Composite Free Flap Research Articles

One-Stage Nasal Reconstruction with Full-Thickness Composite Posterior Auricular Artery Perforator Free Flap

INTRODUCTION: Although there are diverse methods of reconstruction of large full thickness defects of the nasal region including zones II and III, these methods require the patients to undergo stepwise operations and thus these methods cannot be used when the patients cannot be followed up.1 In this respect, authors are to report a one-stage reconstruction method for nasal composite tissue defects using full-thickness composite posterior auricular artery perforator free flaps. METHODS: A 25-year-old male patient presented with a nasal composite tissue defect due to a human bite without amputee (Figure 1). He was a foreigner and could not be followed up after he would leave the country three months later. In this respect, the defective nasal region was reconstructed using a one stage full-thickness composite posterior auricular artery perforator flap. The wedge shaped defective region was around 2.5x2.5cm in size. The nasal lining defect was around 0.5x1cm in size. Unlike flaps that had been reported earlier, full-thickness composite tissues were harvested including the conchal skin to include both the conchal cartilage and the posterior auricular skin. The flap was inset so that the conchal skin would become the nasal lining, the conchal cartilage would become the alar cartilage and the posterior auricular skin would become the external skin. The recipient vessel was the lateral nasal artery and since no vein was connected, systemic heparinization was used to perform a salvation of the flap. The donor site was primarily closed.Figure 1: Initial presentation of the patient.RESULTS: The flap and the donor site were maintained well without any particular events postoperatively. Based on the CT taken at 20 days after the surgery, the conchal cartilage of the flap was identified as being maintained well. Silicone sheeting was performed from six weeks after the surgery and an appropriate nasal contour maintained in situ was identified at 10 months (Figure 2). The donor site showed a minor difference in the auriculocephalic angle except for slight narrowing of the intertragic notch.Figure 2: Postoperative 10-month view of the patient.CONCLUSION: The posterior auricular artery perforator flap using the full-thickness tissues of the ear can be used in one-stage reconstruction of nasal composite defects and showed satisfactory results. This is considered to be another good alternative for existing nasal region reconstruction methods that require multiple stages.

The role of composite radial forearm free flap in current head and neck reconstructive practice

The role of composite radial forearm free flap in current head and neck reconstructive practice

Early bone resorption of free microvascular reanastomized bone grafts for mandibular reconstruction – A comparison of iliac crest and fibula grafts

ObjectivesPatients with continuous bone defects of the mandible after ablative tumor surgery need bony reconstruction for proper function and aesthetics. Free microvascular reanastomized bone grafts provide a clinically proven option for such patients, yet the optimal source of donor tissue has not yet been established. The aim of this study was to evaluate and compare the bone volume stability of vascularized bone grafts, particularly in the early highly resorptive phase, from the iliac crest (DCIA) and the fibula and to assess the implantologic rehabilitations. Materials and methodsThirty-six patients with mandibular continuity defects due to tumor resection were reconstructed by the use of vascularized bone grafts; 21 patients received DCIA flaps and 15 patients received a composite free fibular flap, depending on the size and location of the defect. Bone resorption was assessed using digital panographs. Radiographs were taken immediately after bone reconstruction, 6 months postoperatively, prior to implant surgery, and at prosthetic loading. ResultsAfter a mean observation period of 6 months, vertical bone resorption was 6.79% for the patients of the iliac crest group (DCIA), 10.20% after 11 months, and 12.58% after 17 months. Fibular grafts showed a bone resorption of 5.30% after a mean observation time of 6 months, 8.26% after 11 months, and 16.95% after 17 months. Eighteen patients received 71 implants for implant-retained dental reconstructions. ConclusionsMicrovascular reanastomized bone grafts represent a reliable treatment option for reconstruction in cases of large defects of the mandible, with low graft resorption in the early healing phase. Additionally, the compared grafts provide sufficient bone volume to permit implant rehabilitation.

