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Further aesthetic refinement for great toe transfers
Journal of Plastic, Reconstructive & Aesthetic Surgery (2010) 63, e109ee110
CORRESPONDENCE AND COMMUNICATION
Further aesthetic refinement for great toe transfers* We describe a simple effective secondary aesthetic refinement for thumbs reconstructed by a trimmed-greattoe-transfer, or a modification of Morrison’s wrap-around technique that includes the whole distal phalanx in the transfer.1e3 These methods utilise a longitudinal osteotomy on the tibial side of the toe to reduce the transverse dimension of the reconstructed thumb.3 The remaining tubercle and overlying soft tissue can be prominent, which occasionally bothers patients. We offer this operation to patients who actively seek reduction of the prominence, as we have observed the secondary gain of increased selfconfidence to utilise the reconstructed thumb more openly in daily life in those who have undergone the procedure. The following technique is most suitable for modified wrap-around great toe transfers. Following local anaesthesia, exsanguination, and under tourniquet control, a longitudinal incision is completed down to bone immediately dorsal to the peak of the remaining tubercle, avoiding the neurovascular bundle and germinal matrix. Dissection continues subperiosteally to reveal the tubercle, which is electrically burred to a smooth contour whilst protecting adjacent tissues (Figure 1). The wound is closed, tourniquet released, haemostasis secured by compression, and a dry dressing applied. The patient can recommence use of the thumb as tolerated. The technique can be modified for those patients who possess the interphalangeal joint from a trimmed-great-toe or total great toe transfer (Figure 1 inset). The incision is placed in the midlateral line, instead of slightly dorsally, and the tubercle accessed by incising the collateral ligament of the interphalangeal joint between its fibres through its midpoint to create two flaps that can be raised subperiosteally, one based dorsally and the other based plantarly. These flaps are re-draped2 once the tubercle has been debulked.
* Presented at the American Society for Reconstructive Microsurgery, 12the15th January 2008, Beverly Hills, California, United States of America.
The results of the technique can be illustrated with a case example. In October 2003, a thirty-year old bookbinder sustained a non-replantable crush-amputation of his dominant left thumb at the interphalangeal joint. A modified ipsilateral great toe wrap-around transfer, including the distal phalanx as its only bony component,4 was performed seven days post-injury. The tibial-side soft tissues and bone were reduced by one third and the interphalangeal joint fused in 15 flexion. He restarted his job within two months but requested cosmetic improvement of the thumb. Four months after reconstruction he underwent pulp plasty5 but remained deeply embarrassed by the prominence on the ulnar side of his reconstructed thumb (Figure 2a). It was debulked as described in July 2005. The patient was delighted with the result (Figure 2b) and was no longer embarrassed to show and use the reconstructed thumb in public daily life. Nail growth remained normal. Thumb reconstruction by microsurgical transfer of the great toe has become an established procedure that generally meets the functional requirements identified by
Figure 1 The reconstructed thumb is asymmetric in width due to the remaining fibular tubercle and overlying excessive soft tissues (left). Similarly, a thumb reconstructed by trimmed-great-toe-transfer remains prominent on the fibular side (inset). Bone and soft tissues to be debulked by the described technique are indicated.
1748-6815/$ - see front matter ª 2008 British Association of Plastic, Reconstructive and Aesthetic Surgeons. Published by Elsevier Ltd. All rights reserved. doi:10.1016/j.bjps.2008.08.058
e110
Correspondence and communication
Figure 2 (a) Prominence on the fibular side of the transferred trimmed-great-toe. (b) Aesthetic result, in the same clinical case, nine months after the described procedure.
