The ulnar palmar perforator ap: Anatomical

study and clinical application

Pan-Deng Hao
a,f
, Yue-Hong Zhuang
b,f
, He-Ping Zheng
c,
*,
Xiao-Dong Yang
d
, Jian Lin
e
, Chao-Lan Zhang
a
, Zhi-Ping Xie
a
,
Cheng Liang
a
a
Fuzhou General Hospital of Nanjing Command, Fujian Medical University, Fuzhou,
Fujian 350025, China
b
Anatomic Department, Fujian Medical University, Fuzhou, China
c
Anatomical Institution, Department of Orthopedics, General Hospital of Peoples
Liberation Army Nanjing District, Fuzhou, China
d
Department of Microsurgery, YiWu municipal Hospital, YiWu, China
e
Department of Hand Surgery, BoAi Hospital, Taizhou, China
Received 1 December 2013; accepted 26 December 2013
KEYWORDS
Little nger injury;
Perforator;
Trauma;
Flap reconstruction;
The ulnar palmar
perforator ap
Summary Background: Defects sustained at the little nger and the ulnar aspect of the hand
are common and pedicled perforator aps have unique advantages in resurfacing it. The pur-
pose of this study is to reappraise the anatomy of the septocutaneous perforator in the
postero-medial aspect of the hand and present our clinical experience in using perforator aps
based on it.
Methods: This study was divided into anatomical study and clinical application. In the anatom-
ical study, 30 preserved upper limbs were used. Clinically, 16 patients with defects at the little
nger or the ulnar aspect of the hand underwent reconstruction with aps based on the perfo-
rator from the ulnar palmar artery of little nger. The defects ranged from 2.3 1.3 cm
2
to
5.7 3.0 cm
2
.
Results: The septocutaneous perforator was constantly located 1.3 0.3 cm superior to the
fth metacarpophalangeal joint with a diameter of 0.8 0.2 mm. It travelled through the
space between the supercial layer and the deep layer of hypothenar muscles, and ramied
into three branches before entry into the skin. The ascending branch of the perforator has
two patterns of anastomoses with the descending dorsal carpal branch of the ulnar artery: true
anastomoses and choked anastomoses. Clinically, aps in all 16 cases survived uneventfully,
and donor sites healed without deformity.
* Corresponding author. Tel.: 86 0591 24937085.
E-mail addresses: attitudeisaltitude@163.com, zhpfz@163.com (H.-P. Zheng).
f
Both authors contributed equally to this work.
1748-6815/$- seefrontmatter2014BritishAssociationof Plastic, ReconstructiveandAestheticSurgeons. PublishedbyElsevier Ltd. All rightsreserved.
http://dx.doi.org/10.1016/j.bjps.2013.12.048
Journal of Plastic, Reconstructive & Aesthetic Surgery (2014) 67, 600e606
Conclusion: The location of the perforator at the postero-medial aspect of the hand is consis-
tent; the ulnar palmar perforator ap is particularly suitable to cover defects in the little
nger or the ulnar aspect of hand.
2014 British Association of Plastic, Reconstructive and Aesthetic Surgeons. Published by
Elsevier Ltd. All rights reserved.
Soft-tissue defects on the little nger or the palm can be
caused by trauma, tumour resection, surgical infection and
scar release. Under the circumstance when the underlying
bone and tendon are exposed, the defect requires ap
coverage. There are already numerous options in the
literature in terms of ap coverage for defects on the little
nger or the hand, which have their respective advantages
and disadvantages,
1e7
making the nal reparative choice
ultimately determined by the size, the location of the
defect and the individual preference of the doctor and
patient. However, to the best of our knowledge, there are
still few reports about the perforator ap from the ulnar
palmar artery of little nger (the ulnar palmar perforator
ap). Therefore, we present our anatomic study and clin-
ical application of the ulnar palmar perforator ap.
Materials and methods
Anatomic study
Thirty cadaveric upper limbs, 16 male and 14 female, were
used for this anatomic study. The average age of the ca-
davers used was 55 years old, ranging from 30 to 76 years
old. Each cadaver was injected with a mixture of red gelatin
(natural rubber with red-coloured paint) with manual pres-
sure through the axillary artery until the incisions within the
pulp of the ngers stained red. In each cadaveric upper limb,
a longitudinal incision was rst made at the middle of palm
and gradually extended to the ulnar margin of the hand. The
skin, subcutaneous fat and aponeurosis were raised. The
abductor digiti minimi muscle and the exor digiti minimi
brevis muscle were divided and raised to observe and record
the trajectory of the perforator fromthe ulnar palmar artery
of little nger. Then, the perforator extending to the
postero-medial aspect of the hand was carefully identied.
