Grabb’s Encyclopedia of Flaps Upper Extremities, Torso, Pelvis, and Lower Extremities

9. Jaaskelainen SK, Peltola JK. Electrophysiologic evidence for extremely late sensory collateral
reinnervation in humans. Neurology 1996;46:1703.
10. Han SK, Lee BL, Kim WK. The reverse digital artery island flap: an update. Plast Reconstr Surg
2004;113:1753.

Chapter 277
Staged Neurovascular Island Skin Flap From The Middle Finger to
The Thumb Tip
R. Venkataswami
EDITORIAL COMMENT
The concept of reinnervating the island sensory flap with the nerves in the thumb is a good one. The author
executes the procedure in a staged manner; however, the editors feel that if the donor site were on the
ulnar side of the ring or long finger, the integrity of the radial side of those fingers would be retained.
Perhaps an even further advancement would be to take the entire flap from the big toe and do both a nerve
repair and a vessel repair without violating any of the structures in the fingers.
For covering acute skin loss over the thumb tip and the adjacent terminal phalanx, an island flap of skin and
subcutaneous tissue based on the radial neurovascular bundle is transferred from the middle finger in the first
stage. During the second stage of division of the flap from its donor finger, the digital nerve of the flap is
anastomosed to the digital nerve of the thumb.
INDICATIONS
The neurovascular island flap can be used to cover thumb tip injuries in two stages. This procedure differs
from other neurovascular island flaps (1, 2, 3), in that the nerve to the flap is divided and anastomosed to
the nerve in the thumb. The patient therefore gains his original cortical sensory orientation.
This flap can also be used to cover the dorsal aspect of the proximal interphalangeal joint when there is
compound tissue loss.
ANATOMY
The flap is initially based on the neurovascular bundle of the middle finger, as are the classical neurovascular
island flaps. In the second stage, however, the bundle is completely divided. This means that the vascular supply
to the flap is dependent on neovascularization from the thumb. The nerve is anastomosed to the stump of the
nerve in the thumb, thus providing more accurate cortical representation.
FLAP DESIGN AND DIMENSIONS
A cloth pattern of the defect is laid on the radial side of the middle finger. The radial side of the middle finger is
chosen because this brings the donor finger and thumb into the most convenient and comfortable position for the
patient.
The flap is usually taken from the middle phalanx. If a larger flap is needed, it is extended onto the proximal
phalanx, leaving the distal phalanx untouched (Fig. 277.1).
If a wide flap is needed, the dorsal and volar incisions can extend just beyond the midline.
OPERATIVE TECHNIQUE

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First Stage
During debridement of the thumb tip one of the digital nerves is dissected for a centimeter proximally and the end
is tagged with 6-0 nylon for later identification.
After the flap has been designed and marked, the volar and dorsal incisions are made. The volar incision is
deepened to the flexor sheath and the dorsal incision is deepened to the paratenon covering the extensor
tendon. Then the distal incision is made and the neurovascular bundle is divided.
FIGURE 277.1 Schematic outline of the staged neurovascular island skin flap that is used to cover thumb tip
amputations.
The flap is mobilized proximally, keeping the neurovascular bundle well protected by the retinacular fibers. Once
the proximal limit of the flap is reached, the skin alone is divided and the neurovascular bundle is dissected to
convert the flap into an island flap (Fig. 277.2A).
The donor defect is then covered with an intermediate split-thickness skin graft. To prevent scar contracture of
the volar and dorsal incisions, one or two oblique cuts are made and these flaps are shifted distally to create a
zigzag scar line.
The middle finger is then flexed to bring it near the recipient defect. This entails a flexion of 80° to 90° at the
metacarpophalangeal joint and 40° to 50° of flexion at the proximal interphalangeal joint. This is a comfortable
position for most patients. The flap is sutured to the defect and the neurovascular bundle is covered either by the
skin graft or by the skin flap (Fig. 277.2B).
Second Stage
After 2 to 3 weeks, the neurovascular bundle is dissected proximally in the middle finger for a few millimeters and
then divided. The extra length may be useful for a tension-free anastomosis. The digital artery is divided and
ligated. The nerve is then repaired microsurgically (Fig. 277.2B-D).

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SUMMARY
This staged neurovascular island flap provides both cosmetic and functional skin cover to thumb tip
amputations. By anastomosing the donor and recipient nerves, a better cortical sensory orientation can be
achieved than with the classical neurovascular island flaps.
FIGURE 277.2 A: The radial digital nerve and artery comprise the pedicle of this island flap. B: The island
flap covers the thenar amputation stump. C: Appearance of the hand 2 months postoperatively. D: The
thumb length is adequate to permit pinch.
References
1. Moberg E. Transfer of sensation. J Bone Joint Surg 1955;37(A):299.
2. Littler JW. Neurovascular skin island transfer in reconstructive hand surgery. In: Transactions of the
second congress of the international society of plastic surgeons. London: Livingstone, 1960;175-179.
3. O'Brien BM. Neurovascular pedicle transfers in the hand. Aust N Z J Surg 1965;35:2.

Chapter 278
Modified Palmar Skin Flap to The Fingertip
K. S. KIM
EDITORIAL COMMENT
It is important to understand the anatomy of the transverse palmar arterial branches for flap design.
Identification of the vessel on the opposite side of the digit will help to accurately design the pedicle as well.
The modified palmar skin flap to the fingertip is a homodigital, normograde, neurovascular island flap based on
the transverse palmar branch of the digital artery. The stability of palmar skin is critical for finger function;
however, the use of a palmar skin flap can be justified for fingertip reconstruction, because the fingertip is a most
important tactile area and contributes much to finger power. In addition, palmar digital island flaps can be used to
resolve some problems arising with the use of several other flap techniques, despite the sacrifice of important
palmar skin.
INDICATIONS
The so-named palmar digital island flap (1) has earned a place in the armamentarium of reconstructing
fingertip defects, although the palmar surface of the finger is not usually considered a flap donor site (2).
Reattachment of fingertip parts is the best method of preserving both length and the normal nail complex
anatomy. If this is not possible, several flap techniques may be used to resurface the defect, but each
method has some disadvantages. Local advancement flaps (3, 4) provide soft-tissue coverage of similar
quality to that of normal glabrous skin but cannot always be used because of distance limitations regarding
flap advancement. Regional (4, 5) and distant flaps (6) provide enough tissue for reconstruction, but
prolonged immobilization can lead to stiffness of the injured digits. Several homodigital island or
subcutaneous pedicled flaps (7, 8, 9, 10, 11, 12, 13, 14) have been developed to avoid the disadvantages
of local, regional, and distant flaps, but even these have some disadvantages of their own.
The palmar digital island flap can be used to reconstruct all defects of the finger, although it is used mainly
to reconstruct fingertip and palmar defects, particularly large palmar defects of the fingertip, thus justifying
the sacrifice of important palmar skin. This flap offers the advantages of both proximally and distally based
homodigital island flaps, including a constant and reliable blood supply without sacrificing a major artery,
excellent sensory recovery because of the digital nerve branches contained in this flap, coverage of the
palmar defect with skin that has similar qualities in a single operative field, less venous congestion because
of a proximally based and normograde flap, a one-stage procedure for both functional and aesthetic
preservation of the fingertip, and the avoidance of long hospitalization and hand immobilization.
This procedure is also versatile, as it can be raised on any transverse palmar branch of the proper digital
artery, and it is easy to plan because it can reach the wound by means of rotating the adjacent palmar
tissue. An important problem with the flap is palmar scar contracture resulting from the sacrifice of palmar
skin. Skin graft loss may aggravate the palmar scar, because a tie-over bolster dressing is not applied to
prevent direct compression of the pedicle. When a transverse palmar branch is located on the rim of tissue
adjacent to the wound, a flap based on the branch may not be raised because of the possibility of vascular
injury.

P.752
P.753
ANATOMY
According to Strauch and De Moura (15), there are three major transverse palmar branches (or arches) in each
digit: the proximal, middle, and distal transverse palmar branches. The locations of these branches are constant,
and the proximal and middle transverse branches are always associated with the limbs of the proximal and distal
cruciate ligaments. The distal transverse palmar branch lies just distal to the insertion of the profundus tendon
(Fig. 278.1A) and is approximately the same size as the middle branch, which is about 1.5 times larger than the
proximal transverse palmar branch. There are, on average, four palmar branches of the proper digital arteries
from each side at the level of the proximal and middle phalanges. Many small branches from the proper digital
arteries and transverse palmar branches are connected to the palmar arterial network.
Although there may be some exceptions, many hand surgeons have reported not being able to find the venae
comitantes running with the proper digital artery (1, 16, 17, 18). In fact, the perivascular cuff tissue of the proper
digital artery contains tiny venules, but not the venae comitantes (7). Therefore, the
palmar digital island flap is perfused from the proper digital artery through the transverse palmar branch, and is
drained through tiny venules and capillaries in the perivascular soft tissue (Fig. 278.1).

