Plastic Surgery Volume 6: Hand and Upper Extremity (4th Edition) – Peter C. Neligan

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Treatment/surgical technique
one incises the mid-lateral lines on either side of the thumb,
down to the base of the proximal phalanx. The flap is then
elevated from the deeper tissues, directly off the flexor reti­
naculum, with sharp dissection. The flap includes both neu­
rovascular bundles and all of the subcutaneous tissue down
to the flexor tendon sheath. The interphalangeal joint is flexed,
and the flap is inset at the tip. If necessary, a Kirschner wire
can be placed across the interphalangeal joint to stabilize it,
though this is seldom required. This flap can easily cover a
defect of 1–2 cm2 (Fig. 13.4). A variation of the Moberg flap is
an island flap in which the flap is incised transversely across
the proximal base, and the only remaining attachments are
the two neurovascular bundles. The proximal gap at the base
of the flap will then require a small skin graft. Alternatively,
the proximal incision can be in the shape of a V, and following
advancement, this can be closed in a Y, obviating the need for
a donor site skin graft. Unlike the conventional Moberg flap,
this method will allow a small amount of actual advancement,
thereby covering more distal defects.15,16
The cross-finger flap from the index finger is an excellent
reconstructive technique for larger volar and tip defects of the
thumb, up to 2–3 cm2.17 The tissue transferred is reliable and
durable.18 The chief disadvantages to this technique are iatro­
genic syndactyly for 2–3 weeks, and the need for a skin graft
on the index donor site. A radially based rectangular flap is
marked on the dorsum of the index proximal phalanx that
extends from the ulnar to the radial mid-lateral lines (Fig.
13.5). The flap is incised and elevated from ulnar to radial in
the plane between the subcutaneous tissues and the extensor
mechanism. It is critically important to leave the paratenon
on the extensor to allow skin grafting. Upon reaching the
radial aspect of the flap, one must release Cleland’s ligaments
along the length of the base of the flap to prevent kinking at
the flap “hinge”. The flap is then sutured to the thumb – this
may require some trial and error to find the best flap orienta­
tion (Fig. 13.6). A full-thickness skin graft is then sutured to
the dorsum of the index finger. A bulky thumb splint is
bone and length preservation. When there is no bone exposed
at the tip of the thumb, closure can be achieved with either
healing by secondary intention or skin grafting. Secondary
healing of tip amputations has been shown to result in a stable
scar and good two-point discrimination, and is therefore a
relatively easy (and usually the preferred) method of achiev­
ing coverage.13 Secondary healing by wound contracture has
the advantage of bringing stable, sensate skin together to close
the defect, as opposed to skin grafts, which remain insensate.
Defects up to 1.5 cm in diameter with no bone exposure can
be effectively treated with dressing changes. Daily dressing
changes with petroleum or bismuth-impregnated gauze are
relatively easy for patients. Larger defects with a stable base,
however, require skin grafting. Full-thickness grafts are
usually preferred, as they are more durable and stable, espe­
cially in the contact areas subject to pressure and shear. Small
full- or split-thickness skin grafts can be harvested from the
hypothenar eminence or the volar wrist crease. Larger skin
grafts, however, are best harvested from the upper inner arm
or groin crease.
When phalangeal bone is exposed at the thumb tip, vascu­
larized coverage is required to preserve length, and there are
several flaps that can accomplish these goals. The main criteria
for flap selection are defect size and location of soft-tissue loss,
specifically if it is volar, dorsal, or at the tip. The V–Y advance­
ment flap described by Atasoy et al. provides good coverage
of the tip of the distal phalanx when only a very small amount
of bone is exposed14 (Fig. 13.2). The technique involves incis­
ing the volar pulp of the thumb in a V shape. Scissors are then
used to spread the subcutaneous tissue carefully. The subcu­
taneous attachments deep to the flap, which provide the
neurovascular supply to the flap, are left intact. The flap is
then advanced distally to close the defect and the proximal
aspect of the V is closed side to side, thereby creating the Y
shape of the final scar. In practice, there is limited application
for this flap due to the limited advancement that is possible
without devascularizing the flap.
The neurovascular volar advancement flap, which goes by
the eponym of the Moberg flap, is well suited to cover volar
and tip defects of the thumb.11 It is often described as an
advancement flap, but in reality, the amount of advancement
achieved with the conventional rectangular Moberg flap is
limited. Instead, the elevation of the flap allows flexion of the
interphalangeal joint of the thumb, thereby allowing the flap
to appear to “advance” distally (Fig. 13.3). To elevate the flap,
Fig. 13.2  Thumb tip closure via volar V–Y advancement flap. The flap is perfused
by small vessels traversing the subcutaneous tissues immediately deep to the flap.
Fig. 13.3  Moberg thumb volar advancement flap. It is a sensate flap by virtue of
the digital nerves remaining in the flap, and is perfused by the digital vessels.
Neurovascular
bundle
Interphalangeal
joint flexed
Incision

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CHAPTER 13 • Thumb reconstruction: Non-microsurgical techniques
Fig. 13.5  Diagrammatic representation of the cross-finger flap to the thumb. The
flap is elevated from the dorsum of the index finger proximal phalanx and inset to
the thumb volar defect. Once elevated, Cleland’s ligament of the index radial
neurovascular bundle can restrain and kink the flap, therefore release of this
ligament allows greater flap freedom.
Dorsal view
Palmar view
Elevated cross-finger flap
Fig. 13.6  Thumb tip defect resurfaced with a cross-finger flap from the index
finger.
Fig. 13.7  Reconstructed thumb following division of the cross-finger flap seen in
Fig. 13.6.
Fig. 13.4  Thumb reconstructed with a Moberg flap for a distal amputation. Note
the flexed posture of the interphalangeal joint.
applied. At 2 or 3 weeks, the flap is divided and the inset to
the thumb is completed (Fig. 13.7). After division, aggressive
range-of-motion therapy for both the thumb and index finger
should begin.
The neurovascular island flap attributed to Littler is a valu­
able tool in thumb reconstruction.19 It is rarely used as a
primary coverage flap, although it is certainly possible to use
it in that manner. Rather, its most common use is for the res­
toration of sensation to the thumb pulp following reconstruc­
tion.19,20 The flap is based on the ulnar neurovascular bundle
of either the middle or ring finger (Fig. 13.8). The ulnar side
of the digit is chosen because its loss will have minimal effect
on grip and pinch activities. The dimensions of the flap

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Treatment/surgical technique
needed are marked on the ulnar pulp of the chosen donor
finger. Often, the flap will require harvesting of skin over the
distal and middle phalanges of the donor finger. The flap is
incised, and a mid-lateral incision proceeding from the proxi­
mal aspect of the flap is made. The flap is elevated from distal
to proximal, and the entire ulnar neurovascular bundle is
elevated in continuity with the flap. It is critical to raise the
neurovascular bundle with a fairly thick cuff of surrounding
fatty tissue containing the vasa vasorum of the artery, as that
is the only source of venous outflow for the flap. Failure to do
this will result in flap congestion. One must dissect fairly
proximally in the palm to allow adequate transposition to the
thumb, and the other branch of the common digital artery
(i.e., the radial digital artery to the ring or small finger) must
be divided. The common digital nerve can be split along the
fascicles to allow adequate flap mobility. The flap can then be
transposed to the thumb either via subcutaneous tunnel, or a
connecting incision from the donor site to the thumb can be
made (Fig. 13.9). The flap is then inset into the volar defect of
the thumb. The donor site is grafted with full-thickness skin.
In addition to postoperative restoration of motion, patients
must work with a hand therapist on sensory re-education of
the thumb.
The proximally based first dorsal metacarpal artery (FDMA)
flap is an excellent tool to achieve thumb coverage, although
it is better suited for dorsal or lateral thumb defects than
palmar defects21,22 (Figs. 13.10–13.12 and Video 13.2
). Its
harvest causes virtually no donor site functional loss. The
FDMA is found using a conventional Doppler device, begin­
ning proximally with the radial artery at the anatomic snuff­
box. The radial artery then branches into the princeps pollicis
Fig. 13.8  Depiction of neurovascular island flap taken from ulnar side of ring
finger. The flap will then be tunneled through the palm to the thumb to provide
sensate reconstruction of volar thumb.
Tunnel to thumb
Discard or use for
skin graft on donor
Reconstructed
thumb
Digital artery
and nerve
Fig. 13.9  Neurovascular island flap following dissection.
artery radially and the FDMA ulnarly. At approximately the
metacarpal head level, the artery then becomes difficult to
trace further distal. The flap is then centered over the FDMA
(Fig. 13.13). The flap is incised and dissected from distal to
proximal, leaving paratenon over the extensor mechanism for
later skin grafting. To ensure inclusion of the FDMA with the
flap, it is imperative to incise the thin fascia over the first
dorsal interosseous muscle and include it with the flap. Once
the flap is elevated and the proximal vascular leash fully
mobilized, it can then be tunneled to the thumb in the subcu­
taneous plane, or a connecting incision can be made. The
donor defect is then closed with a skin graft. It is critical to
raise the vascular pedicle of the FDMA flap with a fairly thick
pedicle of surrounding fatty tissue containing the venae
comitantes of the artery, as that is the only source of venous
outflow for the flap. It is possible to innervate the FDMA flap
by suturing a branch of the radial sensory nerve in the flap to
a digital or radial sensory nerve in the thumb (Box 13.1).
Middle third
Loss in the middle third of the thumb is more functionally
limiting than that of the distal third. Therefore, the priorities
are both soft-tissue coverage and functional restoration.
BOX 13.1  Clinical tips: distal-third reconstruction
Loss of the distal third of the thumb is minimal in terms of functional
loss.12 Therefore, the chief priority is soft-tissue coverage. The
choice of soft-tissue reconstruction is determined by the location of
loss. Volar defects can be reconstructed with secondary healing
(wound contraction), full-thickness skin grafts, Moberg flaps,
cross-finger flaps, and neurovascular island flaps, while dorsal
defects may be dealt with using skin grafts or first dorsal metacarpal
artery flaps.

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CHAPTER 13 • Thumb reconstruction: Non-microsurgical techniques
Fig. 13.11  Thumb defect from Fig. 13.10, and the first dorsal metacarpal artery
flap raised on its pedicle. Note that all tissues down to and including the first dorsal
interosseous fascia are taken with the flap pedicle.
Fig. 13.10  Dorsal ulnar thumb squamous cell carcinoma. The neoplasm was
resected and reconstructed in one stage.
Commonly, the soft-tissue coverage of amputations at this
level will have been achieved acutely by revision amputation
in which the skeletal components are shortened to allow
primary closure. Reconstruction then occurs weeks or months
after the initial insult.
Phalangization is a set of reconstruction techniques that
increases the effective, rather than the absolute, length of the
thumb. The chief component of phalangization is first web­
space deepening.12 The webspace may be injured or not
injured during the initial injury to the thumb. Webspace
deepening allows better thumb excursion, specifically both
palmar and radial abduction, thereby improving the thumb’s
oppositional function. First webspaces with mild or moderate
tightness can be deepened with skin grafts or local tissue
rearrangement (commonly Z-plasties). The main assessment
of the webspace is whether the contracture is broad or is a
discrete linear band. If it is broad, then scar contracture inci­
sion, followed by skin grafting, is warranted, whereas if the
contracture is linear, Z-plasties are the preferred treatment.
Full-thickness skin grafts are usually used for the first web,
although a thick split-thickness skin graft can be used (Figs.
13.14 & 13.15). A single Z-plasty can be used for a linear scar
band, although two combined Z-plasties are uniquely suited
to this anatomic area. The four-flap Z-plasty (which is essen­
tially two superimposed Z-plasties) (Fig. 13.16) and the
double-opposing Z-plasty (“jumping man” flap) (Fig. 13.17)
have been commonly used for the first web. In both cases, the
scar band itself is the middle limb of both Zs, and the trian­
gular flaps then are mobilized from the dorsal and volar sides
of the scar contracture. When using either skin graft or
Z-plasty for the first webspace, the adductor muscle is often
tight due to scarring. A portion of it can be released to allow
further thumb abduction prior to skin closure.
More significant first webspace contractures can require
transposition of vascularized tissue into the space, rather than
the less-complex local tissue rearrangement. Along with soft-
tissue expansion of the first web, one should consider applica­
tion of a first webspace external fixator or pinning of the
thumb carpometacarpal joint in order to maintain the width
of the first webspace while the reconstruction is healing.
The dorsal hand flap provides a good option for webspace
deepening. This flap is proximally based on the dorsum of the
hand and is vascularized by the metacarpal artery system
(Fig. 13.18). Unlike the FDMA flap, it is not an island flap, and
can include more than one metacarpal artery. The flap’s distal
extent is at the level of the metacarpal heads and is elevated
in the plane between subcutaneous tissue and extensor tendon
paratenon. The flap is then transposed radially into the first

309
Treatment/surgical technique
A
B
Fig. 13.12  (A,B) Healed thumb from Figs. 13.10 and 13.11 following reconstruction with proximally-based FDMA flap.
webspace, following release of all constraining structures in
the space. The donor site is then skin-grafted.
If the dorsal hand skin has been injured, or if a larger
amount of vascularized tissue is required to resurface both
the first web and the thumb itself, then regional flaps will
be necessary. The radial forearm flap and the posterior
interosseous artery flap are good choices. The utility of
the radial forearm flap has been repeatedly demonstrated
in a variety of hand reconstruction settings, including the
thumb. The major drawback to use of a reverse-flow radial
forearm flap is that its use may compromise future thumb
reconstruction. Specifically, if a microvascular toe transfer is
being considered for thumb reconstruction, the radial artery
is the preferred recipient vessel, and the transposition of a
pedicled radial forearm flap will make later microvascular
transfer difficult, if not impossible. It is, however, possible to

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CHAPTER 13 • Thumb reconstruction: Non-microsurgical techniques
Fig. 13.13  Diagram of dorsal metacarpal artery flap (“kite flap”) from index-finger
dorsum. It is important to include subcutaneous fat and interosseous muscle fascia
with the pedicle.
First dorsal metacarpal artery
Skin graft on donor site
Fig. 13.14  Severe wood chipper injury that later resulted in a first webspace
contracture that prevented radial and palmar thumb abduction.
Fig. 13.15  First webspace from Fig. 13.14 that has been deepened with a
full-thickness skin graft. Note improved thumb abduction.
Fig. 13.16  Depiction of four-flap Z-plasty used for deepening of the first webspace
and/or releasing a first webspace contracture.
Scar band
a
a
b
b
c
c
d
d
harvest a radial artery perforator flap, leaving the radial artery
intact.23,24
The radial forearm flap is extremity versatile, and can be
harvested as a fascia-alone flap, fasciocutaneous flap, or a
suprafascial skin flap. For thumb reconstruction, the use of
the fascia-alone flap with skin grafts applied directly to the
flap allows maintenance of the normal contour of the thumb25
(Figs. 13.19 & 13.20). An Allen’s test is always performed to
ensure the digits will remain perfused by the ulnar artery. The
pivot point of the flap pedicle is approximately at the radial
styloid, although it can be more proximal than this. The flap
should then be drawn on the forearm such that the pivot point
is midway between the distal end of the thumb or first web
defect and the proximal end of the radial forearm flap. The
flap is elevated on the radial and ulnar sides. Upon reaching
the ulnar edge of the brachioradialis muscle on the radial side
of the flap, and the radial edge of the flexor carpi radialis
tendon on the ulnar side of the flap, dissection then proceeds
directly down toward the radius. The dissection then proceeds

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Treatment/surgical technique
Fig. 13.17  Diagram of the double-opposing Z-plasty (known as the “jumping man”
flap). This Z-plasty and the four-flap Z-plasty provide similar substantial amounts of
first webspace release.
a
a
b
b
c
c
d
d
x
x
First web scar band
Fig. 13.18  (A,B) Diagram of the dorsal hand flap. This flap can provide a
substantial amount of coverage for first webspace deepening.
A
B
Scar band
Dorsal hand flap
Thumb amputation
stump
Flap inset
Skin graft
Fig. 13.19  Severe dorsal thumb injury from a router. The fractures were stabilized,
and the extensor pollicis longus tendon was reconstructed with a transferred
extensor indicis proprius tendon.
under the deep aspect of the radial vascular bundle. Prior to
dividing the proximal end of the radial artery, a microvascular
clamp can be placed on the artery just proximal to the flap,
and the tourniquet released. After several seconds, if both the
flap and all the digits are well perfused, the proximal radial
artery can then be divided. The flap is then transposed distally
to the first webspace and/or thumb. Depending on the type
of flap used, the donor site is primarily closed (fascia-alone
flap) or skin-grafted (fasciocutaneous or suprafascial). Because
venous outflow from the reverse radial artery flap is retro­
grade through the venae comitantes against the venous
valves, venous congestion can occur. It is imperative to include
the venae comitantes and surrounding fatty tissue with the
arterial pedicle when raising the flap. Performing an ante­
grade venous microvascular anastomosis to a vein in the hand
can reduce venous congestion and flap swelling.
The vascular supply to the posterior interosseous artery
flap is both an advantage and a disadvantage: the flap is
perfused by reverse flow-through in the posterior interosse­
ous artery via anastomotic connections with the anterior
interosseous artery just proximal to the distal radioulnar
joint26 (Figs. 13.21–13.23). This allows preservation of the
radial and ulnar arteries to the hand, but the vascular supply
can be compromised if the zone of injury is anywhere near
the wrist. The posterior interosseous artery is found with a
Doppler and the flap centered over it. The vessel is along a
line drawn between the lateral epicondyle of the elbow and
the ulnar head. The pedicle of the flap runs in the diminutive
septum between the extensor carpi ulnaris and extensor digiti
minimi (quinti) tendons. Dissection is performed from distal
to proximal so as first to locate the anastomotic connection
with the anterior interosseous artery and then include the

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CHAPTER 13 • Thumb reconstruction: Non-microsurgical techniques
posterior interosseous artery with the flap as one dissects
proximally. Once fully dissected, the flap is transposed to the
first webspace, and the donor site is closed primarily or skin
grafted. Another disadvantage of the flap is the appearance
of the donor site, which is on the easily visible dorsal forearm.
Metacarpal lengthening allows increase in the absolute
length of the thumb ray. This is usually performed for more
proximal losses in the middle third of the thumb, and was
popularized by Matev.8,9 Matev reported that the only absolute
contraindication to the procedure is less than 3 cm of remain­
ing thumb metacarpal.27 One should note that this reconstruc­
tion technique requires a long period of time with external
fixation, and multiple outpatient visits, therefore patient
acceptance of the technique should be established prior to
reconstruction. The pins for the distraction device are placed
Fig. 13.20  Thumb from Fig. 13.19 satisfactorily reconstructed with a pedicled
radial forearm fascia flap. The flap was skin-grafted and the donor site closed
primarily as no skin was harvested from the forearm.
Fig. 13.21  Large first webspace defect following firework blast injury. An external
fixator holds the space open.
Fig. 13.22  Posterior interosseous artery flap elevated and attached only to the
pedicle proximally and distally. Note the anastomotic vessels distally curving
radially to join the anterior interosseous vessels.
distally and proximally prior to osteotomy (Fig. 13.24).
Through a dorsal incision over the metacarpal, the distraction
device is applied first, and the bone is then cut at the diaphysis
and the skin closed. Distraction is initiated at 1 mm/day until
the desired length is achieved. While some patients, especially
children, will spontaneously ossify the bony gap of the meta­
carpal, many patients will require bone grafting at a second
surgery. This bone can be harvested from the iliac crest, or
with small defects, from the distal radius. While the bone graft
is consolidating, the original frame may be left in place, or one
may change to internal fixation. In Matev’s experience, a
number of patients had first webspace creep due to the dis­
traction drawing the first web skin distally.27 If this occurs, one
of the first web deepening techniques described previously
may be used (Box 13.2).