Use of a titanium cutting guide to assist raising the composite radial forearm free flap

The use of composite radial free tissue transfer has been overtaken by other composite flaps. This is due to donor site morbidity and the poor volume of bone yielded. The advantages and potential complications of composite radial flaps are well described. Use of the composite radial forearm free flap has been largely superseded in mandible reconstruction, but applications such as a salvage option still exist. Additionally it may be used in the reconstruction of midface defects. The use of a cutting guide to reduce the donor site complications and yet produce a maximal yield of bone is described herein. With the use of a skilled maxillofacial laboratory, the planning allows precise cuts and placement of the free flap and allows accurate prophylactic plating of the radius. A precise titanium cutting guide and custom distal radius plate are used. Details of three cases where these techniques have been implemented are described. The paper demonstrates the significant advantages of using laboratory-based technology to assist in performing composite radial free flaps. This paper reveals that composite radial free tissue transfer still has a place in the reconstruction of very selective defects of the head and neck. In particular, its use in reconstruction of Class 5 and 6 maxillary defects (Brown classification) is illustrated. Correct case selection and planning results in increased confidence to use this flap.

Total nasal reconstruction using composite radial forearm free flap and forehead flap as a one-stage procedure with minor revision

The refashioning of the many distinct structures necessary for successful anatomical and aesthetic reconstruction of the nose after total rhinectomy is difficult. Several significant operations are needed to produce good aesthetic results with functional patency of the nasal airway. We describe a method using autologous grafts that has produced good results on both occasions when it was done. It has the advantage of only one major operation and one subsequent minor revision.

Total Lower Lip Reconstruction Using Free Neurotendinofasciocutaneous Anterolateral Thigh Composite Flap: A Case Report

Total lower lip reconstructions are challenging procedures because of poor aesthetic and functional outcomes and limited availability of donor tissues that anatomically imitate the lip. We hereby report the free neurotendinofasciocutaneous anterolateral thigh composite flap as a new reconstructive option. A 48-year-old man presenting with a squamous cell carcinoma of the lower lip underwent wide resection of tumor, bilateral neck dissection, and lower lip reconstruction with the mentioned flap where the lateral femoral cutaneous nerve and tensor fascia lata tendon were included. No complication was encountered postoperatively. The flap survived totally. Understandable speech, oral competence, and uneventful nutrition were obtained. Furthermore, tactile, pain and heat sensations, and two-point discrimination of 12 mm at the flap were regained. In reconstruction of the lower lip, this flap was first described in the literature and can be a good candidate as a reconstructive option.

OP033: Reconstruction of maxillary defects with fibular osteocutaneous flap: Review of 10 cases

Introduction Maxillary reconstruction represents a challenge for any head and neck surgeon. The development of reconstructive surgery in the last century has changed the objectives in maxillary reconstruction because we have many surgical procedures to get optimal aesthetics and functional results. Material and methods We analyzed all patients treated with reconstructive surgical techniques from 2008 to 2012 in the Department of Oral and Maxillofacial Surgery, Hospital Infanta Cristina, Badajoz. During this period we made 10 reconstructions of maxillary defects with fibular osteocutaneous flap. We reviewed the complications involved in its use as well as the characteristics of the patients. Results During this period we analyzed 10 patients with an average age of 49,3 years, 6 male and 4 female. Four patients presented squamous cell carcinoma of the head and neck, 4 patient presented other malignant tumours, 1 patient had a giant cell granuloma and finally we used fibula free flap to close an orosinusal communication. The rate of global complications was 30% without free flap failure but we had 3 partial necrosis of the skin paddle. According to the Brown and Shaw classification, the most frequent maxillary defect was type IIB which vertical component does not affect the orbit and the horizontal component is less than or equal half hard palate and alveolar process. Conclusion There is not a perfect flap for complex maxillary defects. It depends on the patient and the experience of the surgical team. With composite free flaps we achieve the best aesthetics and functional results because They holds mimic muscles of the face and allow oral rehabilitation with osteointegrated implants. Fibular osteocutaneous flap is an excellent option for type II vertical defects and types b, c and d horizontal defects with better results than other composite free flaps.