FIGURE 278.1 A: Surgical anatomy. B-D: Operative technique. a, distal transverse palmar branch; b, middle
transverse palmar branch; c, proximal transverse palmar branch; d, insertion site of the profundus tendon; e,
distal cruciate ligament; f, proximal cruciate ligament; g, pulp defect; h, flap design; i, elevated flap; j, transposed
flap; k, skin graft to the donor defect. (From Kim KS, Yoo SI, Kim DY, et al. Fingertip reconstruction using a
palmar flap based on the transverse palmar branch of the digital artery. Ann Plast Surg 2001;47:263, with
permission.)
FLAP DESIGN AND DIMENSIONS
Palmar digital island flaps can be designed at distal, middle, or proximal phalangeal areas of the long fingers
according to defect patterns. If possible, a flap should be designed on the lateral or medial palmar skin of the
finger, to maximally preserve the palmar skin. Although the flap can be orientated in any direction, the transverse
palmar branch is placed carefully in the distal region of the flap, and the flap is based on the proximal side of the
wound for fingertip reconstruction (Fig. 278.1B). Even though the flaps are based distally, actual blood flow
always adopts a normograde pattern (Fig. 278.1C). Therefore, the flap can include nearly the entire palmar
surface of the finger and may be 2.5 cm in width and 5 cm in length. However, the usual dimensions are less

than 2.0 cm in width and 3.5 cm in length.
OPERATIVE TECHNIQUE
After a tourniquet has been applied at the base of the finger, a skin incision is made from the side opposite the
vascular pedicle. The flap is elevated carefully, with the aid of a loupe or the operating microscope, to leave the
paratenon in situ to ensure skin-graft take. The transverse palmar branch is first identified, then ligated and
divided at the distal midportion of the flap. The neurovascular pedicle can be best found where the transverse
palmar branch derives from the proper digital artery of the side opposite the vascular pedicle.
The transverse palmar branch and the branch of the proper digital nerve in the pedicle area are then dissected
to enable entrance into the flap. As the dissection proceeds toward the proper digital artery and nerve, it is
essential to divide Grayson's ligament, but Cleland's ligament can be preserved. To avoid kinking and to reduce
tension on the vascular pedicle, fibrous septae should be freed, by scissors dissection, from underlying bone and
tendon sheath. To enable a free range of flap transposition, the pedicle can be dissected safely to the proximal
level to the point where the transverse palmar branch derives from the proper digital artery. During dissection, a
generous cuff of subcutaneous tissue is maintained around the vascular pedicle to preserve tiny perivascular
venules (Fig. 278.1C).
The raised flap is then transposed and sutured loosely to the defect, and the donor site is covered with a split-
thickness skin graft from the hypothenar or plantar area. A tie-over bolster dressing is not applied, to prevent
direct compression of the pedicle (Fig. 278.1D).
The hand is elevated to minimize postoperative venous congestion, but anticoagulants are not used. The finger
is splinted for 1 week to ensure graft success, after which both passive and active mobilization can be carefully
started. In addition, a light protective dressing is worn for approximately 2 weeks.
CLINICAL RESULTS
Although sometimes temporary venous congestion and desquamation in the skin may develop, flap necrosis
due to arterial or venous complication is rare. More than 70 palmar digital island flaps have been performed
at the Chonnam National University Medical School during the past 10 years, and all flaps have survived
well. This high success rate is attributed to an excellent blood supply and careful selection and preservation
of the vascular pedicle. Moreover, long-term follow- up shows good flap durability and elasticity, and
although sensory recovery depends on the severity of digital nerve damage, flap sensibility is usually near-
normal to normal, compared to intact contralateral fingers and the donor site.
Occasionally, temporary cold intolerance, hypersensitivity, or paresthesia develops, but long-term follow-up
demonstrates complete recovery in most patients. The donor site is usually covered with a split-thickness
skin graft from the hypothenar or plantar area, to achieve a better color match with adjacent skin areas. In
addition, it should be noted that donor-site care is important for early finger mobilization, and that skin grafts
may fail to take, partially as a result of subgraft hematoma, because compressive dressing is difficult at the
palmar side. However, scar contracture at most flap donor sites is minimal.
SUMMARY
Although palmar digital island flaps require the sacrifice of important palmar skin, they provide excellent
padding and sensation for fingertip reconstruction. Therefore, despite some difficulties, they appear to be
suitable for fingertip reconstruction and, in particular, are indicated for patients with large palmar defects of
the fingertip.

References
1. Kim KS, Yoo SI, Kim DY, et al. Fingertip reconstruction using a palmar flap based on the transverse
palmar branch of the digital artery. Ann Plast Surg 2001;47:263.
2. Kutler W. A new method for fingertip amputation. JAMA 1947;133:29.
3. Atasoy E, Ioakimidis E, Kasdan ML, et al. Reconstruction of the amputated fingertip with a triangular
palmar flap—a new surgical procedure. J Bone Joint Surg (Am) 1970;52A:921.
4. Tempest MN. Cross-finger flaps in the treatment of injuries to the finger tip. Plast Reconstr Surg
1952;9:205.
5. Miller AJ. Single fingertip injuries treated by thenar flap. Hand 1974;6:311.
6. McGregor IA, Jackson IT. The groin flap. Br J Plast Surg 1972;25:3.
7. Lai CS, Lin SD, Yang CC. The reverse digital artery flap for fingertip reconstruction. Ann Plast Surg
1989;22:495.
8. Kojima T, Tsuchida Y, Hirase Y, Endo T. Reverse vascular pedicle digital island flap. Br J Plast Surg
1990;43:290.
9. Niranjan NS, Armstrong JR. A homodigital reverse pedicle island flap in soft tissue reconstruction of the
finger and the thumb. J Hand Surg (Br) 1994;19B:135.
10. Del Bene M, Petrolati M, Raimondi P, et al. Reverse dorsal digital island flap. Plast Reconstr Surg
1994;93:552.
11. Kayikçiogÿ lu A, Akyürek M, Safak T, et al. Arterialized venous dorsal digital island flap for fingertip
reconstruction. Plast Reconstr Surg 1998;102: 2368.
12. Joshi BB. A local dorsolateral island flap for restoration of sensation after avulsion injury of fingertip pulp.
Plast Reconstr Surg 1974;54:175.
13. Venkataswami R, Subramanian N. Oblique triangular flap: a new method of repair for oblique
amputations of the fingertip and thumb. Plast Reconstr Surg 1980;66:296.
14. Tsai TM, Yuen YC. A neurovascular island flap for palmar-oblique fingertip amputations. J Hand Surg
(Br) 1996;21B:94.
15. Strauch B, De Moura W. Arterial system of the fingers. J Hand Surg (Am) 1990;15A:148.

16. Eaton RG. The digital neurovascular bundle; a microanatomic study of its contents. Clin Orthop Rel Res
1968;61:176.
17. Lucas GL. The pattern of venous drainage of the digits. J Hand Surg (Am) 1964;9A:448.
18. Cormack GC, Lamberty BGH. The arterial anatomy of skin flaps. London: Churchill Livingstone,
1986:186-193.

Chapter 279
Reverse Dorsal Digital and Metacarpal Flaps
P. PELISSIER
EDITORIAL COMMENT
It is critical in this flap design to preserve a wide subcutaneous pedicle, as the 180-degree pivot may cause
venous congestion, especially if the vessels are skeletonized.
Reverse dorsal digital and metacarpal (DMD) flaps use the dorsal skin of the digital or metacarpal areas, and
they are based on the arterial branches anastomosing the volar and dorsal arterial networks of the fingers.
These flaps are transposed as reverse island flaps. Dissection of the flap is easy and rapid, and preserves the
collateral nerve and artery to the fingertip.
INDICATIONS
The DMD flap is actually a proximal extension of previously described flaps (1, 2, 3). These flaps combine
the advantages of an extended skin paddle and a versatile pivot point on the phalanx, and they allow
coverage of wide and distal defects.
ANATOMY
The dorsal vascular network is known to vascularize the dorsal aspect of the hand and fingers (4, 5). This
network is made of terminal branches of the dorsal metacarpal arteries and dorsal branches of the collateral
digital arteries (Fig. 279.1). Anastomosing branches between the palmar and dorsal vascular systems are
present in all three phalanges (4). Four of them, located at the middle and distal third of the proximal phalanx, the
middle of the second phalanx, and at the level of the distal interphalangeal joint, are larger and represent a
constant communication between the volar and dorsal vascular systems. These branches are potential pivot
points for reverse dorsal flaps. Venous drainage depends on a parallel venous system surrounding the arterial
pedicle.
FIGURE 279.1 Arterial blood supply of fingers and flap design. White area indicates the subcutaneous pedicle to
be included in the dissection. 1, dorsal arterial network; 2, anastomosing branches; 3, collateral digital artery; 4,

P.755
skin paddle.
FLAP DESIGN AND DIMENSIONS
Flaps may be harvested from the dorsum of the proximal phalanges or the dorsum of the commissure; they are
supplied by the anastomosing branches. Blood flow is then orthograde in the collateral digital artery and
retrograde in the dorsal vascular network. In addition, the vascular territory of the flap
possibly extends up to the metacarpal area (6), thus increasing both the size of the flap and its arc of rotation.
The flap is designed on the dorsal aspect of the metacarpal area or the dorsal aspect of the finger. The
estimated emerging point and direction of the communicating branch is also marked; it theoretically represents
the pivot point of the flap (Fig. 279.1). Design includes marking the subcutaneous pedicle that will be raised with
the flap. Ideally, it should be almost as wide as the skin paddle to make vascularization safer.
FIGURE 279.2 Loss of dorsal tissue from the index finger, with proximal interphalangeal joint and extensor
tendon avulsion and bone exposure. Reverse metacarpal flap harvested with a large subcutaneous pedicle. This
patient also had an associated extensor fixation and joint immobilization with an external fixator.
OPERATIVE TECHNIQUE
The technique is safe and easy (7). Dissection begins with a “lazy S” incision above the pedicle area. The skin is
undermined, exposing the subcutaneous pedicle. The skin paddle is then incised deep to the paratenon, in
continuity with the lateral edges of the subcutaneous pedicle as far as the pivot point (Fig. 279.2). It is useless
and potentially dangerous to try to visualize the pedicle when dissecting the flap. To protect the pedicle, soft
tissue is taken in a block from the subcutis to the paratenon. The flap is then harvested from proximal to distal,
and dissection stops just before the pivot point. The tourniquet is released with the flap in its original position, to
ensure adequate refill of the vascular pedicle. The flap is then rotated and sutured with a few stitches.
CLINICAL RESULTS
Average time for flap dissection is usually less than 20 minutes. Over a series of 48 cases, two partial flap
necroses were reported that did not impair the final result. The outcome was satisfactory in all patients.
Donor-site morbidity was minimal. The wound was either primarily closed or skin-grafted. No patient
complained about the resulting scars. The pedicle is reliable enough to be twisted over 180 degrees, and
although venous drainage could be considered tenuous, no venous congestion was observed. These flaps,
however, do not seem suitable for restoring sensibility, even when a branch of a dorsal sensitive nerve is
included and anastomosed with a collateral digital nerve.

