Anatomical study and clinical application of the ulnar artery perforator flap for distal forearm and hand coverage

Soft-tissue reconstruction of the distal forearm and hand remains challenging due to the complex anatomy and the need for thin, pliable coverage with minimal donor-site morbidity. The ulnar artery perforator flap offers a reliable, artery-preserving alternative to traditional regional flaps. This study aimed to perform a detailed anatomical and radiological assessment of ulnar perforators and to validate the clinical applicability of both fasciocutaneous and adipofascial ulnar artery perforator flaps.

A combined cadaveric and clinical investigation was conducted at a university anatomy laboratory in France, Sixteen fresh upper limbs from eight adult cadavers underwent dissection, with or without selective vascular injection. The number, position, diameter, pedicle length and course of ulnar perforators were recorded and correlated with radiographic findings. Clinical feasibility was evaluated in three patients undergoing distal forearm or hand reconstruction between 2022 and 2024.

Multiple ulnar artery perforators were identified in all specimens, with a dominant perforator consistently located between 9 and 14 cm proximal to the pisiform bone, with a mean external diameter of 2.0 ± 0.3 mm and pedicle length of 3.4 ± 0.9 cm. Radiographic studies confirmed a constant and homogeneous vascular pattern. Clinically, all flaps survived completely without vascular compromise. Donor sites ≤ 5 cm were closed primarily. At 6-month follow-up, patients demonstrated full wrist and hand mobility and high aesthetic satisfaction.

The ulnar artery perforator flap is a reliable, reproducible, and versatile flap for distal forearm and hand reconstruction. Its predictable anatomy, broad arc of rotation, and low donor-site morbidity make it a valuable alternative to the radial forearm flap. When combined with preoperative vascular mapping and modern adjunctive techniques, the ulnar artery perforator flap ensures stable functional and aesthetic outcomes in both traumatic and oncologic reconstructions. Level of Evidence: Level V, therapeutic study.