Thumb reconstruction for aesthetic reasons using an exteriorised microvascular pedicle

Abstract

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.