SUMMARY
Reverse dorsal digital and metacarpal flaps are recommended for coverage of dorsal defects, as they use
skin from the dorsum of the hand or fingers and do not require the sacrifice of a collateral digital artery. The
reported procedure combines an extended skin paddle and a versatile pivot point on the phalanx and allows
coverage of wide and distal defects. Dissection is rapid and not complex, as there is no need to look for the
vascular pedicle. Moreover, the surgical technique is easy to handle, because residents performed half of
the procedures.
References
1. Del Bene MD, Petrolati M, Raimondi P, et al. Reverse dorsal digital island flap. Plast Reconstr Surg
1994;93:552.
2. Valenti P, Masquelet AC, Begue T. Anatomic basis of a dorso commissural flap from the 2nd, 3rd and 4th
intermetacarpal spaces. Surg Radiol Anat 1990;12:235.
3. Masquelet AC, Valenti P. Les lambeaux dorso-commisuraux. Ann Chir Plast Esthét 1994;39:287.
4. Strauch B, De Moura W. Arterial system of the fingers. J Hand Surg (Am) 1990;15:148.
5. Coleman SS, Anson BJ. Arterial patterns in the hand based upon a study of 650 specimens. Surg Gynecol
Obstet 1961;113:409.
6. Bakhach J, Martin D, Baudet J. Le lambeau paramétacarpien ulnaire: Un experience de dix cas cliniques.
Ann Chir Plast Esthét 1996;41:269.
7. Pelissier P, Casoli V, Bakhach J, et al. Reverse dorsal digital and metacarpal flaps: a review of 27 cases.
Plast Reconstr Surg 1999;103:159.

Chapter 280
Microvascular Free Transfer of The Nail
G. D. LISTER
EDITORIAL COMMENT
This is an excellent technique for that patient who absolutely must have a reconstruction of the nail. The
circulation of the nailbed, as described in this chapter, is mainly from the dorsal branch coming from the
middle phalanx to the proximal matrix arch. By continuing this vessel to the digital vessel, the nailbed and
dorsal bone can be transferred.
Toe-to-hand transfer has become a reliable method of thumb reconstruction and its anatomic bases have been
well established. The entire toe is not always required, and successful microvascular transfer of neurovascular
islands and of composites of pulp and nail—the wraparound flap—has been successfully developed (1). It might
appear that the hemipulp must be included to ensure integrity of the arterial supply to the transfer. However, by
application of the anatomy detailed below, transfer of the nail with a rim of perionychium can be achieved in
those rare cases in which the nail alone has been lost in a patient to whom it has unusual significance.
INDICATIONS
The important properties of the nail are well recognized—protection, prehension, and cosmesis. Loss of the
nail alone inflicts a significant disability, and attempts to restore the entire structure by free composite
transfer have not been uniformly successful (2, 3). Considerable though the disability may be, rarely does it
warrant a lengthy and complex reconstructive procedure. Where the demands of special skills do justify it,
microvascular free transfer of the nail offers the possibility of complete survival and a perfect functional
result.
ANATOMY
The blood supply of the nailbed has been described in detail (4). There are three arterial arcades (Fig. 280.1): a
superficial one at the base of the distal phalanx dorsally, just distal to the extensor tendon insertion, which
receives contributions from both the middle and distal phalangeal segments of the proper digital artery; a
proximal subungual arcade, which runs across the dorsal surface of the phalanx at the level of its narrow waist;
and a distal subungual arcade, which lies at the base of the ungual process. Both of these latter arcades derive
from the digital arteries at their cruciate anastomosis on the palmar aspect of the terminal phalanx via branches
that pass through the rima ungualum, which is the space between the waist of the phalanx and the lateral
interosseous ligament (Fig. 280.2).
The lateral interosseous ligament, which attaches to the ungual spines distally and the lateral tubercles of the
distal phalanx proximally, serves as the strong lateral attachment of the nailbed (5). The means by which the
nailbed is adherent to the phalanx are not clarified in available texts. Certainly common experience shows that
once disrupted, that attachment is rarely reestablished satisfactorily.
OPERATIVE TECHNIQUE

P.757
The procedure is performed as a combined simultaneous dissection, the radial artery being exposed with the
cephalic vein just distal to the snuffbox, while the dorsalis pedis artery and the first dorsal metatarsal artery are
dissected on the foot. In nail transfers to a finger other than the thumb and in the 20% or more of cases where
the dorsal arteries of the foot are unsatisfactory, the microarterial anastomosis can be between digital arteries. In
the thumb, however, access is much superior when the anastomosis is made more proximally. Once satisfactory
vessels have been isolated, preparation of the transfer and of its bed can proceed. This occurs in three stages.
Skin Incisions
Since the nail of the toe is somewhat larger than that of the thumb, the defect created in excision of the thumbnail
remnant must be enlarged somewhat, without discarding uninjured and sensate pulp tissue. This is achieved as
follows. The incisions that skirt the distal and lateral aspects of the nail on the toe are made gently convex
toward the nail and their length C is
measured. Similar but straight skirting incisions are made on the thumb and their length A is measured (Fig.
280.3A).
FIGURE 280.1 There are three dorsal arterial arcades that supply the nailbed (see text). (From Flint, ref. 4, with
permission.)
Back-cuts of length B are then made from the corners at which the thumb incisions meet, in such a way as to
make A + 2B = C. The incision proximally from the nail fold of the thumb is of a zigzag nature, exposing distal
branches of the radial nerve. No skin is discarded from the thumb, other than that immediately adjacent to the
nail. The proximal skin incisions in the toe are designed to excise a V, the apex of which lies over the web space
some 3 to 4 cm proximal to the nail (Fig. 280.3C). This permits dissection of veins and branches of the superficial
and deep peroneal nerves. The flap so created must be elevated in the plane between these nerves and veins
and the underlying extensor tendon, out to a point just distal to its insertion. This point must also be exposed in
the thumb.

FIGURE 280.2 The digital arteries form a cruciate anastomosis from which pass the branches to the proximal
and distal subungual arcades through the rima ungualum, which lies between the waist of the phalanx and the
lateral interosseous ligament. It should be noted that the interosseous ligament passes from the lateral tubercles
to which the distal end of the collateral ligament of the distal interphalangeal joint attaches, to the ungual spines
distally. (From Flint, ref. 4, with permission.)
Arterial Mobilization
The appropriate digital artery is mobilized from the skeleton of the toe by coagulating all of its branches to the
midline of the toe, leaving the digital nerve intact on the toe. Once the distal phalanx is reached, it is necessary
to free the artery sufficiently to permit safe access to the bone for osteotomy. This is achieved by dissecting the
palmar surface of the phalanx until the two attachments of the lateral interosseous ligament can be seen and
divided (Fig. 280.2). This permits the lateral margin of the nail to be lifted sufficiently to allow bone cuts.
Osteotomy (see Fig. 280.3B)
Identical osteotomies are performed in the distal phalanges of toe and thumb. First, an anteroposterior
transverse cut is made one-half way through the phalanx just distal to the insertion of the extensor tendon. Care
should be taken that this is of equal depth across its full breadth and that the dorsal vessels are not disturbed in
the process. Then a coronal cut is made in such a way as to join the first osteotomy and thereby remove the
dorsal half of the phalanx distal to the extensor tendon.
The transfer is then performed (Fig. 280.3C), rigid fixation of the bone being achieved with Kirschner wires (Fig.
280.3D and E), and the artery, vein, and dorsal nerves are joined.
CLINICAL RESULTS
The outcome is pleasing in both appearance and function (Fig. 280.3F and G). The nail is of normal
stability, this being assured by the early union of the large area of cancellous bone that is placed in contact
by the technique of osteosynthesis described above.
SUMMARY
Loss of the nail can have unusual significance to some patients. By application of the anatomy described
above, microvascular free transfer of the nail from the foot to the hand can be achieved.

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P.759
FIGURE 280.3 A: A patient is shown in whom the nail has been destroyed by chemical treatment of a
subungual wart. The incisions around the destroyed nailbed are planned to accommodate the larger mass
of tissue to be taken from the toe, without discarding any of the normal pulp of the thumb. The straight
incisions skirting the nail are labeled A, and the back-cuts shown at the corners of the quadrilateral excision
are labeled B. The length of the back-cut is determined by the fact that A + 2B should equal the skirting
incision made in a curvilinear manner around the toenail, which is labeled C. B: The osteotomy in the distal
phalanx is undertaken in such a way as to remove the nail with a significant sliver of bone while maintaining
the insertion of the extensor and flexor tendons. This osteotomy is identical in both the thumb and the toe.
Reconstruction of the toe is performed by fracturing the plantar sliver and folding it over to close the defect
directly. The toe is shortened by half the length of the nailbed. C: The dissection is shown here completed
on the thumb and the toe. The V portion of skin that has been taken from the toe to preserve the dorsal
nerves and veins is demonstrated. D: The fragment excised from the toe fits well into the defect.
Longitudinal and anteroposterior fixation with Kirschner wires, avoiding the nailbed itself, gives secure and
extensive cancellous bone contact. (Continued)

FIGURE 280.3 (Continued) E: Anastomosis of the dorsalis pedis artery and dorsal vein of the foot to the
radial artery and cephalic vein in the thumb has been completed and the wound closed. Good perfusion is
seen, and the point marked X is that at which subsequent temperature monitoring is performed. F: The
appearance of the hand is relatively normal. G: The healed result, showing normal nail growth and
preservation of the normal contact surface of the thumb. The patient was able to return to his profession as
a classical guitarist, using the nail as a plectrum.
References
1. Morrison WA, O'Brien BM, MacLeod AM. Thumb reconstruction with a free neurovascular wraparound flap
from the big toe. J Hand Surg 1980;5:575.
2. McCash CR. Free nail grafting. Br J Plast Surg 1955;8:19.
3. Buncke HJ, Gonzalez RI. Fingernail reconstruction. Plast Reconstr Surg 1962;30:452.
4. Flint MH. Some observations on the vascular supply of the nail bed and terminal segments of the finger. Br
J Plast Surg 1955;8:186.
5. Shrewsbury M, Johnson RK. The fascia of the distal phalanx. J Bone Joint Surg 1975;57(A):784.

