The evolution and refinements of the distally based dorsal metacarpal artery (DMCA) flaps.

Distally based DMCA flaps are well established in reconstructive hand surgery. They comprise the dorsal flap described by Quaba and the DMCA flaps described by Earley, Milner and others. The most frequent indications for these flaps are soft tissue defects of the dorsum of the proximal phalanx and the total length of the finger. Since its introduction several modifications have been developed to match specific defect requirements; these include: the development of pure fascial DMCA flaps, the use of DMCA flaps in dorsally grafted burned hands and modifications in design to avoid 'tunnelling' and to permit skin-skin defect closure. The purpose of this article is to provide an overview of the evolution and refinements of the DMCA flaps based on the experience of a single centre. The DMCA flaps provide one stage coverage of excellent quality with independent vascularisation and permit primary closure of the recipient site without sacrificing relevant arteries (e.g. proper digital artery). However, the DMCA flaps also possess drawbacks, for example, apart from the fact that this technique is quite demanding, possible hair growth and a visible scar on the exposed dorsal part of the hand present aesthetic problems for some patients. Despite these limitations, DMCA flaps are considered to be extremely useful.