PP180: Reconstruction of total lip defect by mean of composite fasciocutaneos free flap

To show our experience in the reconstruction of total lip defects by means of composite fasciocutaneous – palmaris longus tendon free flap. Three men with a mean age of 66.33 years (range: 54–73) were diagnosed with squamous cell carcinoma of the lip region (2 of the lower lip and 1 of the upper lip). Sixty-six percent of patients received radiotherapy as the first choice of treatment, being necessary subsequent surgery for recurrent disease. All patients were reconstructed using the composite radial forearm – palmaris longus tendon free flap. In all cases, the tendon of palmaris longus was anastomosed to the orbicularis oris muscle. At a mean follow-up of two years (range: 1–3) no signs of locoregional recurrence were observed. A good aesthetic and functional result were obtained in all patients, achieving an excellent lip competence. No postoperative complications were perceived. All patients were satisfied with their final reconstructive result. Lip reconstruction is a challenge for the head and neck surgeon. In situations where large defects are originated after wide resections, reconstruction with composite microvascular flaps constitutes an excellent option.

The Reconstruction of Two Large Full-Thickness Wounds of the Upper Lip with Different Operative Techniques: When Possible, a Local Flap Repair Is Preferable to Reconstruction with Free Tissue Transfer

Large full-thickness wounds of the upper lip are often referred to operating room-based surgeons for repair given the perceived difficulties in restoring upper lip form and function with simpler operative techniques. To illustrate the functional, aesthetic, and cost differences between two techniques used to repair full-thickness wounds of the upper lip. Two patients with difficult full-thickness wounds of the majority of the upper lip were reviewed. One patient underwent reconstruction with a composite free flap in an operating room, and one underwent repair using local tissue rearrangement using bilateral modified nasolabial flaps in an outpatient setting. Both patients were adequately reconstructed, but the patient repaired using local tissue rearrangement had a better aesthetic outcome and superior preservation of oral competency. In addition, the costs of this patient's reconstructive care were less than 2.4% of the costs of the care of the patient repaired using a free flap. When possible, large, full-thickness wounds of the upper lip should be repaired with local tissue rearrangement in an outpatient setting to offer patients potential improvements in functional and aesthetic outcomes while minimizing treatment costs.

Repair of hand defects by transfer of free tissue flaps from toes

There are very few reports on the use of a free composite flap from the toe to repair small tissue defects in the hand. Here, we describe our experience using a free composite flap from the great toe and second toe. Fifteen patients sought surgical treatment for tissue defects of the hand at our medical institution from July 2008 to December 2010. These defects included: dorsal defect of the distal thumb, dorsal-radialis defect of the proximal thumb, degloving injury of distal index finger, pulp defect of the middle finger and these were repaired with toe side pulp flaps. In five subjects, treatment of the metatarsophalangeal joint (MPJ) or proximal interphalangeal joint (PIPJ) involved a combined extensor tendon defect with a composite flap with MPJs and PIPJs and the extensor tendon of the second toe. All flaps were transferred as free flaps. All flaps survived. At 34.8 months of follow-up, the average subjective satisfaction score was 8. Eleven patients (73.3 %) experienced cold intolerance, and one patient (6.7 %) dysesthesia. The Semmes-Weinstein Sensitivity Score was 3.48-4.71 at the flap and 0-4.21 at the donor site. The mean two-point discrimination was 7.13 mm. Grip strength was 10 % less than in the unaffected hand. Mobility loss in the MPJ and PIPJ was <10°. No patients had complications at the donor sites. Based on the unique characteristics of the free flap from toes, we consider them to be good options for reconstruction of small tissue defects in the hand according to various sizes, shapes, and sites.