Chapter 281
Radial Innervated Cross-Finger Skin Flap to The Thumb
J. S. GAUL
J. E. ADAMSON
The purpose of this procedure is to reconstruct the volar surface of the injured thumb with a cross-finger skin flap
containing a sensory nerve supply from the dorsum of the proximal phalanx of the index finger (1, 2, 3, 4, 5).
INDICATIONS
This flap is especially suitable for medium (2 cm) or large (3 cm or greater) volar thumb defects, both
terminal and intercalary, which preferably retain some deep soft-tissue base. The radial innervated dorsal
skin is itself not thick enough to replace all of the pulp. The flap can also be used as a secondary procedure
for cases of volar sensory denervation of the thumb from local damage.
The radial innervated cross-finger skin flap should not be used for small thumb defects of 1 cm or less,
which can usually be repaired by local or pulp advancement flaps. On the other hand, this is a thin flap and
is not indicated for massive thumb avulsion, where there is no soft-tissue covering the skeletal stump.
A diagnostic median nerve block should be done to determine that the dorsal innervation of the superficial
radial nerve extends sufficiently distal to the MP joint, to supply the intended flap adequately. In cases
where there is an associated severe median nerve sensory defect, in which the superficial radial innervation
to the lateral sides of the thumb and to the proximal phalanx of the index finger supports a primitive pinch
function, the index should not be used as a donor site.
A relative contraindication may be the presence of a single digit with extensive palmar destruction. Such a
useless digit may contribute a valuable neurovascular island flap to the thumb prior to its amputation.
FIGURE 281.1 The basic incision should be Y-shaped, extending from the radial aspect of the wrist where
the superficial nerve is identified to both the donor site on the index finger and the ulnar aspect of the defect
on the thumb pulp.
FLAP DESIGN AND DIMENSIONS
A conventional cross-finger flap is designed from the proximal phalanx of the index finger to accommodate the
adducted thumb without undue stress. These flaps usually range from 1 to 2 cm in length (which represents the
transverse dimension of the donor digit). Flaps can be designed between 1.5 and 4.0 cm in width (which
represents the longitudinal dimension of the donor digit).
The flap typically hinges at its base somewhere along the midlateral line of the donor index finger (Fig. 281.1),
and normally it must rotate outward 90° to 150°. Despite this somewhat acute turn, no flaps have been lost.

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OPERATIVE TECHNIQUE
First Stage
An incision is made over the radial aspect of the dorsum of the wrist in a Y-shaped configuration. One limb
extends distally to the index finger flap and the other limb extends to the ulnar aspect of the thumb defect. That
part of the incision over the wrist should be zigzagged as necessary to avoid a straight-line scar.
The superficial radial nerve is identified as it branches to the thumb and to the index finger. The one or two
branches to the dorsum of the index finger are carefully traced out to the transverse margin of the flap. A
generous layer of subcutaneous tissue around the nerves is preserved, along with a few small vessels if
possible.
The distal and ulnar margins of the skin flap (Fig. 281.1) are incised through skin and subcutaneous tissue. The
incision
is then made cautiously over the proximal transverse margin of the flap, to avoid damaging the terminal nerve
fibers entering that margin of the flap at the subcutaneous level.
FIGURE 281.2 The flap and its nerve bundle have been mobilized from the index finger and hand. The ulnar
volar skin envelope of the thumb has been undermined, and the flap is fitted into the thumb defect as the nerve
bundle is simultaneously tucked under the volar ulnar skin margin.
FIGURE 281.3 A radial innervated skin flap now furnishes useful tactile sensation to the thumb pad of a
carpenter, whose thumb had been previously denervated by local tissue damage. This patient immediately
regained light touch sensation and has used his hand for at least 10 years. The flap “felt like the thumb and the
index finger” for several years, but more recently has been interpreted as “thumb,” according to the patient.

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The recipient thumb is then brought to the donor index finger. The nerve bundle should pass under the edge of
the thumb web and into the thumb volar skin pocket, which has been generously undermined, passing almost
directly over the flexor pollicis longus sheath (Fig. 281.2).
After the flap is inset, a skin graft is placed over the donor site.
Second Stage
Approximately 3 weeks later the flap is divided. It is apparent at this stage why it is so important to locate the
nerve bundle deep under the volar skin flap of the thumb: the nerve then lies deep to the proximal transverse flap
suture margin, and should not be at risk when the flap is severed from the index finger.
CLINICAL RESULTS
Twenty-seven cases have been performed with follow-up data by the two authors and their associates
working in independent practices in two different communities. No flaps have been lost. Some sensation is
almost always restored, usually obvious to the patient the following day (Fig. 281.3).
Two-point discrimination testing has produced variable, but often good, results. The testing depends very
much on the technique of the individual examiner. Many cases have produced good two-point
discrimination, frequently in the 6-, 8-, and 10-mm range, while other cases have shown only consistent light
touch. All patients have demonstrated the ability to handle objects effectively with the reconstructed thumb,
although one patient complained of persistent numbness even though he had functional use of his thumb.
None of these patients had symptoms of neuroma formation, causalgia, or sympathetic dystrophy. The
donor site healed well, although most retained an area of anesthesia in the region of the skin graft.
SUMMARY
The radial innervated cross-finger flap can be used to provide both cover and sensation to volar thumb
defects.
References
1. Adamson JE, Horton CE, Crawford HH. Sensory rehabilitation of the injured thumb. Plast Reconstr Surg
1967;40:53.
2. Gaul JS. Radial innervated cross-finger flap from index to provide sensory pulp to injured thumb. J Bone
Joint Surg 1969;51(A): 1257.
3. Brailler F, Horner RH. Sensory cross-finger pedicle graft. J Bone Joint Surg 1969;51(A):1264.
4. Wilkinson TS. Reconstruction of the thumb by radial nerve innervated cross-finger flap. South Med J
1972;65:992.
5. Miura T. Thumb reconstruction using radial innervated cross-finger pedicle. J Bone Joint Surg
1973;55(A):563.

(Trang không có chữ)

Chapter 282
Neurovascular Skin Kite Flap From The Index Finger
G. FOUCHER
F. VAN GENECHTEN
The skin overlying the dorsal aspect of the proximal phalanx of the index finger can be transferred as a
neurovascular island flap (1). Anatomically this flap is an axial pattern skin flap that extends proximally from the
level of the metaphalangeal (MP) joint and distally to the level of the proximal interphalangeal (PIP) joint. The
neurovascular pedicle contains the first dorsal metacarpal artery, one or two dorsal veins, and the terminal
branches of the radial nerve.
INDICATIONS
Advantages of the flap can be summarized as follows. There is a constant and reliable anatomy with ease
of dissection. A one-stage procedure provides neurovascular skin cover and it is possible to cover the entire
dorsal or palmar aspect of the thumb. The flap can be combined with a radial forearm flap or a
neurovascular island flap to cover a complete degloving injury of the thumb. The flap provides sensation.
Venous return is so good that it is possible to use the veins to graft a vein defect in cases of replantation
with associated skin cover problems (two cases in our series).
ANATOMY
The dorsal metacarpal artery arises from the radial artery at the apex of the first interosseous space, before the
radial artery disappears toward the palmar aspect of the hand. The artery runs over the first dorsal interosseous
muscle toward the metacarpophalangeal joint of the index finger, giving off at various points the internal dorsal
artery of the thumb and a few perforating branches that join the deep palmar arch. The dorsal metacarpal artery
was found to be constant in all of 30 specimens dissected (2). Injection studies with methylene blue demonstrate
that this artery supplies a skin territory that includes the entire dorsum of the proximal phalanx of the index finger
(1).
The sensory branch of the radial nerve and one or two veins are easily found through the same dorsal incision. It
is useful to know that in certain cases the sensation to the distal third of the skin flap is provided by the dorsal
branch from the neurovascular bundle on the volar aspect of the index finger, the latter coming from the median
nerve. This is an important point, particularly when a sensory flap is required. A preoperative local nerve block is
mandatory and a selective block of radial or median nerve helps to establish a possible median nerve innervation
of the distal third of the skin kite flap.
The two-point discrimination of this area averages 12 to 15 mm (3).
OPERATIVE TECHNIQUE
A reverse S-shaped incision is made over the radial border of the second metacarpal. We dissect the distal part
of the radial artery only to identify the origin of the first dorsal metacarpal artery and to avoid confusion with a
princeps pollicis artery or a deep muscular branch (Fig. 282.1). The fascia overlying the interosseous muscle is
then cut at its radial side and lifted from the muscle en bloc with the artery. This maneuver will prevent damage
to the vascular system. In certain cases a protective cuff of muscle fibers is dissected with the artery.

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FIGURE 282.1 The “kite” island flap from the dorsum of the proximal phalanx of the index finger transferred to
the thumb. Note the neurovascular pedicle composed of the first dorsal metacarpal artery (together with the
perivascular fat and the adjacent part of the aponeurosis), one or two superficial veins, and the radial nerve
branches to this area of skin. (From Littler, ref. 5, with permission.)
The dissection then proceeds more superficially toward the ulnar side to free one or two veins and the sensory
radial nerve branches, leaving some subcutaneous tissue around these neurovascular elements. The axial skin
artery anastomoses with a deep interosseous artery at the radial neck of the second metacarpal bone. The
dissection at this key point is usually facilitated by first raising the skin flap just before the neurovascular bundle
is completely liberated. The sensory axial pattern flap is then ready for transfer. For the transfer of the flap to the
thumb, one can tunnel the pedicle underneath the skin of the first web space.
CLINICAL RESULTS
We used this flap in 27 cases between 1976 and 1982, with only partial loss of skin in one case where a
small scar crossed the distal part of the skin flap. Our series included 23 cases of injuries to the thumb.
Eight cases required skin cover for complex loss of tissue over the dorsal aspect and nine cases required
cover of proximal palmar or proximal lateral skin defects. Only in six cases was the flap used to cover the
entire palmar aspect of the thumb, with a two-point discrimination averaging 11 mm (a minimum of 9 and a
maximum of 14 mm) after 3 months of sensory reeducation (4). Although this twopoint discrimination is less
than in Littler's experience with the neurovascular island flap (5), a larger area of skin can be transferred
with the skin kite flap.
There are only a few disadvantages with this flap. The donor site obviously requires a graft. A full-thickness
graft provides a better cosmetic result with minimal hyperpigmentation. The dorsum of the index finger has
hair-bearing skin matching the normal dorsal skin of the thumb, but not the palmar skin. A similar problem
exists in the conventional cross-finger flap. Finally, the index finger requires splinting to avoid any loss of
extension or flexion.

