The First Dorsal Metacarpal Artery Perforator Free Flap

The Comet Flap

Amjed Abu-Ghname, M.D.; Daniel Lazo, M.D., M.Sc.; Salomao Chade, M.D., Ph.D.; Alex Fioravanti, M.D.; Olimpio Colicchio, M.D.; Daniel Alvarez, M.D.; Ernani Junior, B.A.; Marco Maricevich, M.D.


Plast Reconstr Surg. 2022;150(3):671e-674e. 

In This Article

Abstract and Introduction


Background: Distal extremity defects pose a particular challenge to the reconstructive surgeon; however, advances in perforator flaps have expanded the potential reconstructive options. In this article, the authors present their experience in reconstructing distal extremity defects using a thin, cutaneous free flap based on the perforator of the first dorsal metacarpal artery: the comet flap.

Methods: A retrospective review was performed on all patients who presented with a distal extremity defect and underwent reconstruction using a comet flap between 2015 and 2019. Patient demographics, flap anatomy and harvest, and postoperative course were reviewed and analyzed.

Results: A total of 16 patients were included. The mean patient age was 36.5 years. Trauma was the most common cause. The average defect size was 5.4 × 3.2 cm. The average pedicle length of the comet flap ranged from 3.5 to 30 cm, depending on involvement of the radial vessels. All donor sites underwent uncomplicated closure with local rhomboid flaps. One flap was complicated by an acute venous thrombosis that was successfully treated operatively. The flap survival rate was 95 percent. All patients were able to maintain their preoperative range of motion and were satisfied with their final outcome. Follow-up time ranged from 6 to 50 months.

Conclusions: Local flaps remain an important reconstructive approach for distal extremity defects; however, in complex soft-tissue injuries, free tissue transfers become necessary. The comet flap is a safe, versatile, and reliable flap for reconstructing upper and lower extremity defects that can be performed in a single procedure under regional anesthesia.

Clinical Question/Level of Evidence: Therapeutic, IV.


Defects of the distal extremities are frequently encountered by reconstructive surgeons. Although several approaches can be used to reconstruct the soft tissue of the hands and feet, ranging from skin grafts to complex microvascular tissue transfer, selecting the ideal reconstructive approach can be challenging, with unique case-by-case considerations.[1–4] When the area to be reconstructed demands thin, pliable tissue, suitable options become scarce. The ideal thickness for the reconstruction of distal defects must be "like-with-like" thickness.[5] Furthermore, tissue characteristics including color, texture, hairiness, sensitivity, and donor-site morbidity play an intricate role in determining the best approach.

Advances in perforator flaps and microsurgery have allowed surgeons to harvest well-vascularized cutaneous flaps with minimal donor-site morbidity.[6] In this study, we present our experience in reconstructing distal extremity defects using a thin cutaneous free flap based on the perforator of the first dorsal metacarpal artery: the comet flap.