313
Treatment/surgical technique
muscle fascia is incised and elevated with the flap to prevent
kinking of the pedicle. Typically, dissection to the medial
border of the sartorius is sufficient length for a thumb groin
flap. The proximal end of the flap is tubed upon itself. At this
point, an iliac crest tricortical bone graft may be harvested
from the lateral aspect of the groin flap incision. An oscillating
saw allows rapid and neat harvest of the bone graft. The bone
graft is then fixed to the distal end of the thumb stump (either
proximal phalanx base or distal metacarpal). Fixation can be
provided in a variety of ways; however, plate and screw fixa­
tion allows early motion (Fig. 13.25). Following bone graft
fixation, the groin flap is then wrapped around the graft and
inset to the thumb. The groin flap is usually divided 2–3
weeks after inset. Several stages of flap thinning are usually
Fig. 13.23  Healed first webspace of patient from Figs. 13.21 and 13.22.
Fig. 13.24  Thumb metacarpal lengthening as described by Matev.
Thumb metacarpal
Trapezium
BOX 13.2  Clinical tips: thumb metacarpal lengthening
Metacarpal lengthening of the thumb is a good procedure and can
achieve meaningful restoration of thumb length in patients who are
not able or willing to undergo a toe transfer. However, it is an
arduous process, most importantly for the patient.
1. Patient education is paramount. They must understand that the
process involves at least two surgeries, multiple clinic visits, and
a real potential for complications such as pin infection or
distractor loosening
2. Pain is not a trivial issue with this procedure. Patients are in
near-constant pain from the stretching of the soft tissues.
Practitioners must be prepared to manage pain for a number of
weeks.
3. Younger patients may ossify the bone gap, but older adults may
require iliac crest bone grafting. This bone grafting procedure is
a good time to place internal fixation. The internal fixation should
be strong enough to prevent flexion of the lengthened
metacarpal that often happens with these cases.
Osteoplastic thumb reconstruction allows restoration of
good thumb length, and when combined with a neurovascular
island flap, can result in fairly good thumb pulp sensation.
While not absolute prerequisites, the osteoplastic thumb
reconstruction method works best when there is intact and
functioning thenar musculature and a working thumb carpo­
metacarpal joint. It is generally accepted that osteoplastic
thumb reconstruction is performed in three stages: (1) skeletal
reconstruction with iliac crest bone graft wrapped with a flap
(typically a groin flap); (2) groin flap division and serial thin­
ning; and (3) pulp reconstruction with a neurovascular
island flap.
The groin flap is a versatile and reliable flap.28 It is an axial
flap, perfused by the superficial circumflex iliac artery, which
runs parallel to and 2 cm below the inguinal ligament. The
flap is centered over this line. It is incised and elevated from
lateral to medial just superficial to the muscle fascia. Upon
reaching the lateral border of the sartorius, the sartorius
Fig. 13.25  Iliac crest bone graft used for osteoplastic reconstruction of a thumb.
The fixation of the bone graft is in progress, and will be covered by a groin flap.

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CHAPTER 13 • Thumb reconstruction: Non-microsurgical techniques
index and the end of the thumb stump are usually made.
Perhaps the most important part of the surgery is the dissec­
tion of the dorsal veins. At least one vein must be preserved,
but when possible, it is recommended that the majority of the
dorsal vein arcade be taken with the digit. Volarly, both neu­
rovascular bundles to the index are carefully dissected. Either
before or after index dissection, the thumb is prepared for
receipt of the transferred digit. This consists of soft-tissue
elevation and metacarpal exposure for bone fixation. Internal
fixation is preferred because it does not need to be removed,
and early motion can be performed. At this time, a microvas­
cular clamp is placed on the ulnar digital artery to the index,
and the tourniquet released. If the index stump is perfused,
then the ulnar digital artery is divided. Alternatively, the
radial digital artery to the middle finger can be divided, and
the common digital artery taken with the index. The ulnar
digital nerve will need to be separated from the common
digital nerve to allow transposition. As this is a damaged
index stump, the flexor and extensor mechanisms are not
usually transferred (in contrast to pollicization), and can be
divided. The second metacarpal is cut at the appropriate
length for the thumb reconstruction. The remainder of the
second metacarpal (down to proximal metaphyseal flare) is
removed to allow a full first webspace. Fixation of the index
metacarpal neck to the thumb metacarpal shaft or base is then
performed. In order to gain webspace closure and ensure an
adequately deep webspace, a dorsal hand flap may need to
be transferred to the webspace (Box 13.3).
Proximal third
Loss of the thumb at the level of the proximal third is a
challenge for reconstruction, as this is essentially total thumb
loss. While the divisions between middle-third and proximal-
third loss are somewhat arbitrary, one chief difference is that
loss at the proximal third can include loss of some or the entire
cuff of thenar musculature. This muscle loss then precludes
use of previously mentioned techniques such as osteoplastic
reconstruction, distraction osteogenesis, and perhaps on-top
plasty. Because of the paucity of local reconstruction options,
required (Fig. 13.26 and Video 13.1
). At approximately 3–6
months after skeletal and soft-tissue reconstruction, sensibil­
ity is achieved by transfer of the neurovascular island flap.
The chief disadvantages of the osteoplastic reconstruction
technique for the thumb are possible bone graft resorption,
the multiple stages required, and the bulky appearance of the
reconstructed thumb.
Osteoplastic thumb reconstruction is not necessarily per­
formed only with the groin flap.29 There are other flaps that
can be used to cover a bone graft, most notably the reversed
radial forearm flap. The other option with this type of recon­
struction is to utilize an osteocutaneous radial forearm flap,
rather than an iliac crest bone graft for the skeletal restoration.
The flap may also be innervated by harvesting the lateral
antebrachial cutaneous nerve with it, and then coapting it to
the ulnar digital nerve of the thumb. While some authors tout
this as a one-stage osteoplastic reconstruction, the flap often
requires at least some debulking as it can be somewhat
bulbous on the thumb.
Quite often, thumb amputations do not happen in isolation
– there is often damage to other finger(s), especially the index
finger. In the ultimate example of “spare-parts” surgery, the
damaged/amputated index finger stump can be transferred
on to the thumb amputation stump. This is an excellent
reconstructive option for patients with a middle-third ampu­
tation of the thumb, especially at the proximal end of that
zone.12,30 The index transfer procedure has been variably
referred to as “pollicization” and “on-top plasty”. On-top
plasty is probably more accurate as pollicization is most often
used to denote transfer of a normally functioning index to the
thumb. On-top plasty does not necessarily need to be accom­
plished with the index stump – the middle- or ring-finger
stump may instead be used.
On-top plasty may be accomplished with a variety of skin
incisions; however “racket”-type incisions at the base of the
Fig. 13.26  Osteoplastic reconstruction from Fig. 13.25 following thinning of the
groin flap.
BOX 13.3  Clinical tips: middle-third reconstruction
For thumb losses in the middle third, length restoration becomes a
primary goal. This is done by extending either the absolute length or
the relative length of the thumb:
• Relative length (“phalangization”): restoring or deepening the
first webspace. This may be accomplished as follows:
•
Small webspace deepening: either skin grafting or
Z-plasties. If the patient has a linear scar band, Z-plasties;
skin grafting is required for broader scar contractures
•
Large webspace deepening: vascularized tissue imported
from another location, achieved by the dorsal hand flap,
radial forearm flap, or posterior interosseous artery flap
• Absolute length: several techniques can increase absolute
length of the thumb:
•
Metacarpal lengthening
•
Osteoplastic reconstruction: bone graft wrapped with a flap,
most commonly the groin flap
•
On-top plasty: transposition of a damaged index finger on
to the remaining thumb ray

315
Treatment/surgical technique
interosseous tendons are divided from the muscles. The flexor
and extensor tendons are dissected after opening the first
and second annular pulleys. The thumb is then prepared by
dissection of the soft tissue and exposure of the metacarpal
remnant. The thenar and adductor pollicis muscles or their
remnants are also prepared. At this point, the tourniquet is
released. There are two possibilities for the ulnar digital artery
of the index finger: it can be divided if the radial digital artery
adequately perfuses the finger, or the radial digital artery to
the middle finger can be divided and the common digital
artery to the second webspace can be taken with the index
finger. The second metacarpal is then cut at the neck. The
remainder of the second metacarpal down to the metaphyseal
flare is removed to open the new webspace. The index is
transferred and rotated.
In general, the pulp of the new thumb should be facing the
ring finger when bony fixation is completed. The tendon of
the first dorsal interosseous muscle is sutured to the thenar
muscle remnant (opponens pollicis if possible) and the tendon
of the palmar interosseous muscle is sutured to the adductor
pollicis muscle or its remnant. Some authors recommend no
shortening of the extrinsic extensor and flexor tendons,
whereas others advocate tendon plication.12,31 The metacarpo­
phalangeal joint is pinned for 6 weeks in slight flexion to
counteract the tendency of the index metacarpophalangeal
joint to hyperextend. The skin is then closed. If any of the skin
closure appears tight, one should have a low threshold for
placement of skin grafts to complete the closure. As with
on-top plasty, the thenar musculature may be later found to
be inadequate for functional opposition, and in these cases,
opposition transfer (ring-finger flexor digitorum superficialis
or extensor indicis proprius) can be performed at a later time
(Box 13.4). Some authors have reported using a digit other
than the index finger for pollicization, including one group
who has studied transposition of the small finger into the
thumb position.32
Prosthetics
Prosthetics for thumb loss are a viable option for patients who
do not wish to undergo reconstruction. Prosthetics are gener­
ally aesthetic in nature, which is to say they have minimal or
no function. Pillet has the largest experience with upper
extremity prosthetics, and his aesthetic results are impres­
sive.33 There are scattered reports of osseointegrated digital
microvascular techniques play a primary role in thumb recon­
struction at this level. This primarily is performed with
various types of toe transfer, and these techniques are detailed
in a separate chapter.
There are some instances of proximal-third loss in which
on-top plasty may be appropriate. As stated, if some or all of
the thenar musculature is missing, mobility of the transferred
index will be limited, and may need to be augmented by an
opposition transfer at a later time. In the adult, this opposition
transfer can be accomplished with either the ring-finger flexor
digitorum superficialis tendon, or the extensor indicis pro­
prius tendon. The technique of on-top plasty is performed the
same way as discussed in the section on middle-third loss.
Short of microvascular techniques, index-finger polliciza­
tion is the only other viable technique for proximal-third
thumb reconstruction (Figs. 13.27 & 13.28). The procedure’s
utility in children with thumb hypoplasia or aplasia is undis­
puted. Its use in adults is also fairly reliable, although it may
be more difficult for adults than children to adapt to the new
finger position. In Brunelli and Brunelli’s description of pol­
licization in adults, the authors highlight one of the chief
differences in pollicization between children and adults: in
children, the thenar musculature and the adductor pollicis are
entirely missing, whereas in adults, there may be at least a
remnant.31 This then slightly changes what is done with the
index palmar interosseous (becomes the adductor pollicis)
and the dorsal interosseous (becomes the thenar muscles). In
children, these muscles are transferred with the index, whereas
in adults, the muscles themselves are eliminated and their
tendons sutured to the thenar and adductor remnants.
A variety of skin incision patterns can be used. Once the skin
is incised, the dorsal veins are carefully dissected. Vein pres­
ervation is critically important, and is often the most tedious
portion of the pollicization surgery. Next, the neurovascular
bundles to the index are dissected. The palmar and dorsal
Fig. 13.27  Completed index-finger pollicization following traumatic thumb loss at
the base of the thumb ray.
Fig. 13.28  Pollicization from Fig. 13.27 demonstrating good opposition of the
pollicized finger and good tip pinch.

316
SECTION II
CHAPTER 13 • Thumb reconstruction: Non-microsurgical techniques
good. If all five cannot be restored, then, at the least, restora­
tion of a stable thumb with adequate length will allow some
grip and pinch activities.
Secondary procedures
First webspace deepening is frequently required after thumb
trauma and possibly after prior reconstructive procedures.
This can be done with skin grafts or local tissue rearrange­
ment, as discussed previously. Other scar contractures that are
functionally limiting or aesthetically unpleasing can be treated
with a variety of releases and transpositions, including
Z-plasties and Y–V-plasties.
Tendon adhesions are also common after thumb recon­
struction. The primary method of treatment of this problem
is early and aggressive hand therapy to minimize their impact.
If therapy cannot overcome the adhesions, then flexor and/
or extensor tenolysis may be required. Following tenolysis,
therapy should resume within 24–48 hours.
As mentioned in the section on metacarpal lengthening,
bone grafting is often required. Nonunions in the hand are
rare but may require later bone grafting. Malunions of the
thumb ray are extremely well tolerated and compensated;
however, severe malunions may require osteotomy and
fixation.
Joint contractures in the non-thumb digits can be particu­
larly detrimental, especially the proximal interphalangeal
joint. However, in the thumb, these are less an issue, and in
fact can help with thumb stability. If there is a severe flexion
contracture of the metacarpophalangeal joint, this may need
joint release.
Distal-third thumb loss may result in painful neuromas
that require later excision. However, this can largely be miti­
gated by traction neurectomy of the digital nerve(s) at the
time of initial reconstruction.
Future directions
One exciting development in the last several years is the
development of perforator flap surgery. This has enabled soft-
tissue reconstruction using local tissue that in the past may
have necessitated use of a free flap. Some authors have dubbed
this “microsurgery without the microscope”. One group has
described use of a princeps pollicis perforator flap for local
thumb ray reconstruction, and it is likely that more hand-
based perforator flaps will be described in the future.36
It was mentioned at the beginning of the chapter that
perhaps the best thumb reconstruction is actually replantation
of the amputated thumb when possible. The advent of super­
microsurgery in the last decade has enabled replantation of
more distal amputations, even at the nail bed level. Better
replantation techniques will potentially allow salvage of more
native thumb tissue.
Finally, advances in prosthetics for the upper extremity are
occurring at an astounding pace. It is possible that more
durable osseointegrated thumb prosthetics will allow more
function without autologous tissue reconstruction, and one
day, these prosthetics may even enable sensation.
and thumb prosthetics, which would render them slightly
more functional and durable.34 In general, there must be at
least a remnant of thumb proximal phalanx for an aesthetic
prosthetic to remain on the thumb.12 Otherwise, a hand-based
extension may be required for prosthesis stabilization.
Postoperative care
Immobilization is the cornerstone of any hand postoperative
care, and the thumb is no exception. Generally, distal-third
thumb reconstruction is soft tissue alone and, therefore,
immobilization in a postoperative plaster splint is only done
for approximately a week. After that, the thumb can be sup­
ported with a removable splint, and normal showering and
hand washing can begin. Sutures are removed at 2 weeks
postoperatively.
More proximal reconstructions can involve skeletal recon­
struction, in addition to soft tissue. Plate and screw fixation
allows early mobilization, typically initiated at 1–2 weeks
postoperatively. Kirschner wire fixation can be slightly less
rigid; however, at least some passive gliding exercises can still
be initiated at 2 weeks. Again, removable splinting allows
hand washing and bathing.
At approximately 6 weeks, bony consolidation will have
proceeded to the point that some resistive exercises can be
started (provided that on radiographs the fixation has
remained stable and there is at least some evidence of consoli­
dation). It is also at this point that scar modification techniques
can usually begin in earnest.
Outcomes, prognosis,
and complications
Unfortunately, there is a scarcity of well-controlled outcomes
studies related to the various types of thumb reconstruction.35
There are, however, a number of large retrospective series for
each of the above-listed reconstruction methods that, in
general, demonstrate good results.11,14–16,19,27,29
There are five goals when reconstructing a thumb: restora­
tion of (1) functional length; (2) stability; (3) mobility (espe­
cially opposition); (4) sensibility; and (5) aesthetic appearance.
The treating physician should help the patient choose the
technique that will allow restoration of (hopefully) all five of
these aspects to the thumb. If all five are restored, then the
prognosis for a functional thumb and a satisfied patient is
BOX 13.4  Clinical tips: proximal-third reconstruction
Losses in the proximal third of the thumb are not adaptable, and are
challenging reconstructions for patient and surgeon. The entire
thumb ray requires restoration. Microsurgical methods are now the
standard for losses at this level. However, there remains a role for
pollicization of the index finger, which can still be very functional. In
cases where there is a concomitant damaged index finger, one can
transpose the remaining index on to the thumb ray (on-top plasty)
to restore a stable, mobile, and perhaps sensate thumb ray.

317
Future directions
1. Littler JW. On making a thumb: one hundred years of surgical
effort. J Hand Surg Am. 1976;1:35–51. Authored by one of the pioneers
of hand surgery, this manuscript is a detailed and richly illustrated
history of thumb reconstruction up to 1976. Many of the techniques
described in this article remain common today. These include digit
transfer, toe transfer, osteoplastic reconstruction, and phalangization.
12. Muzaffar AR, Chao JJ, Friedrich JB, et al. Posttraumatic thumb
reconstruction. Plast Reconstr Surg. 2005;116:103e–122e. The authors
present a comprehensive review of the classification of thumb loss in
thirds, as well as reconstructive options for each level of amputation. This
article includes both microsurgical and non-microsurgical reconstructive
techniques. The focus of the article is reconstruction of the traumatically
injured thumb, but the principles contained within are applicable to other
thumb loss etiologies.
27. Matev I. Thumb metacarpal lengthening. Tech Hand Up Extrem Surg.
2003;7:157–163. This paper by Dr. Matev describes his experience with
thumb metacarpal lengthening over a 40-year period. It is both a historical
reference as well as an excellent technical guide to the procedure. While
most of his patients required bone grafting following distraction, he
describes situations in which the gap spontaneously ossified. Finally, Dr.
Matev addresses other considerations such as the effects of distraction on
the first webspace and the thumb carpometacarpal joint.
30. Bravo CJ, Horton T, Moran SL, et al. Traumatized index finger
pollicization for thumb reconstruction. J Hand Surg Am.
2008;33:257–262. This article is one of a very few that analyze the on-top
plasty (pollicization of a damaged index finger). The authors review 7
patients who underwent this reconstruction method, including pinch
strength and sensibility. They find that, in general, this is a sound method
of thumb reconstruction, and most patients reported favorably on their
postoperative functionality. The article also includes a valuable list of
technical points necessary to accomplish the procedure.
31. Brunelli GA, Brunelli GR. Reconstruction of traumatic absence of
the thumb in the adult by pollicization. Hand Clin. 1992;8:41–55.
This is a technique manuscript describing index finger pollicization which
can be used for proximal third thumb loss. The authors present in detail
the steps required to accomplish pollicization. Additionally, they address
important considerations including management of the dorsal and palmar
interosseous muscles of the index finger, as well as management of the
transferred metacarpophalangeal joint. They also briefly describe
pollicization of other digits if the index finger is unavailable.
Access the complete reference list online at

