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

plantar pushoff callused skin to remain on the foot, and it has prevented any significant donor site problems in
the foot.
The incision is then made circumferentially around the big toe and carried in a curvilinear fashion over the
dorsum of the foot, located equally between the great saphenous vein and the dorsalis pedis artery. Dissection
of the first web area is designed to identify several large branches draining the first web and medial big toe
regions. The soft tissues between these two large venous branches are included with the transfer (Fig. 288.3B),
as mentioned previously, to act as a recipient bed for a thick skin graft, if soft-tissue reconstruction is needed in
the dorsal first web region. The dorsal venous branches are identified and the extensor hallucis brevis is divided
at its muscle tendon junction and turned proximally and distally to expose the dorsalis pedis artery and its dorsal
extension, the first dorsal metatarsal artery. Adjacent to the first dorsal metatarsal artery, the deep peroneal
nerve is found, half of which will supply the dorsal sensibility of the big toe.
Communication between the hand dissection team and the foot dissection team is imperative, to avoid dividing
the toe structures at a point that will be insufficient for reconstruction in the hand. Great care must be taken in
tracing the first dorsal metatarsal artery over the distal transverse intermetatarsal ligament. Here the vessel
comes close to the ligament and may be damaged in its pathway to join the dominant plantar digital vessels of
the big toe. Vessels supplying the second toe must be divided at this point.
The plantar dissection is then undertaken, identifying the lateral plantar digital nerve that runs sufficiently deep to
the plantar fascia. This nerve will be found near the mid-axis of the big toe laterally. The flexor hallucis longus
tendon will be identified in the midline of the big toe in its plantar location, and the pulley overlying the proximal
big toe phalanx should be left intact. The medial digital nerve to the big toe is identified and, through a small
longitudinal plantar incision, both of these nerves can be traced well back into the foot.
With this exposure, the nerves can be divided 4 to 7 cm proximal to the metatarsophalangeal joint of the toe; this
usually provides ample nerve length to allow a tension-free repair in the hand. If this is not adequate, further
exposure for these nerves can be achieved through extension of the plantar incision. The flexor hallucis longus
tendon is usually divided by a separate midplantar incision in the foot, as division of this tendon behind the
malleolus frequently is accompanied by requirement for an additional incision. All the structures of the big toe are
divided, except for the perfusing artery and vein. The tourniquet is released to allow the big toe to have a final
drink before reelevation and toe amputation. The toe dissection usually requires a full tourniquet run of 2 to 2½
hours. The big toe is allowed to perfuse for 20 minutes prior to completion of the amputation and transfer of the
toe to the hand.
Microvascular Free Tissue Transfer
The big toe metatarsal donor site is narrowed by removing the medial cortical bone projection from the big toe
metatarsal, to avoid undue pressure on the foot flap closure. In addition, the sesamoids are left with the big toe
metatarsal where possible, and are attached through a small drill hole in the metatarsal, to maintain their position
during the healing phase. Intrinsic muscles (abductors and adductors) of the toe should be sutured into position,
to maintain soft-tissue bulk in the region of the distal end of the toe metatarsal. When the metatarsal head itself is
left with the foot, the narrowing procedure is still carried out, to allow the remaining skin envelope to be closed in
a tension-free manner.
In the hand, bony fixation is initially completed, using an internal wire compression twist-down fixation technique
(18). If a new metacarpophalangeal joint is being created in the hand, and the toe has been disarticulated, then
capsular repair and volar plate plasty are carried out at this point (Fig. 288.2). Flexor and extensor tendon repairs
are completed, and slips of the adductor and abductor brevis are repaired, if present, to the extrinsic extensor
mechanism. We usually prefer to repair the dorsalis pedis artery to the dorsal branch of the radial artery end-to-
end or end-to-side. The greater saphenous vein is repaired to a branch of the cephalic vein, as the single

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venous drainage of the big toe. Prior to release of the clamps, all vessels are bathed in a topical 2% xylocaine
solution to relieve any vascular spasm. Capillary filling to the big toe should be appreciated, although this may
sometimes require several minutes that can seem like hours! Vessel patency tests should always be done to
confirm anastomosis patency (19).
Dorsal and palmar nerve repairs are finally completed, using microneural technique, after hemostasis is carefully
achieved.
All skin and soft tissues are carefully approximated, and the dorsal thick skin graft is placed, if needed, and is
treated open as it lies directly over the venous drainage.
A full and noncompressive supporting plaster dressing is made for the foot, ankle, and lower leg, as well as for
the hand and forearm. Both the foot and the hand are elevated, and the distal big toe is monitored with surface
thermocouple monitoring.
Hand active range of motion exercises are begun 3 weeks postoperatively. Significant passive exercises are not
done for 6 weeks, and no dynamic splinting, other than first web space static night splinting, is allowed for 8 to
10 weeks. As the Tinel's sign progresses distally, the patient is begun on a sensory reeducation program and is
encouraged to use the thumb actively in small object grasp, despite incomplete reinnervation.
CLINICAL RESULTS
Although none of the 30 toe-to-hand transfer operations done on our service at the Massachusetts General
Hospital has failed, a vascular problem has been corrected successfully in two cases to allow full tissue
survival. Ultimate sensibility has ranged in our series from two-point discrimination of 5 mm in the young to
protective sensibility in the older adult.
Preoperative and postoperative gait analyses in all patients undergoing thumb reconstruction by toe-to-
hand transfer have been performed (20). In our studies the patients' follow- up examinations have
suggested no significant adverse gait effects. In the foot, the normal weight-bearing balance shifts from the
medial big toe metatarsal region preoperatively laterally to the second ray postoperatively, but has had no
adverse effect on gait (20, 21, 22).
SUMMARY
In the carefully selected patient, big toe-to-hand transfer for major thumb reconstruction in the mutilated
hand can play an important role in upgrading overall hand function.
References
1. Cobbett JR. Free digital transfer. J Bone Joint Surg [Br] 1969;518:677.
2. Buncke HJ, McLean DM, George PT, et al. Thumb replacement: great toe transposition by microvascular
anastomosis. Br J Plast Surg 1973;26:194.
3. Buncke HJ. Toe digital transfer. Clin Plast Surg 1976;3:49.
4. O'Brien BM, MacLeod AM, Sykes PJ, Donahoe S. Hallux-to-hand transfer. Hand 1975;7:128.

5. Tamai S, Hori Y, Tatsumi Y, Okuda H. Hallux-to-thumb transfer with microsurgical technique: a case report
in a 45-year-old woman. J Hand Surg 1977;2:152.
6. O'Brien BM, Brennen MD, MacLeod AM. Microvascular free tissue transfer. Clin Plast Surg 1978;5:223.
7. May JW, Jr, Daniel RK. Great toe-to-hand free tissue transfer. Clin Orthop 1978;133:140.
8. Gilbert A, Tubiana R. Reconstruction of the mutilated hand using microsurgery. In: Reid DAL, Gosset J,
eds. Mutilating injuries of the hand. Edinburgh: Churchill Livingstone, 1979.
9. Kutz JE, Thompson CB, Klein HW. Toe-to-hand transfer. In: Urbaniak J, ed. AAOS symposium on
microsurgery. St. Louis: Mosby, 1979.
10. May JW Jr. Aesthetic and functional thumb reconstruction: great toe-to-hand transfer. Clin Plast Surg
1981;8:357.
11. Littler JW. Neurovascular pedicle method of digital transposition for reconstruction of the thumb. Plast
Reconstr Surg 1953;12:203.
12. Campbell R. Reconstruction of the thumb. J Bone Joint Surg [Br] 1960; 42:444.
13. May JW Jr, Bartlett S. Staged groin flap in reconstruction of the pediatric hand. J Hand Surg 1981;6:163.
14. Gilbert A. Composite tissue transfers from the foot: anatomic basis and surgical technique. In: Strauch B,
Daniller AI, eds. Symposium on microsurgery. St. Louis: Mosby, 1976.
15. May JW, Chait LA, Cohen BE, O'Brien BM. Free neurovascular flap from the first web of the foot in hand
reconstruction. J Hand Surg 1977;2:387.
16. May JW Jr, Smith RJ, Peimer C. Toe-to-hand free tissue transfer for thumb construction with multiple
digit aplasia. Plast Reconstr Surg 1981;67:205.
17. Leung PC, Ma FY. Distal reconstruction using the toe flap: Report of 10 cases. J Hand Surg 1982;7:366.
18. Daniel RK, Terzis JK, eds. Replantation of upper extremity amputations. In: Daniel RK Terzis JK, eds.,
Reconstructive microsurgery. Boston: Little, Brown, 1977. Fig. 5-14A-D, p. 147, Fig. 5-10C (x-ray), p. 141.
19. Acland RD. Signs of patency in small vessel anastomosis. Surgery 1972;72:744.
20. Clarkson P. Reconstruction of hand digits by toe transfers. J Bone Joint Surg 1955;37(A):270.
21. Clarkson P. Toe-to-hand transfers. In: Flynn JE, ed. Hand surgery. Baltimore: Williams & Wilkins, 1966.

22. O'Brien BM, Black MJM, Morrison WA, MacLeod AM. Microvascular great toe transfer for congenital
absence of the thumb. Hand 1978;10:113.