SUMMARY
The skin kite flap is a reliable and versatile island flap and provides a large and well-vascularized skin area
with some sensory discrimination. The length of the neurovascular pedicle provides a wide arc of rotation
and allows the flap to reach even the tip of the thumb.
References
1. Foucher G, Braun JB. A new island flap transfer from the dorsum of the index to the thumb. Plast Reconstr
Surg 1979;63:344.
2. Braun JB. Les Arteres de la Main. Thesis, University of Nancy, 1977.
3. Gellis M, Pool R. Two point discrimination distances in the normal hand and forearm: application to various
methods of fingertip reconstruction. Plast Reconstr Surg 1977;59:57.
4. Dellon AL. Evaluation of sensibility and re-education of sensation in the hand. Baltimore: Williams &
Wilkins, 1981.
5. Littler JW. Neurovascular pedicle transfer of tissue in reconstructive surgery of the hand. J Bone Joint
Surg 1956;38(A):917.

Chapter 283
Innervated Dorsal Index Finger Skin Flaps to The Thumb
F. J. RYBKA
F. E. PRATT
In lengthening or reconstructing the thumb, local sensory flaps are favored over distant nonsensory flaps. Among
neurovascular island flaps, one adjacent to the thumb, as described below, is generally preferred over a more
remote hand flap, e.g., from the ulnar side of the ring finger (1, 2, 3). This is because the dorsal index flap is less
risky and time-consuming in dissection, and because it can offer a greater paddle of sensory skin (4, 5, 6, 7).
Although it can be argued that dorsal skin is not as refined in sensation as the more specialized volar skin, this
does not appear to be of great clinical importance.
INDICATIONS
Sensory skin from the second metacarpophalangeal dorsal surface has been examined as a possible
source for thumb reconstruction for some time (4), but the procedure was originally in two stages. Used as a
rotation flap, it is very useful for (1) reconstructing a denuded thumb or lengthening a foreshortened one, or
(2) expanding a contracted first web space (8), a situation that can frequently occur after an otherwise
successful replantation of an amputated thumb.
Since 1977 (5) it has been demonstrated that an island flap could reliably be derived from the covering over
the proximal phalanx of the index finger, divided from its metacarpal skin yet retaining the nutrient vessels
and sensory nerves. This can be used for resurfacing more distal cutaneous defects of the thumb in one
stage (6, 7).
ANATOMY
The external dorsal branch of the first dorsal metacarpal artery supplies the dorsum of the index proximal
phalanx, and this branch is constant (1, 6). Two veins usually drain the flap, and the dorsal branch of the radial
nerve runs close to these veins on either side of the dorsum (3). The neurovascular elements are not fixed to
dermis, but are carried in their own perivascular areolar plane and can be separated from proximal skin without
compromise.
FLAP DESIGN AND DIMENSIONS
Prior to the procedure, the dorsal branch of the radial nerve may be blocked, to ascertain its pattern of sensory
distribution. If used as a rotation flap, as for expansion of the first web space, an S-shaped incision is planned
between the defect and the second metacarpophalangeal joint, lateral to the dorsal veins that are usually
included in the flap. The flap may be extended without any delay, to include skin over the proximal phalanx of the
index finger, depending on the need for length. When this is done, the longitudinal incisions are volar to each of
the dorsal veins that are again included in the flap.
OPERATIVE TECHNIQUE
If used as a neurovascular island flap, dissection is begun from distal to proximal. Under a high-intensity light,
the neurovascular elements are identified and are carefully dissected in their perivascular areolar tissue, away
from the overlying dermis back toward the midmetacarpal level. The flap can then be rotated subcutaneously

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over and onto the thumb. Depending on the case, dog-ears in the flap may be accepted at this point, rather than
risking flap refinement. A full-thickness skin graft is used to cover the index donor area (Fig. 283.1).
CLINICAL RESULTS
Our series of 14 cases is cited as evidence for the dependability of the dorsal flap in thumb reconstruction.
Use of the flap as an island resulted in success in six out of seven cases. In the last case, partial necrosis of
the flap occurred in a hand crushed by a machine press. Not only was the thumb devascularized, but the
dorsum of the hand was edematous from the impact. The failure was thought to be the result of this soft-
tissue trauma in the donor area.
In all cases the reconstructed thumbs were used actively and painlessly and sensation was retained,
although “relearning” was not accomplished. No neuromas developed and there was no loss of function to
the donor finger.
SUMMARY
The thumb can be reconstructed with a sensory dorsal index finger skin flap. If elevated with its
neurovascular elements intact, it can be extended over the proximal phalanx without delay.
FIGURE 283.1 Use of the dorsal index flap as a neurovascular island. A: Diagram of the flap. An umbilical
tape is passed beneath the neurovascular bundles to the skin paddle as they are separated from the
overlying dermis. B: A 45-year-old man, victim of a water ski rope avulsion of his thumb. C: Immediate
reconstruction, with transfer of the island flap. D: Late results at 3 months. (From Rybka and Pratt, ref. 7,

with permission.)
References
1. Tubiana R, Duparc J. Restoration of sensibility in the hand by neurovascular skin island transfer. J Bone
Joint Surg 1961;43(B):474.
2. Chase R. An alternative to pollicization in subtotal thumb reconstruction. Plast Reconstr Surg 1969;44:421.
3. McGregor I. Less than satisfactory experience with neurovascular island flaps. Hand 1969;1:1.
4. Adamson JE, Horton C, Crawford H. Sensory rehabilitation of the injured thumb. Plast Reconstr Surg
1967;40:53.
5. Rybka FJ, Pratt FE. Thumb reconstruction using a sensory flap from the dorsal index finger. Presented at
the Annual Meeting of the American Association of Hand Surgery, San Francisco, Calif., Oct. 29, 1977.
6. Foucher G, Braun J. A new island flap transfer from the dorsum of the index to the thumb. Plast Reconstr
Surg 1979;63:344.
7. Rybka FJ, Pratt FE. Thumb reconstruction with a sensory flap from the dorsum of the index finger. Plast
Reconstr Surg 1979;64:141.
8. Flatt A, Wood V. Multiple dorsal rotation flaps from the hand for thumb web contractures. Plast Reconstr
Surg 1970;45:258.

Chapter 284
Infraclavicular Skin Flap to The Hand and Fingers
V. R. HENTZ
EDITORIAL COMMENT
This location is a good source of skin for the thumb and fingers. Not only is the quality of the skin good, but
it allows the patient to rest the hand comfortably in an elevated position. The only drawback in comparison
with the inguinal donor site is the scarring that results in a more exposed area.
An ideal flap for hand and digital coverage would incorporate the following characteristics: First, the skin and
subcutaneous tissue should be thin and pliable, with a minimum of subcutaneous fat (1, 2). The tissues of the
hand, especially on the volar aspect, are well fixed to the underlying skeleton, permitting more stable grasp. The
placement of a thick or bulky flap to reconstruct the prime contact surfaces would seriously diminish the stability
of grasp. Second, the skin should be hairless. Except for the dorsum, the hand is relatively hairless.
Fullthickness losses, particularly on the glabrous surfaces of the hand, should be replaced by hairless tissue.
INDICATIONS
From very few parts of the body do the skin and subcutaneous tissue meet these special requirements for
soft-tissue coverage of the hand and digit. Several alternatives for coverage include the volar aspect of the
forearm, the internal surface of the upper arm, the dorsum of the foot, and the infraclavicular area. Of these
the infraclavicular area has probably been used the longest, for replacement of full-thickness loss of the
hand and digits that is not reconstructable by split-thickness or full-thickness skin grafts or local rotation
flaps.
The infraclavicular area usually remains free of thick subcutaneous fat, even in somewhat obese people,
and it is usually hairless or relatively hairless, even in the most hirsute individuals.
Fashioned with its pedicle based along the clavicle and with adaptability in positioning the arm and hand,
the flap can be used to cover almost any area of the hand and digits. The arm lies comfortably across the
chest and the hand is in an elevated position, promoting venous drainage and reducing edema formation.
The donor site is reasonably well hidden by shirt or dress, and a surprising amount of skin can be removed,
with the donor site still closed primarily.
ANATOMY
The skin and subcutaneous tissue of the infraclavicular area are supplied by several independent vascular
systems (Fig. 284.1). Medially the principal vascular supply is through the intercostal perforating branches from
the internal mammary artery. These branches are direct cutaneous arteries arising from each intercostal space,
beginning with the second rib, and they are well described in the chapter on the deltopectoral flap (Chapter 127).
Superiorly the skin receives some circulation via branches of the thyrocervical trunk, principally the transverse
cervical and transverse scapular arteries. Lateral to this area the infraclavicular skin is supplied by branches of
the thoracoacromial trunk, another direct cutaneous artery. Blood supply is also derived from muscular
perforators via the pectoralis major muscle and its principal vascular contributions of the medial and lateral

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pectoral arteries.
FLAP DESIGN AND DIMENSIONS
When used to provide cover for the hand or digit, the flap is usually based superiorly and somewhat laterally.
The area will accommodate a flap of 7 to 8 cm in width and 14 to 15 cm in length, when the distal portion of the
flap is directed toward the subaxillary region. Frequently this length allows the pedicle portion of the flap to be
tubed. A technical error that frequently accompanies its use for thumb reconstruction is designing the flap with
insufficient width to cover the complete circumference of the reconstructed thumb, particularly once a bone graft
has been placed inside the skin envelope. The flap needs to be at least 8 cm in width.
Because the skin is thin, pliable, and hairless, it has also been used to resurface digits after degloving injuries,
and is particularly well suited for replacing skin deficits in the first web
space following release of adduction contractures. Typically the tissues of the first web space comprise a
tetrahedron, and replacement involves covering two adjacent sides of the tetrahedron. The flap is designed,
therefore, with a triangular paddle that is inset initially into the dorsal defect, and the pedicle is tubed. At the time
of flap takedown, the pedicle is unfolded and trimmed to fit the volar triangle.
FIGURE 284.1 Sources of cutaneous circulation to the infraclavicular and anterior chest wall are illustrated.
There are three distinct arterial pedicles supplying this area: perforators from the internal mammary artery
medially, branches from the transverse cervical and scapular arteries of the thyrocervical axis superiorly, and
contributions from the thoracoacromial trunk laterally. (From Conley, ref. 1, with permission.)
OPERATIVE TECHNIQUE
Because this is a random flap, there are no particular technical difficulties encountered in elevating the flap. The
underlying muscular fascia is probably best included with the flap.
The flap has been particularly useful in reconstruction of the thumb by osteoplastic pollicization (Fig. 284.2).

