The Thumb pp 331-365 | Cite as

Microsurgical Reconstruction

  • Sang Hyun Woo


Microsurgical reconstructive options are available to treat thumb amputation at different levels based on author’s experience. I reference techniques used by other surgeons and identify the most suitable technique for different clinical situations. Indications and techniques for microsurgical partial or composite transfer of the great or second toe for thumb reconstruction are summarized. Different microsurgical transfer techniques suggest a great freedom of surgical choices. However, the choices are considerably restricted if all functional and cosmetic requirements are to be met. I recommend individualized surgical design and reconstruction because each case of thumb amputation is unique.


Toe-to-thumb transfer Microsurgical reconstruction 


  1. 1.
    Buncke HJ Jr, Buncke CM, Schulz WP. Immediate Nicoladoni procedure in the Rhesus monkey, or hallux-to-hand transplantation, utilising microminiature vascular anastomoses. Br J Plast Surg. 1966;19:332–7.CrossRefGoogle Scholar
  2. 2.
    Cobbett JR. Free digital transfer. Report of a case of transfer of a great toe to replace an amputated thumb. J Bone Joint Surg Br. 1969;51:677–9.CrossRefGoogle Scholar
  3. 3.
    Foucher G, Merle M, Maneaud M, et al. Microsurgical free partial toe transfer in hand reconstruction: a report of 12 cases. Plast Reconstr Surg. 1980;65:616–26.CrossRefGoogle Scholar
  4. 4.
    Hirase Y, Kojima T, Matsui M. Aesthetic fingertip reconstruction with a free vascularized nail graft: a review of 60 flaps involving partial toe transfers. Plast Reconstr Surg. 1997;99:774–84.CrossRefGoogle Scholar
  5. 5.
    Wei FC, Chen HC, Chuang DCC, et al. Aesthetic refinements in toe-to-hand transfer surgery. Plast Reconstr Surg. 1996;98:485–90.CrossRefGoogle Scholar
  6. 6.
    Michon J, Merle M, Bouchon Y, et al. Functional comparison between pollicization and toe-to-hand transfer for thumb reconstruction. J Reconstr Microsurg. 1984;1:103–12.CrossRefGoogle Scholar
  7. 7.
    Jones NF, Hansen SL, Bates SJ. Toe-to-hand transfers for congenital anomalies of the hand. Hand Clin. 2007;23:129–36.CrossRefGoogle Scholar
  8. 8.
    Nguyen JT, Bakri K, Nguyen EC, et al. Surgical management of subungual melanoma: Mayo Clinic experience of 124 cases. Ann Plast Surg. 2013;71:346–54.CrossRefGoogle Scholar
  9. 9.
    Kovachevich R, Giuffre JL, Shin AY, Bishop AT. Immediate great toe transfer for thumb reconstruction after tumor resection: report of 3 cases. Ann Plast Surg. 2016;76:280–4.CrossRefGoogle Scholar
  10. 10.
    Morrison W, O’Brien BM, MacLeod AM. Experience with thumb reconstruction. J Hand Surg Br. 1984;9:223–33.CrossRefGoogle Scholar
  11. 11.
    Gilbert A. Thumb reconstruction using microvascular techniques. In: Tubiana, editor. The hand, vol. III. Philadelphia: WB Saunders; 1988. p. P1142–51.Google Scholar
  12. 12.
    Zhu J, Hu B. Sonography of the first dorsal metatarsal artery of the foot. J Clin Ultrasound. 2006;34:1–4.CrossRefGoogle Scholar
  13. 13.
    Xu L, Yang K, Wei P, et al. Computed tomography angiography allows the classification of the first dorsal metatarsal arteries. J Reconstr Microsurg. 2016;32:675–82.CrossRefGoogle Scholar
  14. 14.
    Hou Z, Zou J, Wang Z, Zhong S. Anatomical classification of the first dorsal metatarsal artery and its clinical application. Plast Reconstr Surg. 2013;132:1028e–39e.CrossRefGoogle Scholar
  15. 15.