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Chapter 289
Microneurovascular Free Transfer of The Second Toe
B. STRAUCH
E. J. HALL-FINDLAY
The second toe has potential in the reconstruction of both thumb and finger losses. Advantages over the big toe
can exist in both minimized donor site morbidity and better recipient site appearance (1, 2, 3, 4).
INDICATIONS
The second toe is smaller than the big toe for thumb replacement, but size varies so much from individual to
individual
that the second toe may have a more pleasing cosmetic effect. In societies where sandals are standard
footwear, surgeons have been reluctant to sacrifice the big toe and have often preferred the second toe for
thumb reconstruction. The extra joint of the second toe and the flexion attitude of the interphalangeal joints
usually are not a problem in the thumb.
FIGURE 289.1 Preparation of the donor site. A curvilinear incision is made over the dorsum of the foot to
harvest adequate vessel, nerve, and tendon lengths.
The second toe has been used less frequently for finger loss, except when all four fingers have been
amputated. For salvage of a “metacarpal” hand, the second toe has provided excellent function. It tends to

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be short and the interphalangeal joints are continually flexed, both of which characteristics would be
inappropriate if normally functioning fingers remained on the hand.
The second toe filleted has been used to replace pulp loss of the finger. In contrast to standard insensitive
flaps and neurovascular island flaps from other fingers, the toe transfer provides skin of texture and
structure similar to those of the finger, with the correct cortical representation.
ANATOMY
The second toe has three phalanges. Both interphalangeal joints are maintained in varying degrees of flexion,
while the metatarsophalangeal joint is almost always held in a considerable degree of extension.
The arterial supply to the foot is by way of an interconnected two-arch system. The plantar arch is formed from
the posterior tibial artery, and the dorsal arch is formed from the dorsalis pedis artery. The second toe is supplied
by two dorsal digital arteries, one from the first dorsal metatarsal artery and one from the second dorsal
metatarsal artery. However, it is mainly supplied by two larger plantar arteries that receive contributions both
from the plantar arch and from the metatarsal arteries.
The second toe can easily survive if one uses the first dorsal metatarsal artery as the donor artery. The first
dorsal metatarsal artery is a branch of the dorsalis pedis artery, usually arising at a superficial level but
occasionally branching from a deeper location of the dorsalis pedis artery as it descends between the first and
second metatarsals. The first dorsal metatarsal artery can be found either superficial to or at varying levels within
the first dorsal interosseous muscle.
Venous drainage occurs by the venae comitantes of the arterial system, but mainly by way of the superficial
veins that drain into the dorsal venous arch and then into the saphenous system.
The second toe is innervated by two plantar digital nerves (branches of the medial plantar nerve) and by the
lateral portion of the deep peroneal nerve that supplies both sides of the first web space of the foot. The plantar
digital nerves can be found with their accompanying digital arteries, and the deep
peroneal nerve can be found lying adjacent to the first dorsal metatarsal artery.
Extra skin and subcutaneous tissue can be taken from both plantar and dorsal aspects of the foot, including all
the skin of the first web space, depending on recipient site requirements.
The second toe has both long and short extensors and flexors, as well as intrinsic tendon contributions. The
tendons used for the transfer of the toe to the hand are usually the long extensor and the long flexor.
FLAP DESIGN AND DIMENSIONS
The arterial anatomy of the foot should be outlined preoperatively by palpation, by Doppler, and by lateral
arteriograms. Recipient site requirements are determined and mapped out at the donor site, always weighing the
potential benefits to the recipient site against the possible morbidity at the donor site. This refers mainly to extra
dorsal foot skin beyond what would allow primary donor site closure. Skin grafts over the dorsum of the foot have
a bad reputation. However, skin grafts on the hand may be perfectly acceptable, except in areas requiring
padding or sensation or where required for coverage of the vascular pedicle.
OPERATIVE TECHNIQUE
Donor Site
A curvilinear incision is made over the dorsalis pedis artery. A straight-line incision is avoided, to minimize skin
contracture at both donor and recipient sites and to allow wider exposure (Fig. 289.1).

The veins are quite superficial and care must be taken to preserve them. Once the dissection has progressed,
the best donor vein can be chosen and the remainder can be ligated.
The dissection is kept medial to the dorsalis pedis artery, to avoid injuring branches to the second toe. The first
dorsal metatarsal artery and the deep peroneal nerve are identified either superficial to or within the substance of
the first dorsal interosseous muscle. The intermetatarsal ligament is carefully divided to allow better exposure.
Both dorsal and plantar arteries on the medial side of the toe are identified, and the connection of the latter to the
first plantar metatarsal artery is divided and ligated. The arcuate artery supplying the remaining dorsal metatarsal
arteries can be ligated as it passes laterally from the dorsalis pedis artery, as can the descending branch of the
dorsalis pedis artery as it passes to join the plantar arch.
The deep peroneal nerve and the plantar digital nerve may need to be separated proximally under magnification,
from those branches to the big toe. Both plantar digital nerves are best identified through the racquet-shaped
incisions on the plantar aspect of the toe. The plantar digital artery to the lateral aspect of the toe can be
identified and traced back (with the nerve) as far proximally as necessary. This can be used for a separate
arterial anastomosis, if required. Again, the digital nerve may need to be split proximally, to allow adequate
length, always taking more than was indicated by recipient site measurements.
Both the long flexor and the long extensor are divided proximally in the foot or at the ankle. The toe may be either
disarticulated at the metatarsophalangeal joint or divided more proximally in the metatarsal. Some of the
metatarsal must nevertheless be removed to allow primary donor site closure. Some attempt should also be
made to repair the intermetatarsal ligament between the third and big toes, to prevent splaying of the foot.
Recipient Site
The recipient site will determine the structures available for anastomoses (Fig. 289.2). These will depend on
whether the second toe is being used for thumb or finger replacement. At least one flexor and one extensor, and
one or two arteries and veins, will be needed. Bony fixation can be accomplished with peg fixation, Kirschner
wires, or 90°/90° interosseous wiring. Care must be taken to evaluate the position of the toe joint, to place it in
appropriate angulation at the recipient site.
Both plantar digital nerves should be anastomosed to the corresponding digital nerves (or more proximal
counterparts). The branch of the deep peroneal nerve should be anastomosed to the appropriate radial or ulnar
dorsal sensory branches of the hand (Fig. 289.3).

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FIGURE 289.2 Preparation of the recipient site for a second toe to thumb transfer. Note that the web space
contracture has been released.
FIGURE 289.3 Second toe transfer. Note that all three nerves are repaired along with the vascular
anastomoses. Note that the toe has three phalanges where a thumb usually has two phalanges.

CLINICAL RESULTS
The donor site can be closed primarily after removing some of the metatarsal. This leaves an almost
normal-looking foot that often deceives the casual observer. Some patients have complained of temporary
discomfort, perhaps from the partial loss of the plantar arch. If skin grafts are used, especially if extensions
of skin into the web space or onto the dorsum of the foot have been made, some patients have had trouble
with hyperkeratotic irregularities.
The functional and cosmetic results depend on careful preoperative and intraoperative planning but also on
the anatomy of the transferred toe. Some toes are unacceptable for transfer because of the extreme amount
of interphalangeal joint flexion. Again, more flexion is probably acceptable for thumb replacement rather
than for finger replacement.
Return of function is the ultimate goal, and this depends on the development of adequate sensation.
Reported two-point discrimination has varied from 7 to 15 mm. Actual functional correlation often depends
more on patient attitude than on two-point testing.
SUMMARY
The second toe can be used to reconstruct thumb or finger loss. It can also be filleted and used for volar
soft-tissue loss of a finger. It has the advantage over all other techniques of being a neurovascular transfer
with appropriate cortical representation.
References
1. Buncke HJ, Schulz WP. Immediate Nicoladoni procedure in the rhesus monkey, a hallux-to-hand
transplantation, utilizing microminiature vascular anastomoses. Br J Plast Surg 1966;19:332.
2. O'Brien B McC, MacLeod AM, Sykes PJ, Donahoe S. Hallux-to-hand transfer. Hand 1975;7:128.
3. Ohmori K, Harii K. Transplantation of a toe to an amputated finger. Hand 1975;7:134.
4. Strauch B. Microsurgical approach to thumb reconstruction. Orthop Clin North Am 1977;8:319.

Chapter 290
Wraparound Toe Flap
W. A. MORRISON
The hallux has all the characteristics of a thumb, including nail, pulp, and glabrous skin; but it is usually too large
and after such a total transfer the secondary defect in the foot is cosmetically unacceptable. The uniquely thumb-
like properties of the big toe can be transferred and wrapped around either a degloved thumb or a bone graft
while the hallux is reconstructed (1, 2).
INDICATIONS
The wraparound toe sleeve is optimally indicated to resurface traumatically or surgically degloved thumbs,
where skeleton and tendon anatomy remain intact. Combined with a bone graft, it is the method of choice
for thumb reconstructions distal to the metacarpophalangeal joint, as it achieves the best compromise
between function, aesthetics, and secondary morbidity. In these cases, restoration of articular function is
not essential.
ANATOMY
Approximately three-quarters of the integument of the hallux, including the nail, is transferred by vascular
anastomosis of the dorsalis pedis system of the toe, to the radial artery system at the wrist. This macro type of
microvascular anastomosis ensures survival on the order of 100%.
FLAP DESIGN AND DIMENSIONS
The ipsilateral toe is chosen, because the scar seam will lie on the nondominant radial aspect of the
reconstructed thumb, and the dominant lateral plantar digital nerve will become the dominant ulnar digital nerve
in the thumb.
The circumference and length of the opposite normal thumb are measured, and a template is made for marking
the donor toe. A medial skin bridge extending around the tip is preserved, the width being the difference between
the circumference of the thumb and the circumference of the toe (Fig. 290.1A and B). Dorsal veins and the
dorsalis pedis artery are identified proximally on the dorsum of the foot and traced into the toe flap.
OPERATIVE TECHNIQUE
Donor Site
The dorsal metatarsal artery becomes continuous with the plantar system as it passes plantarward around the
intermetatarsal ligament. The plantar system is ligated, as is the branch to the second toe. The toe flap is then
elevated (Fig. 290.1C), including the terminal one-third of the distal phalanx of the hallux, which is preserved with
the flap still attached to the nongerminal nailbed (Fig. 290.1D). The nailbed proximal to this level is raised
subperiosteally, using a flat elevator to avoid damage to its undersurface. This provides a vascularized bone
segment and nailbed support to the reconstructed thumb. Paratenon is preserved over the extensor and flexor
tendons, and the digital nerves are located in the pulp and sectioned as far proximally as is required for repair
with proximal thumb nerves.
The flap is now totally freed, except for its arterial and venous attachments dorsally. If the nail is wider than the

P.782
corresponding thumbnail, then the flap can be turned upside down and the proximal lateral limits of the nailbed
easily defined. The proximal corners of the nailbed are excised obliquely, so that the outgrowing nail will be
appropriately narrowed.
A bone graft from the iliac crest or the subcutaneous border of the tibia is removed and shaped for the skeleton.
No matter what the sculptured shape, all bone grafts under stress will mold themselves straight, so that
excessive contouring is naive. The graft should be made as large as can be accommodated within the toe flap, to
allow for some possible resorption.
Simultaneous with the thumb revascularization, the toe defect is closed. A further one-third of the distal phalanx
is removed, leaving only the proximal one-third intact. The tip flap is folded around the tip and any portion of
doubtful viability is excised. A large cross-toe flap from the dorsum of the second toe is raised based medially,
and is used to close the plantar defect of the hallux (Fig. 290.1F). The dorsum of the big and second toes is
covered with a split-thickness skin graft. The cross-toe flap is divided at 2 months; at that time some cosmetic
revision of the thumb pulp may be undertaken, because there is considerable variance in the aesthetics of the
hallux pulp from one person to another.
FIGURE 290.1 A: Toe markings, dorsal view, showing retained medial and tip flap and dorsal foot incision. B:
Toe markings, medial view. C: Toe flap dissection, with dorsal vasculature. D: Toe flap wrapped around the
interposition bone graft and transfixed with a longitudinal Kirschner wire. E: Toe flap sutured into position. F:
Toe defect reconstructed on plantar surface with a cross-toe flap.
Recipient Site
The dorsal radial artery and cephalic vein are located just proximal to the wrist crease, and the nerves to the
thumb are isolated and trimmed. The bone graft is measured for interposition between the thumb stump
proximally and the hallux segment distally, where it will be fixed with Kirschner wires.
The toe flap is then detached from the foot and transferred to the thumb, where it is wrapped around the bone
graft and sutured loosely into position. A longitudinal Kirschner wire transfixes the bony segments (Fig. 290.1D).