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FIGURE 284.2 An application of the infraclavicular flap for thumb reconstruction is demonstrated. A: The thumb
has been amputated just distal to the metacarpophalangeal joint. The proposed flap, based proximally, is
outlined along the lateral border of the pectoralis major muscle. The pedicle is tubed and the donor site is closed
by advancing the margins of the defect. B: A dorsal V-shaped extension of the flap avoids a circular scar and
broadens the area of inset. This improves the rate of neovascularization of the flap from the recipient site, and
increases the length of flap supportable by recipient site circulation once the pedicle is divided. C: The
reconstruction is completed by placement of a bone graft within the tubed pedicle and by replacement of the
insensible skin of the volar surface of the flap by a neurovascular island pedicle taken from the ulnar border of
the middle finger. (From Chase, ref. 2, with permission.)
Other technical considerations include methods to immobilize the arm and hand to the donor site. Except in small
children I have not had to resort to plaster immobilization. I have found immobilization with strips of adhesive tape
satisfactory, with additional padding in the axilla to maintain the arm in abduction.
If the area of inset of the flap is small as in osteoplastic pollicization, the flap should be detached from the chest
in increments of a third, performed commonly under local anesthesia, 3 to 5 days apart. Typically the pedicle of
the flap may be safely divided sometime in the second or third week. The fact that the pedicle can be tubed
allows a non-crushing clamp to be placed across the pedicle base, and the fluorescein technique is used to
confirm flap viability based on the new blood supply from the recipient site.
CLINICAL RESULTS
Because scars on the anterior chest wall tend to stretch and hypertrophy, the donor site may be
unacceptable to some patients, especially to women who wish to wear “off the shoulder” clothing. This is a
hardy flap, however, and complications secondary to inadequate circulation are uncommon.
SUMMARY
For many years the infraclavicular flap has been a reliable source of tissue for hand and digit
reconstruction.
References
1. Conley J. Regional flaps of the head and neck. Philadelphia: Saunders, 1976;189.
2. Chase RA. Atlas of hand surgery. Philadelphia: Saunders, 1973.

(Trang không có chữ)

Chapter 285
Cross-Forearm Neurocutaneous Flap
B. H. DOLICH
These innervated flaps allow for the resurfacing of rather large areas with a composite of handlike skin, along
with its underlying subcutaneous tissue and nerve (1). This composite flap provides durable sensory coverage in
which there has been a minimum of disruption of sensory cutaneous relationships (2).
INDICATIONS
The cross-forearm neurocutaneous flap can be a useful means of restoring epicritic sensation to a hand
that has been completely or partially deprived of its unique soft-tissue covering.
ANATOMY
The flap is based on the superficial branch of the radial nerve (Fig. 285.1) because of its constant anatomy and
easy accessibility in the forearm. In addition, the nerve has a long conducting length before branching, and an
overall diameter similar to that of the proposed recipient nerve stumps (3). Finally, it innervates an area of
handlike skin with a minimum of bulky subcutaneous tissue that has a much finer two-point discrimination than
that found in other potential donor sites (4).
The superficial sensory branch of the radial nerve moves into a subcutaneous position some 8 cm proximal to
the radial styloid. Here it exists between the tendons of the brachioradialis and the extensor carpi radialis longus,
so that it is superficial to the abductor pollicis longus. At this point it courses obliquely across the underlying
brachioradialis and extensor pollicis longus in close proximity to the cephalic vein, which serves as a good
landmark for its location (5).
FIGURE 285.1 The superficial branch of the radial nerve entering into a subcutaneous position between the
tendons of the brachioradialis and the extensor carpi radialis longus. Relationship of the superimposed
neurocutaneous flap to the nerve is shown. (From Dolich et al., ref. 1, with permission.)
Continuing distally, it arborizes into two or three branches that innervate the radiodorsal aspect of the hand, as
well as the first web space, proximal thumb, and index finger. Its blood supply is of a random pattern, while its
innervation is axial in nature.
FLAP DESIGN AND DIMENSIONS
After plotting the course of the nerve on the donor forearm, a flap of the necessary proportions is superimposed
over the area (Fig. 285.1). In an adult it may be 5 cm wide and 7 cm long. The axis of the flap may be parallel to

the nerve or somewhat oblique, as dictated by the most comfortable carrying position.
OPERATIVE TECHNIQUE
First Stage
The proximally based flap is incised on three sides and the dissection is carried down to fascia with a minimum of
undermining. The nerve fibers located at the distal end are identified and transected. The nerves are tied off with
6-0 nylon ligatures, in an attempt to prevent neuroma formation. The flap is then raised at a level deep to the
nerves, so that there is minimal interruption of its sensory cutaneous relationships.
The recipient site on the opposite hand is brought into the field and inset under the flap with a single layer of
nylon sutures (Fig. 285.2). The hand may be fixed to the donor forearm with a Kirschner wire and/or soft
bandage. The donor site defect is covered with petrolatum gauze.
FIGURE 285.2 The proximally based flap is cut on two or three sides and the raw surface of the opposite hand is
inset under it. (From Dolich et al., ref. 1, with permission.)
Second Stage
As an option, the skin overlying the base of the flap may be cut and sutured at 10 days. This delay can be done
as an office procedure under local anesthesia.
Third Stage
At 18 to 21 days, the proximal unbranched portion of the nerve is located. As a separate entity, it may be
dissected as far proximally as necessary, to obtain enough length for a tension-free neurorrhaphy with the
proposed recipient nerve stump. The hand is then separated from the donor forearm. A fascicular repair is
carried out between the unarborized sensory branch of the radial nerve and the recipient nerve stump in an
isodromic manner. This is done under magnification, using 9-0 nylon sutures. The composite flap is tailored and
inset into the recipient site. The donor site may be closed primarily or covered with a split-thickness graft (Figs.
285.3 and 285.4).

FIGURE 285.3 Using a bone graft from the iliac crest, the superficial radial nerve in the flap is sutured to the
radial digital nerve stump of the thumb. The flap is then draped over the bone graft to provide sensory coverage.
(From Dolich et al., ref. 1, with permission.)
CLINICAL RESULTS
To date, there have been no failures or complications in a small but controlled series where these
techniques were used to obtain sensory coverage (6, 7, 8). This may be explained by the fact that they are
actually a hybrid of “tried and true” random flap techniques that incorporate axial neurorrhaphies to give
them sensibility. Aside from the difficulties with certain activities of daily living during the first stage, there
have been no permanent functional deficits. In some male patients a part of the skin may be hairbearing, but
this has not interfered with function.

FIGURE 285.4 A 22-year-old right-handed factory worker suffered a crush avulsion injury of the left thumb
just distal to the metacarpophalangeal joint. A cross-forearm neurocutaneous flap, based on the superficial
radial nerve, was used with a bone graft to reconstruct the thumb. He returned to work in his original
capacity in 3 months. Five months postoperatively, his two-point discrimination was 8 mm. A: Crush
avulsion injury at the metacarpophalangeal joint of the left thumb. B: Cross-forearm neurocutaneous flap is
raised. The arrow points to the superficial branch of the radial nerve. C: Inset of flap over raw thumb stump.
D: A carved bone peg from the iliac crest is fixed into the stump of the first phalanx of the thumb and a
microfascicular neurorrhaphy is done between the superficial branch of the radial nerve and the ulnar digital
nerve stump of the thumb. E: Intraoperative result. F: Postoperative result. (From Dolich et al., ref. 1, with
permission.)
Using donor composites with two-point discrimination of 20 to 30 mm would seem to be a potential
drawback (4). In practice, all patients have shown an exciting phenomenon of “sensory upgrading” in which
the two-point discrimination improves to 8 to 10 mm. This would seem to be explained by the splicing of an
undisturbed neurocutaneous composite into a corticosensory area that was, and still is, able to supply
epicritic sensibility.

SUMMARY
The cross-forearm neurocutaneous flap, based on the sensory branch of the radial nerve, can be used to
provide sensory coverage to important areas of the hand.
References
1. Dolich BH, Olshansky KJ, Babar AH. Use of a cross-forearm neurocutaneous flap to provide sensation
and coverage in hand reconstruction. Plast Reconstr Surg 1978; 62:550.
2. Terzis J, Williams B. Functional aspects of reinnervation of skin grafts. Surg Forum 1974;25:518.
3. Sunderland S. Nerves and nerve injuries. Edinburgh: Livingstone, 1968;705.
4. Ruch TC, Patton HD. Physiology and biophysics. Philadelphia: Saunders, 1965;160.
5. Kaplan EB. Functional and surgical anatomy of the hand. Philadelphia: Lippincott, 1965;163.
6. Moberg E. Peripheral nerves and hand function. J Bone Joint Surg 1961; 43(B):423.
7. Michon J, Dolich B. The metacarpal hand. Hand 1974;6:285.
8. Michon J, Moberg E. Traumatic nerve lesions of the upper limb. Edinburgh: Livingstone, 1975;53.

