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Dorsal digital perforator flap for reconstruction of distal dorsal finger defects
Journal of Plastic, Reconstructive & Aesthetic Surgery (2010) 63, e46ee50
CASE REPORT
Dorsal digital perforator flap for reconstruction of 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, Japan b 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
KEYWORDS Dorsal digital perforator flap; Distal part of the finger dorsum; Rotation flap; V-Y advancement flap
Summary Three patients are presented in whom defects of the distal part of the dorsum of the finger were covered with a rotation flap or V-Y advancement flap based on a single perforating branch of the digital artery running from the volar to the dorsal side. This method is useful for the reconstruction of the distal dorsal region of the fingers, because the flap is more mobile, has a smaller skin island and is less invasive compared to the previous flaps. This type of 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 by Elsevier Ltd. All rights reserved.
It is difficult to cover distal defects of the dorsum of the finger like those of the nail matrix or a terminal extensor tendon, because there is little soft tissue in this region. Therefore, various flaps have been employed, including a rotation flap,1 dorsal V-Y advancement flap,2 reverse dorsal metacarpal flap3 and a reverse dorsal digital island flap.4 However, the reported flaps can only be used to
* Corresponding author. Department of Plastic and Reconstructive Surgery, Sumiya Orthopaedic Hospital, 337 Yoshida, Wakayama-shi, Wakayama 640e8343, Japan. Tel.: þ 81 73 433 1161; fax: þ 81 73 432 6054. E-mail address: [email protected] (M. Kawakatsu).
cover small defects, require a large skin island or are too invasive. Our flap is a rotation or a V-Y advancement flap based on a single perforating branch of the digital artery running from the volar to the dorsal side of the finger. Thus, the flap conforms to the concept of a perforator flap.7 The advantages of our flap are that it is more mobile, has a smaller skin island and is less invasive compared with previous flaps reported for use in reconstruction of distal defects on the dorsum of the finger. To our knowledge, this is the first report about the use of a dorsal digital perforator flap (DDPF) to reconstruct a distal defect on the dorsum of the finger in the literature published in English.
1748-6815/$ - see front matter ª 2009 British Association of Plastic, Reconstructive and Aesthetic Surgeons. Published by Elsevier Ltd. All rights reserved. doi:10.1016/j.bjps.2009.05.014
Dorsal digital perforator flap for reconstruction of distal dorsal finger
Surgical technique First, the locations of dorsal perforators arising from the proper digital artery are identified by Doppler flowmetry and are marked near the defect for reconstruction. Then a rotation flap or V-Y advancement flap that has a single digital dorsal perforator at its base is designed [Figures 1-A, 2-A, 3-B, 4-B, 5-B]. Under a digital block and tourniquet, the flap is elevated in the distal to proximal direction along a plane above the extensor paratenon. The base of the flap is dissected carefully so as to preserve the dorsal perforator arising from the proper digital artery [Figures 1-B, 2-B]. The perforator is very small; however, it is not difficult to detect a single perforator at the lateral border of the extensor tendon near the marked position as a slightly whitish string-like structure (due to the tourniquet) using a loupe and microsurgical techniques [Figures 3-D, 4-C]. Once the perforator is identified, the circumference of the pedicle of the flap is narrowed gradually. The fascia or soft tissue near the perforator needs to be retained for allowing venous return, but it is better for it to be as thin as possible [Figures 1-C, 2-C] because a flap with a broad pedicle cannot be easily mobilised in this region. However, the most important point is not the width of the pedicle, but the definite identification of the perforator within the pedicle. The rotation flap has a narrow strip of skin on its pedicle, but the V-Y advancement flap has no skin cover for the pedicle. When a rotation flap cannot cover the defect sufficiently, skin grafting should be performed [Figures
e47
1-D, 3-E]. A V-Y advancement flap is then elevated as an island flap, while taking care to avoid rupture or kinking of the 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 the right index while ironing clothes. She presented to our hospital with soft tissue damage to the finger, that had developed localised necrosis at 2 weeks after injury [Figure 3-A]. Examination showed necrotic skin on the dorsum of the right index finger from the distal interphalangeal (DIP) joint to the nail matrix. Although the finger could be extended, the terminal extensor tendon was suspected to have a partially necrotic region. After 1 week, debridement of the finger was carried out and it was found that the terminal extensor tendon only showed necrosis of its superficial layer [Figure 3-B]. The patient did not want scarring proximal to the proximal interphalangeal (PIP) joint, so a rotation flap (1.5 1.2 cm) was designed as a DDPF with a narrow pedicle based on a single, small dorsal perforator. This flap was elevated including a thin layer of fascia and transposed to cover the extensor tendon and nail matrix [Figures 3-C, D]. The perforator maintained flap viability and there was also
Figure 1 Surgical procedure for the rotation flap. (A) A rotation flap (b) is designed near the defect (a). The pedicle of the flap contains a dorsal perforator (c) arising from the proper digital artery (d). (B) The flap is elevated above the plane of the extensor paratenon. (C) The base of the flap is dissected carefully so as to preserve the perforator and must be made narrow as possible along with the skin pedicle. (D) Skin grafting should be performed if the flap does not cover the defect sufficiently(e).