317.e1
References
References
1. Littler JW. On making a thumb: one hundred years of surgical
effort. J Hand Surg Am. 1976;1:35–51. Authored by one of the pioneers
of hand surgery, this manuscript is a detailed and richly illustrated
history of thumb reconstruction up to 1976. Many of the techniques
described in this article remain common today. These include digit
transfer, toe transfer, osteoplastic reconstruction, and phalangization.
2. Nicoladoni C. Daumenplastik und organischer Ersatz der
Fingerspitze (Anticheiroplastik und Daktyloplastik). Arch Klin Chir.
1900;61:606–628.
3. Guermonprez F. Notes sur Quelques Resections et Restaurations du
Pouce. Paris: Assselin; 1887.
4. Littler JW. Subtotal reconstruction of the thumb. Plast Reconstr Surg.
1952;10:215–226.
5. Littler JW. The neurovascular pedicle method of digital
transposition for reconstruction of the thumb. Plast Reconstr Surg.
1953;12:303–319.
6. Gosset J. La pollicisation de l’index (technique chirurgicale). J Chir
(Paris). 1949;65:403–411.
7. Gosset J, Sels M. Technique, indications et resultats de la
pollicisation du quatrieme doigt. Ann Chir. 1964;48:1005–1014.
8. Matev IB. Thumb reconstruction through metacarpal bone
lengthening. J Hand Surg Am. 1980;5:482–487.
9. Matev IB. Thumb reconstruction in children through metacarpal
lengthening. Plast Reconstr Surg. 1979;64:665–669.
10. Mehrara BJ, Abood AA, Disa JJ, et al. Thumb reconstruction
following resection for malignant tumors. Plast Reconstr Surg.
2008;121:1279–1287.
11. Heitmann C, Levin LS. Alternatives to thumb replantation. Plast
Reconstr Surg. 2002;110:1492–1503, quiz 1504–1505.
12. Muzaffar AR, Chao JJ, Friedrich JB, et al. Posttraumatic thumb
reconstruction. Plast Reconstr Surg. 2005;116:103e–122e. The authors
present a comprehensive review of the classification of thumb loss in
thirds, as well as reconstructive options for each level of amputation. This
article includes both microsurgical and non-microsurgical reconstructive
techniques. The focus of the article is reconstruction of the traumatically
injured thumb, but the principles contained within are applicable to other
thumb loss etiologies.
13. Bickel KD, Dosanjh A. Fingertip reconstruction. J Hand Surg Am.
2008;33:1417–1419.
14. Atasoy E, Ioakimidis E, Kasdan ML, et al. Reconstruction of the
amputated finger tip with a triangular volar flap. A new surgical
procedure. J Bone Joint Surg Am. 1970;52:921–926.
15. Pet MA, Ko JH, Vedder NB. Reconstruction of the traumatized
thumb. Plast Reconstr Surg. 2014;134:1235–1245.
16. Thibaudeau S, Tremblay DM, Tardif M, Chollet A. Moberg
modification using the first web space: thumb reconstruction
following distal amputation. Hand (N Y). 2012;7:210–213.
17. Hynes DE. Neurovascular pedicle and advancement flaps for
palmar thumb defects. Hand Clin. 1997;13:207–216.
18. Woon CY-L, Lee JY-L, Teoh L-C. Resurfacing hemipulp losses of the
thumb: the cross finger flap revisited: indications, technical
refinements, outcomes, and long-term neurosensory recovery. Ann
Plast Surg. 2008;61:385–391.
19. O’Brien B. Neurovascular island pedicle flaps for terminal
amputations and digital scars. Br J Plast Surg. 1968;21:258–261.
20. Thompson JS. Reconstruction of the insensate thumb by
neurovascular island transfer. Hand Clin. 1992;8:99–105.
21. Muyldermans T, Hierner R. First dorsal metacarpal artery flap for
thumb reconstruction: a retrospective clinical study. Strategies
Trauma Limb Reconstr. 2009;4:27–33.
22. Gregory H, Heitmann C, Germann G. The evolution and
refinements of the distally based dorsal metacarpal artery (DMCA)
flaps. J Plast Reconstr Aesthet Surg. 2007;60:731–739.
23. Page R, Chang J. Reconstruction of hand soft-tissue defects:
alternatives to the radial forearm fasciocutaneous flap. J Hand Surg
Am. 2006;31:847–856.
24. Hansen AJ, Duncan SFM, Smith AA, et al. Reverse radial forearm
fascial flap with radial artery preservation. Hand (N Y).
2007;2:159–163.
25. Friedrich JB, Katolik LI, Vedder NB. Soft tissue reconstruction of the
hand. J Hand Surg Am. 2009;34:1148–1155.
26. Agir H, Sen C, Alagöz S, et al. Distally based posterior interosseous
flap: primary role in soft-tissue reconstruction of the hand. Ann
Plast Surg. 2007;59:291–296.
27. Matev I. Thumb metacarpal lengthening. Tech Hand Up Extrem Surg.
2003;7:157–163. This paper by Dr. Matev describes his experience with
thumb metacarpal lengthening over a 40-year period. It is both a historical
reference as well as an excellent technical guide to the procedure. While
most of his patients required bone grafting following distraction, he
describes situations in which the gap spontaneously ossified. Finally, Dr.
Matev addresses other considerations such as the effects of distraction on
the first webspace and the thumb carpometacarpal joint.
28. Friedrich J, Vedder N. Groin flap coverage of the hand and wrist.
In: Cooney W, Moran S, eds. Soft Tissue: Master Techniques in
Orthopaedic Surgery Series. Baltimore, MD: Lippincott, Williams &
Wilkins; 2008:233–244.
29. Cheema TA, Miller S. One-stage osteoplastic reconstruction of the
thumb. Tech Hand Up Extrem Surg. 2009;13:130–133.
30. Bravo CJ, Horton T, Moran SL, et al. Traumatized index finger
pollicization for thumb reconstruction. J Hand Surg Am.
2008;33:257–262. This article is one of a very few that analyze the on-top
plasty (pollicization of a damaged index finger). The authors review 7
patients who underwent this reconstruction method, including pinch
strength and sensibility. They find that, in general, this is a sound method
of thumb reconstruction, and most patients reported favorably on their
postoperative functionality. The article also includes a valuable list of
technical points necessary to accomplish the procedure.
31. Brunelli GA, Brunelli GR. Reconstruction of traumatic absence of
the thumb in the adult by pollicization. Hand Clin. 1992;8:41–55.
This is a technique manuscript describing index finger pollicization which
can be used for proximal third thumb loss. The authors present in detail
the steps required to accomplish pollicization. Additionally, they address
important considerations including management of the dorsal and palmar
interosseous muscles of the index finger, as well as management of the
transferred metacarpophalangeal joint. They also briefly describe
pollicization of other digits if the index finger is unavailable.
32. Ince B, Gundeslioglu AO, Cicekcibasi AE, et al. Transfer of the fifth
finger to replace an amputated thumb: a preliminary study. Surg
Innov. 2015;22:462–468.
33. Pillet J, Didierjean-Pillet A. Aesthetic hand prosthesis: gadget or
therapy? Presentation of a new classification. J Hand Surg Am.
2001;26:523–528.
34. Manurangsee P, Isariyawut C, Chatuthong V, et al. Osseointegrated
finger prosthesis: An alternative method for finger reconstruction. J
Hand Surg Am. 2000;25:86–92.
35. Parvizi D, Koch H, Friedl H, et al. Analysis of functional outcome
after posttraumatic thumb reconstruction in comparison to
nonreconstructed amputated thumbs at the proximal phalanx of the
thumb ray: a mid-term follow-up with special attention to the
Manchester-modified M2 DASH questionnaire and effect size of
Cohen’s d. J Trauma Acute Care Surg. 2012;72:E33–E40.
36. Al-Dhamin A, Cox J, Bissell MB, et al. Anatomical study of the
princeps pollicis artery perforator flap. Ann Plast Surg.
2016;76:564–568.

SECTION II • Acquired Traumatic Disorders
14 
Thumb reconstruction:
Microsurgical techniques
Nidal F. Al Deek and Fu-Chan Wei
SYNOPSIS
■ Microsurgical toe-to-hand transplantation allows “like-with-like”
reconstruction, achieving the best functional and aesthetic results in
the hand that is missing digits.
■ Preservation of neurovascular bundles, flexor and extensor tendons,
mobile joints, and viable skin with minimal bone shortening in the
amputation stump ensures optimal functional results and less
morbidity at the foot donor site.
■ Retrograde dissection of the vascular pedicle at the first webspace
during toe harvest is a key technique to alleviate concerns regarding
variations in the vascular anatomy of the donor vessels.
■ A missing thumb, traumatic or congenital, can be successfully
reconstructed with the second toe, great toe or modifications of the
great toe including trimmed great toe, partial great toe, and great-toe
wrap-around flaps.
■ Missing fingers, traumatic or congenital, can also be successfully
reconstructed with various configurations from the lesser toes, achieving
good outcomes, especially in those distal to the insertion of flexor
digitorum superficialis. Timing of toe-to-hand surgery does not have an
effect on flap survival, complications, and secondary procedures.
■ The “metacarpal hand” refers to a hand with amputations of all fingers
proximal to their functional length with or without accompanying thumb
amputations. Toe-to-hand transplantation can help restore maximal
hand function to this once crippling condition, even for bilateral
defects.
■ The “metacarpal-like hand” is an ill-defined term and entity of
debilitating condition that also benefits from toe-to-hand surgery.
■ Our extensive experience of over 2200 cases of various toe-to-hand
transplantations allows pioneering of new concepts and refinements of
existing techniques, classification systems and strategic management
algorithms, and patient-reported outcomes, which all shall improve
how we think and perform toe-to-hand surgery.
Introduction
Microsurgical toe-to-hand transplantation is one of the earli­
est free tissue transfers dating back to 1966.1–3 The technique
was first developed to overcome functional deficits following
fingers traumatic injury then congenital deformities but
evolved to address even aesthetic concerns. Over 40 years of
history, toe-to-hand transfer has already reached its zenith.
When confronted with digit amputations, replantation
remains the standard of care.4–6 However, in unreplantable
cases or after failed replantation, toe-to-hand transplantation
is the next best option superior to the use of prosthesis
or other non-microsurgical techniques, fulfilling the “like-
with-like” reconstruction principle without the need for
immunosuppression.7–13
For replacing a mutilated or unreplantable thumb, micro­
surgical toe-to-thumb transfer is the gold standard; a surgery
well-justified based on the fact that the thumb constitutes
40–50% of hand function.14–17
For multiple finger amputations, although the resultant
disability is comparable to the loss of the thumb and drasti­
cally alters the appearance of the hand, indications for micro­
surgical toe-to-finger transplantation remain controversial.8,18–21
It worth noting that toe transfer to the missing finger distal to
the insertion of the flexor digitorum superficialis generally
yields superior functional and aesthetic results compared
with other techniques.22–26
Single finger amputation is not an exception to multiple
finger amputation in controversy; although toe-to-finger
transplantation could be indicated to help certain patients
keep their jobs.22–26
The metacarpal hand, a more severe and extensive type of
injury,12,27,28 is a strong indication for toe-to-hand transfer,
especially in bilateral injuries,29,30 and in the era of hand
allotransplantation its indication is more justified for amputa­
tions distal to the wrist given the good results at the price of
prolonged immunosuppression.31
A critical look at the literature on toe-to-hand surgery may
not reveal significant changes since the middle of the 1980s,
but it does show slightly increased interest in toe-to-finger
transplantation; a sign of change in surgeons’ attitudes.32 It
also shows a growing interest in refining the appearance of
the transplanted toe33–40 and camouflaging the donor site.41–43
  Access video content for this chapter online at expertconsult.com

319
Diagnosis/patient presentation
Fig. 14.1  Number of cases performed at Chang Gung University Medical College
Hospital from 1985 to 2015.
963
252
213
200
143
114
45
4
3
2nd toe
Great toe
Combined 2nd & 3rd toe
Glabrous skin & pulp
Vascularized joint
Wrap-around (great & lesser)
3rd toe
4th toe
Combined 3rd & 4th toe
Total: 1937 operations, 2153 toes transferred
From Jan. 1985 to Dec. 2014
Fig. 14.2  (A,B) Coverage of an injured hand with a pedicled groin flap before toe
transplantation.
A
B
Long-term outcomes have also been studied that shall further
establish the safety and efficacy of the procedure.44,45 This
chapter outlines the current experience of toe-to-hand trans­
plantations, drawing from the authors’ experience of more
than 2200 cases over a 30-year period at Chang Gung Memo­
rial Hospital and Medical College (Fig. 14.1).
Access the Historical Perspective section online at

Diagnosis/patient presentation
The initial management of the potential toe-to-hand trans­
plantation patient is similar to any other trauma or patient
requiring digital replantation, with resuscitation and manage­
ment of concomitant life-threatening injuries if necessary,
and appropriate preservation of the amputated digits. Initial
assessment of the injured hand allows preemptive discussion
of toe-to-hand transplantation with the patient, especially
when the possibility of a successful replantation is in doubt,
such as in severely avulsed, crushed, or multiple amputations.
In particular, patients whose occupation requires a high-
demand use of their hands or those with special needs and
hobbies requiring a fine degree of dexterity and ten fingers,
e.g., musicians or athletes, should be given all information
available concerning different reconstructive options. If there
is significant tissue damage, or anticipated tissue lack follow­
ing debridement, the use of pedicled groin flap with or
without iliac bone graft to replace missing soft tissue and bone
should be considered at the time of the initial operation and
discussed with the patient (Fig. 14.2).
The initial operation
Anticipation of either primary or secondary toe-to-hand
operations ensures careful preservation of all viable structures
at the initial debridement or following failed replantation.55,56
Excessive shortening of structures in order to achieve direct
wound closure or the use of local and regional flaps should
be avoided10 and electively replaced by distant pedicled flaps
such as the groin flap that allows for: (1) maintenance of all
important structures in the amputation stump; (2) primary
closure at the foot donor site; (3) enough soft tissue to create
adequate webspaces and avoid skin grafts in the hand
improving overall cosmetic appearance; and (4) preservation
of potential recipient vessels in the hand for microsurgical toe
transplantation. Although some reports have suggested other
methods of additional soft-tissue harvest with the toe trans­
plantation, either as a single-stage microvascular procedure
with combined free flaps,57 or the use of native foot tissue,33,58
we still recommend the groin flap for the majority of cases; it
is simple and reliable and leaves an almost negligible donor
scar. In some severe cases of extensive soft-tissue loss, a
pedicled anterolateral thigh (ALT) flap in sandwich technique
fashion could be an alternative.
As the use of intraosseous wires is an effective method of
osteosynthesis59 and only requires 0.5 cm of bone for wire
placement, as much remnant bone should be preserved as
possible. In transjoint amputations, any intact articular carti­
lage and accompanying ligaments should be preserved to
facilitate joint reconstruction with disarticulated toe joints.60
Amputations at the level of the thumb metacarpals can be
augmented with the use of bone blocks, thus avoiding the

319.e1
Historical perspective
Historical perspective
The first ever report on toe-to-hand transfer was performed
in a staged, pedicled manner on a 5-year-old child over a
four-week period of time by Carl Nicoladoni in 1897. Unfor­
tunately, the resultant transfer was stiff due to prolonged
immobilization but still superior to the tubed pedicled flaps
popular at that time.46 Davis was the first to combine staged
transfer with microanastomosis of the dorsalis pedis artery,
opening the door for many innovations to follow.47 But, it was
not until 1967 that the first microvascular toe-to-thumb trans­
plantation was performed by Yang and Gu2 who transplanted
the second toe to the thumb.2 Notably, Buncke and Schulz’s
experimental work on monkeys48 preceded Yang’s operation
by one year and probably inspired Cobbett, who successfully
transplanted the great toe to the thumb in 1969.3 Recent
follow-up of Cobbett’s first patient at 30 years showed good
subjective sensation and no evidence of osteoarthritis.49
Partial toe transfer, another frontier in toe-to-hand surgery,
was deemed feasible in 1979 after Buncke and Rose performed
the first neurosensory pulp flap for finger tip reconstruction.50
Koshima further pushed the limits of microsurgery by per­
forming, for the first time, a free vascularized nail graft in
1988.51
The success of toe-to-hand transfer in adults encouraged
pediatric toe-to-hand transfer with O’Brien first reporting the
procedure for congenital absence of the thumb52 and Gilbert53
and Cooney and Wood54 for the replacement of congenitally
missing fingers.
The long and incredible history of toe-to-hand transfer has
yielded it the current “state of the art” with the focus now on
refinements of the functional and aesthetic results, long-term
and patient-reported outcomes, and strategic guidelines. Toe-
to-hand transplantations for traumatic and congenital hand
defects will remain an important tool in the armamentarium
of the reconstructive microsurgeon.

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CHAPTER 14 • Thumb reconstruction: Microsurgical techniques
significant injuries of the ipsilateral upper limb, primary toe-
to-hand transplantation offers the ideal method of replacing
digit loss. It is worth noting though that earlier transfer may
also result in better sensory recovery than delayed transfer.
On the other hand, the procedure should be postponed or not
even performed in patients who are unsure about their deci­
sions and who cannot undergo rehabilitation as expected.
Injury factors
Decision-making for the thumb
The functional thumb depends on adequate length, sensibil­
ity, stability, and the function of the thenar muscle group to
perform opposition. Microvascular toe-to-thumb transplanta­
tions allow these four objectives to be achieved in a single
stage with a superior aesthetic result. The function of the
thumb decreases by 50% once the amputation level is proxi­
mal to the proximal interphalangeal joint and reaches 100%
once it crosses the metacarpophalangeal joint.72 Amputations
distal to the interphalangeal joint are generally well tolerated
but, in certain patients, the additional length, stability, and
sensibility from a transplanted distal toe transfer should
always be offered as an option.65,73
Various classifications and reconstructive algorithms exist
for thumb defects,74–76 although the underlying principles
relate mainly to the types of tissue and the length of thumb
missing.77 Toe-to-thumb transplantations can be successfully
reconstructed with various modifications of the great toe,
including whole great toe,73 trimmed great toe,78 great-toe
wrap-around flaps,79 pulp flaps,80 and the second toe.29,58 The
decision to use which toe or its variation should be individu­
alized not only to the thumb defect and the patient’s needs,
but also with careful consideration of the donor site. In
general, thumb reconstruction using the great toe or its vari­
ants provides better functional outcomes in terms of tripod
pinch, side-to-side and pulp-to-side pinch, as well as appear­
ance than the lesser toes do, although augmentation proce­
dures for second toes to improve bulk have been described.58
If the great toe is used, at least 1 cm of the proximal phalanx
should be preserved in the foot to ensure better push-off and
preservation of foot appearance; the great toe is therefore an
ideal option for thumb amputation levels distal to the mid-
metacarpal shaft. In a more proximal amputation, additional
challenges are inadequate bone stump length and thenar
muscle function. The first can be overcome by a transmetatar­
sal transfer of the second toe or preliminary distraction
lengthening of the existing metacarpal ray or interpositional
bone grafting between the transferred toe and the metacarpal
without sacrificing the base of proximal phalanx or the meta­
tarsophalangeal joint of the great toe.12,30,65 The destruction of
the thenar musculature and the subsequent loss of opposition,
however, may necessitate pronation osteosynthesis, but is
better corrected by primary opposition transfer in the authors’
experience.81
Decision-making for fingers
Classification of finger defects is similar to the thumb and
pertains to the type of tissue and length of finger missing,
with the additional consideration of which finger is involved
and whether there are single or multiple amputations. The
need for a transmetatarsal osteotomy in great-toe harvest, as
preservation of the metatarsophalangeal joint is important for
foot function and appearance.12,61
Avulsed or shredded extensor and flexor tendons should
be debrided but never sacrificed for the sole purpose of
obtaining wound closure. In fingers, preserving the native
intrinsic extensor apparatus as far as possible, especially over
the proximal interphalangeal joint, allows preservation of the
arrangement of the intrinsic and extrinsic extensor systems62
following reconstruction. Similarly, preserving the insertion
of the flexor digitorum superficialis, wherever possible, has
proved useful in achieving better functional results.56,63
Excessive shortening and the use of cauterization of arterial
and venous ends are to be avoided in order to minimize
intimal damage and preserve length, avoiding more extensive
foot dissection and the need for vein grafts which prolong the
operation and increase complications.64 The same applies to
nerves. Traditional teaching of the “pull and cut” method for
prevention of neuromas in amputated stumps is to be avoided,
as sensory recovery is much faster when nerve length is pre­
served and neurorrhaphy performed nearer to the transferred
toe.65 All neurovascular bundles should be tagged carefully
with 10/0 sutures to ensure easier identification at the subse­
quent reconstruction.
Patient selection
Patient factors
Careful patient selection is the key to success. Age in itself is
not a contraindication for microsurgical toe-to-hand surgery.66
Instead, it may impact sensory recovery and range of motion
with the best results achieved in younger patients.67 Ideal
patients should be highly motivated, clear about their needs
with realistic goals and in good health. Decision-making for
each patient is individualized not simply for the injury status
but also to take into account the hand dominance and occupa­
tion as well as socioeconomic status.
Timing: primary versus secondary
reconstruction
The time window once advocated by Godina for microsurgi­
cal reconstruction of lower extremity is not applicable in
toe-to-hand surgery.68 Acute, subacute, and chronic recon­
structions cause confusion and have no significant impact on
the result and, therefore, are better to be avoided; primary and
secondary reconstructions should be used, instead. Primary
refers to microsurgical reconstruction done at any time as long
as the wound has not healed yet, while secondary refers to
transplantation after the wound has healed. With that under­
standing, secondary toe-to-hand procedures may ensure
better wound control and definition of the injury zone, while
primary reconstruction allows one-stage procedure, earlier
rehabilitation, and subsequent return to work, as advocated
by several authors.24,69–71 In our study of 26 primary cases
versus 96 secondary cases, there was no significant difference
in terms of flap survival rates, vascular re-exploration rates,
recipient site complications including infection, or require­
ment for secondary revision.71 In a well-informed and moti­
vated patient without extensive soft-tissue loss or other

