Operative Technique in Plastic Surgery – Kevin C.Chung

54
CHAPTER
Digital Artery
Sympathectomy
John R. Lien and Kevin C. Chung
DEFINITION
■ Raynaud disease (RD) is characterized by cold hypersensitivity and color
changes to digits secondary to an exaggerated vasoconstrictive response to cold
temperature, emotional stress, or trauma.
■ There is no underlying associated cause for these vasospastic events in RD.
■ Raynaud phenomenon (RP) occurs in patients with a diagnosis of underlying
collagen vascular disease such as scleroderma.
ANATOMY
■ The superficial palmar arch is the continuation of the ulnar artery in the palm.
The common digital arteries arise from this palmar arch (FIG 1).
■ The common digital nerves course alongside the common digital arteries,
supplying sympathetic fibers to the adventitial layer of the arteries.

FIG 1 • Palmar neurovascular anatomy. The ulnar artery
provides dominant flow to the superficial palmar arch
(deep palmar arch not shown).
PATHOGENESIS
■ The function of arterial smooth muscle is to constrict and decrease blood flow.
■ Vasospastic disorders are characterized by reversible changes in flow, whereas
occlusive disorders involve decreased flow unrelated to vasoconstriction.
■ In occlusive disorders such as scleroderma, ischemia of the digit may result
from inadequate collateral vessels or inadequate flow through collaterals
secondary to vasospasm.
NATURAL HISTORY

■ Natural history of the digital ischemia is largely dictated by the underlying
cause.
■ Patients with underlying mixed connective tissue disorder often have
worsening digital symptoms/ischemia as their disease progresses. This can lead
to trophic changes such as ulcers and gangrene.
PATIENT HISTORY AND PHYSICAL FINDINGS
■ Patients typically report a triphasic color change (white, blue, red) in both RD
and RP.
■ Obtain a thorough rheumatologic history. Patients with suspected primary RD
may have unrecognized mixed connective tissue disorders.
■ Frequency and severity of ischemic episodes, extent of cold sensitivity,
numbness, pain
■ Association of symptoms with emotional changes
■ Active nicotine use is a contraindication to surgical intervention.
■ Allen testing should be performed to assess patency of palmar arches.
■ Note trophic changes such as ulcers and gangrene.
■ Assess for laterality; focal unilateral symptoms may be concerning for embolic
disease.
IMAGING
■ Angiography provides excellent anatomic detail and structural information.
Vasospastic contribution to ischemia can be enhanced by the use of intra-
arterial vasodilators. If the patient fails medical management, we obtain this
study as part of our preoperative evaluation.
■ Noninvasive vascular studies
■ Digital brachial index (DBI) values assess total flow to the digit. DBI less
than 0.7 indicates abnormal flow.
■ Doppler sonography
■ Digital plethysmography (pulse volume recordings) can differentiate
vasospastic from vaso-occlusive disease, particularly with cold stress testing.
DIFFERENTIAL DIAGNOSIS
■ Primary Raynaud disease
■ Secondary Raynaud phenomenon
■ Rheumatic disease, eg, scleroderma, systemic lupus erythematosus
■ Hematologic disorder

■ Atherosclerotic disease
■ Embolic disease
NONOPERATIVE MANAGEMENT
■ Lifestyle modification
■ Tobacco cessation
■ Avoidance of cold environment (gloves, warmer climate in winter)
■ Biofeedback therapy
■ Medical management1
■ Calcium channel blocker such as nifedipine is a first-line treatment.
■ Phosphodiesterase-5 inhibitors (sildenafil, tadalafil, vardenafil), topical
nitroglycerin, angiotensin-receptor antagonist (losartan), and selective
serotonin reuptake inhibitors (fluoxetine) are other among second-line
medications.
■ There may be a role for botulinum toxin type A injection, but larger controlled
trials are necessary to establish its effectiveness.2
SURGICAL MANAGEMENT
■ Indications for digital sympathectomy include digital ischemic pain and/or
trophic changes refractory to medical management. This commonly includes
patients with autoimmune disorders such as scleroderma. Often, this is a
surgery of last resort in patients with persistent and unrelenting ischemic pain.
■ Patients with primary RD often respond to medical management. We rarely
offer surgical sympathectomy to these patients.
■ We do not offer this surgery to active smokers.
■ Contraindication to sympathectomy includes severe primary atherosclerotic
occlusive disease.
■ For the sympathectomy to produce increased flow to the digit, there must be
a reversible vasospastic component to either the digital artery or its distal
collaterals.
Preoperative Planning
■ If preoperative studies demonstrate vasospastic disease with secondary
occlusion of the radial/ulnar artery or palmar arch, we consider arterial
reconstruction with vein grafting.
Positioning

■ Supine with hand table and arm tourniquet
Approach
■ For single-digit sympathectomy, we perform an extensile Bruner zigzag
incision over the ray of the digit in the distal palm.
■ In the setting of multiple-digit sympathectomies, we perform a transverse
oblique incision at the palmar crease (FIG 2).
FIG 2 • Incision for multiple-digit artery sympathectomy
(A) and single-digit sympathectomy (B).
T E C H N I Q U E S
■ Exposure
■ Under tourniquet control, perform a Bruner incision overlying the
appropriate ray in the distal half of the palm (or transverse oblique incision
for multiple-digit sympathectomies; TECH FIG 1A).
■ Elevate full-thickness skin flaps and expose the superficial palmar arch
proximally.
■ Identify the origins of the common digital arteries supplying the radial and
ulnar aspects of the appropriate finger.

■ Dissect the common digital arteries and nerves from proximal to distal,
ensuring exposure of 2 to 3 cm of vessel length (TECH FIG 1B).
TECH FIG 1 • A. Brunner incision is marked. Trophic
changes to the index and middle fingertips can be
seen in this patient with scleroderma and persistent
middle finger pain. B. Exposure of radial and ulnar
digital neurovascular bundles to middle finger.
■ Sympathectomy
■ Under microscope magnification, systematically strip the common digital
artery adventitia for 2 to 3 cm.
■ While doing this, any communicating sympathetic nerve branches from the
digital nerve to the artery should be divided (TECH FIG 2).
■ Take care to avoid injury to the digital artery. Small arterial branches should
be tied off using microsurgical technique.
■ Release the tourniquet and ensure hemostasis.
■ Loosely close the wound.