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The vascular pedicle is tunneled through a widely undermined dorsal skin bridge to the snuffbox and the
anastomoses performed, the flap artery end-to-side of the radial artery, and the flap vein end-to-end to the
cephalic vein (Fig. 290.2C). The digital nerves are finally repaired and the skin closed (Fig. 290.1E). Great care
is required to monitor the tension at the suture line, particularly distally at the nail area, where in many cases
some sutures will require release to restore circulation.
SUMMARY
The wraparound toe flap is an excellent method to reconstruct thumb degloving injuries and is indicated for
total thumb reconstruction when sacrifice of the toe is not desired.
FIGURE 290.2 A: Complete traumatic amputation of the thumb just distal to the metacarpophalangeal joint
in a 33-year-old man. B: Toe flap raised, including the distal one-third of the distal phalanx. C: Toe flap
wrapped around the bone graft and the vascular pedicle transferred to the snuff box. D,E: Twelve months
following reconstruction by the “wraparound” method of thumb reconstruction. F: Toe defect reconstructed
with a cross-toe flap to the dorsal surface. (This differs from current policy where the toe flap is now

routinely taken from the dorsum of the second toe and applied to the plantar surface of the hallux. The
dorsal defect is grafted.)
References
1. Morrison WA, O'Brien BM, MacLeod AM. Surgical repair of amputations of the thumb. Aust N Z J Surg
1980;50:237.
2. 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.

Chapter 291
Microneurovascular Partial Toe Transfer
G. FOUCHER
F. VAN GENECHTEN
Since the first successful experimental toe-to-hand transfer in 1965 (1), numerous techniques have been
described, including partial toe transfer either as a single-tissue transfer (pulp) or as a combination-of-composite-
tissue transfer (pulp, nail, bone, joint, epiphysis, tendons).
INDICATIONS
Transfers can be separated into six groups, according to the parts transferred. Different methods of partial
transfer can be used, whether from the first toe, the second toe, or both toes: free toe pulp; composite
transfer with pulp; nailbed; pulp and nail-complex combination of pulp, nail, and bone fragment; nail complex
on its own; double composite toe transfer; and free joint transfer.
Free Pulp Transfer
This technique can replace a traumatic or surgical loss of tissue (tumor), an insensitive pulp (abdominal
flap), or an atrophic or painful pulp. It can also provide sensation at the radial aspect of a mitten hand that
has been covered with an insensitive abdominal flap.
Indications for transfer appear when it seems impossible or inadequate to use local heterodigital or distant
flaps (2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13, 14). This situation can occur in cases with extensive tissue loss or
when it is not possible to obtain good quality skin cover for the thumb or index finger, especially as regards
skin texture or skin sensation. Another good indication is the hand with multiple injured digits. The free toe
pulp transfer avoids the cold intolerance at the donor site frequently noted after a heterodigital island flap.
But the island flap still remains useful in the reconstruction of a moderate loss of skin on a thumb.
Tailor-Made Composite Pulp Transfer
Sometimes it is desirable to transfer toe pulp together with other necessary structures at the same time,
e.g., with nailbed, with nailbed and chip of bone, or with nailbed, nail matrix, and bone. It is thus possible to
avoid a nail horn deformity in certain complicated amputations by lengthening the nailbed support with a
fragment of bone.
Filleted Toe Transfer (3)
There are only a few indications for this technique. One category is the transfer of a filleted toe cap,
transferring the nailbed and the pulp. This technique is comparable to the wraparound procedure (see
Chapter 290). The filleted transfer is used to cover a digit that is not to be amputated, either for aesthetic or
functional reasons. (This second technique was used in only one case of skin avulsion of second and third
fingers.)
Transfer of the Nail Complex
We have done such a procedure once on a dominant thumb of a child. It has been well proven that the nail
plays an important role in grip precision and in the quality of sensation.
Double Composite Transfer
In cases of amputation of the thumb at the interphalangeal joint or at the proximal phalanx, transfer of the
big or second toe is rather unaesthetic. The big toe is too voluminous and the second toe too thin.

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Sometimes it is possible to use only partial composite tissue transfer of the big toe, but this technique is
often insufficient, particularly in male patients. Therefore, a more elaborate vascularized double transfer is
possible: a tailor-made skin pulp with nail is dissected from the big toe in continuity with the adjoining pulp
of the second toe and part of its bony structure and neighboring joint (see Fig. 291.5).
Free Joint Transfer (4)
The majority of experimental studies have shown that in the absence of vascularization, the transferred
joints show progressive changes in the cartilage and growth plate. However, a few successful clinical
results have been reported (5, 6) where the epiphysis remained active after nonvascularized transfer.
Experimentally, only vascularized joints have shown both little histologic alteration and that the epiphysis
remains open (7, 8) (see Fig. 291.6).
Indications for a microsurgical joint transfer must be weighed against the use of a nonvascularized transfer,
Swanson spacers, or even arthrodesis. Whichever technique is used, the results are usually not above
merely average. The microsurgical transfer, in our opinion, finds its strongest indication in
multiple proximal interphalangeal joint trauma of index and middle fingers with loss of skin, joint, bone, or
tendon elements, in young patients. It has the great advantage of providing composite tissues with growth
potential and will result in a useful range of motion.
FIGURE 291.1 A: Pulp transfer (seven cases). B: Web transfer (one case).
ANATOMY
Anatomic studies (9, 10) have clearly shown the double arterial vascularization of the toes. The vascular supply
comes from the dorsal arch (dorsal metatarsal artery) and from the plantar arch, anastomosing with each other at
the distal level of the first intermetatarsal space. This distal communicating artery is important, as it will make it
possible to dissect the dorsal artery in continuity with the collateral plantar arteries when necessary.
DESIGN AND DIMENSIONS
Free Pulp Transfer
This procedure allows the transfer of pulp from the first or second toes, with its neurovascular bundle, to an
important finger such as the thumb or index. The ipsilateral foot is used for thumb and the contralateral for index
reconstruction.

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FIGURE 291.2 A: Pulp + nailbed (one case). B: Pulp + nail + bone (four cases). C: Pulp + nailbed + bone (six
cases).
We prefer to use a transfer from the big toe (Fig. 291.1A). Although in our experience sequelae at the level of the
second toe are rare, the discrepancy in the size of the plantar nerves forces a Y-shaped anastomosis to only one
recipient digital nerve. Sensory discrimination at the donor site is also of some importance. It has been
established that the second toe has a two-point discrimination of less than 10 to 25 mm, compared with 7 to 18
mm for the first toe pulp (11). Furthermore, there is an important advantage to the large surface area available at
the big toe. Since the description of an advancement island flap (12), we have seen no further indications for
second toe pulp transfer.
In cases of complex amputation, it is sometimes useful to cover the thumb and the radial lateral side of the hand
by a first web transfer (9, 13, 14). After such transfers, a sensory reeducation program is necessary. The best
two-point discrimination we obtained was in the range of 3 to 4.5 mm after a 6-month reeducation program (Fig.
291.1B).
Tailor-Made Composite Pulp Transfer
A bone chip attached to the pulp is dissected from the big toe and the distal nail flap is turned over 90° in contact
with the bone fragment. In cases of trauma of the nail matrix, it is desirable to replace the matrix as well. In these
cases, either the distal part of the second toe or part of the nail matrix of the big toe can be used (Fig. 291.2).
FIGURE 291.3 A: Distal second toe (two cases). B: Wraparound (one case).

FIGURE 291.4 Nail complex (one case).
Free Filleted Toe Transfer
When the avulsed finger skeleton is still intact, with well-vascularized flexor tendon structures, it is feasible to
cover more than two-thirds of the whole finger. The remaining one-third is usually covered with skin grafts. The
result is cosmetically acceptable because of the presence of the nail, and functionally acceptable because of
distal sensibility and the well-maintained vascularization of the flexor tendon (Fig. 291.3).
Transfer of the Nail Complex
It is possible to transfer only the nail (with the nail root and the nailbed) from the big toe, as a free transfer with its
arterial and venous elements (Fig. 291.4).
FIGURE 291.5 Double composite (twisted two toes) (four cases). A: Type I. B: Type II.
Double Composite Transfer
In one case we used the vascularized total skeleton of the second toe, wrapped in a skin envelope coming only
from the big toe. When necessary, even the flexor and extensor tendons can be left attached to the skeleton of
the second toe. After turning the two elements 180°, the skeleton of the second toe can be wrapped in the
composite skin nail flap of the big toe. The recipient thumb will be functional, with an acceptable aesthetic result.
The immediate vascularization of the bone graft will avoid the risk of absorption of the iliac bone graft used in the
wraparound procedure (3). In the foot the denuded bone of the big toe is then covered with the filleted remaining
skin and nail of the second toe, after the secondary ray is removed more proximally (Fig. 291.5).
Vascularized Joint Transfer
Between 1975 and 1982, six cases of free vascularized joint transfers were done. It is difficult to compare these
transfers with more conventional techniques, as indications differ. The advantage of a vascularized transfer lies
in the very fact that it is possible to use it as a composite transfer, allowing restoration in a single stage of skin,
bone, joint, and tendon loss. If growth is desirable, a vascularized transfer is strongly indicated (Fig. 291.6).
The transfer of the proximal interphalangeal joint of the second toe, rather than of the metatarsophalangeal joint,
is chosen because of its better range of motion. The metatarsophalangeal

