Partial Second Toe Pulp Free Flap for Fingertip Reconstruction

HAND/PERIPHERAL NERVE

Partial Second Toe Pulp Free Flap forFingertip Reconstruction

Dong Chul Lee, M.D.Jin Soo Kim, M.D., Ph.D.

Sae Hwi Ki, M.D.Si Young Roh, M.D.Jae Won Yang, M.D.

Kevin C. Chung, M.D., M.S.

Kyung-Ki Do, Korea;and Ann Arbor, Mich.

Background: The authors present their clinical experience and surgical meth-ods of fingertip coverage using a short-pedicle partial medial second toe pulpfree flap. The surgical steps for reducing surgical time and donor-site morbidityare described.Methods: Between April of 1999 and September of 2006, 929 partial second toepulp free flaps were performed in 854 patients. The indications for this flap werepreservation of digital length to cover exposed bone and replacement of skinover unstable fingertip scars. A total of 156 patients were assessed more than 1year postoperatively with the two-point discrimination test.Results: The mean patient age was 34 years (range, 20 months to 72 years); 747of 854 were male. The overall survival rate was 99.7 percent. Fifty-seven patientshad two fingertip defects covered with bilateral second toe pulp flaps and ninehad three defects covered with bilateral second toe pulp flaps and a third toepulp flap. Donor-site complications occurred in 59 cases (hematoma, n � 39;wound separation, n � 20). No gait disturbance or painful toes were observedat the donor site. Static two-point discrimination averaged 8 mm (range, 4 to 15mm). A total of 264 patients required additional surgical procedures, includingskin grafting at the recipient site (n � 154) and secondary flap revision (n �110).Conclusions: The shorter pedicle and smaller flap can reduce the surgical timeand morbidity associated with this procedure. This flap is the authors’ first lineof treatment for covering fingertip wounds by transferring similar pulp tissuefrom the toe to the finger. (Plast. Reconstr. Surg. 121: 899, 2008.)

Fingertip amputation is a common injuryaround the world. The treatment for thisinjury is controversial. Many techniques have

been described, including simple revision ampu-tation, skin grafting, local flaps, island flaps, dis-tant flaps, and free flaps.1–9 If the bone is notexposed, allowing the wound to heal by secondaryintention can yield surprisingly good outcomes.1,2

No one technique is applicable to the wide varietyof fingertip injuries. The optimal treatment de-pends on many factors, such as patient preference,national culture, health care system, and expertise

of the treating surgeon. We prefer the toe pulpfree flap because it replaces the glabrous tissueover the fingertip with a similar tissue type, andour technical refinement has markedly decreasedthe operative time associated with this free flapprocedure.

It is crucial that the treating surgeon has cleargoals to preserve functional and aesthetic appear-ance of the injured digit. Although revision am-putations may be the most expedient treatmentoption, painful neuromas can occur, and the aes-thetic appearance associated with the amputationstumps can be quite bothersome to certainpatients.1,2 The hand is the second most noticeablepart of the body after the face, and restoring theaesthetic appearance of the hand is increasingly rec-ognized as an important goal of reconstruction.10

From the Department of Plastic and Reconstructive Surgery,Kwang-Myung Sung-Ae General Hospital, and the Sectionof Plastic Surgery, Department of Surgery, University ofMichigan Health System.Received for publication February 6, 2007; accepted April 5,2007.Presented at the 10th Triennial Congress of the InternationalFederation of Societies for Surgery of the Hand, in Sydney,Australia, March 11 through 15, 2007.Copyright ©2008 by the American Society of Plastic Surgeons

DOI: 10.1097/01.prs.0000299945.03655.0d

Disclosure: None of the authors has a financialinterest in any of the products, devices, or drugsmentioned in this article.