321
Patient selection
Table 14.2  Metacarpal hand type II defects and proposed reconstruction algorithm
Subtype
Thumb amputation level
Reconstructive options
Stage
IIA
Distal to the metacarpal neck
Whole or trimmed great toe
Simultaneous
IIB
Proximal to the metacarpal neck with
adequate thenar muscle function
Whole or trimmed great toe ± lengthening
or bone augmentation
Transmetatarsal second-toe transfer
Simultaneous
IIC
Any level with inadequate thenar musculature
Same as in IIA or IIB
Opponensplasty
Staged
IID
Any level with damaged carpometacarpal joint
Same as in IIA or IIB
Immobile thumb post
Staged
definition of proximal or distal amputations is determined by
its relation to the insertion of the flexor digitorum superficialis
tendon.55,65,82 Toe transplantation to more distal finger ampu­
tations can be achieved by a wide variety of options, including
the use of vascularized nail grafts,51,83,84 pulp flaps,85 wrap-
around flaps,35 and partial second toes,23 depending on what
tissues are missing. These operations are rewarding due to the
restoration of high-density pulp sensation, fine pinch, and
cosmetic appearance of the nail.82,83,86 A partial second-toe flap
which includes the distal interphalangeal joint or both the
proximal and distal interphalangeal joints is indicated in
amputations distal to the flexor digitorum superficialis inser­
tion.22,82,87,88 In contrast, a whole second-toe flap is indicated in
carefully selected patients with more proximal amputations;65
the ideal level, however, is distal to the middle of the proximal
phalanx as reconstructions for more proximal amputations
usually result in a slightly shorter finger.89
Decision-making for patients with multiple finger ampu­
tations are largely guided by the specific occupational and
cosmetic needs of the patient. In general, two adjacent
fingers should be reconstructed wherever possible to allow
a stable tripod pinch or hook grip.12,21,88 Preferential recon­
struction of the radial two fingers should be recommended
for patients who require fine pinch and the ulnar two digits
for manual workers who require a strong grip.19,90 However,
multiple finger amputation could be too complicated to be
addressed with toe-transfer alone, and additional procedures
such as lengthening and ray amputation could be necessary,
as well.86
Decision-making for the metacarpal hand
The term “metacarpal hand” refers to a hand injury with
multiple finger amputations at the level of the metacarpopha­
langeal joint, or immediately proximal or distal to it. Delitala
was perhaps the first to coin this term91 and, since then,
various classification systems have been proposed,92–95 with
varying levels of clinical usefulness. A classification system
based on reconstructive options and different stages of injury
has proved useful in our experience12,61,91 (Tables 14.1 & 14.2).
This takes into account the level of finger amputations and
thumb involvement, and provides guidelines for the recon­
structive technique as well as prediction of the functional
outcome after reconstruction. Type I refers to four-finger
proximal amputations without the thumb or only distal-
thumb involvement (no thumb reconstruction necessary). In
type IA where the amputation level is distal to the
metacarpophalangeal joint, the focus is on the selection of two
separate toes or combined second and third, or third and
fourth toe transplantations depending on the presence of
webspace (Fig. 14.3). To ensure that the different digits curve
around an object more evenly in grasp prehension, the length
of the remaining amputation stumps should not be longer
than that of a normal little finger when considering a com­
bined second- and third-toe transfer.90 For type IB, where the
amputation level is through the joints with intact articular
surfaces, combined second and third toes are harvested as
composite joint transfers. For type (IC) where the amputation
level is proximal to the metacarpophalangeal joints, combined
second and third toes as transmetatarsal transfers is indicated.
Reconstruction of two adjacent fingers allows for a stable
tripod pinch, although reconstruction of all four fingers is
possible in certain selected patients with acceptable donor site
morbidity (Fig. 14.4).12
Type II injuries refer similarly to four-finger proximal
amputations but with various levels of thumb involvement
proximal to the base of proximal phalanx. The reconstruction
of fingers with toe transplantations follows a similar decision-
making process as for type I defects, but reconstruction of the
thumb is determined by the presence or absence of a func­
tional thenar musculature. If the thenar muscles are intact or
possess adequate function (types IIA and IIB), a one-stage
procedure to reconstruct the thumb and two adjacent fingers
is recommended. If the thenar muscles are missing or have
inadequate function (IIC), the thumb reconstruction should
follow finger reconstructions in a second stage and only after
the thumb position is determined by the aid of prosthesis
while the fingers assume their final positions (Fig. 14.5). Either
Table 14.1  Metacarpal hand classification for type I defects
Subtype
Thumb amputation
levels
Finger amputation levels
IA
Amputation distal to
the interphalangeal
joint
Distal to the level of
metacarpophalangeal
joint
IB
At the level of the
metacarpophalangeal
joint
IC
Proximal to the level of the
metacarpophalangeal
joint

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CHAPTER 14 • Thumb reconstruction: Microsurgical techniques
Fig. 14.3  Indications for combined second- and third-toe harvest versus bilateral toe harvest. A combined second- and third-toe transplantation is preferred for:
(A) amputations proximal to the webspace (indicative of a level at or proximal to the metacarpophalangeal joints); or (B) when the remaining fingers are at the level of, or
shorter than, the little finger. Using this technique when the remaining finger is longer than the little finger will produce a hand with gross unequal finger lengths and an
uneven digital arcade (C). (D) Bilateral second toes are best suited when the webspaces are preserved, indicative of amputations distal to the metacarpophalangeal joints
with adequate bone for osteosynthesis.
A
B
D
C
Fig. 14.4  The reconstructed tripod pinch of a type I metacarpal hand, showing
stability of grip and good opposition with the thumb.
pronation osteosynthesis or an opposition transfer can be
performed to provide better pinch.81,96
Decision-making in bilateral metacarpal hand injuries
requires a careful balance of the severity of injury (type I or
II), patient’s needs, and donor site morbidity. Other options
should also be discussed with the patient. Type II injuries are
much more difficult than type I, requiring up to but not
exceeding five toes to achieve a functional level of
Fig. 14.5  Use of a prosthetic thumb for a type IIC metacarpal hand after combined
second- and third-toe transplantation for middle- and ring-finger reconstruction.
This is useful for determining the exact position of the future transplanted thumb
and for planning additional procedures (e.g., opponensplasties).
prehension.30 In general, the use of a great toe, usually from
the left foot, is sacrificed for dominant thumb reconstruction
together with a combined two-toe reconstruction from the
opposite foot to achieve a tripod pinch. In the non-dominant
hand, single-digit pulp-to-pulp pinch is considered adequate
with the use of a lesser toe for thumb reconstruction.30
Although the option of sacrificing both great toes or more

323
Treatment/surgical technique
minimizing tedious and destructive dissection in the foot. In
the 20% of cases where a first plantar metatarsal arterial
(FPMA) system is dominant, as identified by its plantar rela­
tions to the deep intermetatarsal ligament (see Fig. 14.7), the
FDMA is then ligated, reducing time spent on dorsal dissec­
tion, and the plantar dissection continued together with the
harvest of the digital nerves. The length of the arterial pedicle
harvested should be able to reach the chosen recipient artery.
However, in a dominant FPMA system, dissection should be
limited to the non-weight-bearing zones, with the use of vein
grafts if necessary to increase pedicle length. In cases where
both the FDMA and FPMA appear equally dominant (10%;
see Fig. 14.7), the dorsal system is always selected due to its
easier harvest and less donor morbidity. Following toe har­
vests, at least 20 minutes should be allowed for observation
of adequate perfusion before detaching the flap.
Fig. 14.6  (A,B) Appearance of bilateral metacarpal hands and donor sites after toe-to-hand transplantations. Up to a total of five toes can be harvested for the most severe
defects of bilateral type II metacarpal hands requiring reconstruction of opposing digits in both hands.
A
B
lesser toes for hand reconstruction may seem attractive, we
have found that the donor morbidity reaches a level that is
incompatible with activities of daily living. In instances where
multiple toes are needed, the patient needs to participate fully
in the decision-making with regard to the foot morbidity,
especially in certain populations where patients are far less
tolerant of sacrificing their toes to reconstruct their hands (Fig.
14.6).29
Treatment/surgical technique
Despite the many configurations and combinations of toe-to-
hand transplantations available, a few important principles
exist for all cases which, when adhered to, allow easier dis­
section, reduced foot morbidity, and improved overall func­
tional and aesthetic outcomes.
General principles in vascular dissection
The venous drainage system should be identified and selected
before the arterial system. One sizeable vein located in the
intermediate layer and drained by the great saphenous vein
is usually enough, but should not be confused with the arte­
rial system.
As for the arterial blood supply, we recommend the vascu­
lar pedicle dissection starts at the first webspace and proceeds
in retrograde manner. This method alleviates concerns regard­
ing vascular anatomy and allows early detection of system
dominance pattern (dorsal vs. plantar) which shall guide the
rest of surgery minimizing damage and reducing time.97,98 In
our experience, the first dorsal metatarsal artery (FDMA) is
usually dominant (70%) and identified by its dorsal relation
to the intermetatarsal ligament (Fig. 14.7).65,99 Once this is
confirmed, it permits early ligation of the plantar system,
Clinical hints and tips
• Always start the vascular pedicle dissection from the first
webspace and identify the trifurcation (two branches to two
adjacent toes and one communicating branch to the
plantar artery) then trace the arterial pedicle in a retrograde
fashion. In 70–80% of cases, the first dorsal metatarsal
artery can be used as the arterial pedicle.
• To avoid “cobra-head” disfigurement, create four mobile
flaps through a cruciate incision, and interpose these with
the V-shaped flaps of the transplanted toe.
• The neurovascular bundles are skeletonized during the
dissection to avoid difficult inset and bulky appearance at
the junction of transplanted toe and amputated stump.

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CHAPTER 14 • Thumb reconstruction: Microsurgical techniques
General principles in recipient preparation
A two-team approach greatly reduces the overall operating
time, surgeon fatigue, and risks of anesthesia.55 Proper prepara­
tion of the recipient site allows a smooth transition from flap
harvest to inset without any delays. Preservation of all viable
lengths of bone, joints, neurovascular bundles, and tendons
should have been performed at the initial operation by a
surgeon who has working knowledge of toe-to-hand transplanta­
tions.56 A cruciate incision allows the creation of four equal
triangular flaps for smooth interdigitation with the V-shaped
flap of the transplanted toe and prevents the ugly “cobra”
appearance that features prominently at the toe–digit junction
(Fig. 14.8). Following preliminary inset, excess fatty tissues are
trimmed by skeletonizing the neurovascular bundles of the
recipient flaps. All these maneuvers allow the creation of a
finger or thumb with a more natural-looking appearance.
Fig. 14.7  (A) Retrograde dissection of the arterial pedicle
begins in the first webspace and allows early confirmation
of a dominant dorsal or plantar system. (B) In 70% of
cases, a dominant first dorsal metatarsal artery is present
(MAKE DORSAL VESSEL THREE TIMES LARGER THAN
PLANTAR VESSEL), whereas in 20% of cases, a dominant
first plantar metatarsal artery is present (C) (MAKE
PLANTAR VESSEL THREE TIMES LARGER THAN DORSAL
VESSEL). In 10% of cases, both systems are equally
dominant, in which case the dorsal system is selected (D).
A
B
D
C
Dominant dorsal
blood supply
(70%)
Dominant plantar
blood supply
(20%)
Equal dominance
of dorsal and
plantar blood
supply (10%)
Fig. 14.8  A cruciate incision at the recipient site allows the creation of four equal
triangular flaps and prevents a bulbous appearance at the subsequent toe-to-finger
junction.
Clinical hints and tips
To reduce foot morbidity and avoid the use of skin grafts, pay
careful attention to the placement of incisions on the foot.
Webspace incisions should not cross the midline on to the
territory of the contralateral toes, and all proximal incisions
should converge to a V proximal to the osteotomy sites. In
addition, scars should be kept away from all weight-bearing
sites.
General guidelines in donor closure
Careful placement of incision lines in the donor foot mini­
mizes weight-bearing pain and scar tenderness and permits
earlier mobility. V-shaped flaps are placed proximal to the
osteotomy site whereas distally, the incisions are situated
midway between the webspaces to permit tension-free
closure, even with combined second–third or third–fourth-toe

325
Treatment/surgical technique
transplantations. Incisions on weight-bearing areas as well
as extensive foot dissection should be avoided. Skin grafts
are generally discouraged due to difficulties in replacing gla­
brous skin, wound breakdown due to repeated pressure from
weight-bearing and footwear, and also because it prevents
early ambulation. When skin grafts are required, for example,
after pulp flap, webspace flap, and wrap-around flap harvests,
they should be carried out meticulously with strict prevention
of ambulation until the grafts are healed.
General principles in flap inset
Intraosseous wires provide a stable, not rigid, method of fixa­
tion, achieving a union rate of 98.5%.59 They are also advanta­
geous for the following reasons: a shorter segment of recipient
bone is required for osteosynthesis; and the semirigid fixation
allows early postoperative correction if the transplanted toe
is found to be malaligned or malrotated (Fig. 14.9).
Fig. 14.9  A prepared recipient site with interosseous wires inserted, ready for inset
of the toe flap.
Clinical hints and tips
• To preserve maximum bone length in the amputation
stump, use parallel intraosseous wires as the preferred
method of osteosynthesis, as this requires only 0.5 cm of
available bone, achieves a good union rate, and allows
postoperative correction of any malalignment or
malrotation.
• Careful attention to tendon repairs increases range of
motion and also corrects the natural tendency of the toe to
claw. The extensor tendons are always reconstructed first.
Preserving the extensor tendon apparatus over the proximal
interphalangeal joint, wherever possible, allows the intact
intrinsic system of the hand to work synergistically with the
reconstructed extrinsic system. Release of the extensor
digitorum longus attachment from the metacarpophalangeal
joint capsule, suturing of the extensor digitorum brevis to
the dorsal expansion or to the interosseous
musculotendinous structure, and a tight extensor repair in
full extension are different ways of overcoming the naturally
flexed position of the toe.36 In addition, a K-wire is also
inserted at the end of the procedure, transfixing the distal
Clinical hints and tips
• To achieve the best functional outcome of the reconstructed
tendons, preserve all extensor apparatus as far as possible
to allow synergistic action of the native intrinsic system with
the reconstructed extrinsic system. To correct the natural
tendency of the toe to claw, perform a tight extensor tendon
repair and insert a K-wire with the distal and proximal
interphalangeal joints in extension for 6 weeks followed by
splinting for up to a year.
• To achieve maximal stability of the interphalangeal joint
following a trimmed great-toe harvest, ensure that the
perijoint flap consisting of the periosteum, medial collateral
ligament, and joint capsule is redraped and closed in a
tight manner around the trimmed interphalangeal joint of
the great toe.
Clinical hints and tips
• To ensure maximal success and reduce vascular
complications, harvest the combined second- and third-toe
flap with the first dorsal metatarsal artery as the dominant
pedicle, and the second and third common digital artery as
a backup in case of inadequate perfusion.
• To reduce donor site morbidity, close the donor site
primarily in all cases. It is not necessary to reconstruct the
transmetatarsal arch even when disturbed, for example, in
transmetatarsal osteotomies, as this does not affect gait
and walking ability in the long term.
interphalangeal joint and the proximal interphalangeal joint
in full extension.
• The flexor tendon repair is carried out against the tension of
the extensor repair to restore a normal digital cascade. In
proximal amputations, the flexor tendon of the transplanted
toe should be pulled through proximally into zone III for
repair to prevent an increased risk of tendon adhesions in
“no man’s land” (zone II).
Nerve repair is carried out next. The proper digital nerves are
selected for end-to-end anastomosis with recipient digital
nerves that have been trimmed back to reveal healthy nerve
stumps. If additional dorsal recipient nerves are available,
these can be sutured to any harvested branches of the super­
ficial and deep peroneal nerves. Following nerve repair, the
skin flaps are closed temporarily to allow for final skin adjust­
ments if necessary. Care must be taken to prevent a tight
closure which may eventually compress the pedicles. If in
doubt, a skin graft should be used rather than try to force
primary closure. A single arterial anastomosis is then per­
formed and perfusion of the toe checked before the venous
anastomosis. If it is judged to be inadequate, the entire pedicle
should be assessed for any kinking, twisting, or compression
with further stripping of the adventitia if necessary. If required,
further shortening or a vein graft should be used to ensure
healthy inflow.

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CHAPTER 14 • Thumb reconstruction: Microsurgical techniques
Specific operations
Trimmed great toe (Video 14.1 )
Harvest of the trimmed great toe begins with measurements
taken and compared at three locations on the normal contra­
lateral thumb and the great toe to reconstruct a new thumb
with matching proportions: the nail eponychium, the inter­
phalangeal joint, and the middle of the proximal phalanx (Fig.
14.10). The size discrepancies are marked on the medial aspect
of the great toe as an area of tissue to be excised, with an
excess of 2–3 mm on each side and tapering of both the proxi­
mal and distal ends to facilitate closure.
Elevation of the trimmed great toe begins in the first web­
space to identify the dominant blood supply and carry out
retrograde dissection, as previously described. Following
identification of the flexor and extensor tendons and also
after careful preservation of the deep peroneal nerves, the
In a combined second- and third-toe transplantation, two
anastomoses should be prepared as a higher rate of arterial
spasm, and re-exploration rates of up to 20%100 have been
found when using a single dominant artery. A second anasto­
mosis using the second and third common plantar artery
should be carried out when the perfusion to the third toe is
uncertain. Once perfusion is established, the hand is then
turned around, and the venous outflow checked for healthy
back-bleeding. Venous anastomosis is carried out through a
separate incision on the dorsum of the hand. A recipient vein
of suitable caliber is selected and mobilized from the adjacent
fingers if necessary. The skin incisions are then loosely closed
definitively over small silastic drains placed in the dorsum of
the hand and fingers, and finally the K-wire is inserted across
the distal and proximal interphalangeal joints in full exten­
sion. The hand is then wrapped in a non-circumferential,
non-compressive dressing with the transplanted toe largely
exposed to monitor perfusion.
Fig. 14.10  Trimmed great-toe harvest technique.
(A) Markings of the thumb are made at three positions on
the thumb and transposed to the toe: nail eponychium,
widest point (interphalangeal joint), and middle of
proximal phalanx. (B, C) The discrepancies are marked on
the medial side as an area to be excised. (D) The skin flap
is elevated superficial to the collateral ligament and joint
capsule. (E) The perijoint flap is created by raising the
periosteum, medial collateral ligament, and joint capsule
as a single flap, exposing the phalanges. The medial joint
prominence and 2–4 mm of the proximal and distal
phalanges are removed by an oscillating saw.
(F) Following tight redraping of the perijoint flap, the skin
is closed to create a toe of smaller circumference, ready
for transfer.
A
B
C
D
E
F

327
Treatment/surgical technique
harvested in preference of the plantar digital nerves. The dis­
section is then continued on the plantar aspect of the foot,
similarly with a V extending from the base of the toe and
further extension with avoidance of any weight-bearing areas.
The flexor sheaths are opened and the flexor tendons pulled
out and cut at a proximal level to ensure adequate length. The
plantar nerves are traced proximally to the bifurcation of the
common digital nerves and internal neurolyses carried out if
necessary to obtain adequate length before dividing them.
The removal of excess fibro-fatty tissues by skeletonization of
each neurovascular component is routinely carried out, as this
greatly facilitates wound closure and improves the aesthetic
appearance of the transplanted toe. This is especially so for
partial toe transfers, due to the relative lack of space for flap
inset at the level of the middle phalanx.
The bone length required for a complete second-toe transfer
is achieved by an osteotomy at the proximal phalanx, the
metatarsal shaft, or via a metatarsophalangeal joint disarticu­
lation preferably. In a partial toe transfer, the neurovascular
bundles are freed distal to the osteotomy sites at the middle
or proximal phalanges or the disarticulated joint. Metatarso­
phalangeal joint disarticulation is usually necessary to permit
direct skin closure, even following partial toe transfers.
Partial second-toe transfer has further evolved into specific-
structure partial transfer such as vascularized nail, pulp or
joint with preservation of the second toe. The donor site of
such a specialized partial second-toe flap can be covered with
a full-thickness skin graft.101
The second-toe flap can also be modified to improve the
appearance of the reconstructed new thumb. Although the
second toe can be transferred to create a functionally
trimming of the great toe commences. The marked area of
redundancy is excised with incisions down to and superficial
to the medial collateral ligament of the interphalangeal joint.
The next step is removal of bony excess. To facilitate access to
the phalanges, a plantar-based perijoint flap composed of
periosteum, joint capsule, and medial collateral ligament is
raised. About 4–6 mm of the joint prominence and 2–4 mm of
the phalanges are removed with an oscillating saw and the
remaining bones smoothed with a burr. The perijoint flap is
then redraped with the excess tissue excised and sutured in a
tight manner to ensure the stability of the joint. Finally, the
medial skin incisions are approximated and the overall
appearance checked before carrying out the transverse oste­
otomy at the level of the proximal phalanx and the flap
islanded, ready for inset (see Fig. 14.10).
Second toe: total and partial (Video 14.2 )
Transplantation of a partial second toe is used for distal
digit amputations whereas a transplantation of total second
toe is used for the reconstruction of more proximal finger
amputations.
For either, the skin markings encircle the base of the second
toe and cross the midpoints of the first and third webspaces,
finally converging as a V proximally and extending at least
5–10 mm beyond the osteotomy site (Fig. 14.11). The toe
harvest commences by identifying the dominant arterial
supply in a retrograde fashion and one sizeable vein, as previ­
ously described. Both the extensor digitorum longus and
brevis tendons are identified and traced proximally for ade­
quate length. Branches of the peroneal nerves are usually not
Fig. 14.11  Second-toe harvest technique. (A,B) A dorsal
S incision is made on the dorsum of the foot to expose
the donor veins, extensor mechanism, and arterial pedicle,
although dissection begins in the first webspace to allow
a retrograde dissection (C). Plantar dissection begins with
a midline incision, avoiding the weight-bearing areas of
the foot, to expose the digital nerves and to harvest the
flexor tendon (D).
A
B
C
D