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joint represents limited flexion and hyperextension of 35° to 45°, necessitating a reverse inset and thereby losing
the advantage of a composite transfer to provide skin cover and tendon reconstruction. The size of this
metatarsophalangeal joint is disproportionate to the proximal interphalangeal joints of the fingers. The proximal
interphalangeal joint of the second toe, although smaller in size, can easily be accommodated as a transfer with
the skin and tendon space at the level of the proximal interphalangeal joint of the fingers. Flexion will reach 90°
after regular night splinting, although the extension deficit will range from 20° to 30°.
FIGURE 291.6 Joint transfer (six cases).
The bone requires sufficiently stable fixation to allow early mobilization. An endomedullary osteosynthesis,
“corkscrew” type with a simple screw or screw plus cement, is our preferred technique. There is often an
important deficit in extension that is difficult to explain, but possible explanations include preexisting flexion of the
toe, difficult tension adjustment of the extensor tendon, too long interposed bony segments, the effect of
bowstringing of the flexor tendon over the transferred joint, or shifting of the lateral extensor slips of the recipient
finger.
OPERATIVE TECHNIQUE
Donor Site
Complete dissection of the vascular supply to the toe could be achieved from the dorsal aspect of the foot in the
majority of cases. When the skeleton of the second ray is used, a high division of the second metatarsal bone
will not only permit access to the plantar vascular system and the flexor tendons, but will also improve closure of
the donor site in the foot after the suturing of the intermetatarsal ligament. The absence of a scar on the sole of
the foot will allow earlier walking by the fifth day postoperatively. This approach also permits exploration of the
plantar metatarsal artery in the second intermetatarsal space in those cases where the dorsal or plantar network
of the first intermetatarsal space appears to be inadequate.
A study of foot pressure prints has shown that resection of the second ray in the foot does not alter the weight-
bearing pattern in any important way. Only in some cases did we notice a tendency to hallux valgus.
The veins are selected out of the dorsal venous network, usually at the side of the greater saphenous vein. The
nerves are chosen according to the type of transfer and the size of the recipient nerve ends. The size of the
plantar nerves of the big toe corresponds, in most cases, to that of the recipient volar digital nerves. However,
there is a discrepancy in size between the nerves of the second toe and the nerves at the recipient site.
Recipient Site
The material used for bone fixation can be introduced at the level of the donor site, before dividing the vascular
pedicle. Kirschner wires are usually sufficient in partial transfer. In certain cases, however, we recommend an
intramedullary type of osteosynthesis, such as with intramedullary screws, a “block nail,” or a “bilboquet.” This
type of osteosynthesis, sometimes cemented, will allow burying all the material in the medullary canal with stable

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fixation of the bone, and it facilitates the manipulation of tissues later in the procedure. Sometimes it is possible
to telescope the toe phalanx into the phalanx of the recipient digit and fix it with an axial Kirschner wire. We use
this latter technique in many cases involving children.
Meticulous nerve anastomoses are important, because the functional result will often depend on the quality of
sensation regained. The anastomosis must be placed as distal as possible on the recipient nerve. In cases of
partial second toe transfer, there will often be a marked discrepancy between size in the donor and the recipient
nerves. In these cases we join both donor nerve ends as a Y to one recipient nerve. In selected cases it is
advisable to suture some branches of the musculocutaneous nerve of the foot to the radial nerve of the hand.
The extensor tendons are sutured with overlap of both ends; the flexor tendons are sutured in the classic way,
staggering the position of the suture lines of the flexor profundus and flexor superficialis tendons. Discrepancy in
size between the flexor tendons of the second toe and the hand flexors is managed by wrapping the larger
tendon around the smaller one. Only the flexor profundus has to be repaired in the thumb, but resecting the
superficial flexor tendon slips of the foot too distally must be avoided.
We then deal with the arterial anastomosis. In cases of thumb reconstruction we use the radial artery as the
recipient vessel, with an end-to-side or end-to-end anastomosis. In the end-to-end anastomosis we shift the
radial artery from underneath the extensor pollicis longus. In a few cases we used the pollicis princeps artery as
recipient with an end-to-end anastomosis. In other cases it was feasible to dissect the proximal end of a donor
artery in a T shape at the level of the dorsal or plantar arch in the first intermetatarsal space. This T shape can
be interposed as an arterial graft with end-to-end anastomosis, thereby preserving the continuity of the radial
artery at the donor site. But this depends on the length of the vascular pedicle and is not always possible.
In reconstruction of a long finger, we also use an end-to-end anastomosis between the division of the common
digital artery and a dorsal or plantar intermetatarsal artery of the same diameter. This has the advantage of not
excessively disturbing the digital vascular supply through the contralateral digital artery and the transverse
retrotendinous vessels.
Finally, after tunneling the vein under a dorsal skin bridge, the anastomosis is performed through a small
transverse incision on the dorsum of the hand, to keep external scarring to a minimum. The donor vein is
preferably drained through a side branch, to avoid venous congestion.
CLINICAL RESULTS
In our unit at Strasbourg, of 65 toe transfers with a 7.7% rate of failure, 33 were partial transfers. The
average age of the patients was 31 years; the youngest was 11 years old and the oldest 46.
SUMMARY
Toe transfer adds a variety of new techniques and alternatives to reconstructive surgery of the hand. It
allows a tailor-made finger reconstruction in an elegant one-stage repair for certain otherwise difficult or
impossible mutilations.
References
1. Buncke HJ, Schulz WP. Immediate Nicoladoni procedure in the rhesus monkey, a hallux-to-hand

transplantation, utilizing microminiature vascular anastomoses. Br J Plast Surg 1966;19:332.
2. Buncke HJ. Toe digital transfer. Clin Plast Surg 1976;3:49.
3. Morrison WA, O'Brien BM, MacLeod AM. Thumb reconstruction with a free neurovascular wrap-around
flap from the big toe. J Hand Surg 1980;5:575.
4. Buncke HJ, Daniller Al, Schulz WP, Chase RA. The fate of autogenous whole joints transplanted by
microvascular anastomoses. Plast Reconstr Surg 1967;39:333.
5. Foucher G, Hoang P, Citron N, et al. Joint reconstruction following trauma: comparison of microsurgical
transfer and conventional methods: a report of 61 cases. J Hand Surg [Br] 1986;11-B:388.
6. Tsai TM, Jupiter J, Kutz JE, Kleinert HE. Vascularized autogenous whole joint transfer: a clinical study. J
Hand Surg 1982;7:335.
7. Hurwitz PH. Experimental transplantation of small joints by microvascular anastomoses. Plast Reconstr
Surg 1979;64:221.
8. Tsai TM, Ogden L, Jaeger SH, Okubo K. Experimental vascularized total joint autografts: a primate study.
J Hand Surg 1982;7:140.
9. Gilbert A. Composite tissue transfers from the foot: anatomic basis and surgical technique. In: Daniller AT,
Strauch B, eds. Symposium on microsurgery. St. Louis: Mosby, 1976.
10. May JW, Chait LA, Cohen BE, O'Brien BM. Free neurovascular flap from the first web of the foot in hand
reconstruction. J Hand Surg 1977;2:387.
11. May JW, Daniel RK. Great toe-to-hand free tissue transfer. Clin Orthop 1978;133:140.
12. 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.
13. May JW, Chait LA, Cohen BE, O'Brien BM. Free neurovascular flap from the first web of the foot in hand
reconstruction. J Hand Surg 1977;2:387.
14. Strauch B, Tsur H. Restoration of sensation to the hand by a free neurovascular island flap from the first
web space of the foot. Plast Reconstr Surg 1978;62:361.

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Chapter 292
Trimmed Big-Toe Transfer for Thumb Reconstruction
N. CARVER
F.-C. WEI
EDITORIAL COMMENT
This is an excellent technique for reconstruction of the thumb, which relies on some of the older methods
but advances them to a new height. By reducing the bone stock, a thumb of normal caliber closely equal to
that on the opposite hand can be reconstructed.
The trimmed big-toe transfer for thumb reconstruction (1) is a combination of the wraparound (2) and total big-toe
transfer methods (3, 4). This technique involves reduction of both bony and soft-tissue elements along the
medial aspect of the transferred big toe, to produce a more normal-sized thumb.
INDICATIONS
Total big-toe transfer would be appropriate when toe size is comparable to that of the normal thumb, and in
cases where there is associated severe injury to the remainder of the hand and optimal hand function is the
main concern. Second-toe transfer would be more appropriate for patients unable to tolerate the loss of the
big toe; when the second toe is comparable in size to the normal thumb; and when less than optimal
function and appearance of the reconstructed thumb are required. The big-toe wraparound flap is more
appropriate for thumb amputation distal to the interphalangeal joint, or for thumb-skin avulsion distal to the
metacarpophalangeal joint, with intact interphalangeal joint function.
The trimmed big-toe transfer is for thumb reconstruction at or distal to the metacarpophalangeal joint. This
technique is indicated when the big toe is much larger than the normal thumb, and when the motion of the
interphalangeal joint and the appearance of the thumb are equally important (5). Patients should expect and
accept the cosmetic deformity and possible functional impairment in the absence of the big toe; however,
these are generally relatively mild.
Among the major techniques for thumb reconstruction, the total big-toe, big-toe wraparound, and trimmed
big-toe transfers
provide greater strength and a more stable surface for pinch and grasp than any second-toe transfer (6),
and are more suitable for some types of manual workers. Because of its relatively small size and the
possible claw appearance, the second-toe transfer generally provides an obviously inferior thumb
replacement.