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Chapter 286
Dynamic Abductor Digiti Minimi Musculocutaneous Flap for The
Thumb
V. R. HENTZ
EDITORIAL COMMENT
The use of the ulnar border of the hand, in an otherwise compromised hand, for coverage with muscle flaps
is an excellent employment of local flaps. (See Chapter 296.)
Of the many transfers available to restore opposition movements of the thumb, one of the earliest described was
transfer of the abductor digiti minimi (1). Its value as a dynamic transfer is widely acknowledged (2). As is the
case with many muscle units, it can be transferred as a musculocutaneous flap (3).
INDICATIONS
See Figure 286.2 for demonstrations of the ability of the flap simultaneously to restore deficits in both
function and skin cover.
FIGURE 286.1 The proximal location of the principal neurovascular hilum arising from the ulnar artery and
nerve is illustrated.
ANATOMY
Vascular injection studies in cadavers have demonstrated the presence of musculocutaneous vessels that
perforate the muscle and then supply the overlying skin and subcutaneous tissue. This occurs either directly or
indirectly through the palmaris brevis muscle that lies between a portion of the abductor digiti minimi and the
overlying skin. The vascular anatomy is shown in Figure 286.1 (see also Fig. 286.1 in Chapter 296).

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FIGURE 286.2 A,B: A progressively expanding A-V malformation has resulted in infection and ulceration of the
thenar skin. An arteriogram demonstrated diffuse involvement of the thenar muscles. C: The tumor mass and
overlying skin were resected and the defect covered with an abductor digiti minimi musculocutaneous flap. The
muscle was attached to the tendon of the abductor pollicis brevis. D: Fifteen months after surgery, the flap has
provided durable skin cover and functional opposition. The donor defect is acceptable and is hidden when the
hands are in most functional positions.
FLAP DESIGN AND DIMENSIONS
Since the skin can be carried as an “island,” the arc of rotation is similar to that illustrated in Figure 286.2 in
Chapter 296.
OPERATIVE TECHNIQUE
Surgical dissection of the musculocutaneous unit is similar to that described for transfer of the muscle alone (see
Chapter 296). As in any musculocutaneous flap, care must be exercised so that the skin is not sheared off the
underlying muscle during elevation (Fig. 286.2).
The donor defect may be closed directly if the skin element is small. More likely, a thick split-thickness skin graft
will serve as permanent cover.
When the muscle alone is used for functional restoration of thumb opposition, the muscle can be folded over as
one would turn over the page of a book. If skin is included, the musculocutaneous unit must be rotated about its
neurovascular pedicle to a greater degree.
CLINICAL RESULTS
The functional deficit resulting from transfer of the abductor digiti minimi is negligible.

SUMMARY
The abductor digiti minimi can be used as a dynamic musculocutaneous flap for restoration of thumb
opposition.
References
1. Huber E. Hilfsoperation der Medianuslahmung. Dtsch Z Chir 1921; 162:271.
2. Littler JW, Cooley SGE. Opposition of the thumb and its restoration by abductor digiti quinti transfer. J
Bone Joint Surg 1963;45(A):1389.
3. Chase RA, Hentz VR, Apfelberg D. A dynamic myocutaneous flap for hand reconstruction. J Hand Surg
1980;5:594.

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Chapter 287
Abductor Digiti Minimi Myocutaneous Flap for Opponensplasty in
Congenital Hypoplastic Thumbs
JANET H. YUEH
KEVIN CHEUNG
AMIR H. TAGHINIA
JOSEPH UPTON
EDITORIAL COMMENT
This transfer is preferable to the other technique outlined in Chapter 251 as it allows for a functional as well
as cosmetic improvement.
INDICATIONS
The abductor digiti minimi muscle transfer is one of the main methods used to restore thumb opposition in
children. This was originally described by Huber (1) in 1921 and later refined by Littler and Cooley (2). It is
an ideal method of opposition transfer for children with types II and IIIA (Blauth classification [3]) congenital
thumb hypoplasia (Fig. 287.1) (4, 5, 6, 7). Furthermore, it is useful for improving weak opposition in patients
with types IIIB, IV, and V thumbs who have undergone index finger pollicization (8). Incorporation of a
hypothenar skin paddle with the muscle enhances the appearance of the thenar eminence by augmenting
the aplastic soft tissues of the palm and thenar area (8, 9). Furthermore, it eliminates the possibility of
muscle ischemia caused by swelling within a tight tunnel.
The abductor digiti minimi flap has also been used in reconstructive surgery to cover defects of the hand
and wrist (10, 11). The standard muscle flap can be rotated to cover small defects around the fourth and
fifth metacarpals and the dorsal aspect of the carpus. It is particularly useful to assist in the
revascularization of the median and ulnar nerves at the wrist following neurolysis or nerve grafts or as
padding over the median nerve following operations for recurrent carpal tunnel syndrome.
Donor morbidity after an abductor digiti minimi transfer is minimal. The small finger can still be abducted by
the extensor digiti minimi and the flexor digiti minimi. Loss of powerful abduction of the small finger may be
noticed in highly dexterous professionals.
ANATOMY
The abductor digiti minimi forms the bulk of the hypothenar eminence, extending from the distal wrist crease to
the distal palmar crease. It is the most superficial of the hypothenar muscles, with the flexor digiti minimi lying
slightly radial and deep. Fibers of the flexor digiti minimi often intermingle with the abductor digiti minimi, making
separation of these two muscles somewhat challenging.
The abductor digiti minimi originates proximally from the pisiform and the flexor carpi ulnaris. It inserts distally
onto the ulnar-volar base of the small finger proximal phalanx and the dorsal expansion of the extensor digiti
minimi. The neurovascular supply to the abductor digiti minimi is constant. It

is innervated by the deep branch of the ulnar nerve in Guyon canal, which arises 1 to 2 mm distal to the pisiform
bone. Its arterial supply is from a branch of the ulnar artery. The neurovascular bundle enters the muscle
proximally on its radial deep aspect.
FIGURE 287.1 Clinical appearance and radiograph of a type IIIA hypoplastic thumb.
FLAP DESIGN AND DIMENSIONS
A generous ellipse of hypothenar skin is designed over the abductor digiti minimi, extending from a point 1.0 cm
distal to the distal wrist flexion crease to the distal palmar flexion crease (Fig. 287.2). This includes both glabrous
and nonglabrous skin.
FIGURE 287.2 Left: A generous skin island is outlined over the hypothenar muscle mass. Center: The flap is
elevated and isolated on the proximal neurovascular pedicle. A palmar incision is made for inset. Right:
Extensive undermining is not necessary.
OPERATIVE TECHNIQUE
The ellipse of hypothenar skin and subcutaneous fat is incised down to the underlying muscle and its fascial
investment. The incision is extended distally to the ulnar side of the proximal phalanx of the small finger.
Proximally, the incision is curved radially along the distal wrist crease. Small chromic sutures secure the skin
component to the underlying fascia and prevent shearing of the small perforators from the muscle to the skin.
Dissection is continued to the tendinous insertion on the proximal phalanx, taking care to preserve the tendon for
later attachment of the muscle. The abductor digiti minimi muscle is then raised in a retrograde fashion to its
origin on the pisiform. Its proximal pedicle is identified and care must be taken not to devascularize the flap along

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its deep radial surface.
A generous subcutaneous tunnel is then created radially to the level of the thenar flexion crease. Particular
attention is paid to the palmaris brevis muscle, which can often kink or partially obstruct the muscle passage. At
this point, the mobilized muscle is draped across the palm externally and the site of the palmar inset incision is
chosen. The palmar incision is usually located near the base of the thenar flexion crease and extends parallel to
the metacarpal of the hypoplastic thumb or pollicized digit. Minimal undermining is necessary. The tendinous
portion of the abductor is inset onto the radial side of the thumb at the metacarpophalangeal joint. A separate slip
can be sutured onto the aponeurosis of the extensor tendon to the thumb, thereby aiding in extension of the
interphalangeal joint simultaneous with abduction. The repair is tensioned to maintain the thumb abducted 90
degrees from the flat plane of the hand. The skin is carefully closed with absorbable sutures.
CLINICAL RESULTS
From our series of over 600 index pollicizations and hypoplastic thumb reconstructions between 1977 and
2007, we have performed 14 abductor digiti minimi myocutaneous flap transfers to improve thumb
opposition. Six patients had types II or
IIIA thumb hypoplasia, and eight patients had types IIIB, IV, and V thumbs who had previously undergone
index pollicization. The average age at the time of operation was 2 years for the type II or IIIA thumb
hypoplasia group and 4.5 years for the index pollicization group. Eleven of the fourteen patients had hands
with a pollicized index on one side and either a type II or type IIIA hypoplastic thumb on the other.
FIGURE 287.3 Six months postoperatively, strong palmar abduction of the right thumb is seen in
comparison with the opposite hand, which had index pollicization 1 year earlier. Note the more acceptable
appearance of the opposite hand.
All of the myocutaneous flaps survived, grew with the children, provided functional palmar abduction of the
thumb, and improved the appearance of the thenar eminence. All of the children used their reconstructed
thumbs. In the 11 children with pollicizations on one hand and hypoplastic thumbs on the other, there was
no apparent correlation between hand dominance, functional preferences, or actual use in activities of daily
living for one side or the other.

FIGURE 287.4 Three-year postoperative image showing that, with time and growth, the transferred muscle
has increased in bulk and the incision almost completely faded.
There was no apparent difference in pinch strength between this cohort and other patients who had
received the traditional muscle transfer. Key pinch strengths were reduced markedly, by an average 40% of
normal in age-matched hands in our practice. Six thumbs had marked limitation of motion in both the
metacarpophalangeal and interphalangeal joints, three following pollicization and three after hypoplastic
thumb construction. All of these thumbs were used effectively as mobile posts for thumb-to-digit prehension.
Illustrative case examples are shown in Figures 287.1, 287.2, 287.3, 287.4.
SUMMARY
The abductor digiti minimi myocutaneous flap is a good alternative to the traditional muscle transfer for
restoration of opposition in congenital hypoplastic thumbs. In children who need opponensplasty and who
have aplastic soft tissues of the palm and thenar area, this flap provides opponensplasty, enhances the
appearance of the thenar eminence, and eliminates the possibility of muscle ischemia due to swelling within
a tight tunnel.
References
1. Huber E. Hilfsoperation bei medianuslahmung. Dtsh Z Chir 1921;162:271.
2. Littler JW, Cooley SG. Opposition of the thumb and its restoration by abductor digiti quinti transfer. J Bone
Joint Surg Am 1963;45:1389.
3. Blauth W. Der hypoplastische daumen. Arch Orthop Unfallchir 1967;62:225.
4. Latimer J, Shah M, Kay S. Abductor digiti minimi transfer for the restoration of opposition in children. J
Hand Surg [Br] 1994;19:653.
5. Manske PR, McCarroll HR Jr. Abductor digiti minimi opponensplasty in congenital radial dysplasia. J Hand
Surg [Am] 1978;3:552.

