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Second Toe Free Flap
Данная книга находится в списке для перевода на русский язык сайта https://meduniver.com/
DariushNikkhah, JuanEnriqueBerner, PetrVondra,
BranSivakumar, andMarkPickford
43
43.1 Introduction
From a functional point of view, the thumb is the most
important digit in the hand, able to effectively oppose with
the remaining four ulnar ngers, which allows the gripping
and manipulation of objects and tools. Congenital absence of
a functioning thumb, or its loss due to acquired conditions,
inevitably results in considerable loss of hand function. Even
though attempts to reconstruct thumbs using tubed pedicled
aps were attempted in the nineteenth century, it was the
Viennese surgeon Carl Nicoladoni who rst described the
use of a second toe for this purpose [1]. It was in 1898 that
the rst pedicled second toe to thumb transfer was performed
for a 5-year-old patient, with its pedicle being divided
16days later.
Thanks to the experimental work of Harry Buncke [2],
the rst successful microsurgical great toe-to- thumb trans-
Supplementary Information The online version contains
supplementary material available at [https://doi.
org/10.1007/978- 3- 031- 07678- 7_43].
D. Nikkhah (*)
Royal Free Hospital, London, UK
J. E. Berner
Barts and the Royal London Hospital, London, UK
P. Vondra
Hand and Plastic Surgery Institute,
Vysoké nad Jizerou, Czech Republic
B. Sivakumar
Great Ormond Street Hospital, London, UK
Sidra Hospital Qatar, Doha, Qatar
M. Pickford
Queen Victoria Hospital, East Grinstead, UK
fer was performed in 1968 by the British surgeon John
Cobbett in East Grinstead [3]. Even though the second toe
tends to be smaller than the thumb, it offers two main advantages over the great toe donor site: (a) the second toe
metatarso- phalangeal joint can be included, which is of use
in proximal amputations and (b) the donor site is cosmetically favourable [4]. The second toe ap is preferred in digital reconstruction and also in children with congenital
differences; it may be the preferred option for thumb reconstruction in children and female patients because of donor
site considerations.
43.2 Anatomy
The second toe is perfused by its proper digital arteries,
which emerge from the conuence of the dorsal and plantar
metatarsal arteries in the area just proximal to the intermetatarsal ligament. The second toe free ap is raised with one or
more dorsal subcutaneous veins, and the dominant metatarsal artery. The latter tends to be the dorsal system, derived
from the dorsalis pedis artery in approximately 70% of the
cases [5]; in these cases, the pedicle can be traced proximally
on the dorsum of the foot to increase pedicle length. If the
dorsal system is non-dominant, then a more tedious plantar
dissection is required, which typically yields a shorter
pedicle.
The second toe ap can be harvested with the metatarsophalangeal joint and metatarsal if needed. The extensor digitorum longus and brevis tendons lie in a subcutaneous plane
in the foot dorsum, while the exor digitorum longus and
brevis run inside a exor sheath on the plantar aspect. Both
proper digital nerves of the second toe derive from common
digital nerve branches of the medial plantar nerve—intraneural dissection allows the principal digital nerves to be harvested with greater length if needed; dorsal cutaneous nerves
should be harvested as well, to optimize sensibility in the
transferred toe.
© Springer Nature Switzerland AG 2023
D. Nikkhah et al. (eds.), Core Techniques in Flap Reconstructive Microsurgery, https://doi.org/10.1007/978-3-031-07678-7_43
419
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D. Nikkhah et al.
43.3 Pre-operative Investigation
Raising this ap for thumb reconstruction requires careful
planning of the recipient site, considering the level of the
amputation and surrounding soft tissues. An adequate rst
webspace is key to obtain an opposable reconstructed thumb,
therefore this should be addressed before transferring a second toe.
The main benet of pre-operative investigations concerning the donor site is to determine the dominant metatarsal artery. High denition computed tomography (CT)
angiography is able to delineate the arterial perfusion of
the foot, including its terminal branches; however, it
involves radiation and use of contrast. Colour duplex
ultrasound provides more information than a hand-held
Doppler, being able to describe the subcutaneous vascular
anatomy.