FIGURE 292.1 Design of the trimmed big-toe flap.
ANATOMY
Although the big toe has most of the features of a thumb, it has a greater circumference (transverse diameter),
nail width, and phalangeal and joint size (1). The widest transverse diameter can be up to 12 mm larger than that
of the thumb, and the nail width 4 mm larger. The difference in the size of the bony elements is approximately 2
mm for the distal phalanx, 4 to 6 mm for the interphalangeal joint, and 4 mm for the proximal phalanx. These
measurements are guidelines for the trimming procedure.
Anatomic variations relating to this flap and other toe transfers primarily concern the anatomy of the vascular
pedicle (7, 8, 9). In most cases, the dominant vessel entering the first web space is the first dorsal metatarsal
artery, which divides to supply the lateral digital artery of the big toe and the medial digital artery of the second
toe. Proximally, this vessel (which is a continuation of the dorsalis pedis artery) can be either superficial or deep
in relation to the first dorsal interosseous muscle, but it always passes dorsally over the transverse metatarsal
ligament. In a minority of cases, a plantar metatarsal artery is the dominant vessel that courses deep to the
transverse metatarsal ligament.
FIGURE 292.2 Operative procedure for trimmed big-toe harvest. A: Elevation of a medial skin strip. B: Elevation
of an inferiorly based periosteum-medial collateral ligament- joint capsule flap. C: Longitudinal osteotomy of the
phalanges and joint. D: Final preparation of the periosteum-medial collateral ligament- joint capsule flap. E:
Closure of the trimmed-toe wound before transfer.
To avoid confusion during pedicle dissection, proceeding in a distal-to-proximal direction is recommended,
starting with identification of the common digital artery and its branches in the first web space (10). The
dissection continues 1 to 2 cm proximally, to determine whether the dorsal or plantar metatarsal artery is
dominant. If both vessels are of similar caliber, the dorsal vessel is preferred, since its dissection is easier and

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the pedicle longer. If the plantar vessel is significantly larger, it should be dissected proximally. However, plantar
dissection to obtain a long pedicle can be tedious and more destructive to the foot; the use of a vein graft should
be considered.
Venous drainage proceeds from the dorsal veins of the big toe to join with others to form the greater saphenous
system.
FLAP DESIGN AND DIMENSIONS
The circumference of the normal thumb is measured at three points: (1) at the nail eponychium; (2) at the widest
point (the interphalangeal joint); and (3) at the middle of the proximal phalanx. A longitudinal line is drawn from
the distal edge of the big toe along the medial side of the nail to the base of the proximal phalanx, preserving the
nail fold. Measurements from the normal thumb are then transposed to corresponding points on the big toe,
starting at the longitudinal line and leaving a medial strip of skin representing the difference between toe and
thumb dimensions (Fig. 292.1). The toenail is not reduced in size, to avoid deformity of the nail fold. To each
circumferential measurement, 2 to 3 mm are added to allow a tension-free closure. The medial skin strip usually
measures 0.8 to 1.5 cm in width, and is tapered to a point around the tip of the toe 2 mm beneath the nail, to
facilitate skin closure.
The proximal circumferential skin-incision line and level of proximal bone division are determined by the level of
thumb amputation.
OPERATIVE TECHNIQUE
Dissection is performed under tourniquet control. The vascular pedicle is dissected from distal to proximal, to
avoid the possible anatomic confusion described above. The medial skin strip is elevated from distal to proximal
(Fig. 292.2A). The
skin incision is deepened to the periosteum at the tip of the distal phalanx, and includes only soft tissue and skin
on the medial side of the toe above the medial collateral ligament. A second dorsal longitudinal incision is then
made through the periosteum along the dorsal margin of the medial collateral ligament and joint capsule. This
tissue is then elevated in a subperiosteal plane to the midplantar surface of the proximal and distal phalanges,
creating a periosteum-medial collateral ligament-joint capsule flap (Fig. 292.2B). This also exposes the medial
bony excess of the proximal and distal phalanges, which is to be removed.
FIGURE 292.3 Traumatic thumb amputation at the level of the interphalangeal joint.

FIGURE 292.4 A-D: Appearance of thumb reconstructed with the trimmed-toe transfer.
A longitudinal osteotomy is then performed with an oscillating saw, to remove 4 to 6 mm of the medial proximal
interphalangeal joint prominence, and 2 to 4 mm of the shafts of the distal and proximal phalanges. Rasping of
the bone edges will ensure a smooth contour (Fig. 292.2C).
The periosteum-medial collateral ligament-joint capsule flap is then redraped over the raw bony surfaces and
closed tightly with interrupted sutures, after trimming any excessive bulk (Fig. 292.2D). The medial skin incision
is closed, and the level of proximal bone division is selected (Fig. 292.2E). At least 1 cm of proximal phalanx
should be left, to preserve the important weight-bearing area. The lengths of the vascular pedicle, plantar digital
nerves, and flexor and extensor tendons are selected from the recipient-site dissection performed by a second
team.
Following flap harvest, the donor site is closed primarily. If necessary, the proximal part of the medial skin strip is
used to achieve tension-free closure.
Transfer of the trimmed big toe is then performed with osteosynthesis, tendon repair, nerve suture, skin closure,
and microvascular anastomoses. Loss of first metacarpal bone length and inadequate soft tissue can be made
up by means of an iliac-crest bone graft and a pedicled groin flap in a pre-toe-transfer procedure. Reconstruction
at the interphalangeal joint level includes the functional interphalangeal joint of the toe transfer. Distal to the
interphalangeal joint, a modified big-toe wraparound flap can be harvested and trimmed of soft tissue and distal
phalanx in a similar manner.

If the pulp is still excessive after thumb reconstruction, it can be reduced at a second stage. Pulp debulking
involves excision of a midline elipse of skin and soft tissue from the interphalangeal crease to the thumb tip.
FIGURE 292.5 Appearance of the donor site following the transfer.
CLINICAL RESULTS
A review of patients following trimmed big-toe transfer (1) has found no patient complaints regarding the
size of properly trimmed toes (Fig. 292.3 and 292.4). Solid, stable, and painless pinch, grip, and movement
have been maintained in all patients. Interphalangeal joint movement averaged 20°, compared with 29° after
total big-toe transfers (11). Maintenance of interphalangeal joint movement facilitates the nail pinch needed
for fine manipulation. In those with isolated thumb injury reconstructed with trimmed big-toe transfer, grip
strength averaged 65% of the normal contralateral hand and key pinch averaged 75%.
Tight repair of the periosteum-medial collateral ligament- joint capsule flap ensures the stability of the
interphalangeal joint. Development of degenerative arthritis has not occurred. Biomechanical analysis and
clinical observation of foot function has shown no significant donor-foot deficits (Fig. 292.5). Preservation of
1 cm of the proximal phalanx improves the appearance and push-off function of the donor foot (12).
SUMMARY
The trimmed big-toe transfer is a useful technique of thumb reconstruction, providing the most normal
aesthetic appearance, as well as stable and mobile interphalangeal joint movement for grip and fine pinch.
References
1. Wei F-C, Chen HC, Chuang CC, Noordhoff MS. Reconstruction of the thumb with a trimmed toe transfer
technique. Plast Reconstr Surg 1988; 82:506.
2. Morrison WA, O'Brien BMcC, Mcleod A. Thumb reconstruction with a free neurovascular wrap-around flap
from the big toe. J Hand Surg 1980; 5:575.
3. Cobbett JR. Free digital transfer: report of a case of transfer of a great toe to replace an amputated thumb.
J Boint Joint Surg 1969;51B:677.
4. Buncke HJ, McLean DH, George PT, et al. Thumb reconstruction: great toe transplantation by
microvascular anastomosis. Br J Plast Surg 1973;26:194.

5. Wei F-C, Chen HC, Chuang CC, Chen SHT. Microsurgical thumb reconstruction with toe transfer
techniques: selection of various techniques. Plast Reconstr Surg 1994;93:345.
6. Leung PC. Thumb reconstruction using second toe transfer. Hand Clin 1985;1:285.
7. Gilbert A. Vascular anatomy of the first web space of the foot. In: Landi A, ed. Reconstruction of the thumb.
London: Chapman and Hall, 1989;199.
8. May JW Jr. Microvascular great toe to hand transfer for reconstruction of the amputated thumb. In:
McCarthy JG, ed. Plastic surgery, vol. 8. Philadelphia: Saunders, 1990;5153.
9. Leung PC. Thumb reconstruction using the second toe. In: Landi A, ed. Reconstruction of the thumb.
London: Chapman and Hall, 1989;199.
10. Wei FC, Silverman RT, Hsu WM. Retrograde dissection of the vascular pedicle in toe harvest. Plast
Reconstr Surg 1995;96:1211.
11. Poppen NK, Norris TR, Buncke HJ. Evaluation of sensibility and function with microsurgical free transfer
of the great toe to the hand for thumb reconstruction. J Hand Surg 1983;8:516.
12. Wei F-C, El-Gammal TA, Ma HS, et al. Biomechanical analysis of foot function following big toe transfer
with preservation of the proximal phalangeal base. Plast Reconstr Surg in press.

Chapter 293
Rhomboid-to-W Flap
H. BECKER
The rhomboid to-W-technique can be used successfully on the dorsum of the hand and on overlying finger joints
(Fig. 293.1). See Chapter 101.
FIGURE 293.1 A: Lesion excised from the dorsum of the hand. Flaps outlined. B: Result after closure. Note that
tissue is borrowed from all four directions. See Chapter 101 for the geometric details of the flap. (From Becker,
ref. 1, with permission.)
Reference
1. Becker H. Rhomboid-to-W flap. Ann Plast Surg 1983;11:125.

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Chapter 294
Palmar and Thenar Innervated Skin Flaps to The Hand
B. B. JOSHI
EDITORIAL COMMENT
The hand surgeon generally does not consider the use of palmar skin for flap source material. This chapter
demonstrates the availability and usefulness of this tissue in selected cases.
In degloved, mutilated hands where skin for transfer is very scarce, palmar flaps have been used following the
principles of sliding and rotation, with later conversion into island flaps for further distal migration and adjustment.
These flaps can provide sensation to the areas of contact needed in pinch and grasp (1, 2).
INDICATIONS
The main indications for these flaps are in transverse amputations of the hand with degloved phalangeal
remnants that have been covered with skin grafts but are anesthetic, or in a metacarpal hand in which
either the thumb or the ulnar post is to be reconstructed by osteoplastic technique, using a tube pedicle and
bone graft.
ANATOMY
The hand is richly supplied by blood vessels. The radial and ulnar arteries anastomose freely in the palm as
superficial and deep palmar arches. Common volar digital vessels arise from the superficial arch and run toward
the respective web spaces, to divide into volar digital vessels for the fingers. The branches from the median and
ulnar nerves accompany the common volar digital vessels in the palm and are deep to the palmar fascia,
continuing to give twigs to it as perforating branches for the overlying skin. If dissection is made in the deeper
plane to the vessels and nerves, arterialized flaps of palmar skin can be raised.
The area supplied by the median and ulnar nerves is well known, although some variations are not uncommon.
In addition, there is sensory overlap provided by the diffuse plexus formed in the palm by cutaneous branches of
the terminal part of the radial nerve, the lateral cutaneous nerve of the forearm, the medial cutaneous nerve of
the forearm, and palmar cutaneous branches of the median and ulnar nerves.
FLAP DESIGN AND DIMENSIONS
The various flaps included in this group are essentially neurovascular and are based on known volar digital
vessels and nerves. They can be converted into island flaps on their specific neurovascular connections.
The initial advancement is by rotation along with the nerves and vessels ensheathed in the flaps, and additional
advancement is achieved by flexing the metacarpophalangeal joints.
The flaps may be designed as Z-plasties, taking advantage of the loose skin over the stumps that is then used to
fit into the defect created at the donor site. Where this is not possible, split-thickness skin grafts are used to
cover the donor defect.