e48
M. Kawakatsu, K. Ishikawa
Figure 2 Surgical procedure for the V-Y advancement flap. (A) A V-Y advancement flap (b) is designed near the defect (a). The pedicle of the flap includes a dorsal perforator (c) arising from the proper digital artery (d). (B) The flap is elevated above the plane of the extensor paratenon. (C) The base of the flap is dissected carefully so as to preserve the perforator and must be made as thin as possible for use as an island flap. (D) Taking care to avoid rupture or kinking of the very thin and weak dorsal perforator.
sufficient venous return. As a result, the flap took completely, although a small skin graft was also needed. Active exercises were initiated 2 weeks later. After 6 months [Figure 3-E], the patient was satisfied with both, the functional and cosmetic results.
This flap was used to cover the defect after the resection of the osteophyte and the mucous cyst [Figures 4-B, C]. The flap 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 the cyst.
Case 2 Case 3 A 53-year-old man presented with pain of the DIP joint in his right little finger. A soft tissue lesion (so-called mucous cyst) was detected in the DIP joint [Figure 4-A] and plain radiographs showed osteoarthritic changes. It was easy to identify the dorsal perforators arising from the radial digital artery by Doppler flowmetry. A V-Y advancement flap (1 2 cm) was designed and elevated as a DDPF based on a single dorsal perforator arising from the digital artery.
A 59-year-old woman presented with pain in the DIP joint of her right index finger. A mucous cyst was detected in the DIP joint [Figure 5-A] and plain radiography showed osteoarthritic changes. A V-Y advancement flap (1 2 cm) was designed as a DDPF based on a single dorsal perforator arising from the ulnar digital artery and was used to cover the defect after resection of the cyst and osteophyte
Figure 3 (A) Necrosis can be seen at two weeks after heat press injury to the right index finger. (B) After debridement, the extensor tendons were found to be viable, but there damage to the superficial layer. Soft tissue defects extended from the nail matrix to the DIP joint of the index finger. (C) Before transfer of the dorsal perforator flap based on a branch of the digital artery. (D) The dorsal perforator arising from the digital artery is indicated by the instrument. (E) Six months after surgery.
Dorsal digital perforator flap for reconstruction of distal dorsal finger
e49
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, the flap took completely. (E) Six months after surgery.
[Figure 5-B]. After elevation of the V-Y advancement flap as an island flap [Figure 5-C], the defect was covered without a skin graft [Figure 5-D] and the flap took completely [Figure 5-E]. After 6 months, this patient has no pain and no recurrence of the cyst.
Discussion Recently, several flaps based on dorsal branches of the digital artery have been reported, including the reverse dorsal digital island flap, and both direct- and reverse-flow proximal phalangeal island flaps.4,5 However, these flaps were not reported as perforator flaps and it is unclear whether a single branch of the digital artery acts as the feeding vessel. Koshima et al.6 reported on the use of a digital perforator flap based on a single volar branch of the digital artery for fingertip reconstruction in 2006. Our flap uses the dorsal perforating branch arising from the transverse palmar arch proximal to the DIP joint or the dorsal perforator arising directly from the proper digital artery as the pedicle. These branches have previously been reported by Strauch and Moura, and BragaeSilvia et al.8 According to Strauch and Moura, the size of each vessel varies, with the former having a diameter of 0.6e1.0 mm and the latter having a diameter of
0.3e0.6 mm. According to BragaeSilvia et al., the dorsal perforator arising directly from the proper digital artery seems to be equal to the fifth cutaneous dorsal branch with a diameter of 0.2e0.4 mm and a location 9e13 mm distal to the PIP joint. These perforating branches of the proper digital artery can be found running from the volar to the dorsal side to nourish the skin. We classify the flap reported by Koshima et al. as a volar digital perforator flap (VDPF), while our flap is a DDPF. It may be considered that our flap includes the dorsal vascular network, and so differs from a true perforator flap. However, the definition of a digital perforator flap has not been clarified and our flap is fed by a single dorsal digital perforator. Therefore, it seems reasonable for our flap to be classified as a perforator flap. We could design a rotation flap based on a single perforator with a very narrow skin pedicle, because we have previously devised a rotation flap based on two dorsal perforators arising from the digital artery in the distal dorsal region of the finger.9 As the next step, we designed a perforator-based V-Y advancement flap for the distal dorsal region of the finger,10 which has not been reported before. There was some doubt about whether the thin and weak perforator could provide a blood supply to reliable flap, but all flaps took completely.