www.PRSJournal.com 899

In the national culture of Korea, the need torestore missing body parts is based on ancientConfucian teaching of respecting the body thatwas given to one by their parents. Korean patientsinvariably will demand replantation following alltypes of finger injuries even though they recognizethat the function may not be optimal and therehabilitation period may be prolonged. In addi-tion, patients are keen to restore the aestheticappearance of the finger when replantation at-tempts are not successful. Based on this demand,we have an extensive experience in performingpartial second toe pulp free flaps to restore thefunctional and aesthetic needs after fingertip am-putations. We have developed a technique to har-vest partial second toe pulp for transfer by meansof a short pedicle that minimizes donor-site mor-bidity. This technique avoids the extensive dorsalispedis artery harvest, and the expediency of per-forming this procedure has expanded our indica-tions for the partial-pulp toe free flap. The specificaim of this article is to share our experience andpresent the outcomes of 929 cases of second toepartial-pulp free flap transfer for reconstructingfingertip soft-tissue defects.

PATIENTS AND METHODSWe retrospectively performed a chart review to

collect demographic and surgical data. A group ofpatients returned for sensory outcomes evalua-tion. One hundred fifty-six patients had more de-tailed examinations using the two-point discrimi-nation test when they returned for additionalreconstructive procedures for associated injuriesor when they had medical checkups for other dis-eases. Our indications for performing this freeflap procedure are defects at the fingertips withexposure of bone after amputations. We also per-form this procedure for painful atrophic fingertipinjuries associated with soft-tissue deficits. Wechose not to perform this procedure in patientswho had uncontrolled diabetes and vascular dis-eases because we had flap failures in the first twopatients with these risk factors, before the datacollection for this series.

Five surgeons contributed patients to this se-ries that consisted of 929 flaps in 854 patientstreated from April of 1999 to October of 2006. Forreconstructing multiple defects, the surgeon har-vested flaps from the second toes of both feet. Foroccasional cases of three-finger defects, we har-vested both second toes and a flap from the thirdtoe using similar techniques.

The flap is limited to the tibial half of the pulptissue. We harvested the medial plantar digital

artery, plantar subcutaneous vein, and the plantardigital nerve at the level of the metatarsophalan-geal joint. The donor site is often closed primarily.To prevent excessively tight closure, we apply skingrafts for donor wounds that cannot be closedprimarily.

Surgical TechniqueWe prefer to use brachial plexus block and

spinal anesthesia for the surgical procedure, butseven patients requested general anesthesia. Allchildren’s procedures were conducted under gen-eral anesthesia. For 15 cases, we performed meta-carpal block for the fingers and metatarsal blockfor the toes under minimal sedation. The opera-tion was performed under tourniquet control andmoderate amount of exsanguination to preservethe visibility of the small volar digital veins.11 Theskin, the medial plantar artery, and the subcuta-neous vein were harvested. The digital nerve sup-plying the flap was used for sensory innervation. Atthe recipient finger (Fig. 1), we anastomosed thevessels to the digital artery and volar subcutaneousveins of the finger.

After adequate debridement of the recipientfinger, the defect was measured with a pattern. Weused a zigzag incision over the volar finger, takinggreat care to preserve the subcutaneous veins lo-cated on either side of the joint crease. The flapincision was made over the medial or tibial side ofthe second toe (Fig. 2). The flap incision does notextend beyond the midline so that the donor sitecan be closed. The average flap measured 2.7 cmin length and 1.7 cm in width. The largest flap thatcould be harvested and donor site closed was 3.3cm in length and 2.3 cm in width. However, to en-

Fig. 1. A 29-year-old industrial worker with a total pulp defect ofthe middle finger.

Plastic and Reconstructive Surgery • March 2008

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sure primary closure of the donor site, the largestflap that we could harvest was less than three-fifths ofthe width of the glabrous toe pulp. We retained a2-mm width of skin adjacent to the eponychial folddistal to the nail matrix to prevent nail problems.Proximally, the flap was designed in a teardropshape, with zigzag incision extending to the medialplantar surface of the toe for vessel harvest.

