Journal of Plastic, Reconstructive & Aesthetic Surgery (2010) 63, e46ee50

CASE REPORT

Dorsal digital perforator flap for reconstructionof distal dorsal finger defects

Motohisa Kawakatsu a,*, Kozo Ishikawa b

a Department of Plastic and Reconstructive Surgery, Sumiya Orthopaedic Hospital, 337 Yoshida, Wakayama-shi,Wakayama 640-8343, Japanb Department of Plastic and Reconstructive Surgery, Otsu Red Cross Hospital, 1-1-35 Nagara, Otsu-shi, Shiga 520-8511,Japan

Received 5 February 2009; accepted 11 May 2009

KEYWORDSDorsal digital perforatorflap;Distal part of the fingerdorsum;Rotation flap;V-Y advancement flap

* Corresponding author. Departmentive Surgery, Sumiya OrthopaediWakayama-shi, Wakayama 640e83431161; fax: þ 81 73 432 6054.

E-mail address: kawakatsu@sumiy

1748-6815/$-seefrontmatterª2009Bridoi:10.1016/j.bjps.2009.05.014

Summary Three patients are presented in whom defects of the distal part of the dorsum ofthe finger were covered with a rotation flap or V-Y advancement flap based on a single perfo-rating branch of the digital artery running from the volar to the dorsal side. This method isuseful for the reconstruction of the distal dorsal region of the fingers, because the flap is moremobile, has a smaller skin island and is less invasive compared to the previous flaps. This typeof flap conforms to the concept of a perforator flap arising from the main artery.ª 2009 British Association of Plastic, Reconstructive and Aesthetic Surgeons. Published byElsevier Ltd. All rights reserved.

It is difficult to cover distal defects of the dorsum of thefinger like those of the nail matrix or a terminal extensortendon, because there is little soft tissue in this region.Therefore, various flaps have been employed, includinga rotation flap,1 dorsal V-Y advancement flap,2 reversedorsal metacarpal flap3 and a reverse dorsal digital islandflap.4 However, the reported flaps can only be used to

t of Plastic and Reconstruc-c Hospital, 337 Yoshida,, Japan. Tel.: þ 81 73 433

a.or.jp (M. Kawakatsu).

tishAssociationofPlastic,Reconstruc

cover small defects, require a large skin island or are tooinvasive.

Our flap is a rotation or a V-Y advancement flap basedon a single perforating branch of the digital artery runningfrom the volar to the dorsal side of the finger. Thus, theflap conforms to the concept of a perforator flap.7 Theadvantages of our flap are that it is more mobile, hasa smaller skin island and is less invasive compared withprevious flaps reported for use in reconstruction of distaldefects on the dorsum of the finger. To our knowledge,this is the first report about the use of a dorsal digitalperforator flap (DDPF) to reconstruct a distal defect onthe dorsum of the finger in the literature published inEnglish.

tiveandAestheticSurgeons.PublishedbyElsevierLtd.All rightsreserved.

Dorsal digital perforator flap for reconstruction of distal dorsal finger e47

Surgical technique

First, the locations of dorsal perforators arising from theproper digital artery are identified by Doppler flowmetryand are marked near the defect for reconstruction. Thena rotation flap or V-Y advancement flap that has a singledigital dorsal perforator at its base is designed [Figures1-A, 2-A, 3-B, 4-B, 5-B]. Under a digital block and tourni-quet, the flap is elevated in the distal to proximal direc-tion along a plane above the extensor paratenon. The baseof the flap is dissected carefully so as to preserve thedorsal perforator arising from the proper digital artery[Figures 1-B, 2-B]. The perforator is very small; however, itis not difficult to detect a single perforator at the lateralborder of the extensor tendon near the marked position asa slightly whitish string-like structure (due to thetourniquet) using a loupe and microsurgical techniques[Figures 3-D, 4-C]. Once the perforator is identified, thecircumference of the pedicle of the flap is narrowedgradually. The fascia or soft tissue near the perforatorneeds to be retained for allowing venous return, but it isbetter for it to be as thin as possible [Figures 1-C, 2-C]because a flap with a broad pedicle cannot be easilymobilised in this region. However, the most importantpoint is not the width of the pedicle, but the definiteidentification of the perforator within the pedicle. Therotation flap has a narrow strip of skin on its pedicle, butthe V-Y advancement flap has no skin cover for thepedicle. When a rotation flap cannot cover the defectsufficiently, skin grafting should be performed [Figures

Figure 1 Surgical procedure for the rotation flap. (A) A rotationcontains a dorsal perforator (c) arising from the proper digital arteparatenon. (C) The base of the flap is dissected carefully so as toalong with the skin pedicle. (D) Skin grafting should be performed

1-D, 3-E]. A V-Y advancement flap is then elevated as anisland flap, while taking care to avoid rupture or kinking ofthe very thin and weak dorsal perforator [Figures 2-D, 4-D,5-D].

