ince its introduction as a suitable alternative forthumb reconstruction,1,2 great toe transfer hasbeen considered the best way of reconstructing
n amputated thumb, especially after mutilating handnjuries.3–6
In the early days of great toe harvesting, when theetatarsal was included with the transferred toe,
lterations in gait and/or foot pain were frequent.7,8
everal researchers have shown, however, that if a-cm stump of proximal phalanx, or at a minimumhe whole first metatarsal, is left in place, minimalnterference with foot function will occur.7–10 Hav-ng overcome the functional aspect, the donor siteas a drawback, which detracted from a wider usage.Several alternatives that minimize the donor siteorbidity, such as use of the second toe11 or the
o-called wrap-around,12 were also available, buteither was ideal. The second toe produces too smallthumb replica, and the wrap-around has among
ther limitations the fact that no motion exists at the
nterphalangeal (IP) joint. s
Foucher at al13–15 devised the twisted-two-toesechnique, in which some motion at the IP joint isbtained by wrapping the skin of the hallux aroundhe proximal interphalangeal joint of the second toe.he foot donor site is closed by filleting the skin of
he second toe, which is wrapped around the bonyramework of the great toe. The twisted-two-toesechnique is technically difficult and has not becomeopular; only a few articles about it have been pub-ished.16–19 The main collateral advantage of theechnique, however—the way the donor site waslosed—went unappreciated.
Bearing in mind this principle, we have developedtechnique to improve the donor site after trimmed
oe20 or hallux harvesting to avoid the classic stumplosure. Three surgical maneuvers are performed: (1)ransposition of the second toe on top of the proximalhalanx of the hallux, (2) enlargement of the secondoe by interposing a flap on its tibial (medial) aspect,nd (3) an eponychial flap to increase the nail
how.21,22
The Journal of Hand Surgery 409
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Our purpose is to present the surgical techniquend results in 6 patients who had this procedure.
urgical Techniquehe skin markings on the foot are similar to thelassic trimmed toe on the medial side, but proximalalmar and dorsal V flaps extension are also includedn the lateral side to allow easy transposition of theecond toe later in the surgery (Fig. 1). The trimmedoe is elevated as recommended by Wei et al,20 withare taken to maintain the blood supply of the tibialmedial) flap that will be used in step 2. The toe isransferred to the hand after 15 to 20 minutes ofeperfusion. To shorten the operative time, usuallyhile the first team of surgeons operates on the handsecond team proceeds on the foot.
tep 1: Second Toe Transpositionhe second metatarsal is exposed subperiostically, andn osteotomy is performed on its proximal fourth. It ishen elevated distally, detaching all muscular insertionsnd dividing the intermetatarsal ligaments. On the fib-lar side care is taken to avoid damaging the secondlantar intermetatarsal artery that at times is closelydhered to the plantar aspect of the metatarsophalangealoint.23 The base of the proximal phalanx is then ex-osed subperiostically, and an osteotomy is performed.his allows us to remove en bloc the metatarsal-meta-
arsophalangeal joint with a small segment of neighbor-ng proximal phalanx.
A 3/0 nylon stitch is preplaced for later recon-tructing the intermetatarsal ligament. The second
igure 1. Modifications on the flap’s design for trimmed toearvesting. Classic skin incisions have been marked with aroken white line. The modified harvesting with proximal Vap extensions in black (A) Dorsal (B) Plantar views.
oe, now pedicled on the intact second plantar meta- h
arsal–fibular digital vessels, is transposed on top ofhe proximal phalanx of the great toe. With bonelamps the first metatarsal is approximated to thehird. Two crossed K-wires (1.4 mm) are insertedrom the medial aspect of the foot, skewering thehird metatarsal. Toe fixation is achieved with cross-wires or Lister’s wiring plus an oblique K-wire.he preplaced stitch in the intermetatarsal ligament is
hen tightened (Fig. 2).
tep 2: Second Toe Enlargementmidline incision is made on the tibial side of the
econd toe. The flaps are elevated in the supraperi-steal level up to the dorsal and plantar midline.reat care is taken in the plantar flap to keep theigital nerve intact (Fig. 3A).The tibial flap that was elevated from the great
oe’s medial aspect to reduce its size is now inter-osed in the medial aspect of the second toe, achiev-ng a Y-V enlargement effect (Fig. 3B). Because thisap might have a marginal blood supply if too
hinned during toe harvesting, care should be taken torotect it during trimmed toe elevation. During theime the tourniquet is released for toe reperfusion, thelood supply to this flap is carefully assessed. Obvi-usly, if this flap blood supply is doubtful, this sec-nd step should be omitted.
tep 3: Eponychial Flapdani et al. and Bakhach et al.21,22 published a
echnique to increase the nail show in cases wherehe fingers have lost a major portion of the nail. Wencorporated this technique in the last 4 patients.
