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10.6 Reconstruction ofType VI Defect oftheThumb
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Fig. 10.43 Reconstruction of type VI defect of the right thumb by free
second toe transplantation combined with great toe nail ap. (a)
Preoperative palmar condition of thumb defect. (b) Preoperative dorsal
condition of thumb defect. (c) Preoperative X-ray. (d) X-ray after primary emergency xation. (e) Design of great toe nail ap. (f) Design of
bular ap. (g) Dissociation of great toe nail ap. (h) The dorsal view
of the reconstructed thumb. (i) The palmar view of the reconstructed
thumb. (j) The situation of the donor site. (k) The palmar view of the
reconstructed thumb 6 months after the operation. (l) The dorsal view
of the reconstructed thumb 6 months after the operation. (m) Holding
function of the reconstructed thumb. (n) X-ray 3 months after the
operation
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10 Reconstruction ofThumb Defects
Fig. 10.44 Reconstruction of type VI defect of the left thumb by free
great toe transplantation. (a) Preoperative palmar condition of thumb
defect. (b) Preoperative dorsal condition of thumb defect. (c)
Preoperative design. (d) The thumb reconstruction by free great toe
transplantation. (e) The dorsal view of the reconstructed thumb 3 weeks
covered by free skin graft. The operation was successful,
after the tourniquet relaxed, the reconstructed nger was
ruddy with moderate tension, wrapped with the sterile cot-
after the operation. (f) The palmar view of the reconstructed thumb 3
weeks after the operation. (g) The situation of the rst nger web 3
weeks after the operation. (h) The situation of the donor site 3 weeks
after the operation
ton, bulked, and stuffed with the broken cotton gauze around,
and she returned to the ward safely. Routine reconstruction
treatment was given after the operation (Fig.10.44).
Reconstruction ofSingle Finger Defects
11
Abstract
Single nger defect reconstruction is in order to let the
patients have a complete nger body and resume the func-
tion of hands. The doctor uses microscopic instruments
for the actual operation to reconstruct the lost nger by
own toe transplantation under a microscope. Because toes
are the closest in shape and function to ngers, and the
absence of a single toe does not affect normal walking
function. Through functional rehabilitation and exercise,
limbs and ngers can be close to the normal state.
Keywords
Finger reconstruction · Single nger defect
11.1 Reconstruction ofType IDefect
Type I defect refers to the partial defect locates in the distal segment of the nger. The traditional view is that the
partial defect of the nger has little effect on the function
of the nger, but mainly affects the appearance. The blood
vessels and nerves of the distal segment are relatively
small, that is difcult for replantation and the success rate
is low, so there is no need for replantation. But with the
development of microsurgery, especially super microsurgery technology, the reconstruction of type I defect is no
longer a difcult problem, which is gradually accepted
since the survival rate has reached more than 90%.
Common surgical methods include great toe tip transplantation and second toe tip transplantation. Due to the small
size of the second toenail, the shape of the reconstructed
ngertip is not ideal. This chapter focuses on great toe tip
transplantation.
11.1.1 Indications
(1) Type I defect of the nger; (2) The patient is young and
has no basic disease; (3) The patient has high requirements
for ngers and a strong desire to reconstruction; (4) There is
no obvious deformity of the donor toe.
11.1.2 Surgical Design
A composite toenail ap with partial phalanx is designed on
the toe tip of the bular side of great toe according to the
defect of the nger. Because the great toe tip is larger than
the nger tip, a lingual ap is left on the tibial side of great
toe to reduce the circumference of the reconstructed nger;
at the same time, the lingual ap could be used to repair the
wound at the donor site and increase the length of great toe.
The great toenail is wider than the nger nail. According to
the actual defect size of the nger nail, a great toenail is
designed on the bular side of the great toe. The end of the
distal phalanx should be included in the ap to form a real
toenail composite tissue rather than a simple great toenail
ap. The supercial plantar digital vein of great toe or bular
supercial dorsal digital vein of great toe is used as the reux
vein of the ap, and the artery and nerve of the ap are used
as the bular plantar digital artery of great toe and bular
plantar digital nerve of great toe.
