Introduction: To improve the arc of motion (AOM) and reduce the extension lag of vascularized toe proximal interphalangeal joint (PIPJ) transfers, simultaneous reconstruction of the extensor mechanism as part of the transfer has been mentioned in our preliminary report. According to diverse tendon conditions of the recipient fingers and donor toes, we rationalize 3 procedures used to reconstruct the extensor mechanism in vascularized joint transfers (VJTs). These include (1) centralization of lateral tendons when intrinsic hand muscles are non-functional, (2) central slip reconstruction when type I toes* are encountered, and (3) direct extensor digitorum longus (EDL)-to-extensor digitorum communis (EDC) repair for type II toes*. In this study, we evaluate the outcomes of VJTs reconstructed using these techniques and propose an updated treatment algorithm based on our findings. Materials and Methods: VJT was performed in a consecutive series of 26 digits in 25 patients (20 males and 5 females). The average age was 30.5 years. There were 14 right hands (dominant) and 12 left hands. Reconstructed digits included 8 index, 10 middle, and 8 ring fingers. Techniques of simultaneous extensor reconstruction included 8 centralization of lateral bands, 5 direct EDL-to-EDC repairs, and 13 central slip reconstructions. Similar protocol of postoperative rehabilitation was applied to all the patients. Results: The patients were followed up for an average of 16.7 months. The overall AOM and extension lag of the reconstructed PIPJ were 57.7° and 17.9° (81.7% functional usage of pretransferred toe PIPJ AOM), respectively. No significant difference in the results was found between the handedness ( P = .23) and between different recipient fingers ( P = .37). Comparing the outcomes of different extensor reconstructions, the extension lag after centralization, direct EDL-to-EDC repair, and central slip reconstruction were 19.4°, 13°, and 18.8° ( P = .42), respectively; The PIPJ AOM was 54.4°, 55°, and 60.8° ( P = .42); the final finger PIPJ AOM compared to the pretransferred toe PIPJ AOM was 76.3%, 79.7%, and 85.9% ( P = .34). Discussion: Due to the varied recipient finger conditions, no single technique is suitable for every scenario. Careful evaluation of recipient finger and toe tendons is required to perform the most appropriate extensor reconstruction. Using our treatment algorithm, consistent outcomes can be produced with reduced extensor lag and maximum usage of potential toe PIPJ AOM. As such, customized extensor mechanism reconstruction is important to improve the outcomes of vascularized toe PIPJ transfers. *In our clinical observations, the majority (>86%) of second toes do not have a strong, definite insertion of central slip at the base of middle phalanx (type I). On the contrary, less than 14% of second toes do have.