Two longitudinal incisions are made following the
igure 2. Step 1: second toe transposition. (A) The secondetatarsal has already been resected, exposing the flexor
endon to be sutured to the flexor hallucis longus. (B) Imme-iate postoperative view. The bony framework of the neo-
allux and the fixation hardware are highlighted.
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ine of the paronichial fold deep to the nail plate andhen to the bone up to the distal interphalangeal jointFig. 4A). Three to 4 mm proximal to the eponichialold a rectangle of skin is de-epithelialized (Fig. 4B).he eponichial fold is then elevated from the naillate and mobilized proximally, closing the de-epi-helialized area (Fig. 4C).
dditional Proceduresn the cases where the long stumps of the tendons ofhe great toe (flexor and extensor hallucis longus)ere not needed at the hand for carrying the suturingroximal to the wrist, then the corresponding flexornd extensor longus tendons of the second toe wereivided and motorized by the great toe tendons. Stan-ard locking stitches were used.
ostoperative Carembulation was permitted on the heel after the sec-nd to third day. Unprotected walking was permittedt 4 to 6 weeks, at the time of the K-wire removal.ow-dose heparin was maintained until then.
esultsix consecutive patients (age range, 29–61 y) had
he initial surgery of transferring a trimmed toe to thehumb. All toes survived, although one required anarly take-back for arterial insufficiency.
The procedure was modified by including theponychial flap after patient 2. In 3 patients long flexor
igure 3. Step 2: Enlargement of the second toe. (A) A mid-ine incision has been made on the tibial aspect of the secondoe, and the flaps have been partially elevated from theeriosteum in preparation for interposing the tibial flap (re-ected proximally and highlighted by dots). (B) Immediateostoperative view. (The eponychial flap is pending). (Sameatient as in Figs. 1, 2).
nd extensor hallucis longus tendons were needed to l
erform the repair proximal to the wrist crease in theand. In the other 3 patients the long flexor and extensorendons were sutured to the corresponding tendons ofhe hallux in an attempt to improve the thrust.8 Noifferences were found, although the sample is smallnd no gait analyses were performed.
Slight valguization was present in all patients athe latest follow-up visit (Figs. 5, 6). We interpretedhis as a consequence of separation of the metatar-als, because they retook their original position oncehe crossed K-wires were removed. One patient de-eloped an early valguization of the second toe. Thisccurred early after surgery, largely because of anncorrect alignment of the proximal phalanges of therst and second toes during surgery. The deformityad not progressed at the 2-year follow-up visit. Theatient rejected a new x-ray at this visit, claiming head neither pain nor limitation. This patient is anctive sportsman and is involved in amateur joggingt the same level as before the surgery.
All patients wear their regular shoes without anypecial inlays. One patient developed a keloid on thecar in the dorsum of the foot. This was treated byteroid injections with partial improvement.
No limitations on walking or at work were re-orted (2 patients retired because of the severity ofheir concomitant hand injuries). Patients were veryatisfied with the cosmetic aspect of their feet, and alluch preferred this modification to the classic stump
losure (Fig. 5).
iscussioneducing donor site morbidity is a must in any
econstructive surgery. It is agreed that the great toeives the best overall results for thumb reconstruc-ion, particularly in multidigital amputations.3–6
igure 4. Step 3: The eponychial flap (different patient). (A)he flap design on the dorsum of the second toe. The area toe de-epithelialized is stippled. (B) After de-epithelializationf the flap, the eponychium is prepared for proximal mobi-ization. (C) The eponychial flap has been sutured proxi-ally. Notice the increase in nail show (previous eponychial
evel has been marked with arrows).
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ather than functional issues, cosmetic morbidity ishe major deterrent for its widespread use.