The fth metacarpophalangeal joint was adopted as the
anatomic landmarks for localisation of the perforator. A
steel rule and a Vernier caliper were used for obtainment of
the related data. All data were expressed as
mean standard deviation (SD).
Clinical application
Between March 2011 and February 2013, 16 patients with
soft-tissue defects on the little nger or the ulnar aspect of
the palm (Table 1) underwent reconstruction with the ulnar
palmar perforator ap. Among them, 11 cases were male,
and the other female. The age of patients ranged from 17 to
62 years, with an average of 31.5 years. The aetiology of
injury: ve cases were caused by crush of press machines,
three by crush of punching machines, four by planers, two by
explosion and two by burn. The defect location were as
Table 1 Patients demographic data.
Case Gender Age Cause Location of
defects
Size of defects
(cm
2
)
Size of aps
(cm
2
)
Flap
complications
Donor-site
complications
Follow-up
(weeks)
1 Male 19 Explosion Little nger 2.3 1.3 2.5 1.5 No No 7
2 Female 30 Crush of
press machines
Little nger 3.0 2.3 3.5 2.8 No No 9
3 Male 17 Explosion Ulnar palm 3.6 1.8 4.0 2.2 No No 13
4 Male 25 Empyrosis Little nger 5.0 2.7 6.0 3.0 No No 8
5 Male 33 Planer Little nger 2.4 1.2 3.0 1.5 No No 10
6 Female 37 Crush of
press machines
Ulnar palm 3.9 1.3 4.5 1.8 No No 9
7 Female 36 Punching Little nger 5.7 3.0 6.0 3.5 No No 10
8 Male 26 Crush of
press machines
Ulnar palm 4.2 2.8 4.6 3.0 No No 8
9 Male 20 Punching Little nger 4.3 2.5 4.6 2.9 No No 9
10 Male 62 Planer Little nger 5.1 2.2 5.5 2.5 No No 16
11 Female 41 Crush of
press machines
Ulnar palm 4.7 2.6 5.1 3.0 No No 8
12 Male 27 Planer Little nger 3.6 1.3 4.0 1.5 No No 9
13 Male 22 Punch Little nger 5.7 1.8 6.0 2.0 No No 7
14 Male 36 Empyrosis Ulnar palm 4.6 2.5 5.0 2.9 No No 8
15 Female 24 Crush of
press machines
Little nger 4.0 2.1 4.3 2.5 No No 11
16 Male 49 Planer Little nger 4.6 2.0 5.0 2.3 No No 8
The ulnar palmar perforator ap 601
follows: three at the proximal and middle palmar segments
of the little nger, ve at the middle and proximal dorsal
segments of the little nger, one at the dorsum of the whole
little nger and ve at the distal segments of the ulnar palm.
The defect size ranged from 2.3 1.3 cm
2
to 5.7 3.0 cm
2
.
After the operation, necessary measures were taken corre-
spondingly to address any arising problems.
Operation technique
The operation procedure was carried out under brachial
plexus anaesthesia with a tourniquet applied on the most
proximal part of the upper arm. After debridement, the
patient was positioned with the face down or up and the
affected limb slightly abducted laterally. A hand-held
Doppler probe or computed tomography angiography was
regularly employed to locate the site of the perforator
preoperatively. The line between the abductor digit minimi
muscle and the fth metacarpal bone was dened as the
axial line with the forearm in neutral posture. A template of
the ap was outlined at the donor site with the dimension
ranging up to 1 cm larger than the defect size, according to
the preoperative design (Figure 1(A)). An incision was rst
made at the lateral superior margin of the ap deep down to
the layer underneath the deep fascia, and extended in a
proximal-to-distal direction until the septocutaneous
perforator site was encountered. A meticulous retrograde
(distal to proximal direction) dissection was performed to
trace the perforator, ligating and dividing the minute vessels
encountered (Figure 1(B)). A small adipofascial cuff should
be preserved around the perforator to avoid damage to it.
Dissection was performed until sufcient length of the
vascular pedicle was obtained. It was unnecessary to trace
the perforator to its source artery whenever a pedicled
perforator ap was planned to cover the defect. Conse-
quently, the source artery of the perforator adopted was not
known in the operation. The tourniquet was deated to
check the blood supply of the ap. If the blood perfusion was
conrmed, the ap was then rotated nearly 180

to the
defect with the vascular pedicle kept free of tension. The
average intra-operative time was 1.5 h.