Bunnell and Littler.3 However, good mechanical thumb function documented in clinic does not necessarily equate with good functional use by the patient in daily life.1,2 Self-consciousness regarding the aesthetics of the reconstruction causing concealment and disuse is an unfortunate outcome. As the great toe possesses a broader nail and is fleshier and wider in anteroposterior and transverse dimensions, a cosmetically acceptable reconstruction can only be achieved when each of these differences is appropriately addressed.5 Morrison’s wrap-around technique first permitted tailoring of each of these discrepancies but failed to gain universal popularity due to its key disadvantages: bone graft resorption and fracture, restricted mobility, pulp instability.1,3 Various modifications have attempted to rectify these, such as: 1) include vascularized distal phalanx for pulp stability; 2) longitudinal osteotomy to reduce the transverse dimension; 3) plantar-side burring to reduce anteroposterior thickness of the phalanx.4 The trimmed-great-toe-transfer incorporates vascularized skeleton distal to a variable portion of the proximal phalanx.2 Each skeletal component can be reduced on the tibial side by up to one third with a longitudinal osteotomy, while interphalangeal joint stability is preserved by repairing the peri-joint flap under proper tension.2 Despite such improvements, minor revisions are not uncommon requests from patients who hope for a more refined reconstruction.5 Pulp plasty, for example, cosmetically enhances the thumb and the flatter pulp improves functional stability in power pinch, and improves sensation.5 The presented technique is a further aesthetic refinement following thumb reconstruction by the trimmedgreat-toe-transfer or the modifications of the great toe wrap-around flap that incorporate the distal phalanx. The
fibular side is better not debulked during the microsurgical transfer to safeguard the nearby vascular pedicle. Prominence of this remaining tubercle is an uncommon complaint but can cause such patients to restrict open use of their reconstructed hand. Patient satisfaction following this operation has been high and the improved cosmesis has encouraged each to use the reconstructed thumb more openly in daily life.
References 1. Morrison WA, O’Brien BM, MacLeod AM. Thumb reconstruction with a free neurovascular wrap-around flap from the big toe. J Hand Surg [Am] 1980;5:575e83. 2. Wei FC, Chen HC, Chuang CC, et al. Reconstruction of the thumb with a trimmed-toe transfer technique. Plast Reconstr Surg 1988;82:506e15. 3. Wei FC, Chen HC, Chuang CC, et al. Microsurgical thumb reconstruction with toe transfer: selection of various techniques. Plast Reconstr Surg 1994;93:345e51. 4. El-Gammal TA, Wei FC. Microvascular reconstruction of the distal digits by partial toe transfer. Clin Plast Surg 1997;24: 49e55. 5. Wei FC, Chen HC, Chuang DC, et al. Aesthetic refinements in toe-to-hand transfer surgery. Plast Reconstr Surg 1996;98: 485e90.
Christopher G. Wallace Fu-Chan Wei Department of Plastic Surgery, Chang Gung Memorial Hospital, Chang Gung University and Medical College, Taipei, Taiwan E-mail address: [email protected]
CORRESPONDENCE AND COMMUNICATION
Further aesthetic refinement for great toe transfers* We describe a simple effective secondary aesthetic refinement for thumbs reconstructed by a trimmed-greattoe-transfer, or a modification of Morrison’s wrap-around technique that includes the whole distal phalanx in the transfer.1e3 These methods utilise a longitudinal osteotomy on the tibial side of the toe to reduce the transverse dimension of the reconstructed thumb.3 The remaining tubercle and overlying soft tissue can be prominent, which occasionally bothers patients. We offer this operation to patients who actively seek reduction of the prominence, as we have observed the secondary gain of increased selfconfidence to utilise the reconstructed thumb more openly in daily life in those who have undergone the procedure. The following technique is most suitable for modified wrap-around great toe transfers. Following local anaesthesia, exsanguination, and under tourniquet control, a longitudinal incision is completed down to bone immediately dorsal to the peak of the remaining tubercle, avoiding the neurovascular bundle and germinal matrix. Dissection continues subperiosteally to reveal the tubercle, which is electrically burred to a smooth contour whilst protecting adjacent tissues (Figure 1). The wound is closed, tourniquet released, haemostasis secured by compression, and a dry dressing applied. The patient can recommence use of the thumb as tolerated. The technique can be modified for those patients who possess the interphalangeal joint from a trimmed-great-toe or total great toe transfer (Figure 1 inset). The incision is placed in the midlateral line, instead of slightly dorsally, and the tubercle accessed by incising the collateral ligament of the interphalangeal joint between its fibres through its midpoint to create two flaps that can be raised subperiosteally, one based dorsally and the other based plantarly. These flaps are re-draped2 once the tubercle has been debulked.
* Presented at the American Society for Reconstructive Microsurgery, 12the15th January 2008, Beverly Hills, California, United States of America.
