Utilization of a Perforator Flap for Stump Closure of the Fifth Digit.
Fingers and toes are important organs functionally and esthetically. Partial or total loss of any of the digits can affect both the functioning and the psychology of the individual. Preserving the length and volume and the functions of the digit and ensuring an esthetically acceptable appearance should be the essential goals in digit reconstruction. Replantation, despite being the gold standard in amputation cases, may not be always possible. Many digit reconstruction techniques from healing by secondary intention to free flaps  have been described for cases in which replantation is not possible. Perforator-based propeller flaps elevated over the perforators that vascularize the skin by preserving the major vascular structures have become popular in the recent years. 
In this report, we aimed at presenting the ulnar palmar digital artery perforator flap (UPDAPF) that we used in the reconstruction of a defect which developed after an amputation of the fifth digit and review the current literature in relation to our case.
A 42-year-old female patient presented to our emergency room with her left fifth finger amputated at the level of the middle phalanx and extensive second-degree deep burn wounds in the hand dorsum and dorsal aspects of fingers after a hot-press accident. Stump closure was proposed because the amputated part was not suitable for replantation. Stump closure with an UPDAPF was planned since the patient wanted to preserve the stump length. The patient was taken to surgery after her written consent.
The forearm being held in neutral position, the perforator was marked with the aid of a hand-held Doppler, one cm proximal to the metacarpophalangeal (MCP) joint, over an axial line drawn between the ulnar margin of the pisiform bone and the ulnar aspect of the fifth metacarp's basis [Figure 1].
Following the debridement of the amputation site, a template of the soft-tissue defect was created. The flap was designed according to the template, and its pivot point was placed over the marked perforator artery. With an incision over the volar margin and through the adipose plane, dissection was performed above the extensor digiti minimi muscle, and perforators were exposed [Figure 2]. Perforator was located at the excact emergence point marked previously with the Doppler device. The marked perforator was observed to be the largest of the three exposed vessels in terms of calibration. Skin incision was finalized, and an island flap was obtained. The remaining perforators were ligated. A mid-lateral incision was planned along the ulnar margin of the fifth finger, and two flaps, one volar- and one dorsal-based, were elevated in the shape of a book jacket. The perforator flap was rotated counterclockwise by an angle of 170[degrees] and adapted to the defect with 5/0 polypropylene. Volar- and dorsal-based flaps were sutured to the volar and dorsal margins of the flap using 5/0 polypropylene. The donor site was sutured subcutaneously using 5/0 polyglactin and primarily with 5/0 polypropylene [Figure 3].
No complications were encountered in the postoperative period. Hand was held in resting position with a cast splint for 1 week. Full flap viability was observed in the 4th week follow-up examination [Figure 4].
Apart from the many conventional flaps described in the literature, use of perforator flaps is seen to increase in the treatment of digit wounds with tissue loss. [1,2]
Cross-finger flaps are frequently used in the treatment of the digits, especially of those with volar defects. There is a need for alternative options that can be used in treating cases without causing severe donor site morbidity in the hand whenever a cross-finger flap cannot be elevated, as was in our case with dorsal burn.
The relatively low amount of soft tissue in the fifth finger reduces the usability of a local flap from this digit. Variations of the dorsal metacarpal artery perforator in the fourth web preclude the safe utilization of this local flap option. 
In cases with fingertip defects where local flap options are limited, as was in our case, free flaps are elevated from the hemi-pulp or toe tips, and venous free flaps can be used as alternative reconstruction methods. Long operating times and requirement of microsurgical anastomosis can be the technical limitations in these flaps. [1,4,5]
From this perspective and given that our elevation time was no more than 60 min, the UPDAPF may be deemed as an ideal solution in such types of specific defects.
Perforator flaps elevated from the palmar region have been described for covering finger defects. In their 2013 article, Hao et al. report a detailed anatomic study in which they elevated the flaps based on the UPDA and successfully closed finger and dorsal hand defects in 16 patients.  Hao et al. report to have elevated the flaps from the same perforator as we did in our case but from a more dorsolateral position. According to their report, keeping the proximal margin of the flap to the distal of the ulnar styloid process provides the maximum safety margin for flap elevation.