The subcutaneous vein was located just underthe dermal layer and the incision made carefullyto prevent injuring the underlying veins (Fig. 3).The medial flap (Fig. 4) was elevated with sharpdissection just under the subcutaneous tissue. Weoften massage the calf to fill the subcutaneousveins to help see the veins. The veins usually runalong the sides of the joint creases. At the base ofthe teardrop flap, careful dissection under 3.5�loupe magnification will enable identification ofthe tenuous subcutaneous vein entering the flap(Fig. 5). We have not encountered situations inwhich the veins were absent, but there are sizevariations of the subcutaneous vein ranging from0.8 to 2 mm in adults. The flap may be suppliedby one or two subcutaneous veins. After identify-ing the vein attaching to the flap, we incised theflap to the pretendinous layer on either side of thepulp tissue (Fig. 6). We performed the dissectiondistally by dividing the vertical fibers attaching theskin to the bone. After clearing the distal verticalfibers, we can then locate the digital artery of thetoe supplying the flap. A landmark that can assistin finding the medial digital artery is to find theconnecting branch with the fibular side of thedigital artery at the level of the proximal distalphalanx. The bleeding point that is seen in Figure7 came from the divided crossing vessel betweenthe two proper digital arteries. Flap dissection con-

tinued proximally by separating the vertical fibers.At the level of the distal interphalangeal joint, wealso found an arterial branch that looped the pha-lanx in its course to the dorsal phalanx (Fig. 8).This side branch must be carefully cauterized tofully expose the arterial pedicle to the level of themetatarsophalangeal joint. This teardrop-shapedflap contained a 2-cm-long neurovascular pedicle(Fig. 9).

The donor site could be closed primarily inmost situations (Fig. 10). We have found that, incertain cases of tight closure, blanching of the toemay occur but perfusion will return after 1 hour.If the toe still shows decreased perfusion after 1hour, a skin graft can be used to cover a portionof the wound after selected suture removal.

The diameter of the digital artery of the toe fitsthe digital artery of the finger quite well at the levelof the middle phalanx. We often use 9-0 or 10-0nylon suture for repair. We repair the nerve asclose to the flap as possible to encourage earlysensory recovery. For distal flap procedures, nerverepair may not always be necessary. However, thesensory nerve to the flap is incorporated into theflap design, and repairing the nerve does not add

Fig. 2. Design of the flap; flap A should be elevated by preservingthe subcutaneous vein.

Fig. 3. The flap incisions are made to the subdermal layer.

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additional effort for us but may enhance patientsensory outcome. The volar finger veins are typi-cally 1.2 to 1.5 mm in diameter in the middle

phalanx level. Occasionally, the vein may not besufficient for drainage and the flap can be con-gested. We have found that using medicinal

Fig. 5. The subcutaneous vein can be seen rather clearly.

Fig. 6. The midline incision goes through the pulp to the pre-tendinous layer.

Fig. 4. Flap A is elevated to identify the subcutaneous vein.


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leeches for 2 to 5 days is quite effective in reversingvenous congestion. Our protocol requires the useof dextran-40 for 5 days and occasional use ofheparin in the subtherapeutic dose. The flap issutured in place, and outcomes are quite satisfac-tory in most cases (Figs. 11 through 13).

RESULTSThe anatomical areas for flap coverage in-

cluded 426 flaps for coverage at the nail level, 287distal to the distal interphalangeal joint, and 216at the middle phalanx level. Five surgeons per-formed 929 flaps in 854 patients from April of1999 to October of 2006. This patient group con-sisted of 747 male patients with ages ranging from2 to 72 years (mean, 34 years). The demographicdata are listed in Table 1.

The overall survival rate of this procedure is99.7 percent; three flaps failed completely. Com-plications included 72 flaps that experienced ar-terial spasm: 15 required segmental arterial resec-tion and primary repair and 57 required repairwith vein grafting. Of these 72 flaps with problems,three failed completely, two required coverage

with a regional flap, and one had a revision am-putation. The data are summarized in Table 2.