The results of the technique can be illustrated with a case example. In October 2003, a thirty-year old bookbinder sustained a non-replantable crush-amputation of his dominant left thumb at the interphalangeal joint. A modified ipsilateral great toe wrap-around transfer, including the distal phalanx as its only bony component,4 was performed seven days post-injury. The tibial-side soft tissues and bone were reduced by one third and the interphalangeal joint fused in 15 flexion. He restarted his job within two months but requested cosmetic improvement of the thumb. Four months after reconstruction he underwent pulp plasty5 but remained deeply embarrassed by the prominence on the ulnar side of his reconstructed thumb (Figure 2a). It was debulked as described in July 2005. The patient was delighted with the result (Figure 2b) and was no longer embarrassed to show and use the reconstructed thumb in public daily life. Nail growth remained normal. Thumb reconstruction by microsurgical transfer of the great toe has become an established procedure that generally meets the functional requirements identified by
Figure 1 The reconstructed thumb is asymmetric in width due to the remaining fibular tubercle and overlying excessive soft tissues (left). Similarly, a thumb reconstructed by trimmed-great-toe-transfer remains prominent on the fibular side (inset). Bone and soft tissues to be debulked by the described technique are indicated.
1748-6815/$ - see front matter ª 2008 British Association of Plastic, Reconstructive and Aesthetic Surgeons. Published by Elsevier Ltd. All rights reserved. doi:10.1016/j.bjps.2008.08.058
e110
Correspondence and communication
Figure 2 (a) Prominence on the fibular side of the transferred trimmed-great-toe. (b) Aesthetic result, in the same clinical case, nine months after the described procedure.
Bunnell and Littler.3 However, good mechanical thumb function documented in clinic does not necessarily equate with good functional use by the patient in daily life.1,2 Self-consciousness regarding the aesthetics of the reconstruction causing concealment and disuse is an unfortunate outcome. As the great toe possesses a broader nail and is fleshier and wider in anteroposterior and transverse dimensions, a cosmetically acceptable reconstruction can only be achieved when each of these differences is appropriately addressed.5 Morrison’s wrap-around technique first permitted tailoring of each of these discrepancies but failed to gain universal popularity due to its key disadvantages: bone graft resorption and fracture, restricted mobility, pulp instability.1,3 Various modifications have attempted to rectify these, such as: 1) include vascularized distal phalanx for pulp stability; 2) longitudinal osteotomy to reduce the transverse dimension; 3) plantar-side burring to reduce anteroposterior thickness of the phalanx.4 The trimmed-great-toe-transfer incorporates vascularized skeleton distal to a variable portion of the proximal phalanx.2 Each skeletal component can be reduced on the tibial side by up to one third with a longitudinal osteotomy, while interphalangeal joint stability is preserved by repairing the peri-joint flap under proper tension.2 Despite such improvements, minor revisions are not uncommon requests from patients who hope for a more refined reconstruction.5 Pulp plasty, for example, cosmetically enhances the thumb and the flatter pulp improves functional stability in power pinch, and improves sensation.5 The presented technique is a further aesthetic refinement following thumb reconstruction by the trimmedgreat-toe-transfer or the modifications of the great toe wrap-around flap that incorporate the distal phalanx. The
fibular side is better not debulked during the microsurgical transfer to safeguard the nearby vascular pedicle. Prominence of this remaining tubercle is an uncommon complaint but can cause such patients to restrict open use of their reconstructed hand. Patient satisfaction following this operation has been high and the improved cosmesis has encouraged each to use the reconstructed thumb more openly in daily life.
References 1. Morrison WA, O’Brien BM, MacLeod AM. Thumb reconstruction with a free neurovascular wrap-around flap from the big toe. J Hand Surg [Am] 1980;5:575e83. 2. Wei FC, Chen HC, Chuang CC, et al. Reconstruction of the thumb with a trimmed-toe transfer technique. Plast Reconstr Surg 1988;82:506e15. 3. Wei FC, Chen HC, Chuang CC, et al. Microsurgical thumb reconstruction with toe transfer: selection of various techniques. Plast Reconstr Surg 1994;93:345e51. 4. El-Gammal TA, Wei FC. Microvascular reconstruction of the distal digits by partial toe transfer. Clin Plast Surg 1997;24: 49e55. 5. Wei FC, Chen HC, Chuang DC, et al. Aesthetic refinements in toe-to-hand transfer surgery. Plast Reconstr Surg 1996;98: 485e90.
Christopher G. Wallace Fu-Chan Wei Department of Plastic Surgery, Chang Gung Memorial Hospital, Chang Gung University and Medical College, Taipei, Taiwan E-mail address: [email protected]