Reconstruction of Large Defects of the Lips and Commissure Using a Composite Radial Forearm Palmaris Longus Free Flap Associated With a Lengthening Temporalis Myoplasty

We performed a single-stage operation to reconstruct a large defect of the lips and commissure using a composite radial forearm-palmaris longus free flap. To obtain cranial traction and a voluntary smile, independently from any jaw movement, traction was achieved by using a lengthening temporalis myoplasty. The tendon attached to the coronoid process was fixed to the palmaris longus tendon, recreating a new commissure and a "neo-modiolus." Physical therapy was started on the 21st postoperative day to facilitate progress from a "mandibular smile," to ideally a spontaneous and symmetric smile after 3 months of therapy. This procedure was able to obtain good oral continence and a good commissural movement during smile which has not previously been mentioned in the published literature.

Great toe transfer survival after thrombosis at 7 days

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

An anatomical study of the blood supply of the soleus muscle in humans

IntroductionThe soleus muscle is a powerful plantar flexor of the ankle joint and receives its blood supply from several different sources. AimThis study was done to describe the distribution of the arterial supply of the soleus muscle. Materials and methodsThe study was carried out at the Faculty of Medicine, University of Alexandria. Forty limbs were dissected, which included specimens from both male and female cadavers. The pattern of arterial supply of the soleus muscle and the distribution of the perforators were studied. ResultsThe soleus muscle is supplied by perforators of the popliteal, posterior tibial and peroneal arteries, the posterior tibial artery gave 38.80% of total perforators while the peroneal artery gave 33.30% of total perforators and the popliteal artery gave 27.80% of total perforators. Perforators of popliteal artery were larger; 12.9±2.07cm in length and 2.55±0.214mm in diameter while those of the posterior tibial artery had a length of 5.1±0.99cm and a diameter of 1.93±0.25mm and perforators of the peroneal artery had a length of 3.8±0.98cm and a diameter of 1.49±1.03mm. ConclusionThe soleus muscle is richly supplied by many arterial pedicles and can be used safely as a free flap, hemisoleus flap or composite flap to cover defects in the lower limb.

Reconstruction of penetrating injuries of the hand with dorsalis pedis composite free flaps: A series of 23 patients

Reconstruction of severe hand injuries remains a challenge. We herein report the use of dorsalis pedis composite free flaps (DPCFFs) for the reconstruction of penetrating injuries of the hand. From July 2001 to February 2009, 23 patients (15 males and 8 females), mean age of 26 years (range, 17-48 years), with penetrating wounds of the hand were treated with DPCFFs. A second toe composite flap was used in cases of bone, joint, tendon and skin defects, and combined flaps were used for patients with only soft-tissue defects. Total joint transplantation using the proximal interphalangeal joint of the second toe was used in 10 cases, compound flaps using the metatarsophalangeal joint of the second toe were used in six, and combined dorsalis pedis flaps were used in seven cases of soft-tissue loss. All flaps survived, no bone nonunion or malunion occurred, and primary healing was achieved at all recipient and donor sites. Mean follow-up was 11 months (range, 6-27 months). In all cases, hand function was satisfactory and aesthetic outcome was good. Sensory recovery ranged from S2 to S3. In six cases with transplanted metatarsophalangeal joints, the mean range of flexion and extension was 45° (range, 30-70°). In 11 cases with transplanted proximal interphalangeal joints, the mean range of flexion and extension was 65° (range, 35-90°). No patient experienced difficulty walking. DPCFFs are useful for the repair of composite tissue defects of the hand. III.

