Sir, Survival of a great toe transfer depends on pedicle patency immediately postoperatively, as with all microvascular free flaps. Over time, neovascularisation from the recipient bed and surrounding wound margins into the graft may be sufficient to maintain flap viability independent of the primary vascular pedicle. It is not known how long the flow in the pedicle must persist for the flap to survive and there is no clear consensus regarding when free flaps become completely independent of their pedicle [1, 2]. The time it takes for a great toe transfer to develop its own blood supply from its recipient bed is still unknown. Our case shows that revascularisation can occur very early. We harvested a wrap-around flap from the great toe to reconstruct an amputated left thumb at the base of the proximal phalanx of a 32-year-old male smoker. The distal phalanx was harvested including the nail, most of the pulp, and the dorsal, lateral, and plantar skin of the great toe. An iliac crest bone graft was interposed between the proximal and distal ‘vascularised bone’ segments of the reconstructed thumb. The first dorsal metatarsal artery and accompanying vein were anastomosed at the ‘anatomical snuff box’. Total ischemic time was 2 h. Postoperatively, the patient received low molecular weight dextran (500 ml for 5 days) and aspirin (300 mg for 7 days). The patient was discharged on day 5—thanks to a perfect capillary refill of the reconstructed thumb. On day 7, clinical examination revealed a sluggish capillary refill, no bleeding from pin pricks on the tip of the reconstructed thumb and no Doppler signal at the microvascular anastomosis level. The patient returned to the operating room for re-exploration which showed complete thrombosis of the vascular pedicle (Fig. 1). All attempts at reanastomosis failed due to the extensive thrombosis throughout the vascular system of the flap. The patient was hospitalized and received intravenous heparin and dextran. He was discharged 2 days later without signs of vascular recovery of the thumb. A secondary surgical procedure was then scheduled. Surprisingly, 1 week later, the reconstructed thumb showed a normal capillary refill on the pulp giving us a reason to believe that the thumb was viable despite the present superficial epidermolysis, a small area of necrosis at the distal tip and still no detectable arterial Doppler signal distal to the anastomosis. After 10 months, the transplanted thumb showed satisfactory results (Figs. 2 and 3). Several authors have described clinical cases of free flap survival despite early loss of the pedicle blood supply [3, 4]. These papers suggest that after 12 days, adequate revascularisation from the recipient bed may allow at least partial flap survival. Recent clinical cases even suggest that the time may be further reduced [2, 5, 6] to 6–9 days. However, many authors have described complete loss of free flaps several months after surgery, thus highlighting the dependency of free flaps on their vascular pedicle up to 1 year after free tissue transfer [7, 8]. The process of revascularisation is believed to be dependent upon a variety of factors including type of flap used, flap thickness, quality of recipient site and ischemic time during transfer [2–4]. Free flaps are more likely to survive after vascular thrombosis if they have a sufficient marginal inset of their cutaneous portion and contact with the recipient bed [9]. It is evident, therefore, that the process of neovascularisation varies [2]. As already reported, the current consensus is that a free flap can survive after early interruption of the vascular pedicle. However, the cases reported describe the use of fasciocutaneous [1–5] or muscle free flaps [6], whereas in our case, we transferred a composite osteo-onychocutaneous free flap. Transplanted toes, similar to replanted thumbs, can survive even L. Lazzaro Hand Surgery Department, Azienda Ospedaliera Universitaria Integrata Verona, Verona, Italy