We used leech therapy in 58 flaps for transientvenous congestion, and all of them were treatedsuccessfully. Although the use of leeches consti-tutes only 6.2 percent of this series, it does notimply that venous anastomosis is not necessary,

Fig. 7. The flap is retracted medially. It shows the arterial bleed-ing at the mid pulp of flap, which is the bleeding point from di-vided arterial arch.

Fig. 8. The digital artery is now exposed along the medial side ofthe skin flap.

Fig. 9. The harvested flap will be dissected under the micro-scope to isolate the artery, vein, and nerve.


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and the flap survives as a composite graft. Giventhat most of the flaps we harvest are sufficientlylarge, they will not survive as composite grafts with-out adequate blood inflow and outflow.

In 57 patients, we covered two finger defectswith partial second toe free flaps from each foot.In nine patients with three fingertip defects, weused bilateral second toe partial toe free flap fortwo of the fingers and a partial toe free flap fromthe third toe.

The mean pedicle length was 2.5 cm for thisshort pedicle technique. The mean operative timewas 90 minutes for the entire procedure becausewe have gained a great deal of proficiency in flapharvest. Initially, flap harvest took 40 minutes, butwe have decreased the mean flap harvest time to14 minutes in recent cases.

Donor-site complications included 59 cases.Thirty-nine were from hematomas and the re-maining 20 were attributable to wound dehis-cence and were treated with secondary closure.These data are summarized in Table 2. All woundsthat could not be closed primarily were left to closeby secondary intention. Most patients were able towalk 5 days after surgery, and gait disturbance wasusually not seen 3 weeks after surgery. We per-formed revision procedures in 264 fingers thatrequired flap contouring or split-thickness skingrafting for coverage of open wounds. The addi-tional surgical procedures required were usuallyattributable to patient demand. In some of thesecases, it was difficult initially to contour the flap tothe recipient site sufficiently to have an acceptableaesthetic outcome for some patients. In 81 pa-tients, volar skin contractures at the fingers werereleased with Z-plasties. We were careful about notharvesting an excessive amount of tissue from thetoe that would cause donor-site problems. There-fore, we have not observed hammer-toe deformity,gait disturbance, or painful toes at the donor site.

We had functional outcomes evaluation in 156patients who had more than 1-year follow-up. We

Fig. 10. The donor site is closed primarily.

Fig. 11. Nine months after surgery.

Fig. 12. Good flap contour on the finger.

Fig. 13. Donor toe appearance.


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found that the mean sensory two-point discrimi-nation was 8 mm (range, 4 to 15 mm). Patientsyounger than 35 years had better sensory recovery(two-point discrimination, 6 mm) than thoseolder than 35 years (9 mm).

DISCUSSIONSince the introduction of the microsurgery

field over 40 years ago, refinement of flap con-structs and better surgical expertise have markedlyimproved the performance of free flaps.12–17 Giventhat very small vessels (�1 mm) can now be anas-tomosed with a high rate of success, it is not nec-essary today to harvest a bulky flap using an ex-tensive proximal exposure incision to find vesselssufficiently large for anastomoses.15–20 With thistechnique, we have markedly decreased the op-

erative time required to harvest a short pedicleand still have a greater than 99 percent success raterepairing vessels that are in the range of 1 mm.This short pedicle technique has the advantage ofmore expedient flap elevation, less trauma to thefoot, and less conspicuous donor-site scarring byobviating a dorsal foot incision to harvest moreproximal vessels. There is also less concern withkinking of a long pedicle and potential compres-sion of the pedicle when tunneling it to reachlarger diameter vessels at the recipient site. How-ever, the disadvantages of this technique must beacknowledged. The volar toe vein is tenuous, andthe surgeon must be quite meticulous in handlingthis tenuous vessel. However, with experience, sur-geons should be able to find these vessels in apredictable fashion. Our relatively short flap har-vest time indicates that, with practice, this tech-nique can be performed with relative ease.19 Thesurvival rate is based on the number of flaps thatsurvived after all surgical intervention (926 of929). However, the high survival rate does notindicate a high rate of patient satisfaction out-come. A high proportion of the reconstructedfingers do require secondary procedures.