Figure 5 (A) The mucous cyst is exised from the DIP joint. (B) After resection, a V-Y advancement flap based on a perforator is designed. (C) It is elevated as an island flap. (D) After covering the defect, the flap survived completely. (E) Three months after surgery.
e50 Using our hand-held Doppler unit (Hadeco smartdop, Hadeco Co. Ltd., Kawasaki, Japan) with 8- and 10-MHz probes, we could identify the digital artery and the dorsal perforators, and could mark two or three points at the dorsal aspect of the radial or ulnar side between the DIP and PIP creases. These points resembled the locations of the dorsal branches reported by Strauch and Moura, or BragaeSilvia et al.8,11 When the flap was elevated at a marked point, we could always detect a perforator.9 However, Khan and Miller12 reported that the hand-held Doppler unit with an 8- or 10-MHz probe picks up signals from perforators smaller than 0.4 mm and has an unacceptably high false-positive rate. Thus, although each DDPF was completely viable, we are not able to definitely state that the marked blood vessels accurately matched the perforators arising from the digital artery. Khan and Miller also reported that the accuracy of colour duplex ultrasound is superior to that of the hand-held Doppler unit, but the results are dependent on the operator having some knowledge about skin perforators. We have not used a colour duplex system so far, but we may consider it as an imaging method with a high degree of accuracy for locating small perforators. Our method seems to be more useful for reconstructing dorsal finger defects compared with previous flaps, especially distal defects. In the future, the blood supply for this DDPF needs further investigation, and the method for detecting perforators needs to be made less invasive and more accurate.
Acknowledgements None.
Conflicts of interest None.
M. Kawakatsu, K. Ishikawa
Funding None.
References 1. Kleinert HE, Kutz JE, Fishmen JH, et al. Etiology and treatment of the so-called mucous cyst of the finger. J Bone Joint Surg Am 1972;54A:1455e8. 2. Yii NW, Elliot D. Dorsal VY advancement flaps in digital reconstruction. J Hand Surg 1944;19B:91e7. 3. Maruyama Y. The reverse dorsal metacarpal flap. Br J Plast Surg 1990;43:28e39. 4. Bene MD, Petrolati M, Raimondi P, et al. Reverse dorsal digital island flap. Plast Reconstr Surg 1994;93:552e7. 5. Bertelli JA. Direct and reversed flow proximal phalangeal island flaps. J Hand Surg 1994;19:671e80. 6. Koshima I, Urushibara K, Fukuda N, et al. Digital artery perforator flaps for fingertip reconstructions. Plast Reconstr Surg 2006;118:1579e84. 7. Geddes CR, Morris SF, Neligan PC. Perforator flaps: evolution, classification, and application. Ann Plast Surg 2003; 50:90e9. 8. Strauch B, de Moura W. Arterial system of the finger. J Hand Surg 1990;15:148e54. 9. Ishikawa K, Kawakatsu M, Kitayama T, et al. Dorsal or volar finger flap: based on the dorsal or volar branches of the digital artery. J Jpn Soc Surg Hand 2001;17:720e5. 10. Yildirim S, Taylan G, Ako ¨z T. Freestyle perforator-based VY advancement flap for reconstruction of soft tissue defects at various anatomic regions. Ann Plast Surg 2007; 58:501e5. 11. Braga-Silva J, Kuyven CR, Fallopa F, et al. An anatomical study of the dorsal cutaneous branches of the digital arteries. J Hand Surg [Br] 2002;27:577e9. 12. Khan UD, Miller JG. Reliability of handheld Doppler in planning local perforator-based flaps for extremities. Aesthetic Plast Surg 2007;31:521e5.