TECH FIG 2 • Microscope view of neurovascular
bundles after sympathectomy.
PEARLS AND PITFALLS
Technique
■ Avoid iatrogenic arterial injury or vasospasm by minimizing
trauma to the digital artery. Use microsurgical technique during
adventitial stripping.
Arterial
reconstruction
■ When possible, consider arterial reconstruction if there is
inadequate collateral circulation with proximal occlusion.
Sympathectomy alone can be performed as a palliative salvage
procedure if occlusive disease is nonreconstructible.
POSTOPERATIVE CARE
■ Patient is placed in a volar forearm-based splint postoperatively.
■ At the first 2-week postoperative visit, sutures are removed and range of
motion is encouraged.

OUTCOMES
■ Reported outcomes on ulcer healing and pain improvement are heterogeneous
due to small case volume and lack of controlled studies.3
■ In general, better outcomes in terms of ulcer healing are noted in patients who
have underlying autoimmune disease as compared to severe atherosclerotic
disease.4
■ Twenty-eight of forty-two digits in patients with autoimmune disease had
complete ulcer healing or decrease in number of ulcers. Two of seventeen
digits had healing in the atherosclerotic group.
■ At a minimum of 23 months of follow-up, 26% (11 of 42) of digits in the
autoimmune disease group ultimately required amputation, whereas 59% (10
of 17) in the atherosclerotic group ultimately required amputation.
COMPLICATIONS
■ Persistent ischemic pain
■ Persistent wound/ulcers necessitating amputation
■ Iatrogenic arterial injury/thrombosis
REFERENCES
1. Wigley FM, Flavahan NA. Raynaud’s phenomenon. N Engl J Med.
2016;375:556-565.
2. Iorio ML, Masden DL, Higgins JP. Botulinum toxin A treatment of Raynaud’s
phenomenon: a review. Semin Arthritis Rheum. 2012;41:599-603.
3. Kotsis SV, Chung KC. A systematic review of the outcomes of digital
sympathectomy for treatment of chronic digital ischemia. J Rheumatol.
2003;30:1788-1792.
4. Hartzell TL, Makhni EC, Sampson C. Long-term results of periarterial
sympathectomy. J Hand Surg [Am]. 2009;34A:1454-1460.

55
CHAPTER
Ulnar Artery to Superficial
Arch Bypass With a Vein
Graft for Ulnar Artery
Thrombosis
Mark Morris and Kevin C. Chung
DEFINITION
■ Hypothenar hammer syndrome refers to post-traumatic digital ischemia
secondary to thrombosis of the ulnar artery.
■ The ulnar artery at Guyon canal and the proximal superficial arch are the most
common sites of occlusion.
■ “Critical” vascular injuries result in tissue death without intervention.
■ “Noncritical” vascular injuries occur when an artery is damaged, but collateral
circulation is adequate and prevents tissue necrosis.
■ A “complete” superficial or deep palmar arch is defined as having a significant
connection to a branch from another independent arterial limb such that it
provides branches to all digits. The superficial arch is complete in 78.5% of
extremities, and the deep arch is complete in 98.5% of extremities.1
ANATOMY
■ The major blood supply to the hand is from the superficial palmar arch, which
is a continuation of the ulnar artery, and the deep palmar arch, which is a
continuation of the radial artery (FIG 1).
■ A median artery may also be present.
■ The radial artery bifurcates into dorsal and volar branches at the level of the
radial styloid. The dorsal branch traverses the floor of the snuffbox and passes
through the first dorsal interosseous muscle, diving volar and becoming the
primary contributor to the deep palmar arch. The volar branch contributes to

the superficial arch.
■ The ulnar artery bifurcates into deep and superficial branches at the level of
the wrist. The deep branch anastomoses with the deep palmar arch, whereas the
superficial branch terminates as the superficial palmar arch.
■ The radial artery and deep palmar arch provide the dominant blood flow to
three or more digits in 57% of normal extremities, whereas the ulnar artery and
superficial arch provide dominant flow to three or more digits in 21.5%, and
there is equal contribution from radial and ulnar arteries in 21.5% of
extremities.2
■ Deep palmar arch runs deep to the flexor tendons at the level of the base of the
metacarpals, 1 cm proximal to the superficial arch.
■ Superficial palmar arch is located at Kaplan line (line drawn across the palm
from the first web space parallel to the proximal palmar crease toward the hook
of the hamate), 1 cm distal to the deep palmar arch.
■ The deep and superficial arches provide common digital arteries to the second,
third, and fourth web spaces at the mid-metacarpal level. These then divide
into proper digital arteries at the level of the MCP joint.
■ A less significant dorsal circulation also exists, receiving contributions from
dorsal carpal branches of the radial and ulnar arteries.
PATHOGENESIS
■ A single or more likely repetitive impact to the hypothenar eminence leads to
ulnar artery thrombosis or aneurysm (FIG 2).
■ Ulnar artery thrombosis has been reported in patients participating in baseball,
golf, weight lifting, karate, mountain biking, volleyball, and overenthusiastic
clapping by fans. At-risk occupations are those requiring vibrating tools such
as carpentry, construction, machine operators, and mechanics.
■ The hook of the hamate acts as an anvil against which the ulnar artery is
crushed.

FIG 1 • Vascular anatomy of the hand. The superficial
palmar arch is supplied by the ulnar artery. The deep
palmar arch is supplied by the radial artery.
FIG 2 • The ulnar artery travels in Guyon canal with the
ulnar nerve. A,B. The floor of the canal is made by the
transverse carpal ligament, and the roof is made by the
volar carpal ligament. The close proximity of the artery
leaves it susceptible to impact into the hook of the

hamate.
■ Repetitive trauma can lead to direct intimal damage, which leads to
thrombosis, or periadventitial thickening of the artery that constricts the vessel
and obstructs flow.
■ Disruption of the internal elastic lamina of the artery leads to aneurysm, which
predisposes to mural thrombosis, complete occlusion, and distal thrombotic
emboli (FIG 3).
■ Arterial occlusion or distal emboli can lead to ulceration, gangrene, and
necrosis of digits.
FIG 3 • Repetitive impact to the ulnar artery leads to
either periadventitial thickening or disruption of internal
elastic lamina. Both conditions leave the artery prone to
thrombosis.

