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Dorsal Metacarpal Artery Flap

The dorsal metacarpal artery (DMA) flap is a fasciocutaneous flap that provides thin, pliable, and sensate skin coverage for small to medium-sized defects of the hand. Based on retrograde blood flow from the DMAs, this flap offers several advantages while avoiding the sacrifice of a major vascular pedicle. Anatomy and Blood Supply The DMA flap receives its blood supply from the three dorsal metacarpal arteries that run distally in the second, third, and fourth intermetacarpal spaces. The second DMA usually provides the most consistent and largest caliber pedicle. The flap is designed over the metacarpal artery, including fascia and a small amount of subcutaneous fat. It does not incorporate the digital arteries. Indications The DMA flap is ideal for resurfacing relatively small soft tissue defects of the dorsal hand, wrist, and fingers. The thin, pliable skin provides excellent contour and padding over exposed tendons, joints, or small bone grafts. The flap has a wide arc of rotation that enables coverage of exposed bone and tendon on the hand, wrist, and multiple fingers from a single flap. Surgical Technique A line is drawn over the chosen DMA from the proximal wrist crease to the proximal interphalangeal joint. The flap can be designed proximally or distally based on the defect. The flap is then carefully elevated in the subfascial plane, preserving the paratenon around the extensor tendons. The dissection is carried distally until bleeding vessels are visible on the flap undersurface. Insetting is performed without tension. Advantages The DMA flap provides thin, sensate coverage that contours well to the hand. It avoids sacrificing the digital or radial/ulnar arteries. Donor site morbidity is minimal, often allowing primary closure. The reliable vascular supply and ease of dissection make the DMA flap an excellent option for small to moderate sized dorsal hand wounds. In summary, the dorsal metacarpal artery flap is a workhorse for hand reconstruction that should be considered for small soft tissue defects where local flaps are not feasible. Proper flap design and dissection technique helps ensure success with this versatile local flap.