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• In congenital cases we wait till the age of 2–3years,
or later, as the vessels are larger calibre and microsurgical anastomoses are easier.
• Keep the patient warm and well hydrated and
pain- free to avoid possible vasospasm. A sympathetic blockade provided by a supraclavicular or
axillary block will help with peripheral
vasodilation.
D. Nikkhah et al.
• Kay SP, Wiberg M.Toe to hand transfer in children. Part
1: technical aspects. J Hand Surg Br. 1996;21(6):723–34.
• Kay SP, Wiberg M, Bellew M, Webb F.Toe to hand transfer in children. Part 2: functional and psychological
aspects. J Hand Surg Br. 1996;21:735–45.
This is a two-part article reviewing technical aspects of
paediatric toe to thumb transfer and its functional and
psychological benets [10, 11].
References
43.9 Selected Readings
• Tsai TY, Fries CA, Hsiao JC, etal. Patient-reported outcome measures for toe-to-hand transfer: a prospective
longitudinal study. Plast Reconstr Surg.
2019;143(4):1122–32.
Prospective patient-reported outcomes study including 23
patients. All the operated individuals reported an important increase in hand function, with no deterioration of
foot function [6].
• Nikkhah D, Martin N, Pickford M.Paediatric toe-to-hand
transfer: an assessment of outcomes from a single unit. J
Hand Surg Eur Vol. 2016;41(3):281–94.
Study demonstrating the technical aspects and outcomes
of 31second toe transfers in 19 children. The paper demonstrated excellent long-term motor and sensory outcomes (S2PD=5mm) and no failures [7].
• Sosin M, Lin CH, Steinberg J, etal. Functional donor site
morbidity after vascularized toe transfer procedures: a
review of the literature and biomechanical consideration
for surgical site selection. Ann Plast Surg.
2016;76(6):735–42.
Systematic review of donor site morbidity following toe
transfer procedures [8].
• Zhao J, Tien HY, Abdullah S, Zhang Z.Aesthetic renements in second toe-to-thumb transfer surgery. Plast
Reconstr Surg. 2010;126(6):2052–9.
This article presents modications to the second toe
transfer to improve its cosmetic appearance for thumb
reconstruction [9].
1. Haeseker B. 1891-1991: the centenary of innovative reconstructive hand surgery by Carl Nicoladoni. Br J Plast Surg.
1991;44:306–9.
2. Buncke HJ Jr, Buncke CM, Schulz WP.Immediate Nicoladoni procedure in the Rhesus monkey, or hallux-to-hand transplantation,
utilising microminiature vascular anastomoses. Br J Plast Surg.
1966;19:332–7.
3. Whitworthm IH, Pickford MA. The rst toe-to-hand transfer: a
thirty-year follow-up. J Hand Surg Br. 2000;25:608–10.
4. Henry SL, Wei F-C.Thumb reconstruction with toe transfer. J Hand
Microsurg. 2010;2:72–8.
5. Spanio S, Wei F-C, Coskunrat OK, Lin C-H, Lin Y-T.Symmetry
of vascular pedicle anatomy in the rst web space of the foot
related to toe harvest: clinical observations in 85 simultaneous bilateral second- toe transfer patients. Plast Reconstr Surg.
2005;115:1325–7.
6. Tsai T-Y, Fries CA, Hsiao J-C, Hsu C-C, Lin Y-T, Chen S-H, Lin
C-H, Wei F-C, Lin C-H.Patient-reported outcome measures for toeto- hand transfer: a prospective longitudinal study. Plast Reconstr
Surg. 2019;143:1122–32.
7. Nikkhah D, Martin N, Pickford M.Paediatric toe-to-hand transfer:
an assessment of outcomes from a single unit. J Hand Surg Eur.
2016;41:281–94.
8. Sosin M, Lin C-H, Steinberg J, Hammond ER, Poysophon P, Iorio
ML, Patel KM. Functional donor site morbidity after vascularized toe transfer procedures: a review of the literature and biomechanical consideration for surgical site selection. Ann Plast Surg.
2016;76:735–42.