6. Oberlin C, Gilbert A. Transfer of the abductor digiti minimi (quinti) in radial deformities of the hand in
children. Ann Chir Main 1984;3:215.
7. Ogino T, Minami A, Fukuda K. Abductor digiti minimi opponensplasty in hypoplastic thumb. J Hand Surg
[Br] 1986;11:372.
8. Upton J, Taghinia AH. Abductor digiti minimi myocutaneous flap for opponensplasty in congenital
hypoplastic thumbs. Plast Reconstr Surg 2008;122:1807.
9. Ishida O, Ikuta Y, Sunagawa T, et al. Abductor digiti minimi musculocutaneous island flap as an opposition
transfer: a case report. J Hand Surg [Am] 2003;28:130.
10. Cirrincione C, Stern PJ. The abductor digiti minimi muscle flap: an adjunct in the treatment of metacarpal
osteomyelitis. J Hand Surg [Am] 1991;16:824.
11. Reisman NR, Dellon AL. The abductor digiti minimi muscle flap: a salvage technique for palmar wrist
pain. Plast Reconstr Surg 1983;72:859.

Chapter 288
Microneurovascular Free Transfer of The Big Toe
J. W. MAY JR.
R. C. SAVAGE
EDITORIAL COMMENT
Over the past decade, the pendulum has swung to the use of toe parts for reconstruction of the missing
thumb. This has allowed for a five-digit hand with a nail on each of the digits. Each of the modifications has
added to the success of these procedures. We direct the reader's attention particularly to Chapter 292 on
the trimmed toe technique, which allows for a toe transplant that, in addition to its functional aspects, also
provides the appearance of a normal thumb. See also Chapters 289, 290, 291.
Over the past 25 years, thumb reconstruction by microvascular toe-to-hand transfer has taken an important place
in the armamentarium of the reconstructive hand surgeon (1, 2, 3, 4, 5, 6, 7, 8, 9, 10). During this period
microvascular toe transfer has emerged through the early phase of declaration (1) into a period of application,
and recently into a period of refinement (10). This procedure is the piece de resistance of complex free-tissue
transfers, in that it involves transfer to the hand of skin-nail, subcutaneous tissue, tendons, bone, joint, nerve,
and vessels.
INDICATIONS
In general, we believe that toe-to-hand reconstruction can be useful in cases of subtotal or total thumb
traumatic loss where four normal fingers are present or where three or fewer digits remain (7, 10). In a hand
with a damaged index finger and three remaining normal fingers, index finger pollicization may be indicated
(11).
It has been said that the thumb in a normal hand comprises between 40% and 50% of the functional
capability in that hand (12). In the mutilated hand the restoration of a strong, sensate, and mobile thumb of
normal length can amount to far more than 50% of function in the assisting hand. In some cases the
reconstructed thumb may be the most useful digit in the hand.
After injury, it is best to maximize the rehabilitation potential of the remaining element of the hand through a
combination of reconstructive surgical procedures and therapy, prior to thumb reconstruction. In a severely
mutilated hand these preliminary procedures may involve joint capsulectomy, fusion, or joint replacement, in
addition to tendon lysis or graft and nerve reconstruction.
If there is soft-tissue shortage or significant damage to the radial side of the hand, with scarring that will
ultimately limit motion, it is often better to transfer a distant flap to this area, prior to toe transfer. This has
the advantage of providing ample soft tissue to the damaged area and avoids taking extensive flap tissue
from the foot (7, 10). The standard groin flap is a useful source of flap tissue, since the tip of the flap can be
thinned at initial application (13) and the base of the flap can be sculpted at the time of toe transfer,
providing thin and extensive flap coverage. The donor site is inconspicuous.
ANATOMY AND FLAP DESIGN

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Knowledge of the similarities and differences between the anatomy of the big toe and that of the thumb is
essential (7) in performing a successful reconstruction. The object of thumb metacarpophalangeal joint
reconstruction is first, to create stability and second, to provide motion without hyperextension. If hyperextension
is allowed to develop, the interphalangeal joint will droop into a compensatory flexed position that detracts from
pulp-to-pulp pinch. If a significant flexion contracture exists (fixed Froment's sign), thumbnail-to-digital pulp pinch
can result. If the metatarsophalangeal joint is taken with the toe, an angled osteotomy (Fig. 288.1) of the toe
metatarsal must be completed, to hyperextend the metatarsophalangeal joint as it is placed on the hand in a
neutral position. This helps avoid further hyperextension of the metacarpophalangeal joint replacement and thus
helps prevent a compensatory flexion deformity of the new thumb interphalangeal joint.
The angled osteotomy can be placed in such a way that the volar extent enters the joint. Here the volar plate is
divided just distal to the sesamoids, which allows the proximal volar plate and sesamoids to stay with the big toe
metatarsal. After transfer, the volar plate is anchored in such a way as to avoid metacarpophalangeal
hyperextension in the thumb position. When the metacarpophalangeal joint is reconstructed as outlined, 30° to
60° of active motion can be seen after transfer.
This may be particularly useful in the mutilated hand, since metacarpophalangeal joint motion will help vary the
range of the first web space. Preservation of the sesamoids with the proximal volar plate on the foot metatarsal
may prevent descent of the metatarsal and create a durable pushoff surface in the foot.
FIGURE 288.1 Angled osteotomy of big toe metatarsal to prevent hyperextension of thumb metacarpophalangeal
joint in transferred position. (From Buncke, ref. 3, with permission.)
Amputation of the big toe through the metatarsophalangeal joint with reconstruction of a new
metacarpophalangeal joint is ideal, if articular cartilage is present in the remaining distal thumb metacarpal in the
hand. Although the fit is not identical, the curvature between the thumb metacarpal head and the toe proximal
phalangeal base provides an adequate match, with excellent potential motion. Here again the volar plate is
shortened and advanced proximally, to provide stability in extension (Fig. 288.2).
When the big toe is transferred to the hand with the metatarsophalangeal joint, the reconstructed thumb can
provide excellent motion and power, as long as appropriate hand extrinsic and intrinsic tendon counterparts are
reconstructed. One can help prevent thumb interphalangeal joint mallet positioning by reconstruction of the
intrinsic slips to the extensor pollicis longus (adductor and abductor brevis tendons).
The vascular anatomy of the first web space has been well described (14, 15). The inflow of the transfer is most

commonly based on the dorsalis pedis artery. The goal, in general, should be to isolate the toe carefully on as
large an artery and vein as possible, thus making the repair safer.
As it branches into the first dorsal metatarsal artery, the dorsalis pedis is followed dorsal to the transverse
intermetatarsal ligament into the distal communicating artery, into the junction with the plantar supply, and out
into the dominant plantar system. No two toes are identical, and care must be taken not to assume any
preconceived vascular pattern. We find it helpful to obtain preoperative anteroposterior and lateral arteriograms
of the foot and hand (16). This helps in the selection of appropriate recipient vessels in the damaged hand, and
helps identify the location of the first dorsal metatarsal artery (78% dorsal, 22% more deeply). Using preoperative
arteriography with identification of the largest vessels possible for anastomoses, no tissue has been lost in foot-
to-hand transfer procedures.
FIGURE 288.2 Recession of volar plate to avoid hyperextension when a new metacarpophalangeal joint is
made, leaving thumb metacarpal articular cartilage intact.
Because the branching blood supply of the dominant plantar digital artery to the big toe is intact, the entire joint
capsule and bony skeleton maintains perfusion after transfer. This perfusion allows prompt capsule healing and
early primary bone osteosynthesis. When early primary healing is achieved, early motion after tendon healing
can be initiated. If primary osteosynthesis is not achieved, and a bony collapse or avascular dissolution (17) or
nonunion is threatened, then prolonged immobilization may be necessary. This awkward situation, seen when
nonvascularized bone grafts are transferred to the thumb position, is obviated by primary vascular perfusion of all
bony tissues transferred with the toe.
The fact that the big toe is somewhat larger than a normal thumb, even after atrophy, may be an advantage in a
mutilated hand, because the larger pulp and increased relative strength may be a welcome assistant to the pinch
mechanism against impaired remaining digits. Despite its larger size

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(Fig. 288.3D), the big toe, several years after transfer, atrophies to a significant degree, when compared with its
initial state (Fig. 288.3C).
FIGURE 288.3 A: A 16-year-old boy 2 years after a bomb blast injury to his left, nondominant hand. An
abdominal flap had been placed on the radial side of his hand prior to referral. The thumb was amputated
through the distal trapezium and the index ray was amputated at the base of the index metacarpal. B:
Transferred toe ready for attachment to hand. Note dorsal toe proximal subcutaneous tissues that will be
covered by skin graft. The distal metatarsal was fixed to the trapezium using compression wire fixation technique,
because the original amputation injury had removed the entire carpometacarpal joint. In addition to standard
extensor and flexor tendon repairs, the extensor carpi radialis brevis was repaired via a palmaris longus tendon
graft at the primary toe transfer procedure to the proximal phalanx of the toe, thus completing an adductor
transfer, as no adductor pollicis remained within the hand. C: Comparison of left and right thumbs, 6 months
postoperatively. D: Comparison of left and right thumbs, 3½ years postoperatively. E: Comparison of left and
right thumbs in tip pinch, with absence of left metacarpal. He has two-point discrimination of 8 mm, with excellent
spatial orientation within the thumb and return of sudomotor activity. Metacarpophalangeal joint active motion is
30° with 55° of active interphalangeal joint motion and adduction key pinch of 7 pounds, adequate for carrying
large objects. Preoperative and postoperative gait analysis comparisons at 6 months, 1 year, and 2 years have
suggested no significant gait disturbances and the patient has returned to avocational baseball and jogging. F:
Adequate adductor function to act as assisting hand.
In the mutilated hand the normal extensor and flexor tendons to the thumb may be missing. Here the intrinsic and