PURPOSE: Non-vascularized toe phalanx transplantation was first described to lengthen or reconstruct fingers, though criticized for high rates of avascular necrosis. More recently, vascularized transfer has improved graft survival, with adequate perfusion enabling increased growth. The aim of this study was to compare the indications, techniques, and outcomes of vascularized and nonvascularized toe-to-hand transfer surgery in patients with congenital hand differences. METHODS: A systematic review was conducted according to PRISMA guidelines. Studies containing data on indications, surgical technique, and outcomes for patients with congenital absence or deficiency of digits or thumb treated with toe-to-hand transfer were included. Confidence intervals (CI) were calculated for outcomes of the two toe transfer techniques. Failure was defined as resorption of the graft or necrosis necessitating removal. The 95% CIs were used to determine difference in outcomes. Statistical significance was determined using a chi-square test. RESULTS: Forty studies published between 1978 and 2020 were included, containing 534 patients and 866 transfers. Twenty-three studies (58%) described only vascularized/microsurgical toe-to-hand transfers, 15 (38%) described nonvascularized, and 2 (5%) included patients with both. There were 133 men (53.4%) and 116 (46.6%) women. Three hundred nineteen patients (59.7%) had vascularized transfers, 214 (40.1%) nonvascularized, and one had both (0.2%). The mean age for vascularized transfers was 2.5 years (range 6 months–17 years) and 3.1 years (range 6 months–22 years) for nonvascularized. Follow-up for the vascularized group was 4 months to 11 years and 6 months to 35 years in the nonvascularized group. Symbrachydactyly was the most common indication in both groups (46.3%, 45.3%). The most commonly transplanted vascularized toe was the second one (91.5%). The fourth toe was most commonly used in the nonvascularized group (61.9%). Vascularized toe transfers were most commonly used to reconstruct the thumb (53.3%) or unspecified fingers (25.9%). The thumb was also most commonly reconstructed in nonvascularized transfers (30%), followed by the middle (19.2%), ring and pinkie (17.8% each), and index finger (14.6%). In cases where hands were bilaterally affected, most often one vascularized toe was transferred to each affected hand (74%, second toe in 88% of these). For bilaterally affected patients in the non-vascularized group, 60% had one transfer to each hand (fourth and fifth toes preferred). Vascular complications were most common after vascularized transfers, occurring in 6.8% of transfers, though 94.7% of these were ultimately successful after reoperation. Resorption accounted for most complications after nonvascularized transfers, with a 12.6% resorption rate. The resorption rate was 0.7% in the vascularized group. Instability occurred after 5.6% of nonvascularized transfers and 0.7% of vascularized. Vascularized toes showed better healing, range of motion, and growth. In the vascularized group, there was a higher success rate of 98.6% (95% CI 97.4%–99.7%). The nonvascularized group had a success rate of 86.8% (95% CI 83.6%–90%), (P < 0.001). CONCLUSIONS: Both toe transfer techniques are good options for reconstruction of congenital absence or deficiency of digits or thumb. Our study found a higher success rate in vascularized compared with nonvascularized transfers. Indications and approach for each technique varied among patients treated by the same author.