43.4 Flap Design andMarkings
The second and third webspaces are marked at their mid
points. From there a “V”-shaped incision is planned on both
the plantar and dorsal surfaces, with the apex lying, approximately, over the metatarsophalangeal joint. The dorsal incision in extended proximally with Brunner aps to allow
adequate exposure of the neurovascular structures and extensors. The plantar incision can be extended proximally up to
the metatarsal heads level with a straight line (Figs.43.1 and
43.2), but is usually limited to avoid tender plantar scarring.
Fig. 43.1 Dorsal markings for second toe transfer Fig. 43.2 Plantar markings for second toe transfer
43 Second Toe Free Flap
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421
43.5 Flap Raise/Elevation: AStep-by-Step
• Step 1—Incision and Venous Dissection: Under tourni-
quet control dorsal incisions are made and thin skin aps
are raised. Supercial veins draining the second toe are
identied and protected, as these need to be included with
the ap (Fig.43.3).
• Step 2—Retrograde Dissection: Arterial dissection
commences distally in the rst web space; retrograde dis-
section determines whether the arterial supply to the sec-
ond toe is dorsal dominant, or plantar dominant (Fig.43.4).
If there is a dorsal dominant circulation (70% cases) the
rst dorsal metatarsal artery can be traced proximally to
its origin at the dorsal pedis. Debakey forceps and ne
microsurgical instruments are used to handle the vessels;
side branches are clipped with micro Ligaclips or cauter-
ised with ne bipolar forceps. The dorsalis pedis is identi-
Fig. 43.3 Thin skin aps raised over dorsal of foot demonstrating
supercial dorsal veins
ed with its associated venae commitans by retracting the
extensor hallucis brevis laterally. It is recommended to
explore the arterial anatomy initially from the distal rst
web space, and simply follow the larger caliber vessels as
they course dorsally or plantar wards i.e. to embark on toe
elevation without preliminary imaging of the arterial supply. It is also recommended to dissect out the artery of the
second web too, while preparing the nerve of that aspect,
since this provides exibility when selecting a suitable
recipient vessel.
• Step 3—Extensor Tendons: The extensor digitorum
brevis and longus can be easily identified and dissected for division and transfer. It is important to take
sufficient length to allow a weave tenorrhaphy
(Fig.43.5).
• Step 4—Cutaneous Nerves: The deep peroneal nerve
lies lateral to the dorsalis pedis, it should be marked
with 6.0 nylon before division. Any sizeable dorsal
cutaneous nerves supplying the second toe are
harvested.
• Step 5—Plantar Dissection and Flexor Tendons: After
raising and defatting the plantar skin ap, dissection proceeds into the rst and second web spaces, where fascial
bands must be divided to identify the proper digital arteries to the second toe; branches going to the great toe and
middle toe are clipped and divided (Fig.43.6). As the dissection proceeds, the plantar digital nerves and exor tendons are also exposed (Fig.43.6). Once adequate exposure
is obtained, the dominant metatarsal artery of the rst web
is preserved and the secondary artery is divided and
clipped. The senior author routinely harvests the second
web artery as a back-up. If there is a plantar dominant
circulation, pedicle length can be extended using an interposition vein graft (rather than an extended plantar dissection). The exor digitorum longus and brevis are
identied for division and transfer.
Fig. 43.4 Retrograde dissection in rst webspace
Fig. 43.5 Extensor tendons identied and divided
422
Fig. 43.6 Plantar dissection is demonstrated in this gure; the plantar
digital nerves are identied, and here a plantar dominant arterial supply
to the second toe is identied
• Step 6—Metatarsophalangeal Joint Disarticulation:
Our preferred level for taking the second toe is at the
metatarsophalangeal joint, but a segment of the metatarsal bone can also be harvested without signicant morbidity. Disarticulation is performed by dividing the
collateral ligaments, volar plate and capsule of the joint.
The tourniquet is let down, after tenotomy of the extrinsic tendons but before division of the vascular supply, to
assess perfusion (Fig.43.7); if there is evidence of vasospasm warm saline or papaverine can be irrigated over
the pedicle. Once the level of harvest is decided, the
artery and vein are divided and the toe can then be
removed and wrapped in a saline moistened gauze
(Fig.43.8).
