Dual-pedicle FDMA flap with intraoperative perfusion testing: a decision-making strategy for reliable thumb...

The first dorsal metacarpal artery (FDMA) flap is a well-established option for reconstructing complex thumb defects. Despite its reliability, inadequate flap perfusion remains a concern with a potential risk of postoperative ischaemia compromising outcomes. This study aimed to introduce and assess a dual-pedicle modification of the FDMA flap combined with an intraoperative perfusion testing protocol to improve flap vascularity assessment and surgical reliability.

Thirty consecutive patients with complex thumb defects underwent FDMA flap reconstruction using a dual-pedicled design incorporating a secondary fasciocutaneous random-pattern pedicle based on the radial side of the index finger. An intraoperative axial pedicle stress test was carried out using temporary occlusion with a sterile finger tourniquet to isolate and assess axial pedicle flap perfusion intraoperatively and based on the test findings, the secondary pedicle was either divided immediately or retained temporarily.

Immediate division of the secondary pedicle was carried out in 27 patients, whereas three required temporary preservation because of inadequate perfusion during intraoperative testing. Complete flap survival was achieved in all patients with no vascular complications. The mean static two-point discrimination was 8.90 (SD 1.21 mm) and the mean Kapandji score was 8.87 (SD 0.96), indicating satisfactory sensory and functional outcomes.

The proposed dual-pedicle modification, combined with intraoperative perfusion assessment, provides a practical method for estimating axial pedicle adequacy and may assist in intraoperative decision-making when flap perfusion is inadequate.

IV.