328
SECTION II
CHAPTER 14 • Thumb reconstruction: Microsurgical techniques
same manner as the partial or complete second-toe flap (see
above). The flap is then carefully degloved from the underly­
ing skeleton, except for the distal phalanx, which is always
included in the flap to maintain distal stability and prevent
bone resorption. Careful consideration is also given to the
placement of scars during flap harvest for their subsequent
positioning on the “trailing” edges of the fingers. Disarticula­
tion at the metatarsophalangeal joint in the remnant toe
provides a donor defect amenable to primary closure and
improved appearance.
Neurosensory pulp flaps
The size of the defect is outlined and marked on the selected
toe (Fig. 14.12). The lateral aspect of the great toe is preferred
for its richer nerve supply, more abundant tissues, and there­
fore increased likelihood of primary closure.65 Principles for
flap harvest are similar to those previously described, but
important considerations are keys to achieving success: (1)
identifying and including both the branches of the deep
peroneal nerve and proper digital nerve to provide the best
sensory outcome; (2) dissection and inclusion of the proper
digital artery by tracing its origin from the first dorsal or
plantar metatarsal artery in the first webspace; (3) skeleton­
izing the neurovascular bundle to allow tunneling of the
vessels during flap inset.
First-web neurosensory flap
This is a useful flap due to its rich sensory innervations, pli­
ability, and size, with dimensions of 14 × 7 cm achievable105
for resurfacing of bigger defects in one or multiple fingers,
and the potential to replace glabrous skin for palm
defects.104,106,107 After outlining the defect in the first webspace,
the vein is first identified, as previously described. The loca­
tion of the intermetatarsal ligament is identified next as this
structure points to the first dorsal or plantar metatarsal artery
and the distal communicating artery that supplies this flap.
Once the dominant blood supply is confirmed, retrograde
dissection continues in a straightforward manner, continuing
with either the dorsal or plantar approach. Branches of the
proper digital arteries must be traced and included if the flap
dimensions extend to the pulps of the great or second toes.
acceptable thumb, the appearance falls short due to narrow
neck, bulbous appearance, and short nail. The lateral pulp
flap from the great toe can be harvested with the second toe
based on the same vascular pedicle and used to augment the
volar aspect of the second toe to give more bulk and correct
the narrow neck and the eponychium of the nail complex
of the second toe can be excised to lengthen the nail and
mimic the thumb nail.102
Third toe
The third toe can also be transferred to reconstruct missing
digits. Indications are: (1) the second toe is not available or is
not suitable for transfer because of previous injury, surgery,
or deformity; (2) the second toe is on the same foot from which
the great toe has been harvested for thumb reconstruction and
therefore the second toe is spared for gait; and (3) the third
toe provides a better size match for finger reconstruction than
the second toe.103
For reliable harvest of the third-toe flap, the key principles
used in great and second toe dissection apply. However, since
the majority of the patients undergoing transplantation of the
third toe have already had transplantation of either the great
or the second toe or will have it, the second metatarsal pedicle
is either not available or must be preserved for subsequent
transfer of the great or second toe. Therefore, the third toe is
preferably transferred based on the third plantar metatarsal
artery, which is usually bigger in caliber than the second or
third dorsal metatarsal arteries. As the pedicle of choice for
the third toe is the plantar pedicle, it will be simpler and
quicker to proceed directly to the dissection of the plantar
vascular pedicle, and if found short, a vein graft is used for
the vascular anastomosis.103 In most cases, however, the
pedicle is long enough to reach the proper digital artery at the
level of the proximal phalanx in the hand.
The donor site is closed in the same way as described for
the second toe.
Wrap-around flaps: great and second toes
The great-toe wrap-around flap was originally used in con­
junction with a non-vascularized iliac bone graft for recon­
structing thumb loss distal to the metacarpophalangeal joint,79
although reconstructions at more proximal levels have been
described.104 The use of these flaps can be extended to the
replacement of skin and nail loss in the thumb and ring avul­
sion finger injuries with an intact skeleton, tendon, and proxi­
mal interphalangeal joints. Reconstruction of the latter is
better achieved with a second-toe wrap-around flap which
provides an excellent contour and nail match and also avoids
using the great toe as a donor.35
Harvest of the great-toe wrap-around flap follows similar
principles as the trimmed great-toe technique, previously
described. Preoperative markings are made with measure­
ments taken from the contralateral thumb and transposed on
to the great toe (see Fig. 14.10A). The flap utilizes the dorsal,
lateral, and plantar skin, leaving behind a cuff of skin and
subcutaneous tissue on the medial aspect for donor closure.
Disarticulating the remaining interphalangeal joint and
closing the medial skin flap over the proximal phalanx is
preferred rather than using a cross-toe flap from the second
toe. The second-toe wrap-around flap begins in exactly the
Fig. 14.12  Pulp flap harvested from the great toe.

329
Postoperative care
Retrograde dissection of the dominant arterial supply is
performed in the first webspace, as previously described. The
second and third plantar arteries should be dissected and
preserved as a backup in case a second set of anastomosis is
required. The common digital nerve to the second and third
toe, together with their respective proper digital nerves, is
also isolated and preserved for transfer during the plantar
dissection. Direct closure of the donor site in a tension-free
manner should be achievable without the need for a skin
graft. In cases where the metatarsals have been osteotomized,
the authors’ present policy is to not replace the foot defect
with a bone graft as previous analysis of patients has demon­
strated no difference in walking and gait performance.65
For situations when one neighboring second toe needs to
be preserved for specific reasons and the amputation level at
the recipient site is distal to the webspace, a bilateral third-toe
transplantation provides an alternative solution. A split com­
bined second and third toe from the other foot can be also
performed and, in this case, two sets of pedicle vessels from
the dorsal or plantar system are prepared and the best selected.
Separation of second and third toes can be done after the
adjacent toes were taken down or before.108
Postoperative care
Immediate postoperative period
The immediate postoperative care is critical to ensure the
success of the microsurgical procedure. Patients ideally should
be kept for close monitoring of the flap in a microsurgical
intensive care unit for a minimum of 5 days. If this facility is
not available, they should be kept in a warm room and nursed
by experienced staff trained in the routine monitoring of free
Likewise, in this situation, the proper digital nerves are har­
vested in conjunction with the deep peroneal nerve branches
to provide adequate sensation. The donor defect is readily
reconstructed with a split-thickness skin graft and tie-over
dressings. Careful attention to detail and strict non-weight-
bearing reduce the incidence of wound-healing complications
and the need for prolonged foot care (Fig. 14.13).
Combined second- and third-toe transplantation
(Video 14.3 )
Combined second- and third-toe transplantations carry the
advantages of only needing potentially one set of microvas­
cular anastomoses, less operative time, and confining donor
morbidity to one foot.90 Its popularity has been limited,
however, by the length of digits achievable following recon­
struction and probably concerns regarding the donor morbid­
ity, especially in certain populations.29 If carried out carefully,
however, this procedure is extremely useful in replacing two
adjacent finger amputations at a level proximal to the web­
space, especially when the other remaining fingers are shorter
than the little finger. It is especially useful in the metacarpal
hand deformity to provide tripod pinch function, hook grip
capability, and lateral stability.
Skin incisions in the first and third webspaces should not
cross the midline to allow primary closure of the donor site,
and converge to a V 1 cm proximal to the level of osteotomy.
In proximal phalanx amputations with at least 5 mm of bone
remaining, the toe is disarticulated from the metatarsophalan­
geal joint and then subsequently shortened to the required
length and osteosynthesized to the finger skeleton. Through
metacarpophalangeal joint amputations are reconstructed
with the corresponding metatarsophalangeal joints of the toes
with their joint capsules intact. Even more proximal amputa­
tions require harvest of the respective metatarsals (Fig. 14.14).
Fig. 14.13  (A–D) First-web neurosensory flap harvest from the left foot for reconstruction of the first webspace of the right hand.
A
B
C
D

330
SECTION II
CHAPTER 14 • Thumb reconstruction: Microsurgical techniques
Motor rehabilitation
Toe-to-hand transplantations require a close collaboration
between surgeons, nurses, physiotherapists, occupational
therapists, and prosthetists to provide the necessary postop­
erative rehabilitation program and maximize the functional
outcome. Individual patient motivation and employment
needs also have to be considered. A five-stage rehabilitation
program65 ensures that these objectives are met:
1. Protective stage (days 1 to 3): Psychological support is
provided while the patient is still in the microsurgical
intensive care unit through interaction with the hand
therapist.
2. Early mobilization stage (day 4 to week 4): The goal is
to prevent excessive swelling and joint stiffness. On day
4, controlled gentle passive range of motion for about
15° is performed on the less involved joints. In the
subsequent weeks the passive movement involves all
joints both proximal and distal to the osteosynthesis site
and is gradually increased in range but not to interfere
flaps. Although both internal devices such as implantable
Doppler109 and external devices such as infrared temperature
assessment and pulse oximetry may be useful modalities,110
the most reliable method of flap monitoring is still clinical
observation. At the first sign of vascular compromise, rapid
action should be taken to avoid further flap deterioration.111
Infection should also be identified and controlled early as it
has been found to be the single greatest factor contributing
to vascular compromise and re-exploration in toe-to-hand
surgery.112 Beside flap monitoring and infection control, all
patients are carefully monitored to ensure they are warm,
well-hydrated, and pain-free. The hand is kept slightly ele­
vated above the level of the heart, but not higher. Non-
constricting, non-bulky dressings should be used as this
prevents clot formation which could induce vasospasm
during dressing change and also prevents early mobilization.
A routine intraoperative bolus of dextran is given, followed
by continuous infusion over the next 5 days. In addition, a
2-week course of oral aspirin is administered to reduce the
incidence of platelet aggregation.
A
B
Fig. 14.14  Combined second- and third-toe harvest as a transmetatarsal transfer for reconstruction of a metacarpal hand. (A) Surface markings on the donor foot before
harvest showing the position of the first dorsal metatarsal artery and a suitable vein. (B) Harvested toe with artery, veins, nerves, and tendons. (C,D) Reconstructed hand
following inset showing primary closure of all wounds without tension.
C
D

331
Outcomes, prognosis, and complications
the differences in texture, size, shape, and consistency
from different surfaces. The significant improvement that
can be seen following this re-education can probably be
explained by the increased cortical reorganization caused
by increased neural activity in the postcentral gyrus that
compensates effectively for the decreased local neural
activity.121–123
Outcomes, prognosis, and
complications
Outcomes and prognosis
The success rates of microsurgical toe-to-hand transplanta­
tions are around 96–98%.53,112,124–126 Therefore, the goal of this
surgery should no longer be flap survival but improved aes­
thetic and functional outcomes. In a series of 2200 procedures
carried out by the authors over 30 years (1985–2015) at Chang
Gung Memorial Hospital and Medical College, a success rate
of 97% was achieved (see Fig. 14.1).
Range of motion
In terms of range of motion, an average of 25° and 29° follow­
ing thumb reconstruction using the great toe should be
achievable at the metacarpophalangeal joint and interphalan­
geal joint, respectively.125 The trimmed great-toe technique
generally results in an anticipated reduction of movement at
the interphalangeal joint of 18°, although this did not seem to
affect pulp-to-pulp pinch prehension.78 In toe-to-finger trans­
plantations, an average total range of motion of 50–60° is
usually achievable for the proximal and distal interphalangeal
joints.60,127 If a metatarsophalangeal joint has been transferred
to reconstruct the metacarpophalangeal joint, the expected
range of movement should average 50°, or 52° if a composite
joint reconstruction has been carried out via a metatarsopha­
langeal joint disarticulation during harvest.12,90
Strength assessment
In general, an average of more than 75–80% approximation
to the opposite thumb has been reported for both grip and
pinch strength following thumb reconstruction, in many
instances exceeding the strength of its counterpart.25,125,128
Independent strength assessment in finger reconstructions
is more difficult to measure and is often dependent on an
intact thumb function to produce a stable tripod or pulp-to-
pulp pinch. The reconstructed finger is also often shorter and
may not be accurately assessed using conventional methods
of assessment like the traditional dynamometer or pinch
meter. These instruments may need to be specially modified
to conform to the length and profile of transplanted toes.
Furthermore, restoring the prehensile patterns of the hand
may be a much more valid measure of outcome and has
been achieved in most series, especially following reconstruc­
tions for multiple-finger amputations and the metacarpal
hand deformity.8,20,82,129,130 In addition, from the authors’
series of toe transfers for isolated finger amputations, we
have also found restoring the digital arcade and storage
function of the hand to be useful both functionally and
psychologically.26,103
with bone union or to induce stress on the repaired
tendons and the neurovascular structures. A protective
splint is provided between exercises.
3. Active motion stage (weeks 5 to 6): While the passive
exercises are still maintained, gentle active exercises
under supervision begin, and the splint is changed to a
dynamic one. Once tendon healing is no longer a
concern, blocking flexion and extension exercises are
started. At this stage, more care can be directed towards
softening the scar and improving appearance, and to
avoiding adhesion by providing compression bandages,
ultrasound, and scar massage.
4. Activities of daily living training stage (weeks 7 to 8):
Depending on patient capabilities, different manual jobs
that simulate daily manual activities are designed to
increase muscle power and range of motion.
5. Pre-vocational training stage (week 8 and beyond): The
goal is to further improve muscle strength, hand
dexterity and coordination. Vocational activities are
encouraged, and a night-time extension splint to
prevent claw deformity is recommended for 1 year at
least. Group sessions with other patients who have also
received toe-to-hand transplants can be helpful to
encourage integrating the reconstructed hand into the
patient’s normal life.
Sensory rehabilitation
The finger and thumb pulps are unique in that they contain
a higher density of sensory nerve endings than other body
areas, packed within a relatively small area of skin that is
tightly adhered to the underlying bone via fibrous septa.113
Although toe transfers allow the replacement of this special­
ized glabrous skin, targeted sensory rehabilitation plays an
important role in producing an optimal functional result.
Several studies have demonstrated the importance of sensory
re-education in maximizing both subjective and objective
sensory recovery following nerve repair in digits;67,114–116 this
is of even greater importance in toe-to-hand transplanta­
tions due to the fewer number of sensory endings in the
toe as compared to the fingertip.117 Two types of sensory
re-education program are used in the authors’ unit: early
and delayed.
Early re-education focuses on improving the local adapta­
tion to the submodalities of light touch, pinprick, and pressure
with correct localization, according to Dellon.67 Static and
moving two-point discrimination tests are usually chosen
to measure local sensory recovery70,87,107,118 following early
re-education, although our unit has shown that there is very
little correlation between this method of assessment and
sensory threshold testing using the Semmes–Weinstein mono­
filament kit.119 These results suggest that subjective recovery
of functional sensibility may not always reflect the actual
recovery of nerve function at the microscopic level. In fact,
from our earlier study, the actual number of Meissner cor­
puscles was found to be decreased after transplantation, even
though good functional sensibility was restored,120 stressing
again the importance of delayed sensory education which
emphasized the retraining of central cortical functions like
concentration, memory, and relearning.
Delayed sensory re-education consists of touching
objects, both blinded and non-blinded, to appreciate further

332
SECTION II
CHAPTER 14 • Thumb reconstruction: Microsurgical techniques
Complications
The most common complication in the immediate postopera­
tive period is vascular compromise due to vasospasm fol­
lowed by arterial, and less commonly, venous thrombosis. In
our earlier experience, the re-exploration rate was 17.6% with
an 89% salvage rate.112 Emergency re-exploration of the anas­
tomosis is warranted following failed bedside measures such
as lowering the hand, release of sutures, topical application
of warm saline and 2–4% lidocaine, and fluid optimization. In
re-exploration, the hematoma is evacuated, the adventia is
sharply excised with free use of warm saline and 2–4% lido­
caine if there is vasospasm, and the anastomosis is revised
once lumen occlusion is confirmed. Additional anastomoses
using another arterial pedicle may be required in certain
cases, for example, combined toe units. In some cases of
intractable spasm, excision of the spasmodic segment, like
that done in thrombotic vessels, and replacing it with vein
graft or flow-through venous flap for tension-free closure may
become necessary.
Venous compromise is usually treated in the same manner,
but it is less critical and does often lead to total toe loss.
Despite careful preoperative planning and early recognition
of problems, around 3–5% still fail, possibly due to irreparable
damage or inherent problems with the suitability of the
vessels.135,136 Once the cause of the problem is identified, a
repeat toe transfer may be indicated with the use of an interim
groin flap.137 Other complications, including skin flap necrosis
or wound-healing problems with resultant exposed structures,
must be remedied as soon as possible to prevent desiccation
of tendons or neurovascular bundles, which result in further
complications from the injury. Longer-term complications
may be directly related to the original injury or indirectly as
a result of suboptimal reconstruction, often correctable by
secondary procedures.
Secondary procedures
Despite meticulous planning and optimization of the
technique, secondary procedures are still required in a
percentage of cases (14–20%) to improve the functional and
aesthetic outcome of the hand and foot following toe-to-hand
transplantations.40,138,139 Revision procedures for functional
improvement such as tenolysis, arthrodesis, and webspace
deepening usually yield good results.40 Flexor tenolysis is
one of the most common secondary procedures described
for most series and may be related to the methods of bone
osteosynthesis or the severity of the original injury requiring
a period of immobilization.40,140
Revision procedures for aesthetic improvement are usually
minor, and aim to increase resemblance of the toe to the finger
or thumb.36,38,141 The most common procedure is a pulp plasty
carried out under local anesthesia to reduce the bulbous
appearance of the toe, although other procedures including
scar revision and flap thinning may be required (Fig. 14.16).
Future directions
Microsurgical toe-to-hand transfer had its principles and
techniques well established by the end of 1990s. And, what
can be expected from the surgery has become well-known to
Appearance and sensory outcomes
A major advantage of toe-to-hand transplantations is the
replacement of tissue that bears a near-normal resemblance of
what was lost. Both Chung and Wei128 and Poppen et al.125
found a much higher use of the reconstructed hand following
toe-to-thumb transplantation as compared to its use before
thumb reconstruction. With improved sensory recovery comes
an enhanced appreciation of the reconstructed digits and also
a better overall integration into the body. These improvements
are largely dependent on a comprehensive sensory re-education
program as described. Performing the toe-to-hand transplan­
tation surgery within a month of the injury has also been
shown to lead to better sensory results.123 Overall, the average
recovered two-point discrimination should not be expected to
exceed approximately 7–8 mm.49,76,107,120
Donor site outcome evaluation
An evidence-based recommendation of the superiority of a
specific type of toe-to-hand transfer is difficult to draw from
the perspective of donor site morbidity.131 Generally, the mor­
bidity is well accepted after isolated second-toe transfer34,35,89
(Fig. 14.15). On the other hand, great-toe harvest followed by
combined second- and third-toe dissection appear to have
more donor site morbidity, but it remains largely acceptable
especially when the gain in hand function is taken into consid­
eration.132,133 And, in spite of increased dynamic and static
loading on the first metatarsal head and heel, this seldom
translates into significant complaints regarding gait or appear­
ance65 (see Fig. 14.15). Even after 16 years median follow-up,
92% of patients reported no or only minor complaints.45
The practice of using non-vascularized bone blocks to
replace harvested metatarsal bones and the repair of the
metatarsal ligament after toe transfer have been abandoned
for a long time, as no problems when walk or take-off
have been documented. However, every measure should be
taken to ensure additional potential complications such as
skin necrosis, hypertrophic scarring, or painful neuroma134
are minimized. The potential donor defect should always
be discussed in detail with the needs of each patient individu­
alized with regard to lifestyle, hobbies, and concerns regard­
ing appearance.
Fig. 14.15  Donor site after combined second- and third-toe harvest in the left foot
and second-toe harvest in the right foot.

