Thumb and fingertip reconstruction by composite microvascular tissue from the toes

Toe-pulp web flaps have the potential to almost replicate the missing tissues resulting from defects of the thumb and fingers. The possibility of short- and long-term donor site morbidity and the technical demands of these transfers limit their use mainly to largish defects on the dominant sensory aspects of the radial digits. This limitation is especially true of the thumb, where a large volume of tissue is usually required. The toenail can be included or transferred alone. A logical extension of these pulp and nail flaps is the wrap-around procedure for total thumb amputations at or distal to the metacarpophalangeal joint. In this procedure, a sleeve of skin, pulp, and nail is wrapped around an iliac crest bone graft to create an almost exact size match of the missing thumb while preserving all of the toes. Palmar or first-web defects in the hand do not need specialized skin replacement for function, and foot flaps are rarely indicated in these sites.