• Step 7—Recipient Preparation and Donor Site
Closure: At the recipient site a cruciate incision can be
used to achieve wide exposure. Extensor and exor tendons are tagged as well as recipient digital nerves; adequate tenolysis ensures good glide in recipient tendons.
The recipient bone stump is usually prepared with an
oscillating saw (Fig.43.9). For thumb reconstruction the
radial artery in the anatomical snuff box and associated
venae commitans and dorsal veins are exposed and prepared; suitable side branches may be used for end-to-side
anastomosis. The donor site is closed by approximating
the soft tissues medial and lateral to the excision defect
with strong PDS sutures. Skin is then closed with ne
sutures.
• Step 8—Osteosynthesis, Tendon Repair, Microsurgery:
Joint capsule is elevated off the base of the toe proximal
phalanx to expose the proximal shaft; soft tissues are then
protected by wrapping the toe in moist gauze, before care-
D. Nikkhah et al.
Fig. 43.7 Tourniquet is let down to assess second toe perfusion
Fig. 43.8 Elevated second toe with structures marked
43 Second Toe Free Flap
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423
Fig. 43.9 Recipient bone prepared with oscillating saw for
osteosynthesis
fully removing the articular surface with an oscillating
saw. Osteosynthesis is performed with two parallel interosseous wire loops, an interosseous wire and single
Kirschner wire (Lister technique) or a single Kirschner
wire (Fig.43.10). It is important make sure that the thumb
is in a good position for opposition. Tendons are repaired
using a Pulvertaft weave. The digital nerves are repaired
with 9.0 nylon. Arterial anastomosis is then performed,
followed by two venous anastomoses if the veins are
smaller than the artery.
• Step 9—Skin Closure: It is important to avoid harvest-
ing excessive fat around the neurovascular structures of
the donor toe, which can create unwanted tension during wound closure and also compromise the aesthetics
of the reconstructed digit (Fig.43.11). If skin closure
without tension is not possible, we apply split thickness
skin grafts over the base of the second toe and in some
cases over the pedicle. This reduces the chance of pedicle compression and vascular compromise. A well-padded splint is applied so that no pressure is applied to the
pedicle.
Fig. 43.10 Single axial Kirschner wire used for osteosynthesis of second toe transfer including metatarsal bone
Fig. 43.11 Second toe inset for thumb reconstruction
424
43.6 Core Surgical Techniques inFlap
Dissection
Retrograde Dissection Retrograde dissection from the distal rst-web space quickly reveals whether the arterial supply is dorsal- or plantar-dominant. Needless dissection over
the dorsum of the foot is avoided if a plantar dominant circulation is identied. The pedicle of a plantar dominant toe can
be lengthened with an interposition vein graft.
Pedicle Dissection Care must be taken when dissecting the
arterial and venous supply to the toe, we nd handling with
microsurgical instruments and use of microligaclips useful.
Dissection should be performed with bipolar cautery on a
low setting [6] and thermal damage can be avoided with heat
sink bipolar technique.
Cutaneous Nerves As many cutaneous nerves as possible
should be identied and repaired, since this improves the
chances of good sensory recovery in the reconstructed digit.
Recipient Vessel In cases of symbrachydactyly there will
be variations in anatomy and care must be taken to choose
suitable veins and arteries for the toe transfer. It is preferred
to go more proximal to larger vessels in the anatomical snuff
box or wrist. Care must be taken to measure the required
pedicle length before transfer and ascertain whether vein
grafts are required.
D. Nikkhah et al.
Osteosynthesis We prefer intraosseous wire xation or
k-wires (particularly in children) over plate xation. It allows
for less dissection and preserves more periosteum. Rapid,
simple and strong xation can be achieved with two parallel
box wires.
Donor Site Closure The morbidity with closure of the
second toe donor site is minimal, we have noticed no longterm issues, apart from mild secondary clinodactyly of the
remaining toes in the paediatric population (Figs. 43.12
and 43.13).