333
Future directions
Fig. 14.16  (A,B) Pulp plasty technique.
A
B
the working reconstructive surgeon today. Nevertheless, there
is still room for improvement.
Patient-reported outcomes and evidence-based studies are
largely missing; the need for these publications will further
determine which toe-to-hand transplantation techniques can
provide the highest reward with the least morbidity. Further­
more, preoperative planning for complicated toe-to-hand
reconstructions may benefit from 3D printing and computer-
aided design and modeling to increase surgical precision and
to enhance aesthetics and function.142,143
Robotic surgery could be another potential, and with the
advantages of physiological tremor suppression, user-friendly
ergonomics, and ultraprecise control of the instruments, ultra
partial toe transfer may become feasible with reduction of
surgical time and complications.144
12. Wei FC, el-Gammal TA, Lin CH, et al. Metacarpal hand:
classification and guidelines for microsurgical reconstruction with
toe transfers. Plast Reconstr Surg. 1997;99:122–128. Metacarpal hand
refers to the hand that has lost its prehensile ability through amputation
of all fingers with or without amputation of the thumb. Functional
restoration can be achieved by a wide variety of microvascular toe
transfer techniques. When deciding which procedure should be used,
careful consideration must be given to the level of amputation of the
fingers as well as the functional status of the remaining thumb. In this
article, a classification is proposed for the various patterns of the
metacarpal hand along with guidelines for selection of the proper toe
transfer procedure.
26. Demirkan F, Wei FC, Jeng SF, et al. Toe transplantation for isolated
index finger amputations distal to the proximal interphalangeal
joint. Plast Reconstr Surg. 1999;103:499–507.
30. Wei FC, Lutz BS, Cheng SL, et al. Reconstruction of bilateral
metacarpal hands with multiple-toe transplantations. Plast Reconstr
Surg. 1999;104:1698–1704.
38. Wei FC, Yim KK. Pulp plasty after toe-to-hand transplantation.
Plast Reconstr Surg. 1995;96:661–666.
56. Wei FC. Tissue preservation in hand injury: the first step to
toe-to-hand transplantation. Plast Reconstr Surg. 1998;102:2497–
2501. This article gives useful guidelines in the initial management of
amputated digits, especially if a preemptive view of future toe-to-hand
transplantation is to be considered and discussed with patients. The main
recommendations outlined in this editorial emphasize tissue preservation,
facilitating future toe-to-hand transplantation in terms of reconstructive
options, functional and aesthetic outcomes in the hand, and donor site
morbidity in the foot. Although tissue conservation is the main goal at
this stage of treatment, this should not be at the expense of tissue
viability. If in doubt about management issues, advice should be sought
from the reconstructive microsurgery unit.
77. Wei FC, Chen HC, Chuang CC, et al. Microsurgical thumb
reconstruction with toe transfer: selection of various techniques.
Plast Reconstr Surg. 1994;93:345–351, discussion 52–57. This review
looked at the established method of thumb reconstruction using different
options. Selection of technique requires balancing the patient’s functional
needs, appearance of the reconstructed thumb, and donor site cosmesis.
Based on their experience with 103 toe-to-thumb transfers performed over
the previous 9 years, this paper attempts to provide guidelines for
appropriate selection among the four most commonly employed toe
transfer techniques (second toe, total great toe, great toe wrap-around,
trimmed great toe) so that both optimal results and patient acceptance
can be achieved.
90. Wei FC, Colony LH, Chen HC, et al. Combined second and third
toe transfer. Plast Reconstr Surg. 1989;84:651–661. This study reported
a 4-year experience with 26 consecutive combined second- and third-toe
transfers to replace missing adjacent fingers in order to delineate the
indications and technical considerations and to emphasize prevention of
donor site complications. The surgical technique is described in detail.
Combined second- and third-toe transfer is reserved for adjacent finger
amputations proximal to the digital webspace with remaining fingers no
longer than the small finger. Radial amputations are replaced with
contralateral combined toe units, while ipsilateral toes are more ideal for
ulnar amputations. When properly applied in selected patients, this
single-stage microsurgical procedure can restore prehensile function,
improve the appearance of the hand with multiple digital amputations,
and preserve near-normal donor foot function.
99. Wei FC, Silverman RT, Hsu WM. Retrograde dissection of the
vascular pedicle in toe harvest. Plast Reconstr Surg. 1995;96:1211–
1214. A retrograde approach to dissection of the vascular pedicle in
toe-to-hand transfer is presented, along with a simplified view of the
vascular anatomy of the first webspace. This paper described the several
advantages of this approach. First, the dominant vascular supply to the
toe is elucidated early in the procedure, allowing for less unnecessary
dissection of an inadequate pedicle. This also eliminates the need for
preoperative arteriography. Furthermore, in cases where a lengthy pedicle
is not required, retrograde dissection dispenses with harvest of a proximal
vessel, which will not be needed for the transfer, thus minimizing donor
morbidity.
119. Lin CH, Lin YT, Sassu P, et al. Functional assessment of the
reconstructed fingertips after free toe pulp transfer. Plast Reconstr
Surg. 2007;120:1315–1321.
121. Wei FC, Ma HS. Delayed sensory reeducation after toe-to-hand
transfer. Microsurgery. 1995;16:583–585.
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14. Lee CK, Buncke GM. Great toe-to-thumb microvascular
transplantation. Clin Plast Surg. 2007;34:223–231, ix.
15. May JW Jr, Bartlett SP. Great toe-to-hand free tissue transfer for
thumb reconstruction. Hand Clin. 1985;1:271–284.
16. McCauley RL. Reconstruction of the pediatric burned hand. Hand
Clin. 2000;16:249–259.
17. Whitworthm IH, Pickford MA. The first toe-to-hand transfer: a
thirty-year follow-up. J Hand Surg [Br]. 2000;25:608–610.
18. Morrison WA, MacLeod AM, O’Brien BM. Digital reconstruction
in the mutilated hand. Ann Plast Surg. 1982;9:392–399.
19. Wei FC, Chen HC, Chuang CC, et al. Simultaneous multiple toe
transfers in hand reconstruction. Plast Reconstr Surg.
1988;81:366–377.
20. Wei FC, Coessens B, Ganos D. Multiple microsurgical toe-to-hand
transfer in the reconstruction of the severely mutilated hand. A
series of fifty-nine cases. Ann Chir Main Memb Super.
1992;11:177–187.
21. Wei FC, Strauch RJ, Chen HC, et al. Reconstruction of four
damaged or destroyed ipsilateral fingers with free toe-to-hand
transplantations. Plast Reconstr Surg. 1994;93:608–614.
22. el-Gammal TA, Wei FC. Microvascular reconstruction of the distal
digits by partial toe transfer. Clin Plast Surg. 1997;24:49–55.
23. Woo SH, Lee GJ, Kim KC, et al. Cosmetic reconstruction of distal
finger absence with partial second toe transfer. J Plast Reconstr
Aesthet Surg. 2006;59:317–324.
24. del Pinal F. The indications for toe transfer after “minor” finger
injuries. J Hand Surg [Br]. 2004;29:120–129.
25. Wei FC, el-Gammal TA. Toe-to-hand transfer. Current concepts,
techniques, and research. Clin Plast Surg. 1996;23:103–116.
26. Demirkan F, Wei FC, Jeng SF, et al. Toe transplantation for isolated
index finger amputations distal to the proximal interphalangeal
joint. Plast Reconstr Surg. 1999;103:499–507.
27. Iselin M. La main metacarpienne. Ann Chir Plast. 1961;6:247–258.
28. Foucher G, ed. Reconstruction in the Mutilated Hand. London:
Martin Dunitz; 1997.
29. Kotkansalo T. The functional results of post-traumatic metacarpal
reconstructions with microvascular toe transfers. J Hand Surg Eur
Vol. 2009;34:730–742.
30. Wei FC, Lutz BS, Cheng SL, et al. Reconstruction of bilateral
metacarpal hands with multiple-toe transplantations. Plast Reconstr
Surg. 1999;104:1698–1704.
31. Shores JT, Brandacher G, Lee WP. Hand and upper extremity
transplantation: an update of outcomes in the worldwide
experience. Plast Reconstr Surg. 2015;135:351e–360e.
32. Waljee JF, Chung KC. Toe-to-hand transfer: evolving indications
and relevant outcomes. J Hand Surg Am. 2013;38:1431–1434.
33. del Pinal F, Garcia-Bernal FJ, Delgado J, et al. Overcoming
soft-tissue deficiency in toe-to-hand transfer using a dorsalis pedis
fasciosubcutaneous toe free flap: surgical technique. J Hand Surg
Am. 2005;30:111–119.
34. Lee DC, Kim JS, Ki SH, et al. Partial second toe pulp free flap
for fingertip reconstruction. Plast Reconstr Surg. 2008;121:
899–907.
35. Wei FC, Chen HC, Chuang DC, et al. Second toe wrap-around
flap. Plast Reconstr Surg. 1991;88:837–843.
36. Wei FC, Chen HC, Chuang DC, et al. Aesthetic refinements
in toe-to-hand transfer surgery. Plast Reconstr Surg. 1996;98:
485–490.
37. Wei FC, Mardini S. Reevaluation of the technique of toe-to-hand
transfer for traumatic digital amputations in children and
adolescents. Plast Reconstr Surg. 2003;112:1870–1874.
38. Wei FC, Yim KK. Pulp plasty after toe-to-hand transplantation.
Plast Reconstr Surg. 1995;96:661–666.
39. Yang JY. The first dorsal metacarpal flap in first webspace and
thumb reconstruction. Ann Plast Surg. 1991;27:258–264.
40. Yim KK, Wei FC. Secondary procedures to improve function after
toe-to-hand transfers. Br J Plast Surg. 1995;48:487–491.
41. del Pinal F, Garcia-Bernal FJ, Regalado J, et al. A technique to
improve foot appearance after trimmed toe or hallux harvesting.
J Hand Surg Am. 2007;32:409–413.
42. Schenker M, Kelley SP, Kay SP. Free hand-to-toe transfer: a method
to minimise donor-site morbidity in free joint transfers. Br J Plast
Surg. 2003;56:57–59.
43. Bourke G, Kay SP. Free phalangeal transfer: donor-site outcome.
Br J Plast Surg. 2002;55:307–311.
44. Kvernmo HD, Tsai TM. Posttraumatic reconstruction of the
hand—a retrospective review of 87 toe-to-hand transfers compared
with an earlier report. J Hand Surg Am. 2011;36:1176–1181.
45. Kotkansalo T, Elo P, Luukkaala T, Vilkki SK. Long-term effects of
toe transfers on the donor feet. J Hand Surg Eur Vol.
2014;39:966–976.
46. Nicolandi C. Daumenplastik. Wien Klin Wochenschr. 1897;10:663.
47. Davis J. Toe to hand transfers: pedochyrodactyloplasty. Plast
Reconstr Surg. 1964;33:422–436.
48. Buncke H, Schulz W. Immediate Nicoladoni procedure in the
Rhesus monkey, or hallux-to-hand transplantation, utilising
microminiature vascular anastomoses. J Bone Joint Surg Br.
1966;19:332–337.
49. Whitworth IH, Pickford MA. The first toe-to-hand transfer: a
thirty-year follow-up. J Hand Surg [Br]. 2000;25:608–610.
50. Buncke HJ, Rose EH. Free toe-to-fingertip neurovascular flaps.
Plast Reconstr Surg. 1979;63:607–612.
51. Koshima I, Soeda S, Takase T, et al. Free vascularized nail grafts. J
Hand Surg Am. 1988;13:29–32.
52. O’Brien B, Brennen MD, MacLeod AM. Microvascular free toe
transfer. Clin Plast Surg. 1978;5:223–237.
53. Gilbert A. Toe transfers for congenital hand defects. J Hand Surg
Am. 1982;7:118–124.

333.e2
SECTION II
CHAPTER 14 • Thumb reconstruction: Microsurgical techniques
54. Cooney WP 3rd, Wood MB. Microvascular reconstruction of
congenital anomalies and post-traumatic lesions in children. Hand
Clin. 1992;8:131–146.
55. Wallace CG, Wei FC. Posttraumatic finger reconstruction with
microsurgical transplantation of toes. Hand Clin. 2007;23:117–128.
56. Wei FC. Tissue preservation in hand injury: the first step to
toe-to-hand transplantation. Plast Reconstr Surg. 1998;102:2497–
2501. This article gives useful guidelines in the initial management of
amputated digits, especially if a preemptive view of future toe-to-hand
transplantation is to be considered and discussed with patients. The main
recommendations outlined in this editorial emphasize tissue preservation,
facilitating future toe-to-hand transplantation in terms of reconstructive
options, functional and aesthetic outcomes in the hand, and donor site
morbidity in the foot. Although tissue conservation is the main goal at
this stage of treatment, this should not be at the expense of tissue
viability. If in doubt about management issues, advice should be sought
from the reconstructive microsurgery unit.
57. Fan CY, Jiang J, Zeng BF, et al. Reconstruction of thumb loss
complicated by skin defects in the thumb-index webspace by
combined transplantation of free tissues. J Hand Surg Am.
2006;31:236–241.
58. Zhang J, Xie Z, Lei Y, et al. Free second toe one-stage-plasty and
transfer for thumb or finger reconstruction. Microsurgery.
2008;28:25–31.
59. Yim KK, Wei FC. Intraosseous wiring in toe-to-hand
transplantation. Ann Plast Surg. 1995;35:66–69.
60. Strauch RJ, Wei FC, Chen SH. Composite finger
metacarpophalangeal joint reconstruction in combined second and
third free toe-to-hand transfers. J Hand Surg Am. 1993;18:972–977.
61. Mardini S, Wei FC. Unilateral and bilateral metacarpal hand
injuries: classification and treatment guidelines. Plast Reconstr Surg.
2004;113:1756–1759.
62. Harris C Jr, Rutledge GL Jr. The functional anatomy of the
extensor mechanism of the finger. J Bone Joint Surg Am.
1972;54:713–726.
63. Wei F, ed. Toe to Hand Transplantations. Philadelphia: Churchill
Livingstone; 2007.
64. Piza-Katzer H. Analysis of complications in digital vein grafts.
Chir Plastica (Berl). 1979;5:23–32.
65. Wei F, ed. Toe to Hand Transplantations. Philadelphia: Churchill
Livingstone; 2005.
66. Bhama PK, Patel SA, Khan U, et al. Head and neck free flap
reconstruction in patients older than 80 years. J Reconstr Microsurg.
2014;30:523–530.
67. Dellon AL. Sensory recovery in replanted digits and transplanted
toes: a review. J Reconstr Microsurg. 1986;2:123–129.
68. Godina M. Early microsurgical reconstruction of complex trauma
of the extremities. Plast Reconstr Surg. 1986;78:285–292.
69. Woo SH, Kim JS, Seul JH. Immediate toe-to-hand transfer in acute
hand injuries: overall results, compared with results for elective
cases. Plast Reconstr Surg. 2004;113:882–892.
70. Woo SH, Lee GJ, Kim KC, et al. Immediate partial great toe
transfer for the reconstruction of composite defects of the distal
thumb. Plast Reconstr Surg. 2006;117:1906–1915.
71. Yim KK, Wei FC, Lin CH. A comparison between primary and
secondary toe-to-hand transplantation. Plast Reconstr Surg.
2004;114:107–112.
72. American Medical Association. Guides to the Evaluation of
Permanent Impairment. Chicago: American Medical Association;
1990:14–55.
73. Morrison WA. Thumb reconstruction: a review and philosophy of
management. J Hand Surg [Br]. 1992;17:383–390.
74. Strickland W, ed. Thumb Reconstruction. Philadelphia: Churchill
Livingstone; 2005.
75. Leung PC. Thumb reconstruction using second-toe transfer. Hand
Clin. 1985;1:285–295.
76. Morrison WA, O’Brien BM, MacLeod AM. Experience with thumb
reconstruction. J Hand Surg [Br]. 1984;9:223–233.
77. Wei FC, Chen HC, Chuang CC, et al. Microsurgical thumb
reconstruction with toe transfer: selection of various techniques.
Plast Reconstr Surg. 1994;93:345–351, discussion 52–57. This review
looked at the established method of thumb reconstruction using different
options. Selection of technique requires balancing the patient’s functional
needs, appearance of the reconstructed thumb, and donor site cosmesis.
Based on their experience with 103 toe-to-thumb transfers performed over
the previous 9 years, this paper attempts to provide guidelines for
appropriate selection among the four most commonly employed toe
transfer techniques (second toe, total great toe, great toe wrap-around,
trimmed great toe) so that both optimal results and patient acceptance
can be achieved.
78. Wei FC, Chen HC, Chuang CC, et al. Reconstruction of the thumb
with a trimmed-toe transfer technique. Plast Reconstr Surg.
1988;82:506–515.
79. Morrison WA, O’Brien BM, MacLeod AM. Thumb reconstruction
with a free neurovascular wrap-around flap from the big toe.
J Hand Surg Am. 1980;5:575–583.
80. Ratcliffe RJ, McGrouther DA. Free toe pulp transfer in thumb
reconstruction. Experience in the West of Scotland Regional Plastic
Surgery Unit. J Hand Surg [Br]. 1991;16:165–168.
81. Lin CH, Lo S, Lin CH, Lin YT. Opponensplasty provides
predictable opposable tripod pinch in toe transfer for proximal
thumb ray defect reconstruction. Plast Reconstr Surg.
2012;130:810e–818e.
82. Wei FC, Epstein MD, Chen HC, et al. Microsurgical reconstruction
of distal digits following mutilating hand injuries: results in 121
patients. Br J Plast Surg. 1993;46:181–186.
83. Brown RE, Zook EG, Russell RC. Fingertip reconstruction
with flaps and nail bed grafts. J Hand Surg Am. 1999;24:
345–351.
84. Cheng G, Fang G, Hou S, et al. Aesthetic reconstruction of thumb
or finger partial defect with trimmed toe-flap transfer.
Microsurgery. 2007;27:74–83.
85. Logan A, Elliot D, Foucher G. Free toe pulp transfer to restore
traumatic digital pulp loss. Br J Plast Surg. 1985;38:497–500.
86. del Pinal F, Herrero F, Garcia-Bernal FJ, et al. Minimizing
impairment in laborers with finger losses distal to the proximal
interphalangeal joint by second toe transfer. Plast Reconstr Surg.
2003;112:1000–1011.
87. Foucher G, Merle M, Maneaud M, et al. Microsurgical free partial
toe transfer in hand reconstruction: a report of 12 cases. Plast
Reconstr Surg. 1980;65:616–627.
88. Wei FC, Colony LH. Microsurgical reconstruction of opposable
digits in mutilating hand injuries. Clin Plast Surg. 1989;16:491–
504.
89. Buncke G, ed. Lengthening by Toe Transfer. London: Martin Dunitz;
1997.
90. Wei FC, Colony LH, Chen HC, et al. Combined second and third
toe transfer. Plast Reconstr Surg. 1989;84:651–661. This study reported
a 4-year experience with 26 consecutive combined second- and third-toe
transfers to replace missing adjacent fingers in order to delineate the
indications and technical considerations and to emphasize prevention of
donor site complications. The surgical technique is described in detail.
Combined second- and third-toe transfer is reserved for adjacent finger
amputations proximal to the digital webspace with remaining fingers no
longer than the small finger. Radial amputations are replaced with
contralateral combined toe units, while ipsilateral toes are more ideal for
ulnar amputations. When properly applied in selected patients, this
single-stage microsurgical procedure can restore prehensile function,
improve the appearance of the hand with multiple digital amputations,
and preserve near-normal donor foot function.
91. Buck-Gramcko D, ed. The Metacarpal Hand. London: Martin
Dunitz; 1997.
92. Pulvertaft RG. Reconstruction of the mutilated hand. Erik Moberg
Lecture 1977. Scand J Plast Reconstr Surg. 1977;11:219–224.
93. Pulvertaft RG. Reconstruction of the severely mutilated hand.
Rheumatol Phys Med. 1971;11:90.
94. Leung PC. Double toe transfers. J Hand Surg [Br]. 1987;12:162–165.
95. Leung PC. Pincer reconstruction using second toe transplantation.
J Hand Surg [Br]. 1987;12:159–161.
96. Lin CH, Mardini S, Lin YT, et al. Osteoplastic thumb ray
restoration with or without secondary toe transfer for

333.e3
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SECTION III • Acquired Non-traumatic Disorders
15 
Benign and malignant tumors of the hand
Justin M. Sacks, Kodi K. Azari, Scott Oates, and David W. Chang
SYNOPSIS
■ Benign and malignant tumors of the hand arise from distinct tissue
types.
■ The majority of these tumors are benign.
■ Accurate assessment, diagnosis, and treatment will optimize clinical
outcomes.
■ Reconstructive procedures of the hand and upper extremity should be
performed only after the diagnosis is confirmed and appropriate
surgical margins are achieved.
Introduction
■ Most tumors of the hand are benign, recognized early,
and treated by excision.
■ Ninety-five percent of hand tumors that do not involve
the skin are benign.
■ Malignant tumors of the hand can be divided into two
categories: primary and metastatic. Primary tumors can
arise from the skin (e.g., melanoma, basal and squamous
cell carcinoma), soft tissues (e.g., sarcoma), or bone
(e.g., osteosarcoma). Metastatic disease originates most
commonly from cancers of the breast, kidney, thyroid,
lung, and colon.
■ Appropriate evaluation, diagnosis, and treatment for
tumors of the hand are required for optimal patient care.
A careful history and physical examination will rapidly
focus the investigation of a suspicious mass found in the
hand.
■ Magnetic resonance imaging (MRI) has become the “gold
standard” to evaluate soft-tissue masses for malignancy.
Computed tomography (CT) is preferred for osseous
lesions.
■ Incisional or excisional biopsy is required for definitive
diagnosis in many cases.
■ Surgical incisions must be planned carefully with definitive
surgery in mind, utilizing a longitudinal incision in line
with or parallel to a potential limb salvage procedure.
■ Reconstructive procedures, in the setting of a neoplasm of
the hand, are performed only after the final pathological
diagnosis and clear resection margins are established.
■ An understanding of both oncologic and reconstructive
principles is required in order to achieve an optimal
clinical outcome.
Basic science/disease process
Tumors of the hand can arise from the skin, adipose tissue,
synovium, tendons, cartilage, bones, muscles, fibrous tissue,
nerves, and blood vessels. The majority of hand tumors are
benign, most are recognized early, and the prognosis is typi­
cally good.1,2 Malignant tumors also occur in the hand and can
be divided into two categories: primary and metastatic. In
addition, premalignant lesions such as actinic keratoses and
atypical nevi can occur on the hands.
In this chapter, benign and malignant tumors are classified
and discussed by their tissues of origin. Understanding the
origin of hand lesions will assist in accurate diagnosis and
appropriate therapeutic interventions.3
Clinical tips
Most hand tumors:
• arise from any cell type
• are benign
• are treated with a favorable prognosis
When in doubt:
• excisional biopsy
• plan incisions carefully
• definitive surgery in mind