Case reports

Case 1

A 20-year-old woman sustained a heat-press injury to theright index while ironing clothes. She presented to ourhospital with soft tissue damage to the finger, that haddeveloped localised necrosis at 2 weeks after injury[Figure 3-A].

Examination showed necrotic skin on the dorsum of theright index finger from the distal interphalangeal (DIP) jointto the nail matrix. Although the finger could be extended,the terminal extensor tendon was suspected to havea partially necrotic region.

After 1 week, debridement of the finger was carried outand it was found that the terminal extensor tendon onlyshowed necrosis of its superficial layer [Figure 3-B]. Thepatient did not want scarring proximal to the proximalinterphalangeal (PIP) joint, so a rotation flap (1.5� 1.2 cm)was designed as a DDPF with a narrow pedicle based ona single, small dorsal perforator. This flap was elevatedincluding a thin layer of fascia and transposed to cover theextensor tendon and nail matrix [Figures 3-C, D]. Theperforator maintained flap viability and there was also

flap (b) is designed near the defect (a). The pedicle of the flapry (d). (B) The flap is elevated above the plane of the extensorpreserve the perforator and must be made narrow as possibleif the flap does not cover the defect sufficiently(e).

Figure 2 Surgical procedure for the V-Y advancement flap. (A) A V-Y advancement flap (b) is designed near the defect (a). Thepedicle of the flap includes a dorsal perforator (c) arising from the proper digital artery (d). (B) The flap is elevated above the planeof the extensor paratenon. (C) The base of the flap is dissected carefully so as to preserve the perforator and must be made as thinas possible for use as an island flap. (D) Taking care to avoid rupture or kinking of the very thin and weak dorsal perforator.

e48 M. Kawakatsu, K. Ishikawa

sufficient venous return. As a result, the flap tookcompletely, although a small skin graft was also needed.Active exercises were initiated 2 weeks later.

After 6 months [Figure 3-E], the patient was satisfiedwith both, the functional and cosmetic results.

Case 2

A 53-year-old man presented with pain of the DIP joint inhis right little finger. A soft tissue lesion (so-called mucouscyst) was detected in the DIP joint [Figure 4-A] and plainradiographs showed osteoarthritic changes. It was easy toidentify the dorsal perforators arising from the radial digitalartery by Doppler flowmetry. A V-Y advancement flap(1� 2 cm) was designed and elevated as a DDPF based ona single dorsal perforator arising from the digital artery.

Figure 3 (A) Necrosis can be seen at two weeks after heat preextensor tendons were found to be viable, but there damage to thmatrix to the DIP joint of the index finger. (C) Before transfer of th(D) The dorsal perforator arising from the digital artery is indicate

This flap was used to cover the defect after the resection ofthe osteophyte and the mucous cyst [Figures 4-B, C]. Theflap covered the defect without any need for a skin graft[Figure 4-D] and took completely [Figure 4-E].

After 1 year, the patient has no pain or recurrence of thecyst.

Case 3

A 59-year-old woman presented with pain in the DIP joint ofher right index finger. A mucous cyst was detected in theDIP joint [Figure 5-A] and plain radiography showed osteo-arthritic changes. A V-Y advancement flap (1� 2 cm) wasdesigned as a DDPF based on a single dorsal perforatorarising from the ulnar digital artery and was used to coverthe defect after resection of the cyst and osteophyte

ss injury to the right index finger. (B) After debridement, thee superficial layer. Soft tissue defects extended from the nail

e dorsal perforator flap based on a branch of the digital artery.d by the instrument. (E) Six months after surgery.

Figure 4 (A) The mucous cyst is exised from the DIP joint. (B) Then the V-Y advancement flap based on a perforator is designed.(C) The flap is elevated; the dorsal perforator of the digital artery is indicated by the instrument. (D) After covering the defect, theflap took completely. (E) Six months after surgery.

Dorsal digital perforator flap for reconstruction of distal dorsal finger e49

[Figure 5-B]. After elevation of the V-Y advancement flap asan island flap [Figure 5-C], the defect was covered withouta skin graft [Figure 5-D] and the flap took completely[Figure 5-E].

After 6 months, this patient has no pain and no recur-rence of the cyst.

Discussion

Recently, several flaps based on dorsal branches of the digitalartery have been reported, including the reverse dorsaldigital island flap, and both direct- and reverse-flow proximalphalangeal island flaps.4,5 However, these flaps were notreported as perforator flaps and it is unclear whether a singlebranch of the digital artery acts as the feeding vessel.Koshima et al.6 reported on the use of a digital perforator flapbased on a single volar branch of the digital artery forfingertip reconstruction in 2006. Our flap uses the dorsalperforating branch arising from the transverse palmar archproximal to the DIP joint or the dorsal perforator arisingdirectly from the proper digital artery as the pedicle. Thesebranches have previously been reported by Strauch andMoura, and BragaeSilvia et al.8 According to Strauch andMoura, the size of each vessel varies, with the former havinga diameter of 0.6e1.0 mmand the latter having adiameter of

Figure 5 (A) The mucous cyst is exised from the DIP joint. (B) Afdesigned. (C) It is elevated as an island flap. (D) After covering thesurgery.