11.1.3 Surgical Method
Preparation fortheRecipient Site
Scar tissue of ngertip should be removed, ngernail stump
should be trimmed, and part of bone at the end of phalanx
should be removed to normal cancellous bone. Dissociate the
© Springer Nature Singapore Pte Ltd. 2023
J. Lin et al., Atlas of Finger Reconstruction, https://doi.org/10.1007/978-981-19-9612-2_11
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11 Reconstruction ofSingle Finger Defects
digital arteries and nerves on both sides of the nger under a
magnifying glass or microscope, and remove the occluded
digital artery until bleeding once the tourniquet is released.
Remove the neuroma at the broken end of the proper digital
nerve, and dissociate it to an appropriate length for use. An
arc incision is made on the dorsum of middle segment of the
nger or the dorsum of proximal segment of the thumb, and
1–2 dorsal digital veins are dissociated for use.
The Cutting oftheToe
First, the dorsal digital vein if great toe is dissociated proximally to an appropriate length before being cut off, and then
dissociated along the branches to the bular tip of the great
toe. The dorsal metatarsal artery and plantar metatarsal artery
are dissociated at the toe web, and then the bular plantar
digital artery and nerve are dissociated to distal. To ligate and
cut off the branches, dissociate the neurovascular bundle to
distal until the bular design line of toe tip. The skin is cut
along the design line in the toe pulp, and several supercial
plantar digital veins are carefully dissociated and to proximal
for 1–2cm before being cut off for use. The subcutaneous
tissue of the toe pulp is further cut deep to the bone. Cut off
the phalange with a bone knife, lift the toe body, and cut off
the arteries and nerves at the appropriate proximal part.
Transplantation
Trim the trochanter on both sides of great toe tip to make the
outer diameter close to that of the nger. The phalange of toe
is xed on the phalange of nger with a diameter of 0.8mm
Kirschner wire. The toenail and the ngernail stump are
trimmed together which should be tightly matched without
any space.
Postoperative Treatment
(a) After the operation, strengthen nursing, keep warm,
closely observe the blood circulation of the reconstructed
nger; (b) After the operation, the patients should be treated
with “three-anti” therapy; (c) Do not get out of bed for 1
week after the operation; (d) No smoking during the perioperative period.
11.1.4 Operation Characteristics
As great toe has a relative larger size and a larger toenail, only
part of the toenail can be transplanted to reconstruct the ngernail. The great toenail can be divided into two parts, one of
which is transplanted to the nger to reconstruct the ngertip,
and the other one remained to maintain the appearance and
function of the great toe. Compared with the reconstruction
by the distal segment of the second toe, this method has less
inuence on the appearance and function of the foot, and the
shape of the reconstructed ngertip is more realistic.
11.1.5 Announcements
For reconstruction of type I defect of nger by great toe tip
transplantation, the difculty of operation is dissociation of
veins. Dorsal digital vein of foot cannot be directly used for
great toe tip transplantation which is without dorsal skin ap.
Although there are supercial subcutaneous veins in the toe
pulp, they are too thin and close to the skin, that is difcult to
be dissociated and anastomosed. The solution is: (a) First,
the dorsal digital vein of great toe should be dissociated, and
then its branch is traced to the distal end of the bular side to
the tip of the toe; (b) A triangular ap to the proximal end of
the toe tip tissue ap of great toe could be attached, and the
vein on the ap could be used to anastomose with the dorsal
digital vein in the middle segment of the nger.
