Eur J Plast Surg (1999) 22:167±172
L. Vaienti ´ D. DeFazio ´ V. Donati ´ F. DeLorenzi
Composite (tenocutaneous) dorsal metacarpal flap with reverse flow
Received: 7 December 1997 / Accepted: 2 February 1998
Luca Vaienti (
Via Europa 7, I-20097 San Donato Milanese (MI), Italy
Tel. +39-2-5560-1068; Fax +39-2-5277-4501
L. Vaienti ´ D. DeFazio ´ V. Donati ´ F. DeLorenzi ´ D. Ottavian
Ospedale Clinicizzato San Donato, San Donato Milanese (MI), Italy
Abstract The composite dorsal metacarpal flap with re-
verse flow can be very useful in providing cover of com-
plex defects of the dorsal side of the metacarpal phalange-
al area. Two cases are presented in which a loss of skin
and tendons was successfully covered with such a flap.
Stable cover and good function is achieved with minimal
donor site morbidity.
Key words Dorsal hand flap ´ Reverse flow flap ´
The dorsum of the metacarpal phalangeal area is particu-
larly exposed during prehension movements, and is cov-
ered by soft, thin skin which is more vulnerable than
the thick palmar skin.
Because the skin is thin and there is little subcutaneous
fat, injuries to this anatomical area are often complex,
with loss of skin and trauma to tendons, bones, and joints.
When such an injury is limited, a homodigital flap 
can be used for cover as can a dorsal hand flap.
Conversely, when the size of the defect precludes the
use of these traditional solutions it is preferable to utilize
reverse flaps based on dorsal intermetacarpal arteries.
In 1990, the reverse dorsal metacarpal flap was de-
scribed . This flap has the advantage of being an island
flap but it has a rather short pedicle. These island flaps have
cutaneous elasticity associated with the dorsum of the hand,
thus they are particularly suitable in reconstructive surgery
of the metacarpal phalangeal area. They cope well with the
continuous bidirectional forces during flexion/extension
movements. In addition, color match, skin thickness, and
texture of this flap produce good aesthetic results. It has
been reported recently  that the blood supply to the ex-
tensor apparatus from the underlying structures, especially
the periosteum, is poor. Thus, the subcutaneous vascular
web (intermetacarpal arteries, perforating branches of inter-
metacarpal arteries) is of fundamental importance in provid-
ing vascularization for the underlying tendons.
The dorsal hand island flap is based on reverse flow from
the dorsal intermetacarpal arteries. This flap, vascularized
by cutaneous perforating branches of intermetacarpal ar-
teries, is considered to be a distally based island flap
(Fig. 1) [12±15].
Perforating branches  lie in the intermetacarpal
spaces and each generally gives rise to extremely small
cutaneous twigs which form longitudinal rows for dermal
vascularization . In this area the reverse flow flap is
based on the existence of distal commissural anastomosis
between the palmar and the dorsal metacarpal arterial
web; these connections assure flap vitality .
Anatomical studies of the first and second intermetacar-
pal space show the constant presence of vascular connec-
tions corresponding to the commissural region. Three prin-
cipal patterns of anastomotic connections can be identified:
± In the first pattern, the intermetacarpal artery of the
first web is represented by a median commissural
branch that crosses the web space distally in order to
reach the palmar side.
± The second configuration consists of a vascular anasto-
motical circle around the metacarpal neck.
± The third pattern is found in the second, third, and
fourth space, and is represented by an indirect anasto-
mosis between the perforating commissural branches
arising from the palmar collateral artery and the termi-
nal branches of the corresponding dorsal metacarpal
artery. This latter vascular system usually guarantees
the viability of the flap. Thus, it has been demonstrated
that two different forms of vascularization can coexist
in the same intermetacarpal space.