CASE REPORT
Dorsal digital perforator flap for reconstruction of 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, Japan b 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
KEYWORDS Dorsal digital perforator flap; Distal part of the finger dorsum; Rotation flap; V-Y advancement flap
Summary Three patients are presented in whom defects of the distal part of the dorsum of the finger were covered with a rotation flap or V-Y advancement flap based on a single perforating branch of the digital artery running from the volar to the dorsal side. This method is useful for the reconstruction of the distal dorsal region of the fingers, because the flap is more mobile, has a smaller skin island and is less invasive compared to the previous flaps. This type of 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 by Elsevier Ltd. All rights reserved.
It is difficult to cover distal defects of the dorsum of the finger like those of the nail matrix or a terminal extensor tendon, because there is little soft tissue in this region. Therefore, various flaps have been employed, including a rotation flap,1 dorsal V-Y advancement flap,2 reverse dorsal metacarpal flap3 and a reverse dorsal digital island flap.4 However, the reported flaps can only be used to
* Corresponding author. Department of Plastic and Reconstructive Surgery, Sumiya Orthopaedic Hospital, 337 Yoshida, Wakayama-shi, Wakayama 640e8343, Japan. Tel.: þ 81 73 433 1161; fax: þ 81 73 432 6054. E-mail address: [email protected] (M. Kawakatsu).
cover small defects, require a large skin island or are too invasive. Our flap is a rotation or a V-Y advancement flap based on a single perforating branch of the digital artery running from the volar to the dorsal side of the finger. Thus, the flap conforms to the concept of a perforator flap.7 The advantages of our flap are that it is more mobile, has a smaller skin island and is less invasive compared with previous flaps reported for use in reconstruction of distal defects on the dorsum of the finger. To our knowledge, this is the first report about the use of a dorsal digital perforator flap (DDPF) to reconstruct a distal defect on the dorsum of the finger in the literature published in English.
1748-6815/$ - see front matter ª 2009 British Association of Plastic, Reconstructive and Aesthetic Surgeons. Published by Elsevier Ltd. All rights reserved. doi:10.1016/j.bjps.2009.05.014
Dorsal digital perforator flap for reconstruction of distal dorsal finger
Surgical technique First, the locations of dorsal perforators arising from the proper digital artery are identified by Doppler flowmetry and are marked near the defect for reconstruction. Then a rotation flap or V-Y advancement flap that has a single digital dorsal perforator at its base is designed [Figures 1-A, 2-A, 3-B, 4-B, 5-B]. Under a digital block and tourniquet, the flap is elevated in the distal to proximal direction along a plane above the extensor paratenon. The base of the flap is dissected carefully so as to preserve the dorsal perforator arising from the proper digital artery [Figures 1-B, 2-B]. The perforator is very small; however, it is not difficult to detect a single perforator at the lateral border of the extensor tendon near the marked position as a slightly whitish string-like structure (due to the tourniquet) using a loupe and microsurgical techniques [Figures 3-D, 4-C]. Once the perforator is identified, the circumference of the pedicle of the flap is narrowed gradually. The fascia or soft tissue near the perforator needs to be retained for allowing venous return, but it is better for it to be as thin as possible [Figures 1-C, 2-C] because a flap with a broad pedicle cannot be easily mobilised in this region. However, the most important point is not the width of the pedicle, but the definite identification of the perforator within the pedicle. The rotation flap has a narrow strip of skin on its pedicle, but the V-Y advancement flap has no skin cover for the pedicle. When a rotation flap cannot cover the defect sufficiently, skin grafting should be performed [Figures
e47
1-D, 3-E]. A V-Y advancement flap is then elevated as an island flap, while taking care to avoid rupture or kinking of the 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 the right index while ironing clothes. She presented to our hospital with soft tissue damage to the finger, that had developed localised necrosis at 2 weeks after injury [Figure 3-A]. Examination showed necrotic skin on the dorsum of the right index finger from the distal interphalangeal (DIP) joint to the nail matrix. Although the finger could be extended, the terminal extensor tendon was suspected to have a partially necrotic region. After 1 week, debridement of the finger was carried out and it was found that the terminal extensor tendon only showed necrosis of its superficial layer [Figure 3-B]. The patient did not want scarring proximal to the proximal interphalangeal (PIP) joint, so a rotation flap (1.5 1.2 cm) was designed as a DDPF with a narrow pedicle based on a single, small dorsal perforator. This flap was elevated including a thin layer of fascia and transposed to cover the extensor tendon and nail matrix [Figures 3-C, D]. The perforator maintained flap viability and there was also
Figure 1 Surgical procedure for the rotation flap. (A) A rotation flap (b) is designed near the defect (a). The pedicle of the flap contains a dorsal perforator (c) arising from the proper digital artery (d). (B) The flap is elevated above the plane of the extensor paratenon. (C) The base of the flap is dissected carefully so as to preserve the perforator and must be made narrow as possible along with the skin pedicle. (D) Skin grafting should be performed if the flap does not cover the defect sufficiently(e).
