Replant patients at this time should show progress in range of motion, strength, and sensory recuperation. Therapy should continue until a plateau is reached and no further major improvements are anticipated. Significant motor deficits, articular problems, or delay in return of nerve function may be addressed by secondary surgery following exhaustion of therapy gains. Secondary surgery is usually not performed before 6 postoperative months have elapsed, except for nerve defects, which may be repaired earlier.

Toe transfer patients receive the same therapies as the replant patients. In addition, the donor foot is carefully progressed to full function. Long-term foot problems are rare.4

Flap patients have much more individualized courses of therapy. Flap protection is gradually replaced by functional rehabilitation as the flap tissue heals into its new site. Functioning flaps are treated to optimize their motor and sensory performances. Secondary procedures on flaps can be performed as early as 3 months after transfer.

Aesthetic prosthetic fitting to functionally and cosmetically improve a disfigured, salvaged part or an associated amputation can be considered 6 months after injury when all wounds are stable. Secondary surgery to improve stump contour or eliminate a neuroma is frequently necessary.

The final stages of therapy for all patients are directed toward helping each patient resume a job and an active life. These programs are instituted when maximum therapeutic return has been achieved and no further surgery is anticipated. Initially, work-hardening and simulation activities are introduced to increase the patient's strength and dexterity in skills related to work performance. Work tolerance screening tests are then administered to document the patient's strengths and weaknesses. The results of these screening tests are used to decide whether the patient could return to his original job or should seek vocational rehabilitation.

The therapist working with microsurgical patients must have skills and expertise ranging from complex, acute wound care to sophisticated approaches to job placement. The reward of this demanding job, however, is seeing an individual patient recover from a devastating injury and complex surgical hospitalizations to return to an active life.

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