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 FIG. 3-82. Clay models have been used to demonstrate to the patient what the transplanted toes will look like and also to plan the various skin incisions.
 FIG. 3-83. Toes have been transplanted and demonstrate some of the disadvantages of second-toe transplants in that the flexion contractures usually persist at the DIP and PIP joints. There are bulkiness and flaring at the base of the toes where the amputation stumps have opened up in a fishmouth manner to receive the transplant. The flaps have been thinned down secondarily. With care and planning, this deformity can be avoided by thinning the flap at the time of surgery.
 FIG. 3-84. The patient has good tubular grip for relatively small objects. He underwent a tenolysis with improvement in the amount of flexion in the transplanted toes.
CASE 17
In this case, four fingers of the dominant hand were lost.
 FIG. 3-85. This patient lost all four fingers from his dominant right hand in a printing press.
 FIG. 3-86. The thumb was normal.
 FIG. 3-87. Simultaneous transplantation of the right and left second toes and metatarsal joints was planned.
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 FIG. 3-88. Removal of the second metatarsal reduces the donor defect deformity on the foot.
 FIG. 3-89. Each toe is transplanted to the hand in sequence, preserving circulation until the moment of transfer.
 FIG. 3-90. The donor defect is minimal, and does not necessitate a change in shoe size.
 FIG. 3-91. The toes are placed on the fifth and fourth metacarpals to take advantage of the breadth of the palm, which contributes greatly to grip.
 FIG. 3-92. Strong grip and sensate chuck three-point pinch have been restored. The patient has returned to work as a printer.
CASE 18
Immediate reconstruction after multiple digital trauma is a reasonable approach in selective cases. The damaging effects of scar contracture and joint ankylosis are avoided. The added surgical insult on top of the devastating psychologic trauma of the accident, however, may be more than the average patient can tolerate.
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