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Yamakawa et al. Plast Aesthet Res 2020;7:24 I http://dx.doi.org/10.20517/2347-9264.2020.20 Page 9 of 11

Table 1. Flap options for reconstruction of dorsal hand defects
Flap options Advantages Disadvantages Representative flaps
Distant flap Technically simple procedure Relatively longer down-time Abdominal flap
High reliability of blood supply High risk of joint contracture Groin flap
Requires at least two surgeries
Inability to reconstruct tendons
Bulky
Free flap Reconstruction in one surgery Technically complex Free anterolateral thigh flap
Low donor site morbidity and risk of Free peroneal flap
joint contracture Free groin flap
Tendon reconstruction is possible
Local flap Good color and texture matching Requires retrograde blood flow Retrograde posterior interosseous flap
Requires no microvascular anastomosis High risk of donor site morbidity when Retrograde forearm flap
a large flap is harvested

Table 2. Advantages and disadvantages of representative local flaps and the radial artery perforator-based adipofascial flap
Local flaps Advantages Disadvantages
Retrograde posterior Good color and texture matching Requires meticulous dissection Relatively high
interosseous flap Low risk of donor site morbidity complication rate
Limitation of flap size
Retrograde forearm flap Technically easier than the retrograde posterior Requires sacrifice of the main artery
interosseous flap High risk of donor site dysfunction
Tendon reconstruction is possible
Radial artery perforator- Retrograde blood flow is not needed Temporary pain due to fascial traction
based adipofascial flap Sacrificing main artery is not required Skin graft is needed
Donor site morbidities are minimal
Possible to reconstruct thin dorsal hand by skin grafting
Tendon reconstruction is possible
Simple and short surgery

[3]
Taghinia et al. recommended a retrograde radial forearm adipofascial flap to avoid functional problems
caused by adhesion at the donor site. Although this flap is technically easier to use than the retrograde
posterior interosseous flap, it has the disadvantage of sacrificing the main artery. In certain cases, such as
Allen test-negative, this flap is not applicable because it requires retrograde blood flow.

In 1989, Koshima et al. reported inferior epigastric artery skin flaps without rectus abdominis muscle
[21]
and called them perforator flaps. Since then, many perforator flaps have been developed. The radial artery
perforator-based flap is one, which does not require retrograde blood flow and can be applied to hand
reconstruction without sacrificing major vessels [22,23] . Donor site problems can be minimized by using this
flap as an adipofascial flap [22-24] . In addition, the thin and pliable dorsal hand skin can be reconstructed by
performing skin grafting over the adipofascial flap. The extensor digitorum tendon can be reconstructed
by including the tendon, such as the palmaris longus or brachioradialis tendon, in the adipofascial flap as
described in Case 2 [23,25] . Furthermore, this flap has a great advantage in that the procedure is simple and
can be completed in a short time [23,24,26] . Although the patients may complain about pain due to fascial
traction, it disappeared in approximately one month in our cases. The advantages and disadvantages of
representative local flaps and radial artery perforator-based adipofascial flaps are summarized in Table 2.

CONCLUSION
The radial artery perforator-based adipofascial flap is an excellent functional reconstructive option for
complex dorsal hand defects with minimal donor site morbidity.

DECLARATIONS
Authors’ contributions
Contributed to data acquisition and also provided administrative, technical, and material support:
Yamakawa S, Hayashida K
Reviewed the manuscript for content and grammar/spelling mistakes: Yamakawa S, Hayashida K