9. Zhao J, Tien HY, Abdullah S, Zhang Z. Aesthetic renements
in second toe-to-thumb transfer surgery. Plast Reconstr Surg.
2010;126:2052–9.
10. Kay SP, Wiberg M.Toe to hand transfer in children. Part 1: technical aspects. J Hand Surg Br. 1996;21:723–34.
11. Kay SP, Wiberg M, Bellew M, Webb F.Toe to hand transfer in children. Part 2: functional and psychological aspects. J Hand Surg Br.
1996;21:735–45.
Great Toe Flaps
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DariushNikkhah andNorbertKang
44
44.1 Introduction
The great toe-to-thumb transplant was rst reported in the
Western literature by Cobbett; this case was followed up
three decades later demonstrating an excellent outcome [1,
2]. ‘Great toes make great thumbs’ a term coined by Harry
Buncke; however at the cost of donor morbidity [3]. Surgeons
have over the years rened the great toe ap to improve on its
appearance and also to reduce the donor site morbidity.
Morrison described the ‘Wrap-around ap’ which involved
transferring the soft tissue components and leaving behind
the bony skeleton of the great toe minimising donor morbidity [4]. Fu Chan Wei rened the appearance of the great toe
transfer by resecting the soft tissue and bony component of
the tibial border of the great toe; the so-called trimmed toe
ap [5]. The great toe pulp can also be transferred for volar
oblique defects of the thumb, providing like for like reconstruction of the pulp with glabrous tissue.
The second toe-to-thumb transplant is more popular in
Asian cultures owing to its reduced donor site morbidity. It is
more commonly used in children with congenital differences; however, its small bulbous appearing pulp makes it
hard to replicate a thumb. The ideal indication for a great toe
transfer is traumatic loss of the thumb through the proximal
phalanx with the toe-transplant reconstructing the interphalangeal joint of thumb. The more proximal the amputation
the more challenging the reconstruction and if the amputation is proximal to the metacarpophalangeal joint; the meta-
Supplementary Information The online version contains supplementary
material available at [https://doi.org/10.1007/978- 3- 031- 07678- 7_44].
D. Nikkhah (*) . N. Kang
Royal Free Hospital, London, UK
tarsophalangeal joint can be harvested in the great toe
transplant but at the cost of donor site morbidity.
44.2 Anatomy
The great toe is supplied by the plantar and dorsal metatarsal
arterial systems and drained by supercial veins which connect with the saphenous system [6]. The rst dorsal metatarsal artery originates from the dorsalis pedis and courses
either supercially or through the interosseous muscles. The
vessel gives off branches to the metatarsals, muscles and
joints. Between the great and second toe the dorsal metatarsal artery lies supercial to the deep transverse ligament. The
rst plantar metatarsal artery originates from the plantar arch
and the deep plantar artery [6].
The dorsal system is the primary choice for the pedicle of
the great toe owing to its supercial course and long pedicle.
However in 10% of cases the dorsal system may be absent
and the plantar system may need to be harvested as the primary pedicle, which has disadvantages of being signicantly
shorter and often needing lengthening with a vein graft. The
anatomical variations of vasculature were described by Alain
Gilbert in a study of 50 cadavers [7].
• Types 1a and 1b both metatarsal arteries arise indepen-
dently—66% of cases: In type 1a the dorsal metatarsal
artery passes supercially to the interosseous muscle, in
Type 1b it passes through the rst dorsal interosseous
muscle.
• Types 2a and 2b 22% cases—In Type 2 cases the dorsal
and plantar metatarsal arteries have a common trunk
located under the rst dorsal interosseous muscle
(Inframuscular). In type 2a a slender supercial branch is
present passing supercially to the muscle and uniting at
the anterior part of the web space with the dorsal metatar-
sal artery. In contrast in type 2b the supercial arterial
branch is not present.
© 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_44
429
430
TYPE Ia
TYPE Ib
D. Nikkhah and N. Kang
TYPE IIa
TYPE III
Fig. 44.1 Clinical illustration of the anatomical variations of great toe
vasculature as described by Gilbert etal. Illustration courtesy of Dr Gio
Patanis
TYPE IIb
• Type 3 12% cases: The rst dorsal metatarsal artery (FDMA)
is slender or absent. The rst plantar metatarsal artery is well
developed and the dominant circulation (Fig.44.1).
