fascia-tendon-skin. 448–450
In 1984, Lin et al. 451 noted ample retrograde flow
into the radial artery from the ulnar artery via the deep
palmar arch and proposed a “reverse” forearm flap.
The flap is nourished by this retrograde circulation and
can be elevated on its long pedicle for reconstruction
anywhere in the hand. The authors described a crossover
pattern of communicating branches between the paired
venae comitantes and identified small superficial
collateral branches of each vein, which effectively bypass
the valves. This system enables the flap to be drained
despite competent valves. Even in cases of significant
hand trauma in which the palmar arches are in question,
the flap has been successfully raised, based on
communications proximal to the wrist. 452,453
The radial forearm flap has two main
disadvantages. Foremost is that a major vessel to the
hand is sacrificed, but Kleinman and O’Connell 454
found the only significant objective difference between
patients who had undergone flap transfer and controls
to be an 18% delay in reconstitution of normothermia
after cold stress testing. Reconstruction of the vessel
rarely is necessary. 455,456 Weinzweig et al. 457 described a
technique for elevating a distally based
fasciocutaneous flap with preservation of the radial
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