11.1.6 Case Description
Case 1 A 23-year-old male patient was admitted to hospital
in emergency for 1h due to pain and bleeding of the left index
nger caused by machine crush injury. Physical examination:
He was in good general condition, with stable vital signs,
traumatic loss of the distal segment of the left index nger
from the nail root, irregular skin of the stump, active bleeding, lightly polluted. The sensation, movement, and blood
circulation in the other ngers were good. The left index nger was reconstructed by free nail skin ap of great toe transplantation under combined brachial plexus and epidural
anesthesia in emergency. The donor site was closed by local
dorsal ap of foot. The operation was successful; after the
tourniquet relaxed, the reconstructed nger was ruddy with
moderate tension, wrapped with the sterile cotton, bulked and
stuffed with the broken cotton gauze around, and he returned
to the ward safely. Routine reconstruction treatment was
given after the operation. Two weeks after the operation, the
reconstructed nger survived successfully. Regular follow-up
was conducted to guide functional exercise. The appearance
and function of the reconstructed nger were satisfactory.
The donor site healed in the rst stage, and the patient was
satised with the appearance and function (Fig.11.1).
Case 2 A 35-year-old male patient was admitted to hospital
in emergency for 2h due to pain and bleeding of the left ring
nger defect caused by the machine. Physical examination:
He was in good general condition, with stable vital signs,
traumatic loss of the nger tip, exposed bone and nail bed,
11.1 Reconstruction ofType IDefect
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Fig. 11.1 Reconstruction of type I defect of the left index nger by
free nail skin ap of great toe transplantation. (a) Preoperative palmar
condition of nger defect. (b) Preoperative dorsal condition of nger
defect. (c) Preoperative design of the ap. (d) Preoperative design of the
active bleeding, moderate pollution. After admission, the nger stump was debrided under general anesthesia, and it was
reconstructed by free ipsilateral nail skin ap of great toe
transplantation. The operation was successful; after the tourniquet relaxed, the reconstructed nger was ruddy with
moderate tension, wrapped with the sterile cotton, bulked and
stuffed with the broken cotton gauze around, and he returned
to the ward safely. Routine reconstruction treatment was
given after the operation. Two weeks after the operation, the
reconstructed nger survived successfully. Regular follow- up
was conducted to guide functional exercise. The appearance
and function of the reconstructed nger were satisfactory.
The donor site healed in the rst stage, and the patient was
satised with the appearance and function (Fig.11.2).
Case 3 A 27-year-old female patient was admitted to hospital in emergency for 2.5h due to pain and bleeding of the left
index nger defect caused by punch press injury. Physical
ap. (e) Palmar view of the reconstructed nger. (f) Dorsal view of the
reconstructed nger. (g) Dorsal view of the donor site. (h) Palantar view
of the donor site
examination: She was in good general condition, with stable
vital signs, traumatic loss of the distal segment of the left
index nger, approximately 1/2 of proximal nail bed
remained, exposed bone, active bleeding, moderate pollution. After admission, the nger stump was debrided under
general anesthesia, and it was reconstructed by free ipsilateral nail skin ap of great toe transplantation. The operation
was successful; after the tourniquet relaxed, the reconstructed nger was ruddy with moderate tension, wrapped
with the sterile cotton, bulked and stuffed with the broken
cotton gauze around, and he returned to the ward safely.
Routine reconstruction treatment was given after the operation. Two weeks after the operation, the reconstructed nger
survived successfully. Regular follow-up was conducted to
guide functional exercise. The appearance and function of
the reconstructed nger were satisfactory. The donor site
healed in the rst stage, and the patient was satised with the
appearance and function (Fig.11.3).
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11 Reconstruction ofSingle Finger Defects
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Fig. 11.2 Reconstruction of type I defect of the left ring nger by free
nail skin ap of great toe transplantation. (a) Preoperative dorsal condition of nger defect. (b) Preoperative palmar condition of nger defect.
(c) A closer look. (d) A closer look. (e) Preoperative dicing of the ap.