Methods proposed for reconstructing finger-tip injuries can be controversial. Some surgeonsprefer simpler techniques such as cross-fingerflaps or shortening of the digits in an effort todecrease the complexity of the surgical recon-struction. However, the surgeon must also con-sider other more optimal options based on thecomplexity of the fingertip wound, patient re-

Table 1. Demographic Data for the Study Subjects

Age Group No. of Subjects Thumb Index Middle Ring Little Total Digits

0–9 yearsMale 14 2 4 5 2 1 14Female 10 1 3 4 2 0 10






�60 yearsMale 10 2 3 1 4 0 10Female 0 0 0 0 0 0 0

Total 854 98 312 295 167 57 929

Table 2. Recipient- and Donor-Site Complications:Arterial Spasms*

Type ofComplication Repair/Treatment

No.of

Cases

Recipient siteArterial spasms* Segmental arterial resection

and primary repair15

Vein grafting 57Total 72

Donor siteHematoma Evacuation and repeated

closure39

Wound dehiscence Secondary closure 20Total 59

*Three of these flaps failed completely. Two required coverage witha regional flap and one had a revision amputation.


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quirements, and surgeon preference to creativelyreconstruct the fingertip to minimize deformityand to enhance function.15,18 Certain patients whowant aesthetic refinement of finger contour afteramputation may be best served by replacing losttissue with like tissue from the foot to enhance theaesthetic appearance of the fingers.13–19 In addi-tion, the rapid sensory regeneration to highly sen-sate glabrous toe skin can minimize neuroma painassociated with a lack of a distal sensory organ.20

From this standpoint, the partial second toe freeflap is an alternative consideration for fingertipreconstruction when this technique can be per-formed with acceptable surgical operative timeand minimal mobility.

The culture preference in Korea has placedgreat demands on reconstructive surgeons in re-plantation procedures and reconstruction of fin-gertip injuries. Most patients will request replan-tation even when the outcome may not befavorable because of the extensive amount of in-jury. When replantation is not successful, Koreanpatients will demand the most suitable procedurewith which to replace similar tissue on the finger.From this societal standpoint, complex microsur-gical procedures such as the partial second toetransfer are particularly well suited for restoringthe functional and aesthetic appearance of thefinger. Although this type of reconstruction maynot be applicable in certain cultures and healthcare systems because of economic strains, thistechnique is an acceptable form of reconstructionfor certain patients, such as musicians or surgeons.We have found that many of our patients willchoose this technique when compared with otherconventional techniques because of better aes-thetic appearance of the fingertip.

The toe pulp is round and has sufficient tissueto harvest for fingertip reconstruction. Our expe-rience has shown that half of the toe pulp can beharvested (Fig. 14) and the toe can still be closedprimarily. Even if primary closure is not possible,skin grafting on the noncontact surface of the footwill not cause painful toe problems. Vasospasmcan be a problem in some patients because ofsmoking or small caliber of the vessels. It has beenestimated that among Koreans, 57 percent of menand 15 percent of women smoke. With this highnational prevalence of smoking, smoking was nota contraindication for this procedure in this series.However, we do prohibit patients from smokingafter surgery. We use only five sutures for 1-mmvessel repair to decrease the operative time and toavoid excessive suture trauma to the vessels in aneffort to decrease the incidence of vasospasm.

When the procedure is performed under metacar-pal and metatarsal blocks, we have not found anyproblems associated with vasospastic events. It is pos-sible that this operation can be performed underregional block anesthesia, given that the foot and thehand procedure each required less than 30 minutesof tourniquet time. Because of the short pure sen-sory nerve in the flap, nerve regeneration is quiterapid. Sensory recovery between 4 and 8 mm at thefingertip is quite acceptable.