In 1980 Foucher et al13 introduced the concept ofwisted-two-toes, in which the bony framework ofhe hallux is preserved in situ and the skin of theecond toe is wrapped around it. In this way theallux was preserved in the foot, and some motionas obtained at the IP joint on the transferred
oe.13–15 Tsai and Aziz16 proposed a slight modifi-ation of Foucher’s surgery that allows preservationf all 5 toes. Unfortunately all of these techniques areifficult, involving dissection of 2 free flaps (hallux,roximal interphalangeal joint), and have not gainedopularity: only a few cases17–19 have been reported.
The second toe has a minimal functional donor siteorbidity and nearly no cosmetic defect when theetatarsal is also removed.7,8 Unfortunately, it pro-
ides the weakest and least cosmetically appealingesult when used as a thumb.10,15,20,24
In an attempt to minimize donor site morbidity, Mor-ison et al12 introduced the wrap-around technique,hich allows preservation of all 5 toes. Problems at the
ecipient site (eg, bone resorption, fractures, nail insta-ilities) and at the donor site (eg, ulcerations, hyperqu-ratoris, pain) have been reported.10,15,24,25
Some motion at the IP joint was thought to be crucialhen reconstructing the thumb for restoring the viserip and also for pinching activities.6 This was the basisf the trimmed toe modification introduced by Wei etl20: the hallux is reduced by means of a tibial flap (asn the wrap-around technique),12 and the tibial aspectsf the distal and proximal phalanges are also reduced.his modification achieved a closer-to-normaleothumb with some motion at the IP joint in a much
igure 5. (A) The result at 1 year of a patient who had thelassic technique compared with (B) the result of the patienthown in Figures 1, 2 and 3.
ess complicated way than the surgery of Foucher et f
l13–15; however, the cosmetic appearance at the footas rather similar to that achieved with the classicallux transfer (Fig. 5A).
Our modification includes 3 surgical maneuvers.ransposition of the second toe compensates for theole left after hallux harvesting. The second toe isevertheless rather small, and by using the tibial flapt is enlarged somewhat. Finally the eponychial flapdds a further cosmetic refinement, achieving alightly larger nail. More important, the basic prin-iple of not altering the first metatarsophalangealoint is accomplished, and the second toe ray ampu-ation is reported to have minimal functional conse-uences.7,8 One bonus of our modification is thaturing toe harvesting a surplus of skin from the foots included, thus enabling the second toe transposi-ion. These 2 triangular flaps can be used for webeconstruction (Fig. 6).
The procedure has the obvious drawback that a toe
igure 6. (A) Dorsal and (B) plantar V flaps can be advanta-eously used to restore the web space.
igure 7. Result at 3 years (no eponychial flap was per-
ormed in this very first case).
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del Piñal et al / Improving Hallux Donor Site 413
eeds to be amputated, adding further complexity ton already complex surgery. Moreover, comparedith our present toe harvesting, in which we use theigital artery or the first metatarsal artery as theonor, a much longer proximal incision is needed toccomplish the proximal metatarsal osteotomy. Oneatient developed a keloid on the proximal foot scar.ome minor degrees of valguization of the second
oe were noted in all, but no alteration of the mor-hology of the metatarsophalangeal joint was de-ected by plain radiograms. Although no complaintsrom the donor site have been reported, neither gaitor functional analysis were performed in our study.If the hallux is smaller than customary and hence
oes not require reduction by elevating the tibial flap,r if the tibial flap has a doubtful blood supply afterarvesting, the benefit of using the medial flap tonlarge the second toe would not exist. All otheraneuvers (toe transposition and eponichial flap)ould help the donor foot equally.This modification may give a wider application to the
rimmed toe transfer, the hallux itself, or other vari-nts26 when the great toe needs to be amputated. Suchn irrationality for a hand surgeon, such as the inabilityo wear thong sandals again,9 may be sufficient for aatient to reject the hallux as a reconstructive option inn environment such as ours where foot exposure is theorm in summertime, particularly for girls and womenFig. 7). The functional donor site limitations to date arenconsequential.
eceived for publication November 20, 2006; accepted in revised formecember 19, 2006.No benefits in any form have been received or will be received fromcommercial party related directly or indirectly to the subject of this
rticle.Corresponding author: Dr Francisco del Piñal, Dr Med, Calderón de la
eferences1. Buncke HJ Jr, Buncke CM, Schulz WP. Immediate Nicola-
doni procedure in the Rhesus monkey, or hallux-to-handtransplantation, utilising microminiature vascular anastomo-ses. Br J Plast Surg 1966;19:332–337.