NATURAL HISTORY
■ Depending on the severity of occlusion and quality of flow from the deep arch,
the natural history will vary.
■ The long, ring, and small fingers may develop cyanosis, pallor, splinter
hemorrhages, ulcerations, atrophy of distal finger pads, or even necrosis of
digits.
■ Most patients will develop cold intolerance.
■ Most patients will have persistent symptoms even after revascularization,
although with decreased frequency and severity.
PATIENT HISTORY AND PHYSICAL FINDINGS
■ Patients with post-traumatic ulnar artery thrombosis are predominantly male
and present with unilateral hand and digit ischemia.
■ The dominant hand is most commonly affected, although bilateral cases have
been reported.
■ History of interest includes vascular disease, smoking, manual labor, use of
palm as a hammer, use of vibrating tools.
■ Symptoms include pain, numbness or tingling, cold intolerance, and weakness
in the ulnar nerve distribution.
■ Signs on physical exam include pallor, cyanosis/mottling, a palpable
hypothenar mass (if an aneurysm is present), atrophy of distal finger pads,
splinter hemorrhages, ulcerations, and gangrene of the long, ring, and small
fingers (FIG 4).
■ Ischemic problems of the thumb have never been described with post-
traumatic ulnar artery thrombosis. If present, a different diagnosis should be
considered.
■ Radial and ulnar pulses are palpated and examined by Doppler probe if not
palpable.
■ Doppler can also be used to assess the palmar arch and radial and ulnar digital
arteries to each finger.

FIG 4 • Signs of ulnar artery thrombosis—pulp atrophy,
ulcerations, cyanosis, pallor, palpable pulsatile mass in
the hypothenar eminence. The thumb should appear
normal. The number of affected digits will vary
depending on perfusion from the radial artery and deep
arch.
■ A modified Allen test should be performed to assess blood flow to the hand
from the radial and ulnar arteries independently (FIG 5):
■ One hand is examined at a time.
■ The patient is asked to clench the fist tightly for one minute.
■ Pressure is applied over the radial and ulnar arteries so as to occlude both.

FIG 5 • Allen test in a patient with ulnar artery
thrombosis. The examiner occludes both the ulnar and
radial arteries and the hand is white as a result of a lack
of perfusion. When pressure is released from the ulnar
artery, the hand remains white because of an occluded
ulnar artery.
■ The patient opens the fingers. Pallor should be observed at this time.
■ Pressure is released from the ulnar artery, and color should return if ulnar
artery supply to the hand is sufficient. Pallor will remain if there is insufficient
ulnar flow. The radial artery is then released and color should return to the
entire hand if the deep arch is complete.
■ The test is repeated, but with pressure being released from the radial artery
first.
■ Several questionnaires exist to assess symptoms and disability related to
ischemia of the hand:
■ The Levine-Katz questionnaire assesses pain, symptoms of dysesthesia, and
hand function.3

■ The McCabe Cold Sensitivity Test assesses cold sensitivity and associated
symptoms.4
■ The Cold Intolerance Symptom Severity questionnaire adds questions and
assessments that are not addressed by the McCabe test.5
IMAGING
■ Noninvasive studies are done first.
■ Standard PA, lateral, and oblique radiography of the hand are performed to
evaluate bony architecture as well as vascular calcifications.
■ Pulse volume recording measures the volume of arterial blood flow.
Inadequate flow to the hand and digits can be detected by comparing proximal
and distal blood flow. The severity and general location of occlusive disease
can be determined by pulse volume recording.
■ Digital brachial index (DBI) compares digital blood pressure to contralateral
brachial blood pressure in order to quantify perfusion to the hand and digits.
The normal range for DBI is 0.75 to 0.97. Values equal or less than 0.7 signify
inadequate perfusion.
■ Doppler or vascular duplex ultrasound can be used to evaluate flow. This
provides audible and color-coded visual information about flow. Duplex can
provide information about flow abnormalities, structural abnormalities of
vessels, presence of thrombus, and aneurysm. The weakness of this study is
the lack of standardization and operator-dependent nature of the study.
■ Invasive tests can be performed if noninvasive tests are abnormal.
■ Computed tomographic angiography (CTA) and magnetic resonance
angiography (MRA) are minimally invasive tests that require venous access
for the administration of contrast dye. Both hands can be evaluated
simultaneously for comparative assessment. Anatomic details provided by
both tests are similar, but both have advantages and disadvantages. MRA
contrast is less nephrotoxic than CTA contrast. MRA is susceptible to motion
artifact and cannot be used in patients with certain metallic implants or
claustrophobia. MRA is significantly more expensive than CTA, although
both are cheaper than conventional angiography.
■ Conventional angiography/arteriography is the standard for evaluation of
ulnar artery thrombosis (FIG 6). Angiography shows the surgeon the features
of ulnar artery thrombosis including a corkscrew appearance of the ulnar
artery, alternation of stenosis and dilation, aneurysm formation, occlusion of
the ulnar artery at the hook of the hamate, or occlusion of the superficial

palmar arch or digital arteries with a normal proximal ulnar artery.
Conventional angiography requires arterial access and contrast dye
administration and has risks of bleeding, hematoma, thrombosis,
pseudoaneurysm, allergic reaction, renal toxicity, and a four-fold higher dose
of radiation than CTA. Conventional angiography is contraindicated in
patients with renal insufficiency.
FIG 6 • Arteriogram demonstrating absent flow from the
ulnar artery into the hand.
DIFFERENTIAL DIAGNOSIS
■ Hypothenar hammer syndrome (post-traumatic ulnar artery thrombosis)
■ Raynaud disease
■ Malignancy, vascular tumors