e48
M. Kawakatsu, K. Ishikawa
Figure 2 Surgical procedure for the V-Y advancement flap. (A) A V-Y advancement flap (b) is designed near the defect (a). The pedicle of the flap includes a dorsal perforator (c) arising from the proper digital artery (d). (B) The flap is elevated above the plane of the extensor paratenon. (C) The base of the flap is dissected carefully so as to preserve the perforator and must be made as thin as possible for use as an island flap. (D) Taking care to avoid rupture or kinking of the very thin and weak dorsal perforator.
sufficient venous return. As a result, the flap took completely, although a small skin graft was also needed. Active exercises were initiated 2 weeks later. After 6 months [Figure 3-E], the patient was satisfied with both, the functional and cosmetic results.
This flap was used to cover the defect after the resection of the osteophyte and the mucous cyst [Figures 4-B, C]. The flap 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 the cyst.
Case 2 Case 3 A 53-year-old man presented with pain of the DIP joint in his right little finger. A soft tissue lesion (so-called mucous cyst) was detected in the DIP joint [Figure 4-A] and plain radiographs showed osteoarthritic changes. It was easy to identify the dorsal perforators arising from the radial digital artery by Doppler flowmetry. A V-Y advancement flap (1 2 cm) was designed and elevated as a DDPF based on a single dorsal perforator arising from the digital artery.
A 59-year-old woman presented with pain in the DIP joint of her right index finger. A mucous cyst was detected in the DIP joint [Figure 5-A] and plain radiography showed osteoarthritic changes. A V-Y advancement flap (1 2 cm) was designed as a DDPF based on a single dorsal perforator arising from the ulnar digital artery and was used to cover the defect after resection of the cyst and osteophyte
Figure 3 (A) Necrosis can be seen at two weeks after heat press injury to the right index finger. (B) After debridement, the extensor tendons were found to be viable, but there damage to the superficial layer. Soft tissue defects extended from the nail matrix to the DIP joint of the index finger. (C) Before transfer of the dorsal perforator flap based on a branch of the digital artery. (D) The dorsal perforator arising from the digital artery is indicated by the instrument. (E) Six months after surgery.
Dorsal digital perforator flap for reconstruction of distal dorsal finger
e49
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, the flap took completely. (E) Six months after surgery.
[Figure 5-B]. After elevation of the V-Y advancement flap as an island flap [Figure 5-C], the defect was covered without a skin graft [Figure 5-D] and the flap took completely [Figure 5-E]. After 6 months, this patient has no pain and no recurrence of the cyst.
Discussion Recently, several flaps based on dorsal branches of the digital artery have been reported, including the reverse dorsal digital island flap, and both direct- and reverse-flow proximal phalangeal island flaps.4,5 However, these flaps were not reported as perforator flaps and it is unclear whether a single branch of the digital artery acts as the feeding vessel. Koshima et al.6 reported on the use of a digital perforator flap based on a single volar branch of the digital artery for fingertip reconstruction in 2006. Our flap uses the dorsal perforating branch arising from the transverse palmar arch proximal to the DIP joint or the dorsal perforator arising directly from the proper digital artery as the pedicle. These branches have previously been reported by Strauch and Moura, and BragaeSilvia et al.8 According to Strauch and Moura, the size of each vessel varies, with the former having a diameter of 0.6e1.0 mm and the latter having a diameter of
0.3e0.6 mm. According to BragaeSilvia et al., the dorsal perforator arising directly from the proper digital artery seems to be equal to the fifth cutaneous dorsal branch with a diameter of 0.2e0.4 mm and a location 9e13 mm distal to the PIP joint. These perforating branches of the proper digital artery can be found running from the volar to the dorsal side to nourish the skin. We classify the flap reported by Koshima et al. as a volar digital perforator flap (VDPF), while our flap is a DDPF. It may be considered that our flap includes the dorsal vascular network, and so differs from a true perforator flap. However, the definition of a digital perforator flap has not been clarified and our flap is fed by a single dorsal digital perforator. Therefore, it seems reasonable for our flap to be classified as a perforator flap. We could design a rotation flap based on a single perforator with a very narrow skin pedicle, because we have previously devised a rotation flap based on two dorsal perforators arising from the digital artery in the distal dorsal region of the finger.9 As the next step, we designed a perforator-based V-Y advancement flap for the distal dorsal region of the finger,10 which has not been reported before. There was some doubt about whether the thin and weak perforator could provide a blood supply to reliable flap, but all flaps took completely.