44.3 Pre-operative Investigation
Pre-operative mapping with colour Doppler ultrasound can
determine the course of the rst dorsal metatarsal artery
and whether it is absent. If this is not present, some groups
use a hand-held Doppler to map out the course of the
FDMA.A prominent signal would indicate a dorsal dominant system.
CT—angiogram has been described and would accurately
indicate whether the great toe has a dorsal or plantar dominant circulation. Pre-operative investigations can help to
determine if vein grafts will be needed in cases where there
is a plantar dominant system.
Fig. 44.2 A racquet-shaped incision is made around the toe and a curvilinear incision is made proximally to the dorsalis pedis. Before tourniquet exsanguination the supercial veins and long saphenous vein are
marked
44.4 Flap Design andMarkings
Great Toe Flap A racquet-shaped incision is made around
the toe and a curvilinear incision is made proximally to the
dorsalis pedis. Before tourniquet exsanguination the supercial veins are marked (Fig.44.2).
Great Toe Pulp Transfer The lateral border of the great toe
is marked, a curvilinear incision is marked proximally and an
incision is marked on the plantar surface of the foot to harvest plantar vessels and nerves for transfer (Fig.44.3).
We will illustrate the elevation and anatomy of the great toe
ap using images from both case scenarios.
Fig. 44.3 The lateral border of the great toe is marked in preparation
of a great toe pulp transfer
44 Great Toe Flaps
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44.5 Flap Raise/Elevation: AStep-by-Step
Guide
44.5.1 Great Toe Flap Elevation
• Step 1 Incision and Approach: The ipsilateral toe is
used to reconstruct the thumb, the length of the toe is
marked just proximal to the PIPJ (Fig.44.4). Under tourniquet control the incision is started in the rst webspace
using a retrograde [8] or antegrade approach from the dorsalis pedis (Fig.44.5).
• Step 2 Venous Dissection: The supercial veins over the
dorsum of the foot that were marked are harvested, thin
skin aps should be raised. Multiple side branches from
the supercial venous system should be ligaclipped
(Figs. 44.6, 44.7, and 44.8). Fine microsurgical instruments should be used to dissect the vein to avoid damage.
431
Fig. 44.5 Incision can be started retrograde in rst webspace or antegrade from dorsalis pedis. The arrow demonstrates a dorsal dominant
circulation emerging from the dorsalis pedis
Fig. 44.4 The ipsilateral toe is used to reconstruct the thumb; the
length of the toe is marked just proximal to the PIPJ
Fig. 44.6 Supercial veins are marked before exsanguination
432
Fig. 44.7 Racquet-shaped incision over great toe with inclusion of
long saphenous vein
D. Nikkhah and N. Kang
Fig. 44.8 Thin skin aps are raised and all supercial veins (see
arrows) are included, side branches are ligaclipped
Fig. 44.9 If there is a dorsal system of adequate calibre, dissection
proceeds along the rst webspace
• Step 3 Arterial Dissection: If there is a dorsal system of
adequate calibre, dissection proceeds along the rst webspace, the dorsal branch supplying the second toe is clipped
off and dissection continues to the dorsalis pedis (Figs.44.9
and 44.10). Dissection is performed with bipolar cautery at
Fig. 44.10 The dorsal branch supplying the second toe is clipped off
(arrow) and dissection continues to the dorsalis pedis
44 Great Toe Flaps
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433
a low setting. The dorsalis pedis is identied under the
extensor hallucis brevis tendon which is divided. The dorsal peroneal nerve is identied. If there is no sufcient dorsal system the plantar arterial system is taken and a
longitudinal incision is made over the plantar aspect of the
foot. The medial and lateral plantar digital nerves are taken.
• Step 4 Tendon Division and Disarticulation: The exten-
sor hallucis longus and exor hallucis longus tendon are
divided, taking sufcient length for tenorraphy at recipient site using Pulvertaft Weaves (Figs.44.11 and 44.12).
Once the arterial and venous drainage to the great toe is
dissected free. The great toe is disarticulated at the metatarsophalangeal joint. Plantar digital nerves and the dorsal
nerves are tagged with 6.0 nylon and divided—as many
sensory nerves are taken for neurorraphy as possible. The
tourniquet is then released assessing circulation to the toe.
• Step 5 Recipient Vessels: Preparing the recipient site for
the great toe transfer should ideally be with a two-team
approach. A second surgeon prepares the recipient artery
and vein in the hand. In this case the radial artery in the snuff
box or the wrist can be prepared (Figs.44.13 and 44.14).
• Step 6 Divide Pedicle: After a sufcient length of pedicle
is harvested, this is double checked at the recipient site
with a ruler to see if it reaches and whether a vein graft is
required. The veins and the arteries are clipped off and
microsurgical clamps are placed in preparation for microsurgery. The nerves are also divided, and tagged with
Fig. 44.12 The extensor hallucis longus and exor hallucis longus tendon are divided—the toe remains attached by neurovascular structures
Fig. 44.11 The great toe is disarticulated from the metatarsophalangeal joint
Fig. 44.13 Markings for preparing the recipient site for the great toe
transfer; access incisions for the radial artery at the wrist are marked
Fig. 44.14 The radial artery in snuff box with associated vena comitans (arrow). The cephalic vein is also prepared in the picture (arrow)
434
Fig. 44.15 Great toe divided and all structures marked for transfer.
The vein and artery are clipped with microsurgical clamps in preparation for transfer
D. Nikkhah and N. Kang
Fig. 44.16 Donor site closure ensuring padding over the metatarsophalangeal joint
either microsuture or blue dye for easy identication
(Fig.44.15).
• Step 7 Donor Site Closure: The donor site is closed in lay-
ers using 3.0 monocryl, ensuring there is enough padding
over the metatarsal head which is preserved (Fig.44.16).
• Step 8 Osteosynthesis: The recipient bone (Fig.44.17) is
prepared with an oscillating saw; the cartilaginous surface
Fig. 44.17 Radiograph of recipient site, showing amputation through
rst metacarpal bone
of the great toe is removed with an oscillating saw. Drill
holes are made for interosseous wires, two can be used in
parallel or at 90°. Another option is a lister loop with single Kirschner wire or a plate as illustrated in this case
(Fig.44.18).
• Step 9 Tenorraphy and Neurorraphy: After identica-
tion with a wide exposure at the recipient site (Fig.44.19),
both the extensor pollicus longus and exor pollicus longus tendons are repaired with Pulvertaft weaves and 3.0
44 Great Toe Flaps
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435
Fig. 44.20 The veins are anastomosed end to end. The arterial anastomosis is completed as an end to side anastomosis to the radial artery at
the wrist
Fig. 44.18 Great toe osteosynthesis with plate xation
Fig. 44.19 The extensor pollicus longus and exor pollicus longus are
tagged and marked with 4.0 Prolene (arrows). The digital nerves are
tagged with 8.0 nylon (arrow)
PDS suture. The plantar digital nerves and dorsal nerves
are repaired under the microscope with 8.0 Nylon.
• Step 10 Microsurgical Anastomosis and Inset: The
veins are repaired rst using single clamps and a posterior wall technique using 9.0 Nylon (Fig. 44.20). The
arterial anastomosis is completed in the same fashion
after checking adequate inow from the proximal artery,
Fig. 44.21 Great toe is inset, skin grafts are applied over areas of tight
closure
in this case an end to side anastomosis was performed to
the radial artery at the wrist (Fig.44.20). Skin closure is
completed once circulation to the toe is sufcient. Skin
grafts can cover areas where primary closure is not possible or tight closure would cause pedicle compression
(Fig.44.21).
