Microsurgery: Transplantation and Replantation by Harry J. Buncke, MD, et al.
  Table of Contents / Chapter 1:
Great Toe Transplantation
  The metatarsal head and the sesamoid bone should not be taken from the foot or functional problems with walking may result. For this reason, when the entire metacarpal or the basilar joint of the thumb is missing, the use of the second toe with the entire second metatarsal shaft is probably a better choice. When the entire first metacarpal length is obtained by use of the second metatarsal, additional soft-tissue cover on the hand is often required, not only to resurface the area of injury on the hand but also to provide skin cover to the medial and lateral surfaces of the second metatarsal, which has no skin cover once it is lifted out of the first web space. We have provided this soft-tissue cover on a preliminary basis with a conventional groin flap, leaving the tubed base of the flap long to cover the transplanted second metatarsal joint and shaft or by simultaneous soft-tissue and toe transplantation using multiple surgical teams. Vascular cover for the thenar area and metatarsal shaft can also be provided with small muscle transplants covered with split-thickness skin grafts. As will be pointed out in the discussion of muscle transplantation, these transplants can be innervated by anastomosing the nerve from the muscle to the motor branch of the median nerve.

Pollicization is probably the method of choice in congenital absence of the thumb with longitudinal deficiencies and an absence of normal recipient structures. It should also be considered in situations when only the thumb is missing and a shortened or injured nonfunctional index finger stump is available. Pollicization becomes less desirable when two or three digits are missing from the hand.8


As stated previously, second toes are useful for partial finger reconstruction, particularly when multiple digits are missing. Partial loss of the ring or long finger produces an obvious deformity in the normal digital arcade. For patients who are active in five-fingered tasks such as typing, multiple finger reconstruction is particularly rewarding. Correction is not only functional but cosmetically beneficial because the hands and face are the most exposed parts of the anatomy and open to constant scrutiny. The primary objective is the restoration of function, but the restoration of contour as an added dividend is well worthwhile.

Toe neurovascular island flap transplants are reserved for loss of pulp substance on the pinch areas of the thumb and index fingers.9 They are particularly valuable in hands with multiple injuries in which a standard neurovascular island flap from the ulnar side of the ring or long finger would add to the magnitude of the primary hand injury. Fingertip cover on the long, ring, or little finger does not require such elaborate microvascular transplantation and can usually be accomplished with conventional cross-finger flaps or other local or distant flaps. The exception to this rule might be when the index and long fingers are missing and the ring and little finger become the primary tactile pinch areas.

next page...

  2002 © This page, and all contents, are Copyright by The Buncke Clinic