Furthermore, Omokawa et al. in their article dated 2000 report to have elevated reverse flaps based on the same perforator in 11 patients. However, in these flaps, the ulnar palmar digital artery is ligated and circulation is supplied retrogradely through the digital artery of the fifth finger.  Although acknowledged as an innovative approach in its time, the possibility of elevating the same flap over the perforator while preserving the ulnar palmar digital artery has rendered Omakawa's flap redundant.
Scrutiny of the perforator flaps elevated from the hypothenar space and transferred as free flaps shows that the authors of both articles have considered the region in three sub-groups. [8,9] In our case, the perforator of the flap was located in the "distal zone" compared to these subgroups. In their respective articles, Omokawa et al.  and Han et al.  report that the ulnar palmar digital artery in this location, on the average, ramifies into more than three perforator vessels. In this study, consistent with these data, three perforator vessels were observed to branch out from the ulnar palmar digital artery.
According to our clinical experience, minimum three perforators branch out from the ulnar palmar digital artery in the distal half of the hypothenar space, at the ulnar margin of the hand. In the light of this information, given that the lateral incisions are planned on the ulnar margin of the hand, if the pivot point is positioned 1 cm proximal to the MCP joint, this flap can be elevated in a free-style fashion, without using a Doppler device.
In tissue losses of the fifth finger, a UPDAP propeller flap enables esthetically and functionally acceptable reconstruction in one session without causing any defects in any of the other fingers. We believe this technique should be borne in mind, especially for its stable anatomic structure, low complication rates, and short return to work period.
Declaration of patient consent
The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.
We would like to thank Dr. Isil Akgun Demir (from the Department of Plastic, Reconstructive, and Aesthetic Surgery of Sisli Hamidiye Etfal Hospital, University of Health Sciences, Istanbul, Turkey) for her contributions for accessing photograph archives.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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[5.] Garlick JW, Goodwin IA, Wolter K, Agarwal JP. Arterialized venous flow-through flaps in the reconstruction of digital defects: Case series and review of the literature. Hand (N Y) 2015;10:184-90.
[6.] Hao PD, Zhuang YH, Zheng HP, Yang XD, Lin J, Zhang CL, et al. The ulnar palmar perforator flap: Anatomical study and clinical application. J Plast Reconstr Aesthet Surg 2014;67:600-6.
[7.] Omokawa S, Yajima H, Inada Y, Fukui A, Tamai S. A reverse ulnar hypothenar flap for finger reconstruction. Plast Reconstr Surg 2000;106:828-33.
[8.] Han HH, Choi YS, Kim IB, Kim SH, Jun YJ. A perforator from the ulnar artery and cutaneous nerve of the hypothenar area: An anatomical study for clinical application. Microsurgery 2017;37:49-56.
[9.] Kim KS, Kim ES, Hwang JH, Lee SY. Fingertip reconstruction using the hypothenar perforator free flap. J Plast Reconstr Aesthet Surg 2013;66:1263-70.
Daghan Dagdelen, Alper Aksoy (1), Selami Serhat Sirvan (2)
Department of Plastic, Reconstructive and Aesthetic Surgery, Balikesir State Hospital, Balikesir, (1) Department of Plastic, Reconstructive and Aesthetic Surgery, Bursa Konur Hospital, Bursa, (2) Department of Plastic, Reconstructive and Aesthetic Surgery, Sisli Hamidiye Etfal Hospital, University of Health Sciences, Istanbul, Turkey
Address for correspondence: Dr. Daghan Dagdelen, Clinic of Plastic, Reconstructive and Aesthetic Surgery, Balikesir State Hospital, Balikesir, Turkey.
How to cite this article: Dagdelen D, Aksoy A, Sirvan SS. Utilization of a perforator flap for stump closure of the fifth digit. Turk J Plast Surg 2018;26:71-3.
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|Title Annotation:||Case Report|
|Author:||Dagdelen, Daghan; Aksoy, Alper; Sirvan, Selami Serhat|
|Publication:||Turkish Journal of Plastic Surgery|
|Date:||Apr 1, 2018|
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