One-stage reconstruction of large lower lip defect and oral competence with free composite anterolateral thigh-tensor fasciae latae flap

Summary Reconstruction for a large lower lip defect is a challenge to reconstructive surgeons. The most challenging problem is to maintain oral competence and prevent sialorrhea. We present three cases of such a defect reconstructed with composite anterolateral thigh-tensor fascia lata free flaps in one stage. The patients reported in this communication had advanced squamous cell carcinoma in the lower lip. A large lower lip defect (>90%) resulted in each case from wide excision of the tumor. A composite anterolateral thigh-tensor fasciae latae free flap was used to reconstruct the defect and to restore the dynamic oral competence in one stage. A tensor fasciae latae sling was attached by two strips sutured together to the upper orbicularis oris muscle in the first case. The four-strip method, a modification of the method described by Serkan, 1 was adopted in the second case. The upper two strips bilaterally sutured to the orbicularis oris muscles in a mode somewhat different from Serkan’s method. The tensor fasciae latae sling was attached by two strips sutured to the periosteum of both zygomatic eminences in the third case. The tensor fasciae latae sling of Case 1 failed with persistent sialorrhea. The second case had good oral competence and comprehensible speech ability without sialorrhea. The third case had an acceptable result before he was lost to follow-up. A composite anterolateral thigh-tensor fasciae latae free flap is a good choice for a large lower lip defect to achieve oral competence reconstruction in one stage. Simultaneous dynamic and static suspensions are suggested to maintain oral competence and prevent sialorrhea.

Compound flaps of foot with joint transplantation bridging severed thumbs and fingers

Objective To report the methods and clinical efficacy of bridging severed thumbs and fingers with foot joint compound flaps. Methods Ten patients with completely amputated thumbs and fingers with extensive defects in the proximal phalanx had bridged and repaired by using composite-free flap with joints from foot. Three of 4 cases of thumb amputation were repaired by using composite flaps of the second metatarsophalangeal and proximal interphalangeal joints in foot,and the other was used composite flap of the second metatarsophalangeal joints in foot.Donor sites underwent the second metatarsals distal osteotomy associated with free skin graft. And 6 cases with absent fingers by using composite-free flaps of the proximal interphalangeal joint to repair. The donor site in foot underwent metatarsophalangeal and toe joints osteotomy.Results All flaps and replanted thumbs and fingers survived. Hand wounds recovered by primary repair.Donor site in foot all healed by primary repair except for 1 case,which healed after several dressing changes.All 10 cases were followed-up from 6 to 28 months,averaged of 9 months.The metacarpophalangeal joint of 4 replanted thumbs extension between -10° and 0°,and flexion between 20° and 50°.The function of fullfield digital mammography recovered well in 3 replanted thumbs, as well as the function of thumb-middle in the other. Three of them could completely 2-5 fingers tapping, one case could complete middle finger tapping,four cases could complete radial abduction.The proximal interphalangeal joints of 6 replanted fingers extension between -10° and 0°,and flexion between 30° and 90°,averaged of 50°.Sensory recovery of 1 case reached S4,two cases reached S3+,five cases reached S3,and 2 cases of S2.All replanted bones and joints healed after transplantations (bone healing time was 6 to 16 weeks), with no occurrence of re-fracture nor nonunion. Walking function was not significantly affected. According to the evaluation criteria of replanted severed fingers by Chinese Medical Association,one was excellent,eight were good,and 1 was poor.The excellent and good rate was 90％. Conclusion Repairing amputated thumbs and fingers with foot joint compound flaps could not only maximize the recovery of replanted fingers shape,but also get some function,which to meet everyday needs of patients. Key words: Fingers; Replantation; Joint transplantation; Foot; Toe ; Microsurgical techniques

A New Option for Autologous Anterior Chest Wall Reconstruction: The Composite Thoracodorsal Artery Perforator Flap

Sternal chondrosarcoma is rare and often requires total or subtotal sternectomy. The authors describe the case of a 70-year-old man with sternoclavicular joint chondrosarcoma who underwent subtotal sternectomy with partial resection of the two clavicles and anterior arches of first to third right ribs. Anterior chest wall reconstruction was performed with a composite thoracodorsal artery perforator free flap with sixth and seventh ribs vascularized on serratus muscle. The postoperative course was uneventful. Seven months after surgery, the patient was doing well. This surgical procedure is a new option for autologous reconstruction without prosthetic material after extensive sternectomy.