    Wei FC, Silverman RT, Hsu WM. Retrograde dissection of the vascular pedicle in toe harvest. Plast Reconstr Surg. 1995;96:1211–4.CrossRefGoogle Scholar
  16. 16.
    Woo SH, Seul JH. Distal thumb reconstruction with a great toe partial-nail preserving transfer technique. Plast Reconstr Surg. 1998;101:114–9.CrossRefGoogle Scholar
  17. 17.
    Buncke HJ, Valauri FA. Reconstruction of the thumb with a trimmed-toe transfer technique (Discussion). Plast Reconstr Surg. 1988;82:514–5.CrossRefGoogle Scholar
  18. 18.
    Adani R, Cardon LJ, Castagnetti C, Pinelli M. Distal thumb reconstruction using a mini wrap-around flap from the great toe. J Hand Surg Br. 1999;24:437–42.CrossRefGoogle Scholar
  19. 19.
    Morrison WA, O’Brien BM, MacLeod AM. Thumb reconstruction with a free neurovascular wrap-around flap from the big toe. J Hand Surg [Am]. 1980;5:575–83.CrossRefGoogle Scholar
  20. 20.
    Pan YW, Zhang L, Tian W, et al. Donor foot morbidity following modified wraparound flap for thumb reconstruction: a follow-up of 69 cases. J Hand Surg [Am]. 2011;36:493–501.CrossRefGoogle Scholar
  21. 21.
    Shen XF, Mi JY, Xue MY, et al. Modified great toe wraparound flap with preservation of plantar triangular flap for reconstruction of degloving injuries of the thumb and fingers: long-term follow-up. Plast Reconstr Surg. 2016;138:155–63.CrossRefGoogle Scholar
  22. 22.
    Wei FC, Chen HC, Chuang CC, et al. Reconstruction of the thumb with a trimmed-toe transfer technique. Plast Reconstr Surg. 1988;82:506–15.CrossRefGoogle Scholar
  23. 23.
    Upton J, Mutimer K. A modification of the great-toe transfer for thumb reconstruction. Plast Reconstr Surg. 1988;82:535–8.CrossRefGoogle Scholar
  24. 24.
    Tsai TM, Aziz W. Toe-to-thumb transfer: a new technique. Plast Reconstr Surg. 1991;88:149–53.CrossRefGoogle Scholar
  25. 25.
    Iglesias M, Butron P, Serrano A. Thumb reconstruction with extended twisted toe flap. J Hand Surg [Am]. 1995;20:731–6.CrossRefGoogle Scholar
  26. 26.
    Kempny T, Paroulek J, Marik V, et al. Further developments in the twisted-toe technique for isolated thumb reconstruction: our method of choice. Plast Reconstr Surg. 2013;131:871e–9e.CrossRefGoogle Scholar
  27. 27.
    Zhang G, Ju J, Li L, et al. Combined foot flaps with iliac bone graft for reconstruction of the thumb. J Hand Surg Eur. 2016;41:745–52.CrossRefGoogle Scholar
  28. 28.
    Barca F, Santi A, Tartoni PL, et al. Gait analysis of the donor foot in microsurgical reconstruction of the thumb. Foot Ankle Int. 1995;16:201–6.CrossRefGoogle Scholar
  29. 29.
    Zhao J, Tien HY, Abdullah S, et al. Aesthetic refinements in second toe-to-thumb transfer surgery. Plast Reconstr Surg. 2010;126:2052–9.CrossRefGoogle Scholar
  30. 30.
    del Piñal F, García-Bernal FJ, Regalado J, et al. A technique to improve foot appearance after trimmed toe or hallux harvesting. J Hand Surg [Am]. 2007;32:409–13.CrossRefGoogle Scholar
  31. 31.
    Al-Qattan MM. Pollicization of the index finger requiring secondary fusion of the new metacarpophalangeal joint. J Hand Surg Eur. 2016;41:295–300.CrossRefGoogle Scholar
  32. 32.
    Woo SH, Seul JH. Various functioning free muscle transfer for restoration of hand function. J Korean Soc Surg Hand. 2002;7:130–8.Google Scholar
  33. 33.
    Ishida O, Taniguchi Y, Sunagawa T, et al. Pollicization of the index finger for traumatic thumb amputation. Plast Reconstr Surg. 2006;117:909–14.CrossRefGoogle Scholar
  34. 34.