0.3e0.6 mm. According to BragaeSilvia et al., the dorsalperforator arising directly from the proper digital arteryseems to be equal to the fifth cutaneous dorsal branch witha diameter of 0.2e0.4 mm and a location 9e13 mm distal tothe PIP joint. These perforating branches of the properdigital artery can be found running from the volar to thedorsal side to nourish the skin.

We classify the flap reported by Koshima et al. as a volardigital perforator flap (VDPF), while our flap is a DDPF. Itmay be considered that our flap includes the dorsal vascularnetwork, and so differs from a true perforator flap.However, the definition of a digital perforator flap has notbeen clarified and our flap is fed by a single dorsal digitalperforator. Therefore, it seems reasonable for our flap tobe classified as a perforator flap.

We could design a rotation flap based on a singleperforator with a very narrow skin pedicle, because wehave previously devised a rotation flap based on two dorsalperforators arising from the digital artery in the distaldorsal region of the finger.9 As the next step, we designeda perforator-based V-Y advancement flap for the distaldorsal region of the finger,10 which has not been reportedbefore. There was some doubt about whether the thin andweak perforator could provide a blood supply to reliableflap, but all flaps took completely.

ter resection, a V-Y advancement flap based on a perforator isdefect, the flap survived completely. (E) Three months after

e50 M. Kawakatsu, K. Ishikawa

Using our hand-held Doppler unit (Hadeco smartdop,Hadeco Co. Ltd., Kawasaki, Japan) with 8- and 10-MHzprobes, we could identify the digital artery and the dorsalperforators, and could mark two or three points at the dorsalaspect of the radial or ulnar side between the DIP and PIPcreases. These points resembled the locations of the dorsalbranches reported by Strauch and Moura, or BragaeSilviaet al.8,11 When the flap was elevated at a marked point, wecould always detect a perforator.9 However, Khan andMiller12 reported that the hand-held Doppler unit with an8- or 10-MHz probe picks up signals from perforators smallerthan 0.4 mm and has an unacceptably high false-positiverate. Thus, although each DDPF was completely viable, weare not able to definitely state that the marked blood vesselsaccurately matched the perforators arising from the digitalartery. Khan and Miller also reported that the accuracy ofcolour duplex ultrasound is superior to that of the hand-heldDoppler unit, but the results are dependent on the operatorhaving some knowledge about skin perforators. We have notused a colour duplex system so far, but we may consider it asan imaging method with a high degree of accuracy forlocating small perforators.

Our method seems to be more useful for reconstructingdorsal finger defects compared with previous flaps, espe-cially distal defects. In the future, the blood supply for thisDDPF needs further investigation, and the method fordetecting perforators needs to be made less invasive andmore accurate.

Acknowledgements

None.

Conflicts of interest

None.

Funding

None.

References

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3. Maruyama Y. The reverse dorsal metacarpal flap. Br J PlastSurg 1990;43:28e39.

4. Bene MD, Petrolati M, Raimondi P, et al. Reverse dorsal digitalisland flap. Plast Reconstr Surg 1994;93:552e7.

5. Bertelli JA. Direct and reversed flow proximal phalangealisland flaps. J Hand Surg 1994;19:671e80.

6. Koshima I, Urushibara K, Fukuda N, et al. Digital arteryperforator flaps for fingertip reconstructions. Plast ReconstrSurg 2006;118:1579e84.

7. Geddes CR, Morris SF, Neligan PC. Perforator flaps: evolu-tion, classification, and application. Ann Plast Surg 2003;50:90e9.

8. Strauch B, de Moura W. Arterial system of the finger. J HandSurg 1990;15:148e54.

9. Ishikawa K, Kawakatsu M, Kitayama T, et al. Dorsal or volarfinger flap: based on the dorsal or volar branches of the digitalartery. J Jpn Soc Surg Hand 2001;17:720e5.

10. Yildirim S, Taylan G, Akoz T. Freestyle perforator-based V-Y advancement flap for reconstruction of soft tissuedefects at various anatomic regions. Ann Plast Surg 2007;58:501e5.

11. Braga-Silva J, Kuyven CR, Fallopa F, et al. An anatomical studyof the dorsal cutaneous branches of the digital arteries. J HandSurg [Br] 2002;27:577e9.

12. Khan UD, Miller JG. Reliability of handheld Doppler in planninglocal perforator-based flaps for extremities. Aesthetic PlastSurg 2007;31:521e5.