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Reverse Dorsal Metacarpal Flap

- Discussion:
    - dorsal metacarpal vessels contribute to the fascial plexus, which supplies the skin of the dorsum of the hand;
    - reverse dorsal metacarpal flap, based on the dorsal metacarpal arteries, can cover small soft-tissue defects in the hand;
    - axis of this flap parallels dorsal interosseous muscles;
    - subcutaneous fat, fascia, and dorsal metacarpal vessels are included in the flap and divided proximally;
    - proximal end of the flap is elevated and dissection of the flap and its pedicle is continued distally to the web space;
    - because fourth and fifth metacarpal arteries are absent in one third of cases, this flap might not be dependable on ulnar side.
    - second dorsal metacarpal artery neurovascular island flap:
         - used after release of first web contractures & to resurface radiopalmar and thumb defects;
         - it is proximally based, and if it is extended beyond proximal interphalangeal joint, distal flapnecrosis and donor-site difficulties can 
         - point at which extensor tendon to the index and long fingers separates is pivot point for flap pedicle;
         - dorsal interosseous fascia must be included with the pedicle over full width of the muscle to safeguard artery;
         - flap is dissected from distal to proximal;
         - communication with the palmar metacarpal artery is identified and ligated when the second web is reached;
         - flap is passed through subQ tunnel and the donor site closed with split thickness or full thickness skin graft