    Sosin M, Lin CH, Steinberg J, et al. Functional donor site morbidity after vascularized toe transfer procedures: a review of the literature and biomechanical consideration for surgical site selection. Ann Plast Surg. 2016;76:735–42.CrossRefGoogle Scholar
  35. 35.
    Lipton HA, May JW Jr, Simon SR. Preoperative and postoperative gait analyses of patients undergoing great toe-to-thumb transfer. J Hand Surg [Am]. 1987;12:66–9.CrossRefGoogle Scholar
  36. 36.
    Poppen NK, Mann RA, O’Konski M, et al. Amputation of the great toe. Foot Ankle. 1981;1:333–7.CrossRefGoogle Scholar
  37. 37.
    Buncke HJ, Buncke GM, Lineaweaver WC, et al. Bad results after large toe to thumb transplantation. Ann Chir Main Memb Super. 1991;10:513–6.CrossRefGoogle Scholar
  38. 38.
    Graham DJ, Venkatramani H, Sabapathy SR. Current reconstruction options for traumatic thumb loss. J Hand Surg [Am]. 2016;41:1159–69.CrossRefGoogle Scholar
  39. 39.
    Gu YD, Zhang GM, Chen DS, et al. Toe-to-hand transfer: an analysis of 14 failed cases. J Hand Surg [Am]. 1993;18:823–7.CrossRefGoogle Scholar
  40. 40.
    Lin YT, Su ST, Lo S, et al. Risk factors for reexploration in toe-to-hand transfer: a multivariate analysis of 363 cases. Plast Reconstr Surg. 2015;135:501–6.CrossRefGoogle Scholar
  41. 41.
    Lister GD, Kalisman M, Tsai TM. Reconstruction of the hand with free microneurovascular toe-to-hand transfer: experience with 54 toe transfers. Plast Reconstr Surg. 1983;71:371–86.CrossRefGoogle Scholar
  42. 42.
    Ozkan O, Chen HC, Mardini S, et al. Principles for the management of toe-to-hand transfer in reexploration: toe salvage with a tubed groin flap in the last step. Microsurgery. 2006;26:100–5.CrossRefGoogle Scholar
  43. 43.
    Wei FC, Epstein MD, Chen HC, et al. Microsurgical reconstruction of distal digits following mutilating hand injuries: results in 121 patients. Br J Plast Surg. 1993;46:181–6.CrossRefGoogle Scholar
  44. 44.
    Rose EH, Hendel P. Primary toe-to-thumb transfer in the acutely avulsed thumb. Plast Reconstr Surg. 1981;67:214–8.CrossRefGoogle Scholar
  45. 45.
    Demirkan F, Wei FC, Jeng SF, et al. Toe transplantation for isolated index finger amputations distal to the proximal interphalangeal joint. Plast Reconstr Surg. 1999;103:499–507.CrossRefGoogle Scholar
  46. 46.
    Woo SH, Kim JS, Seul JH. Immediate toe-to-hand transfer in acute hand injuries: overall results, compared with results for elective cases. Plast Reconstr Surg. 2004;113:882–92.CrossRefGoogle Scholar
  47. 47.
    Woo SH, Lee GJ, Kim KC, et al. Immediate partial great toe transfer for the reconstruction of composite defects of the distal thumb. Plast Reconstr Surg. 2006;117:1906–15.CrossRefGoogle Scholar
  48. 48.
    Kotkansalo T, Vilkki S, Elo P, et al. Long-term functional results of microvascular toe-to-thumb reconstruction. J Hand Surg Eur. 2011;36:194–204.CrossRefGoogle Scholar
  49. 49.
    Huang D, Wang HG, Wu WZ, et al. Functional and aesthetic results of immediate reconstruction of traumatic thumb defects by toe-to-thumb transplantation. Int Orthop. 2011;35:543–7.CrossRefGoogle Scholar
  50. 50.
    Waljee JF, Chung KC. Toe-to-hand transfer: evolving indications and relevant outcomes. J Hand Surg [Am]. 2013;38:1431–4.CrossRefGoogle Scholar

Copyright information

© Springer Nature Singapore Pte Ltd. 2019

Authors and Affiliations

  • Sang Hyun Woo
    • 1
  1. 1.W Institute for Hand and Reconstructive MicrosurgeryW HospitalDaeguSouth Korea

Personalised recommendations