Lower Eyelid and Cheek Reconstruction With the First Dorsal Metacarpal Artery Free Flap: A Case Report

Reconstruction of full-thickness lower eyelid defects remains a complex challenge due to the simultaneous requirements of functional protection, dynamic closure, and aesthetic harmony. Various local and free flaps exist, but limitations such as donor-site morbidity, bulkiness, or poor color match persist. To our knowledge, based on a structured literature search of PubMed, Scopus, and Web of Science (database inception to November 2025), there are no previously published reports describing the use of the first dorsal metacarpal artery (FDMA) flap as a free flap for reconstruction of lower eyelid or adjacent malar defects. We report the case of a 61-year-old male with a 4 × 3 cm left lower eyelid lesion diagnosed as basal cell carcinoma, adenoid (adenocystic) variant. After Mohs micrographic surgery, the resulting 3.6 × 3.2 cm full-thickness defect was reconstructed using a free FDMA flap harvested from the dorsum of the hand. Microvascular anastomoses were performed with the superficial temporal vessels, and the donor site was resurfaced with a full-thickness skin graft. The flap remained viable throughout hospitalization with no ischemic complications. On postoperative day seven, flap integration and donor-site healing were satisfactory. At six months, the patient showed complete eyelid closure (lagophthalmos 0 mm), eyelid margin symmetry within 1 mm, and a palpebral aperture of 9 mm. Objective assessment demonstrated favorable Patient and Observer Scar Assessment Scale scores (observer, 11/60; patient, 13/60), and the FACE-Q Eye Module confirmed high satisfaction (appearance, 88/100; comfort, 92/100). The flap showed stable contour and excellent integration with adjacent tissues. This case demonstrates the feasibility of using the free FDMA flap for complex lower eyelid and malar reconstruction, offering thin, pliable tissue with favorable aesthetic and functional outcomes. As the first reported application of this flap in this anatomical region, it broadens the reconstructive options for periocular oncologic defects and supports further investigation through larger and longer-term studies.