FIGURE 294.1 Line drawings of the various flaps. A: Thenar flap. A is either used as a transposition flap to
cover a thumb defect or as a sliding flap to cover the distal end of an index amputation stump. Flaps B and D are
transposed to cover the remaining distal stumps. B: Flap D is radially based and can be used to cover a radial
hand amputation stump. Flap E is similar to that shown in A and is ulnarly based. (From Joshi, ref. 1, with
permission.)
The flaps have limited advancement, from 2.5 to a maximum of 3 cm, because of restrictions imposed by
neurovascular connections and palmar fascia. Tension on the neurovascular bundles is minimized by mobilizing
them proximally and sectioning the palmar fascia and its septal connections down to the wrist. When one is
undermining the flap, the nerves and vessels entering it are kept clinging to its deeper surface, since the
neurovascular supply is from perforating twigs arising from these structures.
OPERATIVE TECHNIQUE
Palmar Skin from the Thenar Region and Base of the Index Finger (Fig. 294.1A)
The flap A is based mainly on the palmar cutaneous branch of the median nerve and the cutaneous twigs from
the digital branches to the index finger that enter its central portion along with the twigs from common volar digital
vessels. Marking of flap A is shown in Figure 294.1. The thenar crease line is extended to the base of the index
finger and includes the common palmar digital branch of the median nerve.
The thenar flap in Figure 294.2 is used to provide sensation over the palmar aspect of a thumb that has been
reconstructed using a tube pedicle in a radial hemiamputated hand.
The flap can also be used in the form of a sliding island flap, as the nerve and vessels enter it as in an umbrella
(Fig. 294.3A and B). It can easily be shifted distally for about 2.5 cm or so as an island flap, and can later be
converted into a creeping flap for further migration (Fig. 294.3C and D).
Ulnar Flap from the Base of the Index and Middle Fingers (Fig. 294.1A)
This is a rotation flap B developed from the skin over the bases of the middle and index fingers. It incorporates
the digital branches of the median nerve. The flap can be used to provide sensation over the middle finger stump
or the central area of the degloved metacarpal hand (Fig. 294.4). Sensation over the radial aspect of the index
finger can be preserved by sparing the most radial common digital branch in this region and not including it in the
flap.
Radial Flap from the Base of the Middle and Ring Fingers (Fig. 294.1B)

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This flap D is based on a neurovascular bundle and is raised from the base of the index and middle fingers. The
flap will supply the innervated skin over the strategic area on the volar and radial aspects of the index finger
stump.
The three common digital branches of the median nerve are retained and migrated along with the flap after
dissection, to release them proximally in the palm (Fig. 294.5). The distal part of this flap can again be converted
into a creeping type of island flap for further advancement over the longer amputation stump.
Flap from the Ulnar Innervated Segment of the Palm (Fig. 294.1B)
The flap E is raised from the ulnar aspect and has digital nerves and vessels of the little finger and the ulnar
neurovascular bundles of the ring finger supplying the ulnar aspect of the palm. The flap is usually mapped distal
to the proximal palmar crease and is suitable for migration to the little finger stump (Fig. 294.5). It can also be
used to provide sensation to a reconstructed ulnar post in a metacarpal hand (Fig. 294.4).
FIGURE 294.2 Thenar flap transferred to thumb. (From Joshi, ref. 1, with permission.)

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FIGURE 294.3 A,B: Thenar flap as sliding island flap for index finger remnant. C,D: Later conversion of thenar
sliding island flap into sensory island for further migration on neurovascular attachments. (From Joshi, ref. 2, with
permission.)
FIGURE 294.4 Possible use of palmar skin at the strategic area of grasp in a degloved metacarpal hand. (From
Joshi, ref. 1, with permission.)

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FIGURE 294.5 A,B: Rotational advancement of radially based median flap for index finger stump. C,D: Ulnar
innervated flap for little finger. E: Postoperative result. (From Joshi, ref. 1, with permission.)
CLINICAL RESULTS
Following the transfer of these flaps, sensation may be diminished because of nerve stretching, but
recovery is rapid; sensation is regained within 10 to 12 weeks.
Marginal necrosis of the tip of the Z-plasty flap may occur if it is sharply angled, but this can be avoided by
rounding. No case of circulatory embarrassment has been noted.
A salvaged prehensile hand unit can stand positive comparison with an artificial limb because of the added
advantage of having sensation. The flaps described here can be used advantageously to provide a signal
area for the servomotor mechanism. The advancement of these flaps is a limited one, from 2.5 to 3 cm, and
the flaps can be helpful only in providing sensation over remnants of the proximal phalanx in degloved
hands or to a limited area of volar contact in reconstructed radial or ulnar posts in mutilated hands. The
grade of sensation achieved is tactile gnosis. The procedures are well appreciated by patients, as can be
judged by their agreement to surgery in multiple stages.
For sensory rehabilitation of the degloved, mutilated hand, slow advancement by multistage operations is
unavoidable, as failure will add further insult. The creeping method of advancement ensures safety in
conditions of scarcity. If we show a little ingenuity, many of these flaps can find their way into osteoplastic
reconstructive surgery of the mutilated hand.
SUMMARY

Various palmar and thenar innervated flaps can be used to provide some sensation to the injured hand.
References
1. Joshi BB. Sensory flaps for the degloved mutilated hand. Hand 1974; 6:247.
2. Joshi BB. Sensory flaps for the degloved mutilated hand. In: Campbell Reid JA, Gosset J, eds. Mutilating
injuries of the hand, G.E.M. Monograph No. 3. New York: Churchill Livingstone, 1979;12-21.

Chapter 295
First Dorsal Interosseous Muscle Flap
V. R. HENTZ
Use of the first dorsal interosseous muscle is possible in particular clinical instances when a small but
strategically located hand defect may be best covered by one of several muscle or musculocutaneous flaps
available in the hand, although the use of muscle or musculocutaneous flap procedures generally has only
limited application for defects in the upper limb.
INDICATIONS
The particular placement of the first dorsal interosseous muscle allows its use for small defects around the
metacarpophalangeal joint of the thumb, such as might occur with deep avulsion injuries or small electrical
burns with potential or definite joint exposure. Other indications might include small full-thickness injuries to
the dorsum of the hand in circumstances where rotation flaps might be less indicated, such as in ulcers
resulting from extravasation of chemotherapeutic substances, especially those that expose extensor
tendons devoid of paratenon.
Further indications hinge on the fact that the muscle can be transferred in such a way as to minimize the
functional deficit that accompanies complete paralysis of this muscle—as, for example, in an ulnar nerve
palsy with its sequelae of weak pinch and lateral instability of the index finger.
ANATOMY
The abundant blood supply to the upper limb allows the safe transfer of a great variety of intrinsic random flaps
whose use in the lower limb, for example, would fail. Although there are duplicate muscles to perform certain
functions in the upper limb and therefore potential sources for muscle or musculocutaneous flaps, very few exist
in the hand. When necessary, the mobility of the arm allows the hand to be brought easily to other potential
donor sites where, again, safe random flaps (such as the subclavicular or cross-arm flap) or so-called direct
arterial flaps (such as the groin flap) have been used routinely for coverage of both large and small hand defects.
The first dorsal interosseous muscle is a source for one of the several muscle or musculocutaneous flaps
available in the hand that can be used in particular clinical instances when a small but strategically located hand
defect may be best covered by flaps of this type. The muscle is located on the radial border of the index
metacarpal. It can potentially be transferred as either a muscle flap or a musculocutaneous flap, although its
location in the important first web space significantly limits its usefulness as a musculocutaneous flap because
the skin of that area is relatively privileged. It is a functionally important muscle, abducting the index finger at the
metacarpophalangeal joint and participating in stabilizing this digit against the considerable force of the thumb in
pinch, especially lateral or key pinch.
The muscle originates from the bases of the first and second metacarpals and inserts principally into the base of
the proximal phalanx of the index finger (1). There is a somewhat inconstant attachment to the radial lateral band
of the extensor mechanism over the proximal phalanx.
Innervation of the muscle is by way of the deep motor branch of the ulnar nerve that enters the muscle on its
deep surface in its proximal third. The principal blood supply comes from contributions from the dorsal branch of
the radial artery as it dives ulnarward in the first web space to contribute to the deep palmar arch (Fig. 295.1).

There are usually two or three specific branches to the muscle, either separately or as branches from the
princeps pollicis artery or the princeps indicis branch. These vessels supply the muscle in its proximal third, as
well. Therefore, the vascular anatomy of the muscle permits its transfer as a proximally based rotation flap.
In most instances, the muscle is divisible into two discrete masses, a dorsal radial and an ulnar portion (Fig.
295.2). The dorsal radial portion is more superficial, arises from the first metacarpal, and inserts primarily into the
extensor expansion at the proximal phalanx. The more volar and ulnar portion of the muscle, located closer to the
metacarpal, arises from the second metacarpal and has a bony insertion into the base of the proximal phalanx.
These two portions can be separated quite far proximally, and the more superficial portion used as a transfer,
leaving behind sufficient first dorsal interosseous muscle to provide some stability to the radial side of the index
finger, particularly in pinch functions.
FLAP DESIGN AND DIMENSIONS
The potential arc of rotation of the superficial portion of the muscle is demonstrated in Figure 295.3 (2). The
principal vascular pedicle arises from the dorsal branch of the radial artery as it dives palmarward between the
bases of the first and second metacarpals (Fig. 295.4).
FIGURE 295.1 A: The principal vascular pedicle arises from the dorsal branch of the radial artery as it dives
palmarward between the bases of the first and second metacarpals. B: In this dissection the two “heads” of the
muscle have been separated to demonstrate the multiple branches of the radial artery (AR) to each portion of the
muscle.
CLINICAL RESULTS
A significant functional deficit would result from transfer of the entire muscle. This would be particularly
noticeable as weakness in key pinch; for this reason the muscle is seldom used as a total transfer.

FIGURE 295.2 The dorsal radial (superficial) portion of the muscle is generally larger than the volar-ulnar
portion of muscle. It has been detached at its insertion to demonstrate the vascular intercommunications
between the two “heads.”
SUMMARY
The dorsal radial portion of the first dorsal interosseous muscle can be used in a few instances to cover
various defects, particularly around the metacarpophalangeal joint of the thumb (3).
FIGURE 295.3 The arc of rotation is illustrated. (From Mathes and Nahai, ref. 1, with permission.)

FIGURE 295.4 A,B: The dissected specimens illustrate potential sites of application for this flap.
References
1. Mathes SJ, Nahai F, eds. Clinical atlas of muscle and musculocutaneous flaps. St. Louis: Mosby, 1979.
2. Kaplan EB, ed. Functional and surgical anatomy of the hand. Philadelphia: Lippincott, 1953.
3. Stern P. Personal communication.

