Addressing dorsal hand defects using rapid ultrasound-guided freestyle propeller perforator flaps: an illustrative case report

Introduction and importance: Surgical defects of the dorsal hand present reconstructive challenges, particularly at the first web space, an anatomically complex site with significant functional and esthetic implications. Perforator flaps are associated with low donor-site morbidity and represent a robust alternative to traditional skin grafts (± associated with dermal matrices), although they are often considered a complex reconstructive option. Ultra-high-frequency Doppler ultrasound enables precise and rapid preoperative perforator mapping, ensuring rapid and reliable on-demand perforator flap designs. Case presentation: An 83-year-old man presented with a nodular, centrally ulcerated squamous cell carcinoma measuring 1.8 cm on the dorsal aspect of the first web space of the left hand. Following multidisciplinary oncological review, excision with 5 mm margins was performed. Preoperative ultra-high-frequency Doppler ultrasound (18 MHz) identified a perforator from the first dorsal metacarpal artery, which was used to design a freestyle propeller flap, performed in less than 30 minutes in an outpatient setting. Postoperative healing was uneventful, with full flap integration, preserved range of motion, and minimal esthetic sequelae. Clinical discussion: Flap reconstruction in a cancer setting is perfectly appropriate as long as follow-up is performed since surgical revision is always possible. Freestyle perforator flaps provide an excellent tissue match and functional preservation in hand reconstruction. Ultra-high-frequency Doppler ultrasound enhances surgical precision by localizing perforators preoperatively, reducing operative time and the risk of pedicle injury, and improving flap viability. Conclusion: This case illustrates the value of Doppler ultrasound-guided perforator flap design as a safe, accessible, and cost-effective alternative to skin grafts in selected cases in anatomically complex regions of the hand.