335
Diagnosis/patient presentation
Physical examination
The physical examination of the hand involves a complete
examination of the skin, tendons, muscles, ligaments, bones,
and neurovascular structures. An evaluation of the regional
lymph nodes for adenopathy is the cornerstone for assessing
the malignant potential of a hand mass. For example, adenopa­
thy can be observed in epithelioid or clear cell sarcomas.8,9
An inspection of the lesion begins in the examination room.
An adequate light source is essential to visualize the lesion’s
characteristics. Color and texture changes are noted, and an
examination for ulcerations, erythema, and edema is per­
formed. Transillumination of the mass can be helpful in dis­
tinguishing between solid and cystic etiologies. The lesion is
palpated, and the mass size is appreciated along with its
shape and contour. The mobility of the mass is assessed to
determine whether it is fixed to underlying anatomic struc­
tures. Having the patient flex and extend the fingers and wrist
will further delineate whether the lesion is associated with
tendons or deeper structures within the joints. A complete
vascular examination with palpation of pulses is required. If
pulses are not palpable, Doppler ultrasonography can be used
to define the vascular status of the hand and upper extremity.
Allen’s test is mandatory. Neurologic testing of fine and gross
motor and sensory function is also performed.
When benign lesions are to be followed clinically, photo­
graphic documentation is an essential tool to judge the rate of
growth over time. Photographs are also recommended for
patients with multiple and subtle lesions.
Laboratory studies
Laboratory studies are helpful in determining the etiology of
some hand tumors. A hematology profile can determine an
infectious etiology. Serum calcium, phosphorus, and alkaline
phosphatase levels are often increased in patients with meta­
static tumors, and alkaline phosphatase is also increased in
patients with osteosarcoma. An erythrocyte sedimentation
rate assesses for inflammation; the rate is often increased in
Ewing’s sarcoma, lymphoma, and myeloma. An extremely
elevated prostate-specific antigen level is specific for meta­
static prostate cancer. In male patients older than 50 years
with evidence of blastic hand lesions on X-rays, a serum
prostate-specific antigen test should be performed. Although
these laboratory findings are not specific for hand tumors,
they can help focus the search for a diagnosis.
Imaging
Multiple radiologic modalities are available for imaging
benign and malignant hand lesions and masses. Radiographs
are not essential for most skin lesions. However, radiographs
are required for very large skin lesions and for those apparently
The management of hand tumors requires the hand surgeon
to function as both oncologic surgeon and reconstructive
surgeon. A complete understanding of both oncologic and
reconstructive principles is therefore required to achieve an
optimal outcome. The role of the oncologic surgeon is to
eradicate the tumor completely, which can compromise both
aesthetics and function. In contrast, the role of the reconstruc­
tive surgeon is to optimize hand function. Balancing these
sometimes competing goals can be challenging.4
An effective strategy to evaluate, diagnose, and treat
tumors of the hand and associated upper extremity is required
for optimal patient care. A careful analysis of the history and
physical examination will rapidly focus the investigation of a
newly evident hand lesion. The use of radiography (X-rays),
CT, and MRI will strengthen the apparent diagnosis.5 However,
incisional or excisional biopsy will, in most instances, be the
final determinant of diagnosis.
Diagnosis/patient presentation
Patient history
A thorough history and physical examination remain the
foundation of proper initial diagnosis. Questions concerning
the history of the tumor are solicited. These include duration,
changes in size or color, associated pain, and occurrence of
ulceration. Pain can signify a malignancy or a mass that has
encroached on neurologic structures. The sensitivity of the
mass to cold or heat needs to be clarified, as the former typi­
fies a subungual glomus tumor.6
Inquiring about risk factors for tumors of the hand will
strengthen eventual diagnostic conclusions. The patient
should be questioned about a history of cutaneous malignan­
cies, extensive sun exposure or sunburns as a child, chemical
and ionizing radiation exposure, and trauma or infections.
The patient should also be questioned about rheumatologic
conditions, such as gout, psoriasis, and rheumatoid arthritis.
The age of the patient needs to be considered when evalu­
ating a mass in the hand. Certain masses are specific to certain
age groups. For instance, bone cysts are typically seen in
adolescents and young adults, whereas metastatic tumors in
the hand are rare under the age of 50 years.7
Questions about previous biopsies or excisions will complete
a thorough historical evaluation of the patient with a hand
tumor. Pathology reports for previous biopsies or excisions will
need to be obtained and reviewed. Prior operative reports will
help clarify the diagnosis and optimize future surgical interven­
tions in instances in which the current pathology is unknown.
Clinical tips
History
Past medical history:
• rheumatoid arthritis – rheumatoid nodule
• gout – tophus
Pain: suggestive of malignancy
Cold sensitivity: subungual lesion – glomus tumor
Pain relieved by NSAIDs: osteoid osteoma
Infections
Trauma
Clinical tips
Laboratory tests
• Increased ESR: Ewing’s sarcoma, lymphoma, myeloma
• Increased Ca++: metastatic tumors
• Increased alkaline phosphatase: osteosarcoma
• Males, age >50, and blastic bone lesions: check PSA

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SECTION III
CHAPTER 15 • Benign and malignant tumors of the hand
CT is extremely useful for the assessment of bones and
cortical destruction. CT scans have markedly greater bony
resolution than standard radiographs. If bone involvement by
the mass is equivocal on X-rays, CT is the next appropriate
radiographic modality. CT also distinguishes calcification
patterns from ossification and is superior in assessing perios­
teal versus endosteal reactions.
MRI is superior to CT for the evaluation of soft-tissue
masses. MRI is better able to assess the intra- and extraos­
seous extent of soft-tissue masses. It has become the gold
standard to evaluate soft-tissue masses for malignancy.10
The MRI study should include T1-weighted, fat-suppressed
T2-weighted, and short tau inversion recovery images. The
contrast agent gadolinium can further enhance the visual­
ization of soft-tissue tumors. An MRI study obtained with
various views can clearly delineate the extent of soft-tissue
involvement prior to operative intervention. A drawback of
MRI is that it cannot reliably distinguish between benign and
malignant processes. In addition, for MRI of hand masses, a
dedicated hand coil is required.
The next logical progression in the workup of a skin, soft-
tissue, or bony lesion is a biopsy. The accuracy of pathologic
assessment is dependent on the type of specimen obtained. A
frozen-section analysis can be performed to assess the adequacy
of the tissue sample. However, the accuracy of frozen-section
diagnosis is only 80%, whereas permanent-section diagnosis
is accurate 96% of the time. The accuracy of core needle biopsy
is intermediate between the two, at 83–93%.2
A biopsy can be closed or open. In a closed biopsy, a needle
or trephine is used to obtain samples. Closed biopsy is useful
for metastatic workup. However, tissue samples from closed
biopsy are often inadequate for initial diagnosis.11
Open biopsies can take many forms: the type of open
biopsy performed is determined by the patient’s history,
physical findings, and imaging findings. For all open biopsies,
longitudinal incisions should be in line with or parallel to
incisions that would be used in a later limb salvage procedure
if the tumor proves to be malignant. If a tourniquet is used,
the upper extremity must not be exsanguinated because doing
so may cause spread of malignant cells into the lymphat­
ics. Proper hemostasis should be maintained, and adjacent
anatomic compartments should not be violated unless a
radical excision is required. An important tenet is to biopsy
all infections and culture all masses.3,12 Chronic infections
can masquerade as malignancies, and masses can result from
subclinical infections.
In an incisional biopsy, only a piece of the lesion is removed.
A longitudinal incision is made; if soft-tissue masses invade
adjacent compartments, muscle fibers are split longitudinally.
A piece of the lesion is then excised for pathological diagnosis.
An excisional biopsy removes the entire lesion and is
potentially a single-stage cure for a benign lesion. Excisional
biopsy is limited to lesions ≤1 cm.
Enneking developed a method for musculoskeletal tumor
dissection based on the histologic grade, location, and extent
of the mass. An intralesional dissection is through the plane
of the tumor, whereas a marginal dissection is through the
tumor “reactive zone”. A wide dissection involves removal of
the mass plus a margin of normal tissue but remains within
a single compartment.12 A wide dissection is performed
when there is a suspicion of malignancy. A radical dissection
involves extracompartmental resection.
fixed to underlying anatomic structures based upon physical
examination.
The plain X-ray is one of the most important studies for
evaluating lesions and masses of the hand. X-rays are easily
obtained and can evaluate a mass from multiple angles. The
size of the mass can be inferred from X-rays. In the hand, a
mass >3 cm in diameter should be considered potentially
malignant. The architecture of the mass as it relates to the
cortex of the associated bone can be determined rapidly by
X-ray. Sharp cortical margins indicate a benign process, while
a “moth-eaten” or destroyed cortex indicates a malignant
process. Erosions and periosteal elevation on X-rays can
signify a potential malignancy or an infectious process. Soft-
tissue calcifications may signify a malignancy (Fig. 15.1).
Rounded calcifications with central lucencies can portend a
vascular etiology.
Ultrasonography can be helpful in assessing soft-tissue
masses. This technique is non-invasive and inexpensive.
Ultrasonography can determine if a tumor is solid or cystic
and differentiate between a discrete mass and diffuse edema.
In many instances, ultrasonography can be used to guide
needle biopsy.
Scintigraphy or bone scanning is beneficial in screening for
skeletal masses. This technique is sensitive in isolating abnor­
malities, but the findings are not very specific for malignancy.
For example, there is intense uptake with osteoid osteoma, a
benign bone tumor. Bone scans are very helpful when search­
ing for sources of metastasis in the workup of hand and upper
extremity primary malignancies.
Fig. 15.1  In this proximal phalanx lesion of the thumb a destroyed cortex
potentially indicates a malignant process.

337
Treatment/surgical treatment by tissue of origin
in association with a variety of tumors, including epidermal
inclusion cysts, epidermal nevi, fibromas, and pyogenic
granulomas. In addition, cutaneous horns can be associated
with both premalignant and malignant neoplasms such as
actinic keratoses and squamous cell carcinomas. In fact, 10%
of cutaneous horns are found in association with squamous
cell carcinoma.
Cutaneous horns are treated by excisional biopsy with
1–2-mm margins. Incisional biopsy is not recommended for
this lesion because of the potential for sampling errors.2
Epidermal inclusion cyst
Epidermal inclusion cysts are the third most common hand
tumors (Fig. 15.3). These masses, which originate from an
Patient selection
All patients with a lesion or a mass of the hand must be
appropriately evaluated. A history and physical examination
are critical to determining what further workup is needed.
Once the process needed to investigate the lesion or mass is
determined, it is then the physician’s responsibility to deter­
mine the appropriate diagnosis and plan the treatment.
Treatment/surgical treatment
by tissue of origin
Skin tumors
Neoplasms of the skin can be benign, premalignant, or malig­
nant. In addition, there are masses such as sebaceous cysts
and cutaneous horns that can masquerade as tumors but are
not true neoplasms and thus are considered pseudotumors.13
For the majority of benign neoplasms or tumors, an excisional
biopsy will completely eradicate the mass. For malignant skin
neoplasms, such as melanoma, complete excision with clear
margins does not always correlate with complete eradication
of the skin tumor because of the potential for metastatic
spread.1
Clinical tips
Imaging studies
X-ray
• Most important study
• Margin appearance
• Sharp margins: benign
• “Moth-eaten”: malignant
• Size
• Size >6 cm: malignant
Clinical box
Incisional biopsy
• Longitudinal incision
• Tourniquet, do not exsanguinate
• Avoid violating adjacent compartments
• Split muscle fibers longitudinally
• Frozen section to assess adequacy of sample
• Cultures
• “Biopsy all infections. Culture all masses.”
Fig. 15.2  Cutaneous horn. The lesion typically presents on the palmar surface of
the hand. This lesion represents the typical keratin horn.
Fig. 15.3  Epidermal inclusion cyst. These masses, which originate from an
invagination of epithelium, can follow trauma, injection, or an incision. The
epithelium is internalized, resulting in subcutaneous keratin deposition.
Cutaneous horn
A cutaneous horn is an exophytic lesion that originates from
the skin and is composed of keratotic material (Fig. 15.2).13
Cutaneous horns are located on sun-exposed areas of the
body such as the dorsum of the hands and forearms. These
unsightly lesions can interfere with function. They can occur

338
SECTION III
CHAPTER 15 • Benign and malignant tumors of the hand
second-line therapy for lesions unresponsive to topical agents
and offers cure rates of 60–80%. Third-line treatments include
immunomodulatory agents, lasers such as carbon dioxide and
pulsed dye, and photodynamic therapy. It is critical to be
highly suspicious of lesions that do not respond to therapy, as
they may be malignant. Excision is therefore recommended
for treatment-refractory verrucae or to rule out malignancy.
Nevi
A melanocytic nevus or benign pigmented nevus is a benign
proliferation of melanocytes (Fig. 15.6). Nevi can be either
acquired or congenital. The acquired form typically begins to
appear 6 months after birth, and acquired nevi increase in
both number and size throughout childhood and adolescence.
Congenital nevi require surveillance because of the potential
for malignant transformation. Nevi are classified by size as
small (<1.5 cm), medium (1.5 cm to <20 cm), and large or
giant (>20 cm). The lifetime risk for malignant transformation
of giant congenital nevi is 10%.16
Common acquired nevi are defined by their anatomic loca­
tion within the epidermis and dermis. Junctional nevi are
found at the dermal–epidermal junction. These lesions trans­
form into compound nevi when their growth extends into the
dermis. Nevi found completely within the dermis are termed
intradermal nevi. Acral nevi are typically found on the palmar
or plantar surfaces. Longitudinal melanonychia refers to
streaking of the nail secondary to melanin deposits in the nail
plate; these lesions can result from acral nevi involving the
nail matrix.
Nevi of the hand and upper extremity should be evaluated
for any clinically suspicious changes. These include asym­
metry, border irregularities, color changes, diameter >6 mm,
or elevation of the lesion. A useful mnemonic for these changes
is “ABCDE”. When there is any doubt about diagnosis, exci­
sional biopsy is recommended.17
Keratoacanthoma
Keratoacanthoma is thought to be derived from the epithelium
of hair follicles (Fig. 15.7). This skin lesion closely resembles
invagination of epithelium, can follow a trauma, injection, or
incision.2,14 The epithelium is internalized, resulting in subcu­
taneous keratin deposition. Epithelial cysts are typically
painless and most commonly occur in the digits.
Treatment of an epidermal inclusion cyst involves a com­
plete marginal excision of the cyst and its wall. The risk of
recurrence of this lesion following complete excisional biopsy
is extremely low.
Sebaceous cyst
A sebaceous cyst is another lesion originating from the skin
and is similar in appearance to an epidermal inclusion cyst
(Fig. 15.4). Sebaceous cysts arise from an obstructed apocrine
gland, which produces sebum as opposed to keratin.2 When
they occur in the hand, sebaceous cysts are found on the
dorsal aspect. Palmar skin does not contain sebaceous glands,
so sebaceous cysts do not appear there. Treatment is similar
to that of an inclusion cyst, and the risk of recurrence is low.
Verruca vulgaris
The human papillomavirus causes verruca vulgaris or
common warts (Fig. 15.5). Types 1–4, 7, and 10 have been
implicated in the etiology of skin lesions involving keratin­
ized epithelium. Verruca vulgaris presents as a rough raised
surface anywhere on the hand and is 20 times more common
than the verruca plana or flat wart, which is found commonly
on the dorsum of the hand. Verrucae vulgaris are often found
at sites of trauma in the periungual region (such as from
habitual nail biting). The typical course of these benign neo­
plasms is self-limited, with spontaneous resolution in 1–2
years. However, there have been reports of malignant trans­
formation of verrucae vulgaris, most commonly when they
occur on the mucosa.15
Treatment is instituted if the lesions become cosmetically
unacceptable or if they interfere with hand function. The first-
line therapy is topical agents such as salicylic acid, which
results in cure rates of 70–80%. Cryotherapy is considered the
Fig. 15.4  Sebaceous cyst. These pseudotumors arise from an obstructed apocrine
gland, which produces sebum as opposed to keratin.
Fig. 15.5  Verruca vulgaris. This lesion presents as a rough raised surface
commonly on the dorsum of the hand.

339
Treatment/surgical treatment by tissue of origin
Fig. 15.7  Keratoacanthoma. In appearance, this skin lesion closely resembles
squamous cell carcinoma. The lesion begins as a red papule progressing to a large
ulcerated mass.
Fig. 15.8  A dermatofibroma is a fibrous tumor involving the dermis. These lesions
form in young adulthood and are found more typically in females.
Fig. 15.6  Nevus. A benign proliferation of melanocytes, either acquired or
congenital.
squamous cell carcinoma. However, keratoacanthoma growth
is more rapid and central necrosis is more dominant. These
lesions are typically found on hair-bearing regions. A kerato­
acanthoma begins as a small red papule and progresses to a
large ulcerated mass. This mass is “volcano”-shaped, with a
large central crater. The natural course of the lesion involves
regression after a latent phase of 6 months to several years.18
Excisional biopsy is necessary to rule out a malignant neo­
plasm, most commonly squamous cell carcinoma. Treatment
can include curettage if a benign nature is considered likely.
Because the natural history of these lesions is to involute,
classically they have been treated conservatively. However,
poor cosmetic outcomes can result from this approach.
Muir–Torre syndrome is an autosomal-dominant disorder
associated with multiple keratoacanthomas. This clinical
entity is also associated with visceral malignancy, and the
workup of patients with multiple keratoacanthomas should
include colonoscopy and CT.19,20
Dermatofibroma
A dermatofibroma is a fibrous tumor involving the dermis
(Fig. 15.8). This neoplasm contains fibroblasts, collagen, and
histiocytes. The clinical presentation is that of a firm, solitary
mass of varying color. Dermatofibromas usually form in
young adulthood and are found more typically in females.
Excisional biopsy is performed to rule out a malignant lesion
such as a sarcoma, squamous cell carcinoma, or melanoma.21
The malignant form of this lesion is a dermatofibrosarcoma
protuberans, which is occasionally found in the hand.22 While
the metastatic potential is low, there is a potential for recur­
rence after excision. A wide excision with 3-cm margins is
recommended and should include underlying fascia and
muscle. The likelihood of local control associated with this
procedure exceeds 90%, with the probability of regional or
distant metastases being less than or equal to 5%. Adjuvant
radiotherapy is indicated in the event that a patient has
unresectable macroscopic disease.23

340
SECTION III
CHAPTER 15 • Benign and malignant tumors of the hand
carcinoma ranges from 0.25% to 1.00% per year. Regression
can be spontaneous if sun exposure after diagnosis is limited.
Treatment ranges from continued clinical observation to
ablation. Cryotherapy can be used for isolated lesions. For
more dispersed lesions, topical 5-fluorouracil, dermabrasion,
and cutaneous peels such as trichloroacetic acid peel can be
used. Newer reports have shown positive benefits using
photodynamic therapy with porphyrin derivatives acting as
a photosensitizer. Cure rates with this new modality have
been reported as similar to those with topical 5-fluorouracil.24
Basal cell carcinoma
Basal cell carcinoma is the second most common skin malig­
nancy on the hand and is the most common form of skin
cancer (Fig. 15.11). Basal cell carcinomas are malignant neo­
plasms of the basal epithelium. Five major types of basal cell
carcinoma exist: fibroepithelioma, morpheaform, nodulo-
ulcerative, pigmented, and superficial. The nodulo-ulcerative
is the most common form, and the morpheaform variant is
the most aggressive form of the tumor. The lesions form
insidiously and rarely metastasize.1,2,25
Basal cell carcinomas present in sun-damaged areas. The
middle to older age group is commonly afflicted. Clinically,
the lesion is observed as ulcerated skin with pearly elevated
edges. Treatment consists of excisional biopsy with 2-mm
margins. The key is surgical resection until only normal tissue
remains. Regular follow-up is indicated to identify recur­
rences and new lesions. Since there is a low likelihood of
metastasis, no further workup is required.
Squamous cell carcinoma
Squamous cell carcinoma is the most common malignant
tumor in the hand (Fig. 15.12).26 The tumor typically presents
in late middle age or later. Usually, squamous cell carcinoma
is found on the dorsum of the hand secondary to chronic sun
exposure. Squamous cell carcinomas are pink or skin-colored
and can present as firm hyperkeratotic lesions. Since there is
a potential for malignant spread, it is critical to evaluate
lymph node status by physical examination.
Etiologies of squamous cell carcinoma, in addition to sun
exposure, include a history of therapeutic radiation, chronic
Seborrheic keratosis
A seborrheic keratosis is a benign neoplasm that originates
from keratinocytes (Fig. 15.9). Seborrheic keratoses are very
common, typically present in middle-aged and older patients,
and can be distributed widely over the body. Initially, they
appear as a hyperpigmented lesion but later coalesce into
a characteristic waxy, “stuck-on” appearance. The clinical
conundrum with these lesions is that, although they are
benign in nature, they may mimic melanoma. These lesions
require a biopsy to rule out a malignancy. If a malignancy is
not suspected, these lesions can be treated with cryotherapy,
curettage, or excision.
Actinic keratosis
Actinic keratoses are premalignant lesions and in fact are the
most common precancerous skin condition (Fig. 15.10). An
actinic keratosis presents as a rough, scaly, erythematous
plaque found in an area of chronic sun exposure. The lesion
is commonly tender to palpation. Histologically, this lesion
shows dysplastic keratinocytes confined to the lower third of
the epidermis. Actinic keratoses are the direct result of chronic
sun exposure and are more common in fair-skinned persons.
The potential for malignant conversion to squamous cell
Fig. 15.9  Seborrheic keratosis. A benign neoplasm originating from keratinocytes,
common in middle-aged and older patients and distributed widely over the body.
Fig. 15.10  Actinic keratosis. A premalignant skin lesion found on the upper
extremity. It presents as a rough, scaly, and erythematous plaque found in areas of
chronic sun exposure.
Fig. 15.11  Basal cell carcinoma. These lesions are malignant neoplasms of the
basal epithelium forming insidiously but rarely metastasizing.