■ Pseudoaneurysm
■ Trauma, iatrogenic injury
■ Buerger disease
■ Arteritis
■ Peripheral vascular disease (atherosclerosis)
■ Connective tissue disorders (scleroderma, systemic lupus erythematosus)
NONOPERATIVE MANAGEMENT
■ Nonoperative treatment can be considered for patients without impending
digital loss.
■ Smoking cessation
■ Medications can be used to decrease sympathetic tone and vasospasm—
calcium channel blockers, α-blockers, β-blockers, steroids, prostaglandins, and
prostacyclin have been described.
■ Antiplatelet or anticoagulant agents can be used in patients with thrombosis
and embolic disease.
■ Intra-arterial thrombolytics can be percutaneously directed to the site of ulnar
artery thrombosis. Success of this procedure is limited, with a high
complication rate.
■ Digital sympathectomy with botulinum toxin A can be performed, with low
morbidity.
SURGICAL MANAGEMENT
■ Surgical intervention is indicated in patients who have failed medical
management or those with impending digital necrosis.
■ Surgical options include open sympathectomy, exploration and ligation of the
diseased segment of artery, exploration and primary repair of the ulnar artery,
or exploration and revascularization by arterial bypass.
Preoperative Planning
■ Preoperative imaging (eg, CTA, MRA, angiogram) is reviewed to determine
the site of bypass.
■ Donor vessels are identified and marked.
■ Venous or arterial grafts can be used.
■ Vein interpositional grafts must be reversed because of the presence of
valves.
■ Veins are typically more expendable than arteries and provide longer grafts.

■ Arterial grafts are easier to match in size. They are less flimsy and do not
need to be reversed.
■ Table 1 covers donor grafts available for ulnar artery bypass.
■ An operating microscope and microsurgical instruments are used for
microvascular anastomosis.
Table 1 Donor Grafts for Ulnar Artery Bypass
Graft
Length (cm)
Comments
Vein
Greater saphenous
50–85
Found superficially,
easier dissection, but
decreased long-term
patency rates
compared to arterial
grafts. Greater
saphenous and basilic
have poor size match
to the ulnar artery at
the wrist.
Lesser saphenous
35–60
Forearm
14–20
Basilic/cephalic
15–30
Dorsum of foot
5–8
Artery
Subscapular
2–4
Short pedicle length
Superficial inferior epigastric
6–10
Abdominal bulge
Deep inferior epigastric
10–12
Abdominal bulge
Thoracodorsal
11–14
Dissection in axilla
Lateral circumflex femoral
10–18
Deep, variable
anatomy
Positioning
■ The patient is placed supine on the operating table with a hand table for the
operative extremity.
■ A brachial tourniquet is placed.
■ Depending on the graft to be used, another extremity (usually a lower
extremity) may need to be prepped and another tourniquet placed.
Approach
■ The affected segment of artery will be excised. The surgeon must first obtain

proximal and distal control of the ulnar artery and superficial arch.
■ Palmar arches are exposed via zigzag incisions extending proximally from the
phalanges or through an inverted J-shaped incision in the palm. The ulnar
artery is exposed using a zigzag incision more proximally in the palm. The
wrist crease is crossed in an oblique fashion.
T E C H N I Q U E S
■ Approach
■ An incision is made that parallels the thenar crease, zigzags in the palm, and
extends proximally into the forearm between the flexor carpi ulnaris and
palmaris longus (TECH FIG 1).
■ Alternatively, two separate incisions can be made and the graft is tunneled
under the skin, depending on the location of ulnar artery to be resected.
■ The ulnar artery and nerve are identified 3 to 5 cm proximal to the wrist
crease, and vessel loops are placed around each structure.
■ The artery is radial to the nerve at the wrist. The ulnar artery enters the
hand through the Guyon canal. It runs deep to the volar carpal ligament and
superficial to the transverse carpal ligament.
TECH FIG 1 • Planned incision to access the ulnar
artery and superficial palmar arch. The wrist crease is
crossed with an oblique incision. A zigzag incision is

made in the palm. If the entire superficial arch needs
to be accessed, continue the incision along the
proximal palmar crease. The extent of the forearm
incision depends on the length of bypass required.
■ Dissection of the Ulnar Artery
■ Dissect from proximal to distal, following the ulnar artery. First identify the
patent portion of the ulnar artery proximal to the wrist crease (TECH FIG
2A).
■ Identify the arterial branch or branches that accompany the deep motor
branch of the ulnar nerve. Identify the origin of the proper digital artery to the
small finger and the origins of the common digital arteries from the
superficial arch.
■ Mobilize the ulnar artery and superficial arch (TECH FIG 2B). Spread the
artery away from surrounding tissue and venae comitantes using scissors.
Venae comitantes are cauterized with bipolar electrocautery.
TECH FIG 2 • A. The ulnar artery is exposed in the
forearm. B. The superficial palmar arch is exposed in
the hand.
■ Resection of Affected Segment of Ulnar Artery and
Superficial Arch

■ All abnormal segments are resected to normal vessel.
■ Once all damaged vessels are resected, distal outflow can be assessed by
transiently deflating the tourniquet and observing backflow (TECH FIG 3).
■ Measure the size of the defect.
TECH FIG 3 • The thrombosed section of ulnar artery
and superficial arch is resected back to normal artery.
Measure the segment that is resected in preparation
for vein harvest.
■ Harvesting of Vein Graft
■ Select the appropriate donor graft depending on the length and diameter
needed (see Table 1).

■ A vein graft is harvested through a longitudinal incision under tourniquet.
■ Adequate length is mobilized (harvest 10%–30% longer than estimated to
perform the bypass).
■ Draw an axial line down the length of the vein to be harvested while it is still
in situ. This will help the surgeon prevent inadvertent twisting of the graft
during the anastomosis.
■ Occasionally, branches are desired for anastomosis. All other branches are
ligated or coagulated with bipolar electrocautery.
■ Harvest the graft (TECH FIG 4).
■ Reverse the vein graft and prepare for anastomosis.
■ The vein is distended with heparinized saline, and veins are dilated.
TECH FIG 4 • The vein graft is harvested and
reversed. A saphenous vein graft is pictured here.
■ Microvascular Anastomoses
■ The proximal anastomosis is done first. End-to-side or end-to-end
anastomosis of the graft to the ulnar artery stump is performed (TECH FIG
5A).
■ End-to-end or end-to-side anastomoses are performed to the superficial arch
or the common digital arteries, as indicated by the amount of resected artery
(TECH FIG 5B).
■ Size discrepancy is managed by making a closing V in the vein graft, an
opening V in the artery, a sleeve anastomosis, or a 30-degree oblique cut in
the artery (TECH FIG 5C).
■ If multiple anastomoses are required, end-to-end and end-to-side repairs can
be performed serially.
■ Intravenous heparin 2000 units is given prior to tourniquet release. Dextran
40 is started at 20 mL/h in the operating room and continued postoperatively.