2. Cobbett JR. Free digital transfer. Report of a case of transferof a great toe to replace an amputated thumb. J Bone JointSurg 1969;51B:677–679.
3. May JW Jr. Aesthetic and functional thumb reconstruction:great toe to hand transfer. Clin Plast Surg 1981;8:357–362.
4. Lister GD, Kalisman M, Tsai TM. Reconstruction of thehand with free microneurovascular toe-to-hand transfer: ex-perience with 54 toe transfers. Plast Reconstr Surg 1983;71:
372–386.
5. Michon J, Merle M, Bouchon Y, Foucher G. Thumb recon-struction pollicisation or toe-to-hand transfers. A comparativestudy of functional results. Ann Chir Main 1985;4:98–110.
6. Buncke HJ. Discussion of “reconstruction of the thumb witha trimmed-toe transfer technique”. Plast Reconstr Surg 1988;82:514–515.
7. Frykman GK, O’Brien BM, Morrison WA, MacLeod AM.Functional evaluation of the hand and foot after one-stagetoe-to-hand transfer. J Hand Surg 1986;11A:9–17.
8. Barca F, Santi A, Tartoni PL, Landi A. Gait analysis of thedonor foot in microsurgical reconstruction of the thumb.Foot Ankle Int 1995;16:201–206.
9. Lipton HA, May JW Jr, Simon SR. Preoperative and post-operative gait analyses of patients undergoing great toe-to-thumb transfer. J Hand Surg 1987;12A:66–69.
1. Gu YD, Zhang GM, Cheng DS, Yan JG, Chen XM. Free toetransfer for thumb and finger reconstruction in 300 cases.Plast Reconstr Surg 1993;91:693–700.
2. Morrison WA, O’Brien BM, MacLeod AM. Thumb recon-struction with a free neurovascular wrap-around flap fromthe big toe. J Hand Surg 1980;5:575–583.
3. Foucher G, Merle M, Maneaud M, Michon J. Microsurgicalfree partial toe transfer in hand reconstruction: a report of 12cases. Plast Reconstr Surg 1980;65:616–627.
4. Foucher G. Twisted two toes technique in thumb reconstruc-tion. In: Landi A, ed. Reconstruction of the thumb. London:Chapman, 1989:275–279.
5. Foucher G, Binhammer P. Plea to save the great toe in totalthumb reconstruction. Microsurgery 1995;16:373–376.
6. Tsai TM, Aziz W. Toe-to-thumb transfer: a new technique.Plast Reconstr Surg 1991;88:149–153.
7. Yu Z-J. thumb reconstruction. In: Yu ZY, ed. Microvascular sur-gery of the extremities. Berlin: Springer-Verlag, 1993:85–174.
8. Iglesias M, Butron P, Serrano A. Thumb reconstruction withextended twisted toe flap. J Hand Surg 1995;20A:731–736.
9. Koshima I, Kawada S, Etoh H, Saisho H, Moriguchi T. Freecombined thin wrap-around flap with a second toe proximalinterphalangeal joint transfer for reconstruction of thethumb. Plast Reconstr Surg 1995;96:1205–1210.
0. Wei FC, Chen HC, Chuang CC, Noordhoff MS. Reconstruc-tion of the thumb with a trimmed-toe transfer technique.Plast Reconstr Surg 1988;82:506–515.
1. Adani R, Marcoccio I, Tarallo L. Nail lengthening and fingertipamputations. Plast Reconstr Surg 2003;112:1287–1294.
2. Bakhach J, Demiri E, Guimberteau JC. Use of theeponychial flap to restore the length of a short nail: a reviewof 30 cases. Plast Reconstr Surg 2005;116:478–483.
3. Foucher G, Norris RW. The dorsal approach in harvestingthe second toe. J Reconstr Microsurg 1988;4:185–187.
4. Wei FC, Chen HC, Chuang CC, Chen SH. Microsurgicalthumb reconstruction with toe transfer: selection of varioustechniques. Plast Reconstr Surg 1994;93:345–351.
5. Doi K, Hattori Y, Dhawan V. The wrap-around flap in thumbreconstruction. Tech Hand Up Extrem Surg 2002;6:124–132.
6. Upton J, Mutimer K. A modification of the great-toe transferfor thumb reconstruction. Plast Reconstr Surg 1988;82:
