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Thumb reconstruction following amputation is usually performed in order to restore function. Nevertheless, the reconstruction should be cosmetically acceptable in order to be fully functional, and, in some cases, reconstructive surgery may be justified for purely aesthetic reasons. The most satisfying aesthetic results in adults are obtained with microsurgical partial great-toe transfer. The technique that we use for thumb reconstruction is illustrated by two case reports: that of a 26-year-old female patient and that of a 35-year-old male patient. Both patients had a distal thumb amputation with destroyed nail apparatus, and both sought thumb reconstruction for cosmetic reasons. Aesthetic reconstruction was performed in both cases with a partial ipsilateral great-toe transfer, composed of nail apparatus, underlying bone and custom-made pulp tissue. The vascular anastomosis was done at the snuff-box, through a small incision, with an exteriorised pedicle. The result was satisfactory in both cases, with minimal donor-site sequelae. Partial toe transfer has proven to be a reliable technique for thumb reconstruction. It is an evolving technique. Many modifications have been introduced to optimise the aesthetic result and to reduce donor-site morbidity. Our technique allows us to restore thumb length, replace the missing nail and reconstruct the pulp, with acceptable sequelae at the donor toe. The exteriorised-pedicle technique prevents pedicle compression and twisting and reduces scarring and stiffness. It does, however, require delicate postoperative care and a second procedure for pedicle division.
The goal of most thumb reconstructions is primarily functional. Nevertheless, aesthetics is a part of function when it comes to the hand, and we consider that reconstruction of the thumb for purely aesthetic reasons is justified.
Toe transfer was first performed successfully by Cobbet in 1968
and has proven to be a fully reliable thumb-reconstruction technique, providing good functional and aesthetic results. Many modifications have since been introduced, improving the aesthetics of the reconstructed thumb and the donor toe.
We propose a modified technique for aesthetic distal-thumb and nail reconstruction by partial great-toe transfer with a temporary exteriorised pedicle. We illustrate this technique with two case reports of patients treated by the second author.
1. Case reports
1.1 Case 1
A 26-year-old African woman presented to our department seeking aesthetic reconstruction of her amputated left thumb, following a childhood injury. She had a distal amputation through the proximal third of the nail bed, with a sensitive and painless pulp. Function was not altered, but she was deeply affected by the unsightly clawing of her nail (Fig. 1(A)) .
Fig. 1Case 1. (A) Preoperative view showing clawing of nail remnant. (B) Bony fusion 6 weeks postoperatively; note the line of fusion. (C) Postoperative view at 3 months, after healing of distal necrosis. (D) Comparative view. (E) Postoperative appearance of the donor site at 3 months; note the hypertrophic scarring.
We decided to reconstruct the missing part of the thumb in order to recover a full-length natural-appearing nail. We were concerned about the risks of pathologic scarring given the patient's racial origin. After discussing the advantages and risks of the technique with the patient, we performed a partial left great-toe transfer, including the nail, nail bed and nail matrix, with the underlying bone and the lateral hemipulp. The flap was elevated with a large vascular pedicle that included the dorsal lateral artery of the great toe and two subcutaneous veins. Osteosynthesis was performed by means of two Kirschner wires, and end-to-end microanastomoses were undertaken with the radial artery and two subcutaneous veins through a small incision at the anatomical snuff box. The pedicle was left completely exteriorised. The donor site was closed directly except for the nail-bed donor site.
The pedicle was covered by a Vaseline dressing, which was renewed every 2 or 3 days.
After 3 weeks, the patient was readmitted for division of the pedicle. We discovered in the operating room that the pedicle was interrupted and mummified. The transfer was viable despite limited distal necrosis, which required debridement. The nail-bed donor site was covered by a split-thickness skin graft.
The Kirschner wires were removed after 6 weeks (Fig. 1(B)).
At 10 months follow-up, without adjustment, the aesthetic result was satisfactory, with limited scarring at the recipient site (Fig. 1(C) and (D)), and function was not altered. The donor-site sequelae were minimal despite moderately hypertrophic scarring (Fig. 1(E)).
1.2 Case 2
A 35-year-old right-handed male electromechanic was treated in our department following a crush injury to his right thumb, which resulted in amputation of the distal two-thirds of the distal phalanx. The wound healed uneventfully, and the patient returned to work 2 months later. Nevertheless, he was distressed and deeply affected by the disfigurement of his thumb (Fig. 2(A)) .
Fig. 2Case 2. (A) Preoperative view showing the totally missing nail. (B) The exteriorised pedicle. (C,D) Postoperative appearance at 1 year; the reconstructed thumb is on the left in both pictures.
Aesthetic reconstruction was undertaken with a partial right great-toe transfer 4 months after the injury. The transferred part consisted of the nail apparatus, the underlying bone and the corresponding pulp tissue. Osteosynthesis was performed with two Kirschner wires, and end-to-end microvascular anastomoses were undertaken at the snuff box with the radial artery and two subcutaneous veins. The pedicle was left exteriorised (Fig. 2(B)). Nerve repair was undertaken at the ulnar side of the reconstructed thumb.
At 3 weeks, the pedicle was divided after a clamping test. The patient returned to work 3 weeks later. At 18 months follow-up, the aesthetic result is pleasing and stable (Fig. 2(C) and (D)).
2. Discussion
Following a thumb amputation distal to the interphalangeal joint, functional alteration is minimal
and does not, by itself, justify a complex reconstructive procedure. On the other hand, the aesthetic damage is severe and distressing.
We use the term ‘aesthetic reconstruction’ for cases in which function is preserved or only slightly limited and where the main goal of reconstruction is aesthetic. To be ‘aesthetic’, a reconstruction should lead to appropriate thumb length and volume, a full pulp and a healthy nail. Scars should be kept to a minimum on the reconstructed thumb and recipient hand, as well as the donor toe. Function should not be altered.
This kind of surgery is justified for young motivated patients who are ready to assume the risks of microsurgery. Reconstruction will allow them to take out and use their hidden thumbs.
Prosthetic camouflage may, in specific cases, give an excellent aesthetic result and a slight functional improvement.
A prosthesis may be used in isolation or associated with a surgical functional reconstruction. This issue is outside the scope of this article, but it should be emphasised that prosthetic replacement may be a good solution for patients who are poor candidates for surgery and for those who are not ready to undergo a complicated procedure.
Many surgical reconstructive techniques have been described. Aesthetic results vary between these techniques.
When the nail of the injured thumb is preserved, the pulp may be reconstructed by a first- or second-toe custom-made pulp transfer. A sensitive pulp may be obtained in young patients if a nerve is sutured.
The Littler neurovascular flap cannot provide an aesthetic result because of the additional scarring. We do not recommend it for this reason and because of its limitations and sequelae.
Homodigital pulp-advancement flaps may give very good results in selected cases.
If the nail is damaged, as in the cases reported here, it should be repaired in order to obtain an aesthetic result. In these cases, thumb shortening is often obvious and requires correction. Osteoplastic reconstruction, Matev progressive lengthening and phalangisation, used for proximal thumb amputations, cannot be aesthetic procedures. Nevertheless, these procedures may be combined with an aesthetic toenail transfer, as reported by Foucher et al.
A total great-toe transfer leads to a reconstructed thumb that is too bulky and severe donor-site sequelae. In 1980, Foucher et al. introduced the ‘custom-made’ partial great-toe transfer for distal thumb reconstruction.
was another step toward aesthetic reconstruction and minimal donor-site morbidity. The result may be optimised by using the ipsilateral toe, in order to reproduce the ulnar deviation of the thumb and improve pulp opposition.
By using the lateral hemi-pulp of the great toe to reconstruct the ipsilateral thumb, the opposing surface of the reconstructed thumb will be free of scarring, and the scar on the donor toe will not be in contact with the shoe.
In the quest for more aesthetically pleasing results, Wei et al.
described a bone-width reduction procedure of the transferred great toe. This gave good results when the width discrepancy between the thumb and the great toe was important, but it lead to more significant donor-site morbidity and partial destruction of the interphalangeal joint.
Donor-site functional and aesthetic sequelae should be kept to a minimum. In order to avoid functional side effects at the donor site, at least 1 cm of proximal phalanx should be preserved.
When the only structure missing from the thumb is the nail apparatus, many reconstructive techniques are available. Simple skin grafts have been used with limited aesthetic results. Nail grafting gives unpredictable results in post-traumatic cases, partly owing to scarring of the recipient site.
A partial toe transfer may be harvested on a long pedicle and anastomosed at the anatomical snuff box, or harvested on a short pedicle and anastomosed to the digital vessels. Nakayama et al. described a venous nail transfer, harvested with a venous pedicle composed of two dorsal veins. One of these veins was arterialised by anastomosis to a recipient artery.
This technique avoids the need to delicately dissect the great-toe arteries, but carries the risks inherent in the presence of venous valves. In post-traumatic reconstructions, choosing short pedicles or venous transfers carries the risks involved in performing vascular anastomoses with small and altered recipient vessels.
In our reconstructions, we have chosen the more reliable long pedicle. We harvest the nail apparatus with the underlying bony support and, if needed, custom-made pulp tissue.
With very distal reconstructions, there are differing opinions about whether to perform a nerve repair.
We think that there is no need for an innervated transfer in nail reconstruction in the presence of a sensitive pulp.
The recipient site should be well prepared to accommodate the transferred flap, even if this means discarding some normal tissues.
For aesthetic reasons, the scars required for the passage of the pedicle and for microvascular anastomosis should be kept to a minimum. At the thumb, subcutaneous tunnelling is often sufficient to pass the pedicle, but carries a risk of vascular compression and twisting, stiffness and a bulky thumb. We avoid these problems by using an exteriorised pedicle.
This technique allows us to perform microvascular anastomosis to recipient vessels of good quality and calibre, through a limited incision at the snuff-box. Absence of twisting is controlled under direct vision, and scars are kept to a minimum. However, an exteriorised pedicle requires extremely delicate postoperative care. In our first case we could not determine the exact time of accidental blockage of the pedicle. In a total of eight cases of distal thumb and finger reconstruction with an exteriorised pedicle treated in our department in the last 2 years, we have had two other cases of accidental desiccation or tearing of the pedicle, at the sixth and eighth postoperative days. Early pedicle loss did not, however, lead to flap loss, and the limited distal flap compromise was managed conservatively. It is probable that these flaps survived as ‘enhanced grafts’, with a temporary pedicle during the first, most critical, week. Nevertheless, 3 weeks seems to be a wise delay for pedicle division, and a clamping test is good extra security. Another drawback of the exteriorised-pedicle technique is the second operation required for pedicle division. This second stage may, however, be undertaken under local anaesthesia, on an Outpatient basis, and could even be combined with early debulking of some of the excess pulp tissue.
In fact, pulp debulking and nail reduction to achieve symmetry may be performed during the initial reconstruction, during pedicle division or a few months later,
In the two reported cases, some debulking was performed during pedicle division, and no further touch-up procedures have been proposed for the time being.
In conclusion, microsurgical reconstruction of the thumb has proven to be reliable. Surgeons are now more concerned about the aesthetic aspects of their reconstructions. This quest for aesthetics should not sacrifice function.
The technique we have chosen for aesthetic distal-thumb reconstruction uses autologous tissue to lengthen the stump, replace the missing nail apparatus and restore pulp tissue, with acceptable sequelae at the donor site. By using an exteriorised pedicle, operating time is shortened, the risk of vascular compression and twisting are avoided, and scarring and stiffness are reduced. Nevertheless, exteriorised pedicles are fragile and require very delicate postoperative care until they are severed 3 weeks later under local anaesthesia.
References
Cobbet J.R.
Free digital transfer, report of a case of transfer of a great toe to replace an amputated thumb.
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