TECH FIG 5 • A. The vein graft is anastomosed into
place. B. A branched graft is used in order to perform
an end-to-end anastomosis to one common digital
artery and end-to-side anastomoses to the remaining
common digital arteries. C. Several methods of
addressing an oversized vein graft are shown.
■ Assessing Flow and Closure
■ Vascular clamps are released (or the tourniquet is deflated if this has not
been done previously) after all anastomoses have been completed.
■ Compress the radial artery manually for a few minutes to maximize flow
across the anastomoses.
■ Any leaks are repaired.
■ A Doppler probe is used to assess distal arterial flow.
■ Hemostasis is achieved.
■ The wrist incision and vein donor sites are closed using 4-0 nylon sutures.
■ Splint is placed to immobilize the operative site, with care to avoid any
pressure on the underlying anastomosis.

PEARLS AND PITFALLS
Preoperative
planning
■ Adequate arterial inflow and distal runoff is essential.
Technique
■ Resecting to normal intima is critical to success.
■ Use an extensile incision.
■ Close over a drain if indicated.
Vein grafting
■ A vein graft with a larger diameter than the artery does not usually
pose a problem, but a vein graft that is significantly smaller than
the artery leads to higher rates of thrombosis.
■ Anastomoses must be performed in a tension-free manner.
■ Set the tension to prevent kinking.
■ Avoid rotation of the graft.
■ For the proximal anastomosis, end-to-end anastomosis is easier,
but end-to-side anastomosis will help to maintain any remaining
circulation to the hand from the ulnar artery.
Postoperative
expectations
■ Cold sensitivity is expected.
■ Recurrent thrombosis is possible and has been reported up to 10
years postoperatively.
POSTOPERATIVE CARE
■ The operative extremity is splinted from fingertips to elbow, with care to avoid
pressure on the anastomosis.
■ No nicotine, caffeine, or chocolate
■ The patient’s room is kept warm, or alternatively, we use a Bair Hugger over
the operative extremity. The room should also remain quiet and free of
unnecessary stimuli.
■ Dextran 40 is continued at 20 mL/h for 2 to 5 days.
■ The patient is given aspirin 81 mg daily for 3 months.
■ Anxiolytics can be used to protect the patient from damaging the repair
inadvertently.
■ Sutures are removed at 10 to 14 days postoperative.
■ The patient is kept off of work for at least 4 to 6 weeks, or potentially longer
depending on the nature of his or her occupation.
■ The patient is forever forbidden from using the hand as a hammer.

OUTCOMES
■ Most patients have continued symptoms, but with decreased frequency and
severity.
■ In a series of 47 patients, Marie et al.6 found that digital necrosis healed, and
there was no recurrence of hypothenar hammer syndrome after surgical
intervention.
■ Recurrence of hypothenar hammer syndrome was 27.7% after medical
management. Of the patients in this study, 69.2% continued to smoke.
■ Long-term patency rates of arterial grafts are higher than venous grafts.
Venous graft patency ranges from 77% to 88%.7
■ Chloros et al.8 studied 13 patients who underwent reverse interpositional vein
grafting for post-traumatic ulnar artery thrombosis with a minimum of 2-year
follow-up.
■ Ten of 13 grafts (77%) were patent at final follow-up.
■ Patients with patent grafts all significantly improved on the Levine symptom
scale, McGill visual analog pain scale, McCabe cold sensitivity severity scale,
and isolated cold stress testing.
■ Patients with nonpatent grafts were more likely to complain of pain,
numbness, and cold sensitivity.
COMPLICATIONS
■ Persistent cold intolerance
■ Thrombosis of the graft
■ Donor site complications (neuroma)
■ Wound healing complications
■ Hand stiffness
REFERENCES
1. Coleman SS, Anson BJ. Arterial patterns in the hand based upon a study of
650 specimens. Surg Gynecol Obstet. 1961;4:409-424.
2. Kleinert JM, Fleming SG, Abel CS, et al. Radial and ulnar dominance in
normal digits. J Hand Surg Am. 1989;14:504-508.
3. Levine DW, Simmons BP, Koris MJ, et al. A self-administered questionnaire
for the assessment of severity of symptoms and functional status in carpal
tunnel syndrome. J Bone Joint Surg Am. 1993;75A(11):1585-1592.
4. McCabe SJ, Mizgala C, Glickman L. The measurement of cold sensitivity of

the hand. J Hand Surg Am. 1991;16A(6):1037-1040.
5. Ruijs AC, Jaquet JB, Daanen HA, et al. Cold intolerance of the hand
measured by the CISS questionnaire in a normative study population. J Hand
Surg Br. 2006;31(5):533-536.
6. Marie I, Herve F, Primard E, et al. Long-term follow-up of hypothenar
hammer syndrome: a series of 47 patients. Medicine. 2007;86(6):334-343.
7. Hui-Chou HG, McClinton MA. Current options for treatment of hypothenar
hammer syndrome. Hand Clin. 2015;31:53-62.
8. Chloros GD, Lucas RM, Li Z, et al. Post-traumatic ulnar artery thrombosis:
outcome of arterial reconstruction using reverse interpositional vein grafting at
2 years minimum follow-up. J Hand Surg Am. 2008;33A:932-940.