Fig. 43.12 Second toe donor site after unilateral second toe transfer—
note the clinodactyly of remaining toes
43 Second Toe Free Flap
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Fig. 43.13 Donor site after bilateral second toe transfer
43.7 Clinical Scenario
43.7.1 Case Scenario A: Congenital Hand—
Symbrachydactyly—Surgeon Mark
Pickford
425
A 4-year-old boy presented with monodactylous symbrachydactyly. After discussion with his parents they opted for a
second toe transfer to provide large grasp and opposition. A
second toe transfer was performed without complication. At
3-year follow-up the child was able to grasp and had a static
2 point discrimination of 5mm (Figs.43.14 and 43.15).
43.7.2 Case Scenario B: Traumatic Injury
totheHand—Surgeon Mark Pickford
A 45-year-old patient sustained a grenade injury to his left
hand. He sustained a near total amputation of his nondominant thumb, leaving part of his rst metacarpal. In the
rst stage he had a pedicled posterior interosseous artery
(PIA) ap imported into the rst webspace. A second toe ap
was raised and anastomosed to the anatomical snuff box with
a bridging vein graft. He had an uneventful recovery
(Figs.43.16, 43.17, and 43.18).
43.7.3 Case Scenario C: Firework Injury
toHand—Surgeon Petr Vondra
Fig. 43.14 Long-term outcome after second toe transfer for monodac-
tylous symbrachydactyly
A 15-year-old male sustained a devastating rework injury
to his hand. The primary treatment was debridement and
wound closure. The patient sustained complete loss of the
rst ray—only part of the trapezium remained, and only
parts of the second to fourth metacarpal bones remained.
From the fth ray remained a well functional metacarpophalangeal joint and proximal phalanx of little nger (Fig.43.19).
Fig. 43.15 Large grasp showed in same patient
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D. Nikkhah et al.
Fig. 43.18 On table result after second toe transfer to restore thumb
opposition
Fig. 43.16 Traumatic amputation of thumb secondary to a grenade
blast
Fig. 43.17 First webspace in same patient is optimised with a PIA ap
in anticipation for a second to transfer
The patient underwent second toe to “thumb” microvas-
cular reconstruction (Fig.43.20). He regained sensation and
movement and had an excellent donor site outcome
(Fig.43.21), but his webspace was too tight and he subsequently underwent a pedicled PIA ap for widening 6months
Fig. 43.19 Pre-op demonstrating intact fth ray
Fig. 43.20 Elevation of second toe
from toe to hand reconstruction. The nal photos demonstrate good pinch at 1-year follow-up. (Fig.43.22).
43 Second Toe Free Flap
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Fig. 43.21 Donor site outcome
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43.8 Pearls andPitfalls
Pearls
• When incising the plantar triangle of skin one must
leave most of the plantar fat on the foot, transferring
the subcutaneous fat will make inset difcult. This
will reduce bulk and allow for better joint motion in
the reconstructed thumb.
• During osteosynthesis, protect the neurovascular
structures with an aperture made in a glove, or a
moist gauze wrap. This retracts back the soft tissues
and protects them from iatrogenic injury.
• Perform the microsurgical anastomosis proximally
on reliable, large-calibre vessels at the wrist (for
thumb reconstruction), particularly in cases where
is there is aberrant anatomy or unreliable proximal
ow. Our preference is to use a posterior wall anastomosis in end-to-end arterial and venous repair.
• Neuromas can help identify the proximal ends of
digital nerves at the recipient site; these are resected
under the microscope prior to neurroraphy.
• After traumatic thumb amputations it may be necessary to prepare for second toe transfer by initially
optimizing the rst web, for example, using a PIA
ap or a free groin ap.
Fig. 43.22 Demonstration of pinch after second toe transfer
Pitfalls
• During second toe inset it is important not to close
the skin tightly; if necessary apply split thickness
skin grafts over areas (including the pedicle) if there
is skin shortage.
• Ensure that as many cutaneous nerves are repaired
with a tensionless nerve repair; nerve grafts may be
used to bridge the segmental gaps.
• Avoid tight dressings and a so-called bloodcast,
which can impair ap circulation.
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