Figure 5 (A) The mucous cyst is exised from the DIP joint. (B) After resection, a V-Y advancement flap based on a perforator is designed. (C) It is elevated as an island flap. (D) After covering the defect, the flap survived completely. (E) Three months after surgery.
e50 Using our hand-held Doppler unit (Hadeco smartdop, Hadeco Co. Ltd., Kawasaki, Japan) with 8- and 10-MHz probes, we could identify the digital artery and the dorsal perforators, and could mark two or three points at the dorsal aspect of the radial or ulnar side between the DIP and PIP creases. These points resembled the locations of the dorsal branches reported by Strauch and Moura, or BragaeSilvia et al.8,11 When the flap was elevated at a marked point, we could always detect a perforator.9 However, Khan and Miller12 reported that the hand-held Doppler unit with an 8- or 10-MHz probe picks up signals from perforators smaller than 0.4 mm and has an unacceptably high false-positive rate. Thus, although each DDPF was completely viable, we are not able to definitely state that the marked blood vessels accurately matched the perforators arising from the digital artery. Khan and Miller also reported that the accuracy of colour duplex ultrasound is superior to that of the hand-held Doppler unit, but the results are dependent on the operator having some knowledge about skin perforators. We have not used a colour duplex system so far, but we may consider it as an imaging method with a high degree of accuracy for locating small perforators. Our method seems to be more useful for reconstructing dorsal finger defects compared with previous flaps, especially distal defects. In the future, the blood supply for this DDPF needs further investigation, and the method for detecting perforators needs to be made less invasive and more accurate.
Acknowledgements None.
Conflicts of interest None.
M. Kawakatsu, K. Ishikawa
Funding None.
References 1. Kleinert HE, Kutz JE, Fishmen JH, et al. Etiology and treatment of the so-called mucous cyst of the finger. J Bone Joint Surg Am 1972;54A:1455e8. 2. Yii NW, Elliot D. Dorsal VY advancement flaps in digital reconstruction. J Hand Surg 1944;19B:91e7. 3. Maruyama Y. The reverse dorsal metacarpal flap. Br J Plast Surg 1990;43:28e39. 4. Bene MD, Petrolati M, Raimondi P, et al. Reverse dorsal digital island flap. Plast Reconstr Surg 1994;93:552e7. 5. Bertelli JA. Direct and reversed flow proximal phalangeal island flaps. J Hand Surg 1994;19:671e80. 6. Koshima I, Urushibara K, Fukuda N, et al. Digital artery perforator flaps for fingertip reconstructions. Plast Reconstr Surg 2006;118:1579e84. 7. Geddes CR, Morris SF, Neligan PC. Perforator flaps: evolution, classification, and application. Ann Plast Surg 2003; 50:90e9. 8. Strauch B, de Moura W. Arterial system of the finger. J Hand Surg 1990;15:148e54. 9. Ishikawa K, Kawakatsu M, Kitayama T, et al. Dorsal or volar finger flap: based on the dorsal or volar branches of the digital artery. J Jpn Soc Surg Hand 2001;17:720e5. 10. Yildirim S, Taylan G, Ako ¨z T. Freestyle perforator-based VY advancement flap for reconstruction of soft tissue defects at various anatomic regions. Ann Plast Surg 2007; 58:501e5. 11. Braga-Silva J, Kuyven CR, Fallopa F, et al. An anatomical study of the dorsal cutaneous branches of the digital arteries. J Hand Surg [Br] 2002;27:577e9. 12. Khan UD, Miller JG. Reliability of handheld Doppler in planning local perforator-based flaps for extremities. Aesthetic Plast Surg 2007;31:521e5.