Transverse fascial suspension with muscle bow traction: Advantages for full-thickness lip reconstruction involving the oral commissure using free flap

Large full-thickness oral defects involving the oral commissure continue to be a challenge for reconstructive surgeons. Although local flaps are the best option for full-thickness lip reconstruction, they are unavailable for large defects. In particular, recent advances in microsurgery have extended the available surgical options using free flaps, but for full-thickness large oral defects involving the oral commissure, it is still difficult to obtain good function and competence. The major disadvantages are the drooping and loosening of the reconstructed lip and the difficulty in restoring a natural oral commissure. We present two cases of lip reconstruction for full-thickness large defects involving the oral commissure in which free flaps with the muscle bow traction method were used to overcome these problems. In case 1, the lip was reconstructed with a free radial forearm-palmaris longus tendon composite flap. The tendon was sutured onto the orbicularis oris stumps. In case 2, the lip was reconstructed with a free anterolateral thigh flap including the fascia lata. A fascial strip in the flap was sutured to the residual orbicularis muscles. In each case, additional nonvascularised fascia lata was harvested and suspended the reconstructed lip in transverse direction as a muscle bow traction method. Both patients achieved good oral competence without medial deviation of the oral commissure and were able to resume a regular diet without drooping and loosening of the reconstructed lip. For large full-thickness oral defects involving the oral commissure, transverse fascial suspension with muscle bow traction is useful for functional and cosmetic reconstruction.

Repair of Severe Composite Tissue Defects in the Lower Leg Using Two Different Cross-Leg Free Composite Tissue Flaps

This article reports 2 cross-leg free composite tissue flaps for repairing the severe composite tissue defects in lower leg without suitable adjacent recipient vasculature for microvascular anastomosis. The osseous myocutaneous flap of ilium and tensor fascia lata pedicled with ascending branch of lateral femoral circumflex vessels and the osseous muscle flap of scapula and latissimus dorsi pedicled with subscapular vessels were performed, respectively, to reconstruct the bone and soft-tissue defects in the lower leg of 2 patients. Both donor vessels were the posterior tibial artery and great saphenous vein from the contralateral lower leg. The legs and the bone flaps were immobilized by an external fixator. The periods of pedicle division were 43 and 67 days, respectively, after transplantation. Both flaps survived after pedicle division and the patients regained the ability to walk. There were no such complications as joint stiffness or donor site morbidity except for a linear scar. The 2 cross-leg free composite tissue flaps were optional methods for salvaging limbs that were otherwise nonreconstructable. But the indication for cross-leg free-tissue flap should be limited strictly.

Reconstruction of Distally Degloved Fingers With a Cross-Finger Flap and a Composite-Free Flap From the Dorsum of the Second Toe

In this article, we report the reconstruction of degloved fingers using a combination of a cross-finger flap and a composite-free flap from the dorsal aspect of the second toe. From May 2006 until April 2009, we treated 18 degloved fingers in 18 patients (13 male and 5 female patients; mean age, 22 y) using the technique. There were 11 index and 7 ring fingers. The mean volar and dorsal defects were 2.5 × 1.9 cm and 2.7 × 2 cm, respectively. The cross-finger flaps ranged in size from 2.3 × 1.6 cm to 3.5 × 2.6 cm, with a mean of 2.8 × 2.3 cm. The flaps from the dorsal second toe ranged in size from 2.4 × 2.1 cm to 4.5 × 2.3 cm, with a mean of 3.0 × 2.2 cm. At follow-up, we assessed motion and sensation. All cross-finger and free flaps survived. At final follow-up (mean, 17 mo; range, 14-25 mo), motion in the injured fingers averaged 102° and 28° at the proximal and distal interphalangeal joints, respectively. The mean static 2-point discrimination of the reconstructed finger pulps was 5 mm (range, 4-7 mm). The combination of a cross-finger flap and a composite-free flap from the dorsum of the second toe is a useful and reliable technique for reconstruction of a degloved finger. Therapeutic IV.