341
Treatment/surgical treatment by tissue of origin
melanoma is a variant that occurs on the palmar, plantar, and
nail plate surfaces.30,31
Diagnosis is established by incisional or excisional biopsy.
Determination of the depth of invasion is a critical component
of pathologic analysis. The Breslow system, which is most
commonly used, reports the depth of invasion in millimeters
and correlates with rates of lymphatic spread and distant
metastasis. The Clark system reports invasion based on ana­
tomic levels.
Treatment of melanoma in situ is excision with a 0.5-cm
tissue margin. For invasive lesions <1.0 mm thick, a 1-cm
inflammation, chronic sinus sites secondary to osteomyelitis,
and immunosuppression. A Marjolin’s ulcer is a squamous
cell carcinoma present in a chronic burn ulcer. It is important
to beware of non-responsive subungual lesions mimicking
fungal infections. It is essential to biopsy all chronic infections
to rule out malignancy.
Treatment of squamous cell carcinomas ranges from elec­
trodesiccation and curettage for low-risk tumors to excisional
biopsy for high-risk lesions. Excision with 5-mm margins of
normal tissue results in complete clearance of 95% of tumors.27
Other studies have shown that wide local excision with 4-mm
margins has a clearance rate of 96% and that 6-mm margins
clear 99% of tumors. Metastasis is found within the first 5
years in 5% of patients with squamous cell carcinoma. This is
in contrast to basal cell carcinoma, which typically does not
metastasize. Long-term follow-up after treatment of these
lesions is therefore critical to assess for recurrence or meta­
static spread.
A recent study of patients with squamous cell carcinoma
of the fingertips using Mohs technique was performed in 43
cases. Microinvasive disease was diagnosed in 5 cases, in situ
disease in 7 cases, and invasive disease in 45 patients. Recur­
rences were observed in 2 patients (3.5%). No tumor recur­
rences were observed in 4 to 5 years of follow-up. Mohs
surgery provides the highest cure rate for the treatment of nail
squamous cell carcinoma.28
Melanoma
Melanoma is a highly malignant tumor of melanocytes (Fig.
15.13). Although melanomas represent only 5% of all skin
cancers, they are responsible for 75% of the deaths from skin
cancer.2,29 Based on these percentages, the prompt, accurate
diagnosis and treatment of these tumors are critical for the
well-being of all patients who present with a suspicious skin
lesion on the upper extremity. The typical presentation of
melanoma is a pigmented mass with appearance changes
(ABCDE; see above). Melanomas may arise from atypical
moles, but half of these tumors develop de novo and are unre­
lated to a pre-existing nevus (Fig. 15.14).1 Acral lentiginous
Fig. 15.12  Squamous cell carcinoma. The most common malignant tumor in the
hand, typically found on the dorsum of the hand secondary to chronic sun
exposure. It is critical to evaluate lymph node status upon physical exam.
Fig. 15.13  Melanoma. A highly malignant tumor of melanocytes, melanoma may
arise from atypical moles. One-half of these tumors develop de novo and are
unrelated to pre-existing nevus.
Fig. 15.14  Subungual melanoma. These lesions must be differentiated from
hematoma and onychomycosis. Evaluation of lymph node basins must be
determined clinically and pathologically in lesions of intermediate thickness.

342
SECTION III
CHAPTER 15 • Benign and malignant tumors of the hand
mucin-filled structures associated with joint capsules, tendons,
or tendon sheaths. The etiology of these cystic structures is
presumed to be secondary to synovial herniation and trauma
but remains unclear.33
In the hand, ganglion cysts typically occur in the dorsal
carpal region (60–70%) and originate from the scapholunate
interosseous ligament. The volar carpal region is the next
most commonly involved region, with 20% of ganglion cysts
originating from the scapho-trapezio-trapezoid ligament.
Ganglion cysts are also found on the volar retinaculum (10–
20%). Ganglion cysts found on the dorsal proximal interpha­
langeal joint associated with osteoarthritis are termed mucous
cysts (Fig. 15.16). These are treated by excision of the cyst
along with associated osteophytes. If atypical presentations
occur or if clinical examination does not clarify a potential
ganglion cyst, then ultrasonography or MRI can be helpful in
determining a diagnosis.
A key point in the treatment of ganglion cysts is to clarify
their benign nature for the patient. Patients often seek reas­
surance when confronted with this lesion. The natural course
of volar retinaculum ganglion lesions is spontaneous resolu­
tion in almost two-thirds of patients. Aspiration of these
masses results in complete resolution in the same proportion
of patients. Aspiration of volar and dorsal ganglions in other
locations with fenestration techniques has improved results.
However, recurrence is still observed.33
The definitive management of ganglion cysts is surgical
excision with a cuff of retinaculum. For larger ganglions in the
volar and dorsal regions of the hand, removal of the ganglion
with its stalk and a portion of the cuff of the joint capsule is
required. The capsule is not repaired so as not to limit motion.
Arthroscopic removal of ganglion cysts in the dorsal region
of the wrist is currently being performed. Success rates have
been favorable, although long-term follow-up data are cur­
rently lacking.
Giant cell tumor (pigmented villonodular synovitis)
Giant cell tumors are the second most common soft-tissue
masses in the hand (Fig. 15.17). A giant cell tumor is a benign
tumor containing multinucleated giant cells and xanthoma
cells. Giant cell tumors are found in synovial fluid-producing
sites such as joints, capsular ligaments, and tendon sheaths.34,35
They are slow-growing and can have a mass effect on adjacent
structures, at times indenting cortical bone. They are firm,
margin is used. For lesions that are 1–4 mm thick, a 2-cm
margin is used; and for lesions >4 mm thick, a 2–4-cm margin
is used. The risk of metastasis is only 2% for thin (<1 mm)
lesions but higher for lesions that are 1–4 mm thick (addressed
below). It is important to examine clinically the lymph nodes
that drain melanomas.
Lymphatic metastases from melanoma are believed to occur
in an orderly, anatomic progression. The first node to which a
melanoma metastasizes is considered the sentinel lymph node
(SLN) and can be predicted by the lymphatic drainage pattern
of the skin area where the tumor is located. By performing
a biopsy of the SLN in patients with intermediate-thickness
melanomas, the potential for metastasis to other nodes can be
predicted. The SLN is identified at the time of tumor resection
by lymphoscintigraphy and the use of dye.32 Technetium-99m
is given the morning of the operation, with surgery being
performed 4 hours later after Lymphazurin blue is injected
intradermally around the lesion. Next, the “hot” lymph node
is searched for using a radioactive sensor and by visualizing
the path of the blue dye. This lymph node, the SLN, is then
sent for frozen-section pathologic assessment. If the SLN is
positive, a full dissection of the draining lymph node basin(s)
is performed. Consideration should then be given to adjuvant
chemotherapy. No further treatment is given if the SLN is
negative.
For thick melanomas (>4 mm), the risk of nodal metastasis
is high (60–80%). Any clinically identified positive nodes are
resected along with the primary lesion. If the clinical node
examination is negative, SLN biopsy is not routinely indicated
because this group will probably not benefit from loco-regional
disease control.
Subungual melanomas may masquerade as a subungual
hematoma or onychomycosis. Typically, treatment of subun­
gual melanoma is an amputation at the distal interphalangeal
joint.30
Synovial lesions
Ganglion cysts
Ganglion cysts are the most common soft-tissue tumors of the
hand and upper extremity (Fig. 15.15). Ganglion cysts are
Fig. 15.15  Ganglion cysts. The cyst is a mucinous-filled structure associated with
joint capsules, tendons, and tendon sheaths. The etiology of these cystic structures
is presumed to be secondary to synovial herniation and trauma.
Fig. 15.16  Mucous cyst. (A) Ganglions found on the dorsal proximal
interphalangeal joint associated with osteoarthritis are termed mucous cysts.
(B) Excision of the cyst along with excision of osteophytes must be performed to
treat this clinical entity completely.
B
A

343
Treatment/surgical treatment by tissue of origin
The lesions appear histologically as diffuse growths of
Schwann cells, fibrous tissue, and axons. When groups of
these lesions are encountered, von Recklinghausen’s disease
or neurofibromatosis should be considered as a diagnosis.
The treatment for neurofibromas is excision; however, this
is likely to require segmental nerve resection and nerve graft­
ing based on the anatomy of the tumor in that normal nerve
fascicles are incorporated into the tumor.
nodular, and non-tender. Most commonly, they are found
over the volar aspect of the hand.
The treatment for this tumor is careful, complete excision.
When dissecting these tumors out of the hand, the surgeon
must beware of nerve displacement. The main problem with
these masses is the potential for recurrence; the recurrence
rate has been reported to be 5–50%. A malignant form of this
tumor has been described but is extremely rare.
Nerve tumors
Schwannoma/neurilemoma
Schwannomas, the most common benign nerve tumors of the
hand, arise from Schwann cells (Fig. 15.18). The presentation
of schwannoma is one of a slow-growing, well-circumscribed,
eccentric, and essentially painless mass.36 However, there may
be a neurologic deficit or pain if the lesion is in the distribu­
tion of motor or sensory nerves. Schwannomas are mobile
transversely, not longitudinally. They are typically found on
the volar surface of the hand and forearm in the fourth to sixth
decades of life.
The treatment for schwannoma is to “shell it out” from
surrounding intact nerve fascicles, under magnification. The
risk of a postoperative neurologic deficit is 4%. There are very
rare reports of malignant transformation.
Neurofibroma
Neurofibromas are benign, slow-growing tumors arising
within nerve fascicles (Fig. 15.19).
Fig. 15.17  Giant cell tumor (pigmented villonodular synovitis). A benign tumor
containing multinucleated giant cells and xanthoma cells found in synovial
fluid-producing sites such as joints, capsular ligaments, and tendon sheaths.
Fig. 15.18  Schwannoma/neurilemmoma. This soft-tissue mass arises from
Schwann cells and is typically found on the volar surface of the hand and forearm.
Fig. 15.19  Neurofibroma, a benign slow-growing tumor arising within nerve
fascicles. When encountered in groups, von Recklinghausen’s disease or
neurofibromatosis should be considered as a diagnosis.

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CHAPTER 15 • Benign and malignant tumors of the hand
Malignant transformation of neurofibroma is possible, and
rapid enlargement may indicate malignant transformation.2
In patients with neurofibromatosis, malignant degeneration
into plexiform neurofibromas can occur. A pseudoarthrosis,
which is a rare condition frequently associated with neuro­
fibromatosis, can occur in the upper extremity. This appears
as “sucked candy” on radiographs.
Lipofibromatous hamartoma
Lipofibromatous hamartoma represents a fibrofatty infiltra­
tion of the nerves (Fig. 15.20). This tumor is most commonly
found in the median nerve. In a child who presents with
carpal tunnel syndrome, lipofibromatous hamartoma should
be considered part of the differential diagnosis.37 Exploration
of the mass reveals fusiform swelling of the nerve without
invasion into perineural tissue.
Interfascicular resection is not possible and in fact is con­
traindicated for the treatment of this lesion. Instead, simple
decompression is recommended. Gradual deterioration of
nerve function can occur; only then should resection and
nerve grafting be considered.
Fat tumor: lipoma
A lipoma is a benign tumor composed of adipose tissue
(Fig. 15.21). Lipomas can be located subcutaneously or intra­
muscularly. If present in the carpal tunnel or Guyon’s canal,
lipoma can lead to nerve compression. Lipomas typically
have a longstanding history with very slow growth. Physical
examination and history will invariably lead to the diagnosis.
If imaging is warranted, X-rays will reveal lucent soft-tissue
shadows, and MRI will show a signal intensity consistent
with adipose tissue.
The treatment of lipoma is simple excisional biopsy consist­
ing of a marginal resection. The well-defined margins of the
tumor make excision not technically challenging. The primary
indication for excision is size increase and mass effect (nerve
compression).
The malignant form of this mass, liposarcoma, has rarely
been reported in the hand. However, liposarcoma can be
confused with a lipoma if encountered.
Fig. 15.20  Lipofibromatous hamartoma. This mass is a fibrofatty infiltration of the
nerves, most commonly found in the median nerve. In a child who presents with
carpal tunnel syndrome, this should be considered part of the differential diagnosis.
Fig. 15.21  Lipoma. This lesion is a benign tumor composed of adipose tissue.
Commonly they are located subcutaneously or intramuscularly in the upper
extremity.
Fibrous tissue lesions
Benign lesions
The majority of the lesions of fibrous tissue found in the hand
are benign. These include simple scars, hypertrophic scars,
and keloid tissue. Hypertrophic scars are confined within the
original wound margins, whereas keloids grow beyond these
margins. Both exhibit increased cellularity and vascularity.
Other benign fibrous tumors found in the hand include juvenile
aponeurotic fibroma, desmoid tumors, fibrous histiocytoma,
and Dupuytren’s disease. The last of these constitutes fibrosis
of the palmar fascia that leads to subsequent contractures
of the fingers involving the metacarpophalangeal, proximal
interphalangeal, and distal interphalangeal joints.
Sarcomas
Malignant fibrous histiocytoma is the most common soft-
tissue sarcoma in adults (Fig. 15.22).37,38 It develops in the sixth
to eighth decades of life. This tumor presents as a painless
enlarging mass that is most common in the forearm. Treat­
ment is wide excision or amputation. Neoadjuvant therapy
can be administered to reduce tumor bulk and avoid amputa­
tion of the limb. A metastatic workup is required, with the
most common site of metastasis being the lungs.
Synovial sarcoma is among the more common sarcomas
in the hand and wrist. This malignant soft-tissue tumor
occurs near tendons and joints and may invade bone. Its
most common presentation in the upper extremity is that of
a firm, indolent, painless mass on the dorsum of the hand.8
It typically presents in young adults to middle-aged patients.
Synovial sarcoma is a very aggressive tumor. Treatment is wide
or radical surgical excision. Nodal status must be evaluated
because of the high rates (50%) of metastasis from this mass.
Adjuvant radiotherapy or chemotherapy is recommended.
Epithelioid sarcoma is the most common malignant soft-
tissue tumor of the upper extremity (Fig. 15.23). It most
commonly appears on the hand and forearm in adolescents
and young adults as a firm, slow-growing mass.8 Epithelioid

345
Treatment/surgical treatment by tissue of origin
Fig. 15.22  Malignant fibrous histiocytoma. This sarcoma presents as a painless enlarging mass commonly found on the upper extremity. Treatment for this tumor is wide
excision with mandatory metastatic evaluation. (A) Dorsal hand lesion. (B) Specimen revealing composite resection involving extensor tendons. (C) Wide local excision
with proximal and distal extensor tendons tagged for reconstruction. (D) Dorsalis pedis flap elevation, including dorsal foot extensors. (E) Postoperative flap.
A
B
C
D
E
sarcoma can affect the digits and palm with proximal spread
along tendon sheaths. It can be misdiagnosed as a wart or an
ulcer. Treatment of epithelioid sarcoma is wide or radical
excision. Nodal status needs to be evaluated as metastasis is
typically to regional lymph nodes.
Chemotherapy and limb salvage surgery with recon­
struction has become the standard treatment for sarcomas
of the extremities, including the hand. Local flaps are often
inadequate for repairing extensive defects resulting from
tumor resection. Such defects may require free tissue transfer.
The use of free flaps in reconstructing oncologic defects has
enabled reconstructive surgeons to effect a paradigm shift
in limb salvage. Complex free flap reconstructions are now
routinely being used to preserve limbs that, due to locally
advanced disease, would have been previously amputated.
This has redefined the surgical management of sarcomas
of the extremities. This shift toward limb preservation has
prompted surgeons to re-evaluate the indications for amputa­
tion and thus improved patients’ quality of life. In addition,
tremendous advances in the multidisciplinary management
of sarcoma have been made. Neoadjuvant chemotherapy and
radiotherapy are now used to reduce tumor size to enable
neurovascular-sparing resections that preserve limb function.
Vascular lesions
Hemangioma
Hemangiomas are benign capillary malformations. They can
present as superficial, cutaneous lesions; as deep, cavernous

346
SECTION III
CHAPTER 15 • Benign and malignant tumors of the hand
Fig. 15.23  Epithelioid sarcoma. The most common malignant soft-tissue tumor of the upper extremity.
(A) Recurrent epithelioid sarcoma following wide local excision. (B) Composite resection involving both
distal radius and ulna. (C) Bone allograft with internal fixation. Soft-tissue coverage supplied by a reverse
radial forearm flap. (D) Intraoperative flap inset. (E) Postoperative result.
A
B
C
D
E
lesions; or as a mixture of the two forms (Fig. 15.24). Heman­
giomas typically are not present at birth but appear in the first
month of life. They are characterized by a rapid growth phase
during the first year. The rate of involution is 50% by 5 years
of age and 70% by 7 years of age.39
Treatment is typically observation, as most will involute.
However, laser therapy, systemic steroids, intralesional steroids,
and interferon have all been shown to have beneficial effects.
When hemangiomas become symptomatic in adults, they require
a marginal resection. Even after resection, these lesions can recur.

347
Treatment/surgical treatment by tissue of origin
Other vascular malformations seen in the hand are aneu­
rysms and pseudoaneurysms (Fig. 15.27). The former can
originate from the radial, ulnar, or digital artery. Aneurysms
involve all three layers of the vessel wall – the intima, the
media and adventitia. In contrast, pseudoaneurysms repre­
sent a defect in the arterial wall contained by fibrous tissue.
Glomus tumor
A glomus tumor is a benign tumor of the neuromyoarterial
apparatus, which is responsible for controlling circulation to
Infantile hemangiomas can be associated with Kasabach–
Merritt syndrome (Fig. 15.25). This aggressive hemangioen­
dothelioma leads to a consumptive coagulopathy secondary
to platelet trapping. High-dose steroids and vincristine have
been used to treat this syndrome.40
Maffucci’s syndrome is a condition characterized by mul­
tiple hemangiomas and enchondromas.41 The digits in patients
with this condition are short and angulated. There is a risk of
malignant transformation of the enchondromas and heman­
giomas into chondrosarcomas and angiosarcomas.
Vascular malformations
Vascular malformations are typically present at birth, in
contrast to hemangiomas, and represent malformed vascular
channels. Malformations are described by their location as
capillary, venous, lymphatic, or mixed venous–lymphatic
malformations (Fig. 15.26). These are considered “low-flow”
tumors. Treatment can be observation, laser therapy, scleros­
ing agents, or excision.42
“High-flow” vascular malformations have arterial or
arteriovenous components. These masses represent a “time
bomb” with the potential for rapid expansion. Treatment of
these tumors involves preoperative embolization followed by
excision.
Fig. 15.25  Kasabach–Merritt syndrome. This aggressive hemangioendothelioma
leads to a consumptive coagulopathy secondary to platelet trapping.
Fig. 15.26  Vascular malformations are typically present at birth, in contrast to
hemangiomas, and represent malformed vascular channels. Treatment can be
observation, laser therapy, sclerosing agents, or excision.
A
Fig. 15.27  Pseudoaneurysm. This represents a defect in the arterial wall contained
by fibrous tissue as opposed to an aneurysm, which involves all three vessel
wall layers (intima, media, and adventitia). (A) Radial artery pseudoaneurysm.
(B) Radial artery pseudoaneurysm exposed.
B
Fig. 15.24  Hemangiomas present as: (1) superficial in the cutaneous form;
(2) deep, which represents cavernous lesions; or (3) a mixture of both. Not present
at birth, they are characterized by a rapid growth phase during the first year.
Expected involution is 50% by 5 years of age and 70% by 7 years of age.