(f) Preoperative dicing of the ap. (g) Dorsal view of the reconstructed
nger 1 month after the operation. (h) Palmar view of the reconstructed
nger 1 month after the operation. (i) Dorsal view of the reconstructed
nger 2 months after the operation. (j) Palmar view of the reconstructed
nger 2 months after the operation. (k) Dorsal view of the reconstructed
nger 6 months after the operation. (l) Palmar view of the reconstructed
nger 6 months after the operation. (m) Function of the reconstructed
nger. (n) Appearance of the donor foot
11.2 Reconstruction ofType II Defect
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Fig. 11.3 Reconstruction of type I defect of the left index nger by
free nail skin ap of great toe transplantation. (a) Preoperative condition of nger defect. (b) Preoperative design. (c) Dissociation of the
ap. (d) Finger reconstruction with free transplantation. (e) Dorsal view
11.2 Reconstruction ofType II Defect
Type II defect locates in the distal interphalangeal joint of the
nger and the distal nger body, while theoretically loses 45%
of the function of the nger, and the loss of hand function in
different degrees that has little effect on the function of the
whole hand. However, with the development of microsurgery
and the continuous improvement of the level of nger reconstruction, the reconstruction of type II defect is no longer a
difcult problem. Therefore, reconstruction is recommended
for patients with high requirements for nger appearance and
strong desire for reconstruction. The classical method of
reconstruction is the second toe transplantation, but also the
third or fourth toe transplantation could be considered.
11.2.1 Indications
(1) Type I defect of the nger; (2) The severed nger cannot
be replanted; (3) The patient is young and has no basic dis-
of the reconstructed nger 10 months after the operation. (f) Palmar
view of the reconstructed nger 10 months after the operation. (g)
Function of the reconstructed nger 10 months after the operation
ease; (4) The patient has high requirements for ngers and a
strong desire to reconstruction; (5) There is no obvious
deformity of the donor toe.
11.2.2 Surgical Design
The design of the operation is similar to the type I defect.
When the toe is cut, more bone and distal interphalangeal
joint should be retained; exor and extensor tendons should
be retained to reconstruct exion and extension function.
1. Incision design in the recipient site: The incision should
be made according to the shape of the scar and soft tissue
conditions in the nger stump. If the scar is in the coronal
direction, the incision should be cut and exposed according to the coronal plane of the original scar (Fig.11.4). If
the scar is sutured in the sagittal plane, the incision design
should be sagittal or V-shaped. A transverse or oblique
incision is made on the dorsal side to expose the dorsal
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11 Reconstruction ofSingle Finger Defects
digital vein and a longitudinal incision is made on the
lateral side to expose the proper digital artery.
2. Incision design in the donor site: According to the length
of the defect of the nger, the second toe with similar
shape is selected as the donor toe, and the incision design
in the donor site is determined according to the soft tissue
conditions and incision shape in the recipient site. V-V
incision, sagittal plane-V incision, and coronal planecoronal incision could be used (Fig.11.5).
Fig. 11.4 Incision design in the recipient site
11.2.3 Surgical Method
General condition: The patient should be in good general
condition without contraindications related to surgery or
anesthesia, and the anesthesia is performed under brachial
plexus anesthesia plus epidural anesthesia or general anesthesia. The operation could be performed in two groups: the
recipient group and the donor group.
The recipient group: The routine operation area is disinfected, then the towel is laid, and the tourniquet on the affected
limb should be elevated with a pressure of 30–37kPa. First of
all, the nger stump incision is made according to the design,
the skin and subcutaneous soft tissue are cut open, and the
peripheral area is appropriately disintegrated and released, and
the stump of the proper digital neurovascular bundle of the nger should be found on both sides of the nger and marked. In
case of type II defect, the stump of extensor digitorum tendon
and exor digitorum longus tendon should be released and
marked. The bone at the stump should be removed appropriately, and the medullary cavity should be opened. The proximal
segment of nger should be cut according to the design to
expose the proper digital neurovascular bundle and dorsal digital vein of nger, and the subcutaneous tunnel should be opened.