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Chapter 296
Abductor Digiti Minimi Muscle Flap
V. R. HENTZ
The abductor digiti minimi is a relatively expendable muscle, serving only to abduct the little finger—a function
performed somewhat by the extrinsic extensors to the little finger. For many years it has been used as a
functional transfer to replace loss of opposition of the thumb. In fact, it was among the first opponens transfers
described (1).
INDICATIONS
The abductor digiti minimi has been used clinically to cover small defects about the fifth metacarpal (2) and
the dorsal-ulnar aspect of the hand or carpus (3). It is particularly useful either
to assist in the revascularization of the median nerve at the wrist following neurolysis or nerve grafts, or as
padding over the median nerve following operations for recurrent carpal tunnel syndrome. Except for an
inability to widely abduct the little finger, the functional deficit resulting from its transfer is minimal.
FIGURE 296.1 The neurovascular hilum enters the muscle on its deep surface. The motor nerve usually
arises from the ulnar nerve, just as it divides into superficial sensory and deep motor components. The
muscle also receives additional blood supply via more distally located vessels, although the entire muscle
can survive on only its proximal vascular pedicle.
FIGURE 296.2 The volar and dorsal arcs of rotation are illustrated. (From Mathes and Nahai, ref. 4, with
permission.)

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FIGURE 296.3 Cadaver dissections illustrate several potential sites of use, for example, over a scarred
median nerve at the wrist or to cover a small defect on the dorsal ulnar aspect of the hand.
ANATOMY
The abductor digiti minimi takes its origin from the pisiform, the tendinous attachment of the flexor carpi ulnaris
and the base of the fifth metacarpal. It inserts into the base of the proximal phalanx of the little finger and
contributes to the formation of the ulnar lateral band.
The neurovascular anatomy is very constant (Fig. 296.1). Branches from the ulnar nerve and artery enter the
muscle on its deep surface near its origin.
FLAP DESIGN AND DIMENSIONS
The superficial location of the abductor digiti minimi on the ulnar aspect of the hand, and its very proximal
neurovascular arrangement, permit great mobility in transfer. The flap axis of rotation is depicted in Figure 296.2
(4). Several cadaver dissections (Fig. 296.3) demonstrate potential uses.
OPERATIVE TECHNIQUE
The muscle is easily exposed through an incision along the ulnar border of the hand. After detaching the
tendinous insertion, dissection proceeds proximally. Proximal dissection, and particularly separation from the
adjacent flexor digiti minimi, is sometimes difficult, although transfer of the flexor, in addition to the abductor digiti
minimi, seems to result in no greater functional deficit.
SUMMARY
The abductor digiti minimi muscle can be transferred to cover small defects about the dorsal-ulnar aspect of
the hand. Its use results in a minimal functional deficit.
References
1. Huber E. Hilfsoperation der Medianuslahmung. Dtsch Z Chir 1921; 162: 271.
2. McCraw J. Personal communication.

3. Reisman N, Dellon AL. The abductor digiti minimi muscle flap: a salvage technique for palmar wrist pain.
Plast Reconstr Surg 1983;72:859.
4. Mathes SJ, Nahai F. Clinical atlas of muscle and musculocutaneous flaps. St. Louis: Mosby, 1979;617.

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Chapter 297
Palmaris Brevis Turnover Flap As An Adjunct to Internal
Neurolysis of The Chronically Scarred Median Nerve in Recurrent
Carpal Tunnel Syndrome
E. H. ROSE
EDITORIAL COMMENT
This is a useful flap for secondary, tertiary, and quaternary carpal tunnels.
The palmaris brevis “turnover” flap as an adjunct to internal neurolysis, following failed primary carpal tunnel
release, can provide some degree of subjective and objective improvement. This local muscle flap is
recommended as a valuable adjunct in secondary surgery of the scarred median nerve.
INDICATIONS
Treatment failures occur in 3.2% to 19% of patients in large clinical series of carpal tunnel release (1, 2, 3,
4). In large series of reexploration, the most common pathologic findings are tenosynovitis or fibrous
proliferation within the carpal tunnel, compressing the nerve (5, 6). Symptoms return, on average, 1 to 1.5
years after the first surgery (6). In cases of severe epineural fibrosis or interstitial scar, internal neurolysis
has been suggested as an effective means of enhancing axonal regeneration of the chronically compressed
nerve (7, 8, 9).
Local transposition muscle flaps have been used to provide a nutritive interface between the neurolysed
median nerve and the adherent dysesthetic scar (10, 11, 12, 13). Several criticisms of this technique, using
the abductor digiti minimi muscle, have been offered (10). A new flap of palmaris brevis muscle has been
used as an adjunct to internal neurolysis in 11 patients (13 hands) with secondary decompression of the
median nerve in recurrent carpal tunnel syndrome. This broad, thin, vestigial sheet of muscle, immediately
adjacent to the carpal tunnel, is easily rotated over the dissected nerve, with no significant dynamic
functional deficit. The procedure affords additional cushioning superficial to the median nerve, and
apparently enhances neovascularization of ischemic fascicular surfaces.
The palmaris brevis flap affords additional blood supply to the “raw” nerve surface. Although it cannot be
proved that direct inosculation from the palmaris flap occurs at a fascicular level, an improved nutrient bed
is suggested by the indirect means of microangiogram, methylene blue studies, and latex injection.
Magnetic resonance imaging (MRI) demonstrates apposition of the nutrient muscle to the median nerve at 6
months' follow-up. In addition, the literature offers evidence for the efficacy of interposing muscle between
an injured nerve and dysesthetic scar tissue of the skin (10, 11, 12, 13, 14, 15). Improved grip strength
following the procedures is probably related to less tenderness of the palmar scar from aberrant nerve
endings; in addition to enhancing vascularity, the palmaris muscle flap may suppress the growth of nerve
sprouts into overlying skin.
A major advantage of the palmaris turnover flap is the proximity of innervated muscle to the surgical field,
obviating the need for a distant donor site and more lengthy operative procedure. No motor loss is created
by using the muscle; the “unroofed” ulnar neurovascular bundle is still well padded by thick hypothenar skin

and subcutaneous fat.
ANATOMY
The bifascicular, trapezoid-shaped palmaris brevis muscle is of variable size and thickness, but is absent in only
2% of cases (16, 17). The muscle arises from the flexor retinaculum in the midpalm and inserts in the fibrofatty
tissue along the ulnar margin of the hypothenar eminence and the pisiform. It lies palmar to the ulnar nerve and
artery, forming the “roof” of the ulnar tunnel of the wrist (Guyon's canal) (15, 16). Length averages 2.7 cm on the
radial border and 3.6 cm on the ulnar border. The average width is 2.6 cm.
There are two fascicular muscle groups or “heads,” each of which has its own neural and vascular supply. In
microfilm injection studies, both nutrient arteries usually arise from the deep palmar branch of the ulnar artery
distal to its bifurcation (Fig. 297.1). In one cadaver dissection, the proximal branch arose from the ulnar artery
slightly before the takeoff of the superficial arch. In another, the distal branch arose from the common digital
artery to the fourth cleft. In all dissections, the proximal nerve pedicle originated from the ulnar nerve trunk, and
the distal pedicle from either the common sensory to the fourth cleft or the ulnar sensory branch to the little finger
(Fig. 297.2). In one specimen, three motor branches to the palmaris brevis were noted.
FIGURE 297.1 Dual arterial blood supply to the palmaris brevis muscle. These arteries usually arise from the
deep palmar branch of the ulnar artery distal to its bifurcation. (From Rose et al., ref. 19, with permission.)
FIGURE 297.2 Motor branches of ulnar nerve to palmaris muscle. The proximal nerve pedicle arises from the
trunk of the ulnar nerve. The distal originates either from the common sensory nerve to the fourth cleft or the
ulnar sensory branch to the little finger. (From Rose et al., ref. 19, with permission.)
Microangiograms show a brisk vascular arcade within the palmaris brevis muscle mass (Fig. 297.3). Methylene
blue injections demonstrate the punctate capillary perforators on the surface of the muscle. The dorsal fascia,

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where the vascular network enters the muscle, was consistently present in all dissections and clinical cases,
regardless of the thinness of the muscle.
Radially, the dorsal fascia blends with the palmar aponeurosis and ulnarly with the hypothenar fascia. Proximally,
the dorsal fascia merges with the fibrofatty tissue over the antebrachial fascia, and distally with similar tissues in
the palm. The function of the palmaris brevis is “mysterious” (18); it contracts when the adjacent abductor or
flexor digiti minimi contracts, cupping the palm.
FIGURE 297.3 Microangiogram of elevated palmaris flap. Note brisk vascular arcade within muscle. (From Rose
et al., ref. 19, with permission.)
OPERATIVE TECHNIQUE (19)
The incision parallels the thenar wrist crease and extends transversely across the distal flexion crease of the
wrist (Fig. 297.4A). The tip of the skin flap is elevated subdermally to avoid injury to the palmar cutaneous
branch of the median nerve (20). The hypothenar flap is raised superficial to the palmaris brevis muscle fibers.
Sharp scissors or a knife is needed to section the numerous fibrous septa between the muscle and skin. Some
fat usually remains on the muscle.