436
44.6 Core Surgical Techniques inFlap
Dissection
Arterial Anatomy Flap dissection during harvest of the
great toe is best done with a retrograde approach unless there
is certainty that there is a dorsal dominant circulation on preoperative imaging. In 70% of cases, two sizeable vessels proceed in the rst webspace in both the dorsal and plantar
direction. The size of these vessels varies and dorsal vessel
may traverse through the interosseous muscle. In 30% of
cases, the plantar vessel is the more sizeable than the dorsal
artery, which is either small or absent [9].
If both vessels (plantar and dorsal) have the same calibre,
it is prudent to ligate the plantar system and take the dorsal
system since dissection is easier and also it provides a longer
pedicle (Fig.44.22).
If the plantar dominance is identied and dissection pro-
ceeds, this can be destructive to the foot [9]. It is better to
lengthen the pedicle in this scenario with a vein graft. The
vein graft can be attached under the microscope to the plantar artery on a side table before toe inset. Some feel this technique obviates the need for CT angiogram or imaging;
however, in our experience it is prudent to use all modalities
to plan toe transfer.
D. Nikkhah and N. Kang
Fig. 44.23 As demonstrated here it is best to have large calibre recipient vessels in snuff box or wrist outside of the zone of injury or trauma
Instrumentation The vessels supplying the great toe are
fragile and easily at risk of traction injury. Microsurgical
instruments should be used to handle the veins and arteries
and side branches should be ligaclipped to avoid thermal
injury to pedicle. Bipolar cautery should be used carefully on
a low setting and heat sink bipolar techniques should be utilised during side branch ligation.
Recipient Vessels Pedicle length is quickly judged after
recipient vessel preparation, in traumatic cases it may be
necessary to dissect out of the zone of trauma to the radial
artery in the snuff box (Fig.44.23).
Fig. 44.22 Demonstration of a dorsal dominant system identied
through dissection in the rst webspace
Nerves If possible as many nerves should be harvested and
repaired to improve sensory recovery. In children, toe transfer is associated with excellent static 2 point discrimination
of 5mm [10]. Adults are also expected to get acceptable sensory recovery of up to 10mm static 2 point discrimination.
Veins Harvesting at least two veins reduces the chances of
venous congestion, and the authors commonly perform a
second venous anastomosis if there is a suitable calibre vein.
44.7 Clinical Scenario
44.7.1 Scenario A: Delayed Great Toe Flap
Surgeon Norbert Kang
Patient A had oncological resection of his left thumb to the level
of the MCPJ secondary to sarcoma (Fig. 44.24). A great toe
transfer was performed to reconstruct the thumb, parts of the
case are illustrated in the stepwise images for this chapter. His
result at 4years demonstrates excellent range of motion, sensibility and restoration of opposition (Fig.44.25 and Videos 44.1
and 44.2) and an acceptable donor site morbidity (Fig.44.26).
44 Great Toe Flaps
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Fig. 44.24 This patient had oncological resection of his left thumb to
the level of the MCPJ secondary to sarcoma. A great toe transfer was
planned for reconstruction
437
Fig. 44.25 4-year outcome after great toe transfer demonstrating
excellent cosmesis and function
44.7.2 Scenario B: Delayed Great Toe HemiPulp Transfer Surgeon Norbert Kang
Patient B developed a pulp space infection of his left thumb.
The tissue was debrided and grafted with a split thickness
skin graft. This left an atrophic and painful thumb tip
(Fig.44.27). The patient opted for a great toe pulp transfer to
restore a well-padded and glabrous pulp (Fig. 44.28). The
gure demonstrates an excellent outcome and restoration of
the pulp with glabrous like for like tissue (Fig.44.29). He
had no donor site complaints apart from pigmentation from
the full thickness graft inset over the lateral edge of the great
toe (Fig.44.30).
Fig. 44.26 Donor site outcome after great toe transfer
Fig. 44.27 Painful atrophic left thumb pulp
44.7.3 Scenario C: Immediate Great Toe
toHand Transplant Surgeon Dariush
Nikkhah
Patient C had a traumatic amputation to his right dominant
thumb at the level of the interphalangeal joint (IPJ).
Revascularisation was unsuccessful and the pulp was necrotic
and amputated (Fig.44.31). An immediate great toe to hand
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