56
CHAPTER
Second Toe to Thumb
Transfer
John R. Lien and Kevin C. Chung
DEFINITION
■ The thumb is critical for hand function.
■ Toe to thumb transfer is a composite tissue microsurgical reconstructive option
for patients with loss of significant thumb length.
ANATOMY
■ Great toe
■ Wider pulp and nail plate than native thumb and lesser toes; “thumblike”
appearance
■ Significant aesthetic and functional morbidity at donor site; difficulty with
push-off during gait
■ Second toe
■ Pulp is bulbous and more rectangular in appearance than the native thumb or
fingers.
■ Interphalangeal joints tend to claw.
■ Superior cosmetic and functional results on donor foot
■ Arterial anatomy of the foot
■ The anterior tibial artery becomes the dorsalis pedis artery (DPA) distal to the
ankle extensor retinaculum. The DPA courses along the dorsal foot lateral to
the extensor hallucis longus tendon.
■ At the first intermetatarsal space, the DPA terminally divides into the first
dorsal metatarsal artery (FDMA) and the deep plantar artery. The deep plantar
artery communicates with the deep plantar arch of the foot, connecting the
dorsal and plantar arches (FIG 1).
■ The FDMA generally travels deep to the extensor hallucis brevis tendon and

usually dorsal to the first dorsal interosseous muscle. It then communicates
(through the distal communicating artery) with the first plantar metatarsal
artery (FPMA) distal to the deep intermetatarsal ligament. The FDMA also
terminally branches into the lateral dorsal digital artery of the great toe and
medial dorsal digital artery of the second toe, which are of small caliber and
clinically insignificant1 (see FIG 1).
■ FIG 2 shows variants of FDMA anatomy in relation to the first dorsal
interosseous muscle, as well as a variant unfavorable for vascular
anastomosis.
■ The plantar digital arteries are the effective blood source to the great and
second toes. Their origin is the distal communicating artery connecting the
FDMA and FPDA distally (FIG 3).
■ Venous anatomy of foot
■ The superficial dorsal venous system is utilized for venous anastomosis.
■ The dorsal veins of the toes join the dorsal venous arch in the forefoot, which
supplies the greater and lesser saphenous veins.
■ Sensory nerve anatomy of foot
■ The superficial peroneal nerve innervates the dorsal foot while the deep
peroneal nerve innervates the first dorsal web space.
■ Branches from the posterior tibial nerve innervate the plantar foot and toe
pulps. Coaptation of plantar digital nerves are important for pulp sensation.
PATIENT HISTORY AND PHYSICAL FINDINGS
■ Advanced age is not a contraindication to surgery, but the patient must be in
generally good health to tolerate a prolonged surgery.
■ Active nicotine use and a history of atherosclerotic disease are
contraindications to toe transfer.
■ Assess whether there is adequate, supple skin coverage. If not, consider a
staged procedure (groin flap) to increase pliable tissue at the recipient site.
Harvesting too much soft tissue from the foot will lead to foot deformity and
marked donor-site morbidity.

FIG 1 • Dorsal foot arterial anatomy: (1) dorsalis pedis
artery (DPA), (2) deep plantar artery, (3) first plantar
metatarsal artery (FPMA), (4) first dorsal metatarsal
artery (FDMA), (5) dorsal digital arteries, (6) distal
communicating branch (intersection of the FDMA and
FPMA), (7) plantar digital arteries.

FIG 2 • Variants of first dorsal metatarsal artery (FDMA)
anatomy. In type I, the FDMA passes superficial (IA) or
within (IA) the interosseous muscle belly. In type II, the
FDMA passes at the deep aspect of the interosseous
muscle belly but superficial to the intermetatarsal
ligament. Type IIA includes a fine accessory branch
superficial to the interosseous muscle, whereas IIB
does not have an accessory branch. In type III, the
FDMA is miniscule or absent with plantar-dominant
(FPMA) flow.
■ The level of thumb amputation will dictate harvest length.
■ Assess the donor foot (contralateral foot for second toe transfer) to ensure no

prior trauma or surgery that would alter vascular anatomy to the second toe.
Doppler ultrasound examination can be used to confirm presence of DPA and
FDMA.
IMAGING
■ Review preoperative radiographs of the recipient site to prepare for bone
fixation and length requirement of donor toe (FIG 4).
■ We do not routinely obtain preoperative angiography of the foot, but this is an
option if there is concern for altered vascular anatomy on physical and Doppler
exam.
SURGICAL MANAGEMENT
■ Toe to thumb transfer is generally performed after the acute traumatic injury
has healed and adequate soft tissue coverage is obtained.
■ Ensure adequate soft tissue coverage and pliability prior to transfer.
■ Amputations through the thumb metacarpal (with preserved carpometacarpal
joint) or proximal half of the proximal phalanx are good candidates for toe
transfer. We prefer the second toe transfer to minimize donor-site morbidity.
Other options for toe transfer include great toe and trimmed great toe.
Alternatives to toe transfer include metacarpal bone lengthening and on-top
plasty. Osteoplastic reconstruction of the thumb using iliac crest bone graft and
groin flap is of historical significance only.

FIG 3 • First web space arterial anatomy.

FIG 4 • Preoperative radiograph of recipient hand.
Amputation level is at the proximal phalanx base.
Contralateral radiographs help estimate defect length.
■ Amputations at the distal proximal phalanx or distal phalanx often retain
enough length for thumb function. Web space deepening may be performed as
needed.
■ Amputations through the base of the metacarpal or though the carpometacarpal
joint require index finger pollicization to recreate a basilar thumb joint.
Preoperative Planning
■ The contralateral toe vascular pedicle is in a better position for radial artery
anastomosis at the snuffbox.
■ The length of the transferred toe should be based on the length of the
contralateral uninjured thumb (see FIG 4).
■ A two-team approach is preferable to minimize operative time. One team

prepares the recipient site while the other harvests the contralateral toe.
■ Good communication between teams is necessary to harvest tendons, nerves,
and vessels of adequate length and caliber for primary repair.
Positioning
■ Supine
■ General anesthesia
■ Thigh and arm tourniquets
■ The recipient upper extremity and contralateral donor lower extremity are
prepped.
Approach
■ For second toe transfer as well as great toe transfer, the FDMA is the preferred
arterial supply.
■ However, one may need to alter the approach and harvest the FPMA if it is
dominant (about 20% of cases).
T E C H N I Q U E S
■ Foot Exposure and Second Toe Harvest
■ Identify and mark the DPA and FDMA using Doppler ultrasound probe.
■ Identify the course of the dorsal forefoot veins to the greater saphenous vein
on the dorsomedial foot.
■ Design dorsal and plantar curvilinear incisions on the dorsal and plantar foot
(TECH FIG 1A,B).
■ Avoid incision over the thick plantar skin overlying the weight-bearing first
metatarsal head.
■ Gravity exsanguinate the limb and inflate the tourniquet.
■ Perform an incision over the first web space and identify the vascular pattern
of the FDMA using retrograde dissection (TECH FIG 1C). Be sure to
visualize the proper palmar digital artery to the second toe.
■ A dorsal-dominant system is present in most cases. In this case, continue
proximal dissection along the FDMA and DPA after ligating the
communicating branch to the proximal FPMA. If necessary, perform