Results
Anatomic ndings
The septocutaneous perforator was constantly located
1.3 0.3 cm superior to the fth metacarpophalangeal joint
with a diameter of 0.8 0.2 mm. After originating from the
source artery, the perforator travelled through the space
between the supercial layer and the deep layer of
hypothenar muscles, and ramied into three branches
before entry into the skin: ascending branch, transverse
branch and descending branch. The descending branch
travelled downward to nourish the fth meta-
carpophalangeal joint; the transverse branch travelled to
the skin of the ulnar aspect of the palm; and the ascending
branch travelled proximally and anastomosed with the
descending dorsal carpal branch of the ulnar artery even-
tually (Figure 2). According to the anatomic study, there
Figure 1 (A) Flap design; (B) Elevation of the ap. Figure 2 Sketch map of the perforator.
602 P.-D. Hao et al.
were two patterns (Figure 3) of the communicating networks
between the septocutaneous perforator and the descending
dorsal carpal branch of the ulnar artery: true anastomosis in
pattern I (70%) and choked anastomosis
8
in pattern II (30%).
Clinical outcomes
The size of the ap ranged from 2.5 1.5 cm
2
to
6.0 3.5 cm
2
. In some cases, slight congestion of the ap
occurred in the early postoperative period, which subsided
subsequently. Flaps survived uneventfully in all 16 cases.
Donor sites healed uneventfully. After an average follow-up
of 7e16 weeks, the colour of the aps in all patients was
similar to the surrounding tissue; the patients could resume
their daily activities.
Case reports
Case 4
A 25-year-old male suffered a soft-tissue defect at the
dorsal aspect of the right little nger after an empyrosis.
During the operation, the wound was radically debrided at
rst, resulting in a defect measuring 5.0 2.7 cm
2
; then, a
distally based ulnar palmar perforator ap with a size of
6.0 3.0 cm
2
was harvested and transferred to the defect
area. The donor site was resurfaced with a patch of skin
from the right thigh. The ap survived uneventfully. After 8
weeks of follow-up, the ap was excellent in texture and
appearance (Figure 4).
Case 13
A 22-year-old male was injured by a punch, which led to the
loss of his middle and ring ngers. The skin defect was
located at proximal and middle segment of the volar aspect
of the left little nger. After an emergency debridement, the
stumps of the middle nger and the ring nger were closed
directly, but the little nger was resurfaced with the ulnar
palmar perforator ap. Theapsizewas 6.0 2.0 cm
2
, which
was bigger than the defect area 5.7 1.8 cm
2
. The donor site
was closed directly. After 7 weeks of follow-up, the ap was
acceptable in texture and appearance (Figure 5).
Discussion
The increasing use of perforator aps has led to both a
reduction in donor site morbidity and the ability to
Figure 3 Outcomes of our anatomic study. A Pattern: the
true anastomosis between the perforator and the descending
dorsal carpal branch of ulnar artery. B Pattern : the choked
anastomosis between the perforator and descending dorsal
carpal branch of ulnar artery 1. The ulnar palmar artery of
little nger; 2. The dorsal carpal branch of ulnar artety; 3. The
septocutaneous perforator of the ulnar palmar artery of little
nger; 4. The fth metacarpophalangeal joint; 5. The abductor
digit minimi muscle and the Flexor digiti minimi brevis muscle;
6. Opponens digiti minimi muscle.
The ulnar palmar perforator ap 603
individualise reconstruction using tissue from multiple
donor sites.
9e11
Pedicled abdominal ap
12
can be employed
easily to repair the nger tissue defects, but the recipient
limb must be immobilised in a particular gesture after the
operation, and needs a subsequent plastic operation to
divide the pedicle. The reverse hypothenar ap
13
with
ligation of the ulnar palmar artery of little nger is useful,
but it might cause ischaemia of the little nger and cold
intolerance after sacricing the ulnar palmar artery of the
little nger e one of the main arteries of the little nger.
Cross-nger aps
14,15
have been commonly used for
reconstruction of the little nger. However, this procedure
also requires a staged procedure with immobilisation and
has a high risk of stiffness of the joint. Free aps
16
from
forearms are used to resurface the hand defects with good
results, but it is a demanding technique and requires
teamwork.