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FIGURE 297.4 Operative technique. A: Incision in thenar and wrist creases. B: Design of palmaris flap. Muscle
insertions to dermis divided. C: Flap transposed as “book leaf” over carpal tunnel. D: Turnover flap inset into
radial edge of retinaculum. E: Incisions closed. (From Rose et al., ref. 19, with permission.)
After division of the transverse carpal ligament and microneurolysis of the median nerve, the palmaris flap is
elevated by dividing the attachments of the muscle from the
dermal skin at its ulnar border, carefully avoiding injury to the deeper ulnar nerve and artery (Fig. 297.4B).
The dorsal fascia is teased from the fascia of the hypothenar intrinsic muscles, to transpose in a “book leaf”
fashion across the carpal tunnel (Fig. 297.4C). The free edge is secured with sutures to the cut radial remnant of
the transverse carpal ligament (Fig. 297.4D). The vascular surface of the flap convolutes into the dead space of
the tunnel and apposes the “raw” fascicular surfaces of the neurolysed median nerve. Cosmetic closure is within
crease lines (Fig. 297.4E). Postsurgical cross-sectional wrist MRI evaluations demonstrate a cushion of palmaris
muscle between the nerve trunk and the dermal skin surface.
CLINICAL RESULTS

In a series of 13 hands of 11 patients, at surgical exploration the nerves were encased in dense restrictive
scar tissue and often adherent to the radial wall of the carpal canal. The nerve trunk was diffusely narrowed
by epineural fibrosis. Insterstitial scarring was severe and, in most patients, the fine longitudinal perineural
vasa nervorum were obliterated on microscope inspection. No incomplete division of the transverse carpal
ligament was found in any explorations.
Subjective assessment of pain relief ranged postoperatively from 25% to 100%. All hands with abnormal
preoperative two-point discrimination showed numerical improvement. Grip strength improved in 11 of 13
hands (average: 15.2%). Thenar atrophy grossly improved at least one grade in all hands. Pulp pinch
improved in 10 hands (average: 31.9%). Mean key pinch improved by 5.5%.
In one patient, increased numbness of the long finger developed, with worsening of two-point discrimination
at 6 months postoperatively; sensory parameters returned to normal by 1 year. The more complex operative
procedure extended disability time to an average of 4.8 months (longer than the usual 1.5 to 3 months for
simple carpal tunnel release). Six patients returned to previous employment, and four were retrained to less
strenuous occupations. One patient retired after surgery.
No infections occurred in this series. Blistering was noted at the tip of the palmar skin flap in one patient,
but represented only superficial slough and healed by re-epithelialization. Hypothenar tenderness lasted at
least 4 months, also increasing the duration of morbidity over routine carpal tunnel release.
SUMMARY
Although postoperative donor morbidity is lengthened and rehabilitation time prolonged by the procedure
(compared with routine carpal tunnel release), subjective assessment of “pain relief” and clinical
measurements of grip strength, pinch strength, and sensory parameters, appear to justify the usage of the
palmaris brevis turnover flap as an adjunct to internal neurolysis in difficult recurrent carpal tunnel cases.
References
1. Phalen GS. The carpal tunnel syndrome: seventeen years experience in diagnosis and treatment of six
hundred fifty-four hands. J Bone Joint Surg 1986; 48A:211.
2. Phalen GS. Reflections on 21 years experience with the carpal tunnel syndrome. JAMA 1970;212:1365.
3. Macdonald RI, Lichtman DM, Hanlon J, Wilson JN. Complications of surgical release for carpal tunnel
syndrome. J Hand Surg 1978;3:70.
4. Kulick MI, Gordiuo G, Javidi T, et al. Long term analysis of patients having surgical treatment for carpal
tunnel syndrome. J Hand Surg 1986;11A:59.
5. Langloh ND, Linsheid RL. Recurrent and unrelieved carpal tunnel syndrome. Clin Orthop 1972;83:41.
6. Wadstroen J, Nigst H. Reoperation for carpal tunnel syndrome. Ann Chir Main 1986;5:54.
7. Curtis RM, Eversmann WW. Internal neurolysis as an adjunct to the treatment of the carpal tunnel
syndrome. J Bone Joint Surg 1973;55A:733.

8. Rhoades CE, Mowery CA, Gelberman RN. Results of internal neurolysis of the median nerve for severe
carpal tunnel syndrome. J Bone Joint Surg 1985; 67A:253.
9. Mackinnon SE, O'Brien JP, Dellon AL, et al. An assessment of the effects of internal neurolysis on a
chronically compressed rat sciatic nerve. Plast Reconstr Surg 1988;81:251.
10. Milward TM, Scott WG, Kleinert HE. The abductor digiti minimi muscle flap. Hand 1977;9:82.
11. Reisman NR, Dellon AL. The abductor digiti minimi muscle flap: a salvage technique for palmar wrist
pain. Plast Reconstr Surg 1983;72:859.
12. Wilgis EFS. Local muscle flaps in the hand. Anatomy as related to reconstructive surgery. Bull Hosp Jt
Dis Orthop Inst 1984;44:552.
13. Leslie BM, Ruby LK. Coverage of a carpal tunnel wound dehiscence with the abductor digiti minimi
muscle flap. J Hand Surg 1988;13A:36.
14. Mackinnon SE, Dellon AL, Hudson AR, Hunter DA. Alteration of neuroma formation by manipulation of its
microenvironment. Plast Reconstr Surg 1985;76:345.
15. Dellon AL, Mackinnon SE. Treatment of the painful neuroma by neuroma resection and muscle
implantation. Plast Reconstr Surg 1986;77:427.
16. Le Double AF. Traité des variations du systeme musculaire del'homme et leur signification au point de
vue de l'anthropologie zoologique. Paris: Reinwald, 1897;170-171.
17. Shrewsbury MM, Johnson RK, Osterhout DK. The palmaris brevis—a reconsideration of its anatomy and
possible function. J Bone Joint Surg 1972;54A:344.
18. Kaplan EB, Smith RJ. Kinesiology of the hand and wrist and muscular variations of the hand and forearm.
In: Spinner M, ed. Kaplan's functional and surgical anatomy of the hand. Philadelphia: Lippincott, 1944.
19. Rose EH, Norris MS, Kowalski TA, et al. Palmaris brevis turnover flap as an adjunct to internal neurolysis
of the chronically scarred median nerve in recurrent carpal tunnel syndrome. J Hand Surg 1991; 16A:191.
20. Talesnik J. The palmar cutaneous branch of the median nerve and the approach to the carpal tunnel: an
anatomical study. J Bone Joint Surg 1973; 55A:1212.

Chapter 298
Pronator Quadratus Muscle Flap
A. L. DELLON
S. E. MACKINNON
The pronator quadratus muscle can be elevated on a single, well-defined neurovascular pedicle and transposed
within a wide arc to provide a well-vascularized pad of muscle for a variety of clinical needs in the distal forearm
(1). Although the muscle supplies only a small area of soft-tissue coverage, this is often all that is necessary for
reconstructive purposes in this region. For example, recent reports have demonstrated the clinical usefulness of
small muscle flaps for skin and nerve (2) problems in this area. The flap may thus serve as an alternative to
larger distant and more extensive reconstructive flap procedures (3, 4).
INDICATIONS
The distal forearm is devoid of superficial muscles, and vital structures in this area are protected only by
skin and subcutaneous tissue. There is therefore limited musculocutaneous flap potential. The groin flap
has been the most frequently used flap for coverage in the distal forearm (3, 5). The distal flexor aspect of
the forearm would thus benefit from the availability of a local muscle flap to provide a bed for skin grafting
over exposed vital structures, or to provide a well-vascularized bed for a nerve graft, for implantation of
sensory nerves after neuroma resection (6, 7) or elective amputation. Such a flap could provide a nutritive
interface between an internally lysed nerve and overlying dysesthetic or adherent skin (2).
ANATOMY
Cadaver dissections were performed on 16 upper extremities in eight specimens. The muscle was found to
average 5 cm in length and 4 cm in width (with the forearm supinated). There was no significant variation
between right and left or male and female extremities.
The neurovascular bundle uniformly consisted of the anterior interosseous artery and nerve lying on the flexor
surface of the interosseous membrane and entering the muscle on its dorsal surface. The neurovascular bundle
lies on the mid-longitudinal axis of the limb and enters the muscle between 1 and 2 cm distal to its proximal edge.
At this point the dorsal branch of the artery pierces the interosseous membrane.
A series of perforating vessels are found at 2-cm intervals proximal to the leading edge of the muscle. These
vessels branch from the anterior interosseous vessels and pierce the interosseous membrane.
FLAP DESIGN AND DIMENSIONS
If the dissection of the neurovascular bundle is carried proximally as far as the first branch of the anterior
interosseous nerve to the flexor pollicis longus, the muscle can be raised on a neurovascular pedicle that is 5 to
6 cm in length. This provides an arc of rotation that will allow coverage of the distal forearm and the medial and
lateral aspects of the wrist (Fig. 298.1).
It is emphasized further that the flap can provide coverage no further distally than the proximal wrist flexion
crease, and the skin must be mobilized to cover the muscle without tension. Muscle coverage more distal than
this can be provided by the abductor digiti minimi muscle flap (2).

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OPERATIVE TECHNIQUE
The pronator quadratus muscle may be approached through any preexisting palmar wrist scar or longitudinal
incision. The proximal limit of the incision must be extended, usually to 12 cm proximal to the wrist crease, to
permit dissection of the neurovascular pedicle.
The necessary exploration and dissection are carried out before dissection of the pronator muscle. The majority
of the required procedures can be performed then, leaving only the more delicate operative procedures (such as
nerve grafting) until after the pronator quadratus muscle is elevated.
Elevation of the muscle flap is facilitated by approaching the muscle radially between the flexor profundus muscle
group and the flexor pollicis longus tendon (Figs. 298.2 and 298.3). The distal edge of the muscle is divided
sharply from the radius and ulna (Fig. 298.2A), and the terminal branches of the anterior interosseous artery and
nerve (8) are divided (Fig. 298.2B). The insertion of the pronator onto the radius is next divided by an incision at
the most radial border with a scalpel, and then by elevation more medially to the interosseous membrane with an
elevator.
There are deep muscle fibers on the ulnar border of the interosseous membrane. Although the origin of the
pronator from the ulna may be reached through this approach, the next step is facilitated by development of a
plane between the profundus muscle and the flexor carpi ulnaris. Here the ulnar border of the muscle is incised
and the medial dissection is performed with the elevator. The muscle may now be dissected from distal to
proximal aspects by gentle traction, elevating it from the interosseous membrane until the dorsal branch of the
anterior interosseous artery tethers the elevation (Fig. 298.2C).
FIGURE 298.1 A: The pronator quadratus muscle shown schematically. The muscle is supplied by the anterior
interosseous neurovascular bundle with vessels perforating the interosseous membrane. B: The arc of rotation
of the pronator quadratus muscle flap allows coverage of the median and lateral aspects of the forearm and
distally to the proximal wrist crease. C: The flap may be transferred superficially by either a radial or an ulnar
route. (From Dellon and Mackinnon, ref. 1, with permission.)

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FIGURE 298.2 A-D: Technique of pronator quadratus muscle flap elevation (see text for description). (From
Dellon and Mackinnon, ref. 1, with permission.)
FIGURE 298.3 Intraoperative views. A: Pronator quadratus muscle exposed. Note proximal neurovascular
bundle (left). Pronator quadratus muscle elevated to show neurovascular bundle entering its deep side (vessel
loop top right). B: Pronator quadratus muscle elevated. Note neurolysed median nerve and palmar cutaneous
neuroma (overlying background). C: Muscle flap being interposed between skin and neurolysed median nerve.
D: Flap in place. Palmar cutaneous neuroma has been resected and nerve implanted into the muscle. (From
Dellon and Mackinnon, ref. 1, with permission.)
Next, the anterior interosseous neurovascular bundle is identified proximally and dissected to this same tethering