From anatomical knowledge to clinical practice: technical insights into dorsal metacarpal artery and perforator flaps – two case reports

Introduction and importance: Advances in cutaneous vascular anatomy, including the perforasome concepts, have transformed hand reconstruction by enabling thin, pliable perforator flaps that preserve major axial vessels. These flaps may offer advantages over traditional fasciocutaneous designs. Safe and effective use depends on understanding perforator anatomy and adhering to key technical principles. Case presentation: Two cases illustrate the clinical implications of perforator-based reconstruction using the same flap design in its traditional non-perforator and perforator-based variants. A 56-year-old man sustained a chainsaw laceration over the proximal interphalangeal joint of the fifth finger of the left hand. A traditional dorsal metacarpal artery flap was elevated in the subaponeurotic plane, requiring aponeurotic opening, division of intertendinous juncturae, and sacrifice of the fourth dorsal metacarpal artery. Coverage was achieved, but the flap was bulky, and donor-site healing was delayed. A 43-year-old man with a dorsal laceration of the third finger of the left hand from broken glass was reconstructed using a dorsal metacarpal artery perforator flap elevated superficial to the dorsal interosseous aponeurosis. The perforator was found at its expected location, the pedicle was preserved with a perivascular adipose cuff, rotation was tension free, and donor-site closure was primary. Healing was uneventful. Clinical discussion: Perforator flaps may provide thinner, more adaptable tissue with reduced donor-site morbidity. Key principles include avoiding complete microskeletonization, preserving perivascular adipose tissue, and respecting gliding planes. Cadaveric training enhances anatomical understanding and reliability. Conclusion: These cases illustrate the potential role and technical interest of perforator-based local flaps for dorsal digital reconstruction in selected clinical situations.