The postero-medial aspect of the dorsum of the hand is
an ideal area as a skin donor site, from which the ulnar
palmar perforator ap can be harvested for coverage of
soft-tissue defects at the little nger or ulnar aspect of the
hand. The skin is thin and pliable, and the perforator
dissection does not require sacrice of the major arteries of
the hand or the nger. The results of a number of anatomic
studies have demonstrated that the postero-medial aspect
of the dorsum of hand is mainly vascularised by the
Figure 4 The distally based ulnar palmar perforator ap for coverage of the defect at the dorsal aspect of the little nger. (A)
Preoperative defect; (B) Wound debridement and Preoperative design; (C) Elevation of the ap; (D) Transfer of the ap (E) Repair
of the defect and recover of the donor site; (F) The appearance of the ap and donor site 8 weeks after the surgery; both were in
good condition.
604 P.-D. Hao et al.
septocutaneous perforator from the ulnar palmar artery of
little nger and the descending dorsal carpal branch of the
ulnar artery, and there were two patterns of communi-
cating networks between them. In pattern, the ascending
branch is always the largest in diameter among the three
branches of the septocutaneous perforator and has true
anastomosis with the descending dorsal carpal branch of
ulnar artery without diminishing lumen. Consequently,
when this pattern of perforator is encountered during the
surgery, the distal part of the ap can be extended across
the styloid process of the ulna with minimal risk of tissue
necrosis. In pattern , the ascending branch and the
descending branch are almost equal in size, and have
choked anastomoses with the descending dorsal carpal
branch of ulnar artery, indicating the distal part of the ap
should be kept proximal to the styloid process of the ulna
avoid ap necrosis. With the development of modern im-
aging technique, such as the multislice computerised to-
mography angiography, the preoperative observation of the
perforator pattern is now possible.
Figure 5 The distally based ulnar palmar perforator ap for coverage of the defect at the volar aspect of the little nger. (A)
Preoperative defect; (B) Preoperative design; (C) Elevation of the ap; (D) Repair of the defect and direct suture of the donor site;
(E) The appearance of the ap 7 weeks later. (F) The appearance of the donor site 7 weeks later
The ulnar palmar perforator ap 605
The perforator aps included in this study ranged from
2.5 1.5 cm
2
to 6.0 3.5 cm
2
in size. The location of the
perforator was often adjacent to the proximal margin of
the wound, indicating that long pedicle is unnecessary,
which together make this method particularly suitable and
convenient for the coverage of tissue defects in the little
nger or the ulnar aspect of the palm. In all our clinical
cases, aps were harvested subfascially without reverse
intramuscular dissection of the perforator to its source ar-
tery, under the circumstance of which the source artery
makes no difference to the surgical approach and only the
location of the piercing point of the perforator into the
deep fascia matters. The donor site morbidity of this ap is
minimal and there is no impairment to the fth meta-
carpophalangeal joint functions. The ap with the largest
size harvested in the clinical series was 6.0 3.5 cm
2
,
which survived completely, indicating the reliability of the
vascularisation of this ap for reconstruction of defect in
the little nger or the dorsum of the hand.
When the ulnar palmar perforator ap is to be har-
vested, the following considerations should be taken for
account: (1) the handheld Doppler
17
is recommended to be
used preoperatively for location of the perforator e there
are no supercially located main arteries underlying the
postero-medial aspect of the dorsum of the hand, making
the signal obtained from the Doppler more reliable; (2) the
perforator ap is generally bounded superiorly by dorsal
transverse wrist crease, inferiorly by the fth meta-
carpophalangeal joint, laterally by the fourth metacarpal
bone and medially by the junction between the dorsal and
volar aspects of the palm. In summary, the ulnar palmar
perforator ap, with all advantages possessed by a perfo-
rator ap, is particularly suitable and convenient for
coverage of soft-tissue defects at the little nger or the
ulnar aspect of the hand with short operative time. It is a
useful addition to the armamentarium for reconstruction of
defects at the little nger or the ulnar aspect of the hand.
Conclusion
The perforator from the ulnar palmar artery of little nger
is relatively constant in anatomy, which can enable the
harvest of the ulnar palmar perforator ap. Therefore, the
ulnar palmar perforator ap is a useful addition to the
armamentarium for reconstruction of defects on the hand
or the little nger. The procedure is technically easy and
the aesthetic results were acceptable, and our applications
had conrmed its usefulness.
Conict of interest
None.
Acknowledgements
The authors give special thanks to the fund supports from
Fujian Provincial Natural Science Foundation (2012J01410).
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