[Forum: reconstruction of the traumatic thumb. Esthetics and post-traumatic reconstruction of the thumb]

The authors deal with the aesthetic problems of traumatic thumb reconstructions from two complementary points of view: surgical and psychoanalytical. From the surgical point of view, they discuss the aesthetic factors of repair ("aesthetics equals function") in the hand and in the donor site. The features of a "good" reconstructed thumb are recalled, together with the ways of achieving this result, taking into account several imperatives related to the various techniques: the residual scar, the proportions of the thumb (length and diameter) and the appearance of the nail. The morphological sequelae at the principal donor sites (hand, forearm and foot) are also evaluated. Although sacrifice of the great toe is not longer justified, that of the second toe should be weighted up against the limited sequelae of "custom-made" great toe flaps. In the second, psychoanalytical approach to the aesthetic problem, the deep motivations underlying the patient's request are examined. In order to satisfy the patient's demand, it is essential to clearly define the indications and contraindications related to the patient's psychological make-up, the importance of the aesthetic role of his or her hand and the psychological impact of both the initial trauma and the secondary sequelae of surgery, bearing in mind that psychological factors change with time, just as the body image also varies continuously. Finally, the dual, surgical and psychoanalytical approach should allow the surgeon to satisfy the hand injury patient's functional and aesthetic demands under the best possible conditions.