intramuscular dissection through the first dorsal interosseous muscle. If
planning an osteotomy of the second metacarpal shaft to restore length of
significant metacarpal thumb defects, preserve the vascular connections
between the FDMA and second metatarsal. This is performed by preserving
the interposed interosseous muscle.
■ If the patient has a plantar-dominant system, divide the deep intermetatarsal
ligament and dissect the FPMA proximally. We often do dissect out the more
inaccessible FPMA in case the dorsal circulation is insufficient to perfuse the
toe, which may require anastomosis of the FPMA.
■ Extend the dorsal incision proximally and identify the dorsal vein to the
second toe, and extensor digitorum longus. The extensor digitorum brevis is
divided (TECH FIG 1D,E).
■ Perform the plantar curvilinear incision and identify the flexor digitorum
profundus tendon and both plantar digital nerves (TECH FIG 1F).
■ Perform the osteotomy at the planned level with a microsagittal saw while
protecting identified structures.
■ Alternatively, a metatarsophalangeal disarticulation is an option depending
on length needs. Detach the collateral ligaments and volar plate from the
metatarsal head.

DCA D PDN 1st dorsal metatarsal artery Superficial dorsal vein Extensor digitorum longus MT FDL-

TECH FIG 1 • A,B. Donor foot incisions. Dorsal and
plantar curvilinear incisions avoid the weight-bearing
plantar first metatarsal head. C. First web space
dissection. Note the palmar digital arteries (PDA) and
the distal communicating artery (DCA) to the FPMA.
The forceps is overlying the FDMA. D,E. Dorsal
exposure of second toe. F. Plantar foot dissection.
Note the plantar digital nerves (PDN) and flexor
digitorum longus (FDL). G,H. Completion of second
toe harvest. In this case, a metatarsophalangeal
disarticulation was performed. Note the metatarsal
head (MT) in the wound. I,J. Donor foot closure. Note
preservation of the longitudinal and transverse arches
of the foot.
■ Determine the proper length of appropriate structures in the toe. Divide the
nerves and tendons, taking care to tag the nerves with fine suture (6-0
Prolene) for easy identification. Leave the vessels intact.
■ Deflate the tourniquet and check perfusion of the toe. It may take 5 minutes
of warming the toe before adequate perfusion is seen.
■ Once adequate perfusion is appreciated and the recipient site is ready, detach
the dorsalis pedis artery and dorsal vein (TECH FIG 1G,H).
■ Use nonabsorbable suture to repair the deep intermetatarsal ligament if
transected.
■ Obtain hemostasis and then close the wound primarily (TECH FIG 1I,J).

■ Recipient Site Preparation
■ Create an incision at the thumb amputation stump and extend it proximally
with a dorsal zigzag incision toward the anatomical snuffbox (TECH FIG
2A,B).
■ If previous soft tissue transfer was performed, elevate the margin of the
tissue flap dorsally.
■ Identify the radial artery at the snuffbox, cephalic vein, and dorsal branch of
superficial radial nerve (TECH FIG 2C,D).
■ Identify the residual extensor pollicis longus (EPL) tendon and perform a
tenolysis to ensure free gliding. If the EPL is not salvageable, transfer the
extensor indicis proprius (EIP) tendon.
■ Extend the incision on the palmar residual thumb to identify the digital
nerves of the thumb and flexor pollicis longus (FPL) tendon. A
counterincision may be necessary at the carpal tunnel to retrieve the FPL
tendon.
■ Debride the residual metacarpal or proximal phalangeal bone of any fibrous
scar or articular remnants. Preserve thenar muscle attachments to the
metacarpal.

TECH FIG 2 • A,B. Dorsal and palmar thumb
incisions. The dorsal incision must extend proximally
to the anatomical snuffbox to allow for arterial
anastomosis to the radial artery. C,D. Recipient site
preparation. FPL, flexor pollicis longus; EPL, extensor
pollicis longus.
■ Transfer of Second Toe
■ Kirschner wire, 90-90 intraosseous wiring, and rigid plate fixation are
options for bone fixation.
■ We prefer two longitudinal Kirschner wires for ease of fixation and less
soft tissue dissection inherent with plate fixation.
■ However, using plate fixation does have the advantage of initiating more
aggressive tendon gliding exercises.
■ After bone fixation, the flexor digitorum profundus tendon of the toe is
transferred to the FPL tendon using four- or six-core strand repair technique.
■ The extensor digitorum longus is weaved to the EPL or EIP tendon using
Pulvertaft technique. Tension this weave tightly.
■ Using microsurgical technique, the radial and ulnar digital arteries are
coapted as distally as possible to promote early sensory recovery.
■ Repair any branches of the superficial radial nerve to the superficial and
deep peroneal nerves dorsally.
■ The arterial anastomosis is performed in an end-to-side fashion to the radial

artery at the snuffbox. The venous anastomosis is then performed to a dorsal
hand vein, feeding into the cephalic vein.
■ The transferred toe is warmed, and perfusion is assessed.
■ The wounds are then closed loosely to avoid compression of the dorsal
anastomoses (TECH FIG 3).
TECH FIG 3 • A,B. Thumb closure.
PEARLS AND PITFALLS
Preoperative
evaluation
■ Ensure adequate soft tissue coverage and pliability prior to transfer.
Otherwise, wound closure will be difficult and cause potential
compression of the vascular anastomosis.
FDMA
dissection
■ Retrograde dissection of the first web space facilitates efficient
identification of the variations in FDMA anatomy. Identify the
FDMA, the distal communicating artery to the FPMA, and the