The donor group: Elevate the lower limb and tourniquet
with or without exorcism, with a pressure 47kPa. Make a
dorsal incision according to the design, extend it proximally
to nd the dorsal metatarsal vein, and ensure the continuity;
at the same time ligate the unneeded branches. Then expose
extensor tendons, plantar metatarsal arteries and nerves on
both sides, and also exor tendon and mark them (Fig.11.6).
The plantar metatarsal arteries and nerves and tendons
should be cut off with a enough length. The phalangeal bone
or the interphalangeal joint should be cut off according to the
defect length of the nger. At this time, the donor toe is completely dissociated except for the vascular pedicle, and the
tourniquet should be relaxed to observe the blood supply of
the toe. After the recipient group is prepared, the donor site
should be cut off from the vascular pedicle, and the donor toe
is transplanted to the recipient site (Fig.11.7).
Fig. 11.5 Incision design in
donor recipient site
11.2 Reconstruction ofType II Defect
Fig. 11.6 Dissociation of
dorsal vein of foot and the
exposure of plantar digital
nerve, tendon, and blood
vessels of toe
183
Fig. 11.7 Anastomosis of the
palmar nerve, blood vessels,
and exor tendons and the
appearance of the
reconstructed nger
11.2.4 Operation Characteristics
(a) The requirement of microscopic technique is high and
good small vessel anastomosis technique is needed; (b) All
patients with type II defect require reconstruction, and also
have high requirement for nger appearance; (c) The operation needs to be performed under a magnifying glass or microscope, that does not involve metatarsal bone and transverse
ligament, and has no obvious effect on foot weight bearing
and walking; (d) Do not damage the vascular pedicle.
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11 Reconstruction ofSingle Finger Defects
11.2.5 Announcements
11.2.6 Case Description
(a) Preoperative planning is critical. It must be designed in
advance and fully evaluated before operation.
(b) The operation should be gentle and careful to avoid pull-
ing or injury of the vascular pedicle to prevent the occurrence of vascular crisis.
(c) The vascular pedicle must be straighten out to avoid
torsion;
(d) Nerve anastomosis must be carried out without tension;
(e) Pay attention to stop hemostasis to prevent postoperative
bleeding and scab that affect blood supply;
(f) Bandaging must be loose to prevent vascular crisis due
to postoperative swelling and over-tight bandaging of
the reconstructed nger;
(g) After the operation, the surrounding environment of the
patients should pay attention to heat preservation, keep
quiet, strictly smoke-free environment, and the patients
must lie in bed for a week;
(h) Pay attention to the blood supply of the reconstructed
Case 1 A 38-year-old male patient was admitted to hospital in emergency for 30 days after stump repair due to
the right index nger defect caused by machine injury.
Physical examination: He was in good general condition,
with stable vital signs. After admission, routine preoperative preparation for reconstruction was given, and surgical
contraindications were excluded. The index nger was
reconstructed by the left second toe transplantation under
general anesthesia electively, and the donor site was
sutured directly. The operation was successful; after the
tourniquet relaxed, the reconstructed nger was ruddy
with moderate tension, wrapped with the sterile cotton,
bulked and stuffed with the broken cotton gauze around,
and he returned to the ward safely. Routine reconstruction
treatment was given after the operation, and the reconstructed nger survived successfully. The efcacy was
satisfactory (Fig.11.8).
nger to prevent the occurrence of vascular crisis.
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Fig. 11.8 Reconstruction of type II defect of the right index nger by the
free second toe transplantation. (a) Preoperative palmar condition of the
nger defect. (b) Preoperative dorsal condition of the nger defect. (c)
Preoperative design (dorsal side). (d) Preoperative design (plantar side).
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(e) Palmar view of the reconstructed nger 1 week after the operation. (f)
Dorsal view of the reconstructed nger 1 week after the operation. (g)
Palmar view of the reconstructed nger 10 months after the operation. (h)
Dorsal view of the reconstructed nger 10 months after the operation
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