medial and lateral plantar digital arteries to the great and second toe,
respectively.
FPMA
dominant
pedicle
harvest
■ If there is only one sizeable vessel that is plantar to the deep
intermetatarsal ligament, the toe pedicle should be harvested based
on the FPMA through the plantar incision. The dissection is
challenging proximal to the metatarsal neck, and for this reason, we
avoid more proximal dissection and use an interpositional vein graft
to augment our arterial pedicle length.
Claw
deformity of
the
transferred
toe
■ The lesser toes tend to form claw deformities at the interphalangeal
joint. If this causes a functional problem for the patient in
subsequent follow-up, consider interphalangeal joint arthrodesis.
POSTOPERATIVE CARE
■ The hand is placed in a well-padded volar forearm-based thumb spica splint
with dorsal window and elevated at heart level in a warm room.
■ Transferred digit skin color, capillary refill, and Doppler ultrasound checks are
performed hourly for the first 48 hours.
■ Oral aspirin is administered daily for 2 weeks.
■ Prophylactic heparin or low molecular weight heparin anticoagulation per
inpatient hospital protocol is performed.
■ Patient is kept non–weight bearing to the donor foot for two weeks until
sutures are removed.
■ At 4 to 6 weeks postoperatively, we remove the Kirschner wires and begin
tendon motion protocol.
OUTCOMES
■ Toe to hand transfer is a safe procedure, with approximately 95% success rate
in experienced centers (FIG 5).

FIG 5 • Successful toe transfer at 6-year postoperative
visit. A. Radiographs demonstrate preservation of
metacarpophalangeal joint articulation. B. Donor site
with mild hypertrophic scar but overall good aesthetic
appearance. C,D. Clinical photographs of hand.
■ Toe transfer patients have superior outcomes in overall hand function,
activities of daily living, work performance, aesthetics, and satisfaction
compared to patients with thumb MCP level amputations without
reconstruction.2
■ Average static two-point discrimination is approximately 8 mm at long-term
follow-up.3
■ Average digit mobility was 33 degrees of flexion with extensor lag of 34.5

degrees at long-term follow-up for second toe to long finger transfer.3
COMPLICATIONS
■ Arterial vasospasm is a potential complication and may occur within the first
three days postoperatively.
■ If spasm occurs, consider loosening the dorsal sutures, placing the hand in a
more dependent position, and use a warming lamp or warming blanket.
■ Papaverine or lidocaine can be injected.
■ Regional nerve block with a continuous flow catheter can be attempted.
■ If there is no improvement, return to the operative room and explore the
anastomosis for thrombosis or compressive hematoma.
■ If there is development of significant vascular congestion, loosen dorsal
sutures and any potentially compressive dressings.
■ Consider venous exploration if there is no clinical improvement.
REFERENCES
1. May JW Jr, Chait LA, Cohen BE, O’Brien BM. Free neurovascular flap from
the first web of the foot in hand reconstruction. J Hand Surg [Am].
1977;2(5):387-393.
2. Chung KC, Wei FC. An outcome study of thumb reconstruction using
microvascular toe transfer. J Hand Surg [Am]. 2000;25:651-658.
3. Foucher G, Moss AL. Microvascular second toe to finger transfer: a statistical
analysis of 55 transfers. Br J Plast Surg. 1991;44(2):87-90.

57
CHAPTER
Section XI: Dupuytren
Disease
Dupuytren Contracture
John R. Lien and Kevin C. Chung
DEFINITION
■ Dupuytren disease is a benign fibroproliferative disorder affecting the palmar
and digital fascia of the hand.
■ Dupuytren disease can result in progressive contracture of the
metacarpophalangeal (MCP) and proximal interphalangeal (PIP) joints.
ANATOMY
■ The palmar fascia consists of thenar, hypothenar, and central palmar
aponeuroses.
■ The palmar aponeurosis (PA) is usually involved with Dupuytren disease.
■ It is triangular with a proximal apex confluent with the palmaris longus
tendon.
■ The PA is a three-dimensional structure consisting of longitudinal, transverse,
and vertical fibers (FIG 1A).
■ Longitudinal fibers fan out as pretendinous bands that bifurcate and divide
into three layers extending to the distal palm (FIG 1B).
• The first layer inserts into the dermis of the distal palm.
• The second layer continues toward the digit as the spiral band, which lies
deep to the natatory ligament and neurovascular bundle at the level of the
palmodigital crease.
• The third, deepest layer passes vertically toward the flexor tendon sheath.
■ Transverse fibers form the natatory ligament in the distal palm and the
superficial transverse palmar ligament more proximally.

■ Vertical fibers form the septa of Legueu and Juvara, which lie deep to the
palmar fascia (FIG 1C). These eight septa form seven fibro-osseous
compartments separating the flexor tendons from the lumbricals and
neurovascular bundles. Superficial vertical bands of Grapow insert into the
dermis of the palmar skin.
■ Digital fascia
■ Grayson ligament is palmar to the neurovascular bundle.
■ Cleland ligament is dorsal to the neurovascular bundle.
■ The lateral digital sheet receives contributions from the natatory ligament
and spiral band (FIG 2).
■ PIP joint
■ The proximal attachment of the volar plate tapers into separate radial and
ulnar bands, termed the checkrein ligaments (FIG 3).
■ The accessory collateral ligament arises from the head of the proximal
phalanx and inserts on the volar plate.
• The accessory collateral ligaments become lax in flexion and taut in
extension.

FIG 1 • A. Anatomy of the palmar aponeurosis. B.
Sagittal anatomy of the palmar aponeurosis. C. Septa
of Legueu and Juvara are formed from the vertical deep
extensions of the palmar aponeurosis.
PATHOGENESIS
■ Nodules are often the first sign of Dupuytren disease. They are found
superficially in the palm or finger, adherent to the dermis and underlying
fascia.
■ Normal fascial bands become pathologic cords.
■ The pretendinous cord develops from the pretendinous band.
■ Cords are pathologic structures, whereas bands are normal structures.
■ Isolated pretendinous cords can result in MCP joint contracture.
■ The spiral cord is composed of pathologic pretendinous band, spiral band,

lateral digital sheet, and Grayson ligament.
■ The spiral course of this cord around the neurovascular bundle causes
proximal, superficial, and central displacement of the bundle as it contracts
(FIG 4).
■ Spiral cords can cause MCP and PIP joint contracture.
FIG 2 • Digital fascia. Note the contributions of the
natatory ligament and spiral band to the lateral digital
sheet.

FIG 3 • Lateral (A) and volar (B) representations of the
soft tissue support at the PIP joint. Arrows indicate the
radial and ulnar checkrein ligaments. A, accessory
collateral ligament; P, proper collateral ligament; VP,
volar plate.