CONCLUSIONSWe present a large experience with use of the

partial second toe flap with a short pedicle forfingertip reconstruction. This technique has theability to replace skin and soft-tissue defects of thefingertips using a similar tissue type. With increas-ing experience in repairing small-caliber vessels,microsurgeons now have greater flexibility in cre-ative flap design, with acceptable operative time.Our low failure rate indicates that this procedurecan be performed with a high rate of success. Thecomplications associated with this technique aremanageable with relatively simple reconstructiveprocedures. We present this technique as an al-ternative to the more traditional regional flap orrevision amputation procedures for certain pa-tients who require flap reconstruction for finger-tip amputations.

Kevin C. Chung, M.D.Section of Plastic Surgery

Department of SurgeryUniversity of Michigan Health System

2130 Taubman Center1500 East Medical Center Drive

An Arbor, Mich. [email protected]

Fig. 14. Coronal view of the toe flap harvest.


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ACKNOWLEDGMENTThe authors thank Elizabeth A. Petruska for orga-

nizing the tables and editing the article.

REFERENCES1. Holm, A., and Zachariae, L. Fingertip lesions: An evaluation

of conservative treatment versus free skin grafting. Acta Or-thop. Scand. 45: 382, 1974.

2. Rose, E. H., Norris, M. S., and Kowalski, T. A. Microsurgicalmanagement of complex fingertip injuries: Comparison toconventional skin grafting. J. Reconstr. Microsurg. 4: 89, 1998.

3. Lister, G. Local flaps to the hand. Hand Clin. 1: 621, 1985.4. O’Brien, B. Neurovascular island pedicle flaps for terminal

amputations and digital scars. Br. J. Plast. Surg. 21: 258, 1968.5. Russell, R. C., Van Beek, A. L., Wavak, P., and Zook, E. G.

Alternative hand flaps for amputations and digital defects.J. Hand Surg. (Am.) 6: 399, 1981.

6. Cohen, B. E., and Cronin, E. D. An innervated cross-fingerflap for fingertip reconstruction. Plast. Reconstr. Surg. 72: 688,1983.

7. Kojima, T., Tsuchida, Y., Hirase, Y., and Endo, T. Reversevascular pedicle digital island flap. Br. J. Plast. Surg. 43: 290,1990.

8. Shibu, M. M., Tarabe, M. A., Graham, K., Dickson, M. G., andMahaffey, P. J. Fingertip reconstruction with a dorsal islandhomodigital flap. Br. J. Plast. Surg. 50: 121, 1997.

9. Takeishi, M., Shinoda, A., Sugiyama, A., and Ui, K. Inner-vated reverse dorsal digital island flap for fingertip recon-struction. J. Hand Surg. (Am.) 31: 1094, 2006.

10. Manske, P. R. Aesthetic hand surgery. J. Hand Surg. (Am.) 10:383, 2002.

11. Smith, D. O., Oura, C., Kimura, C., and Toshimori, K. Thedistal venous anatomy of the finger. J. Hand Surg. (Am.) 16:303, 1991.

12. Harii, K. Microvascular surgery and its clinical applications.Clin. Orthop. Relat. Res. 133: 95, 1978.

13. Buncke, H. J., and Rose, E. H. Free toe-to-fingertip neuro-vascular flaps. Plast. Reconstr. Surg. 63: 607, 1979.

14. Morrison, W. A. Thumb and fingertip reconstruction bycomposite microvascular tissue from the toes. Hand Clin. 8:537, 1992.

15. Foucher, G., Merle, M., Maneaud, M., and Michon, J. Mi-crosurgical free partial toe transfer in hand reconstruction:A report of 12 cases. Plast. Reconstr. Surg. 65: 616, 1980.

16. Logan, A., Elliot, D., and Foucher, G. Free toe pulp transferto restore traumatic digital pulp loss. Br. J. Plast. Surg. 38: 497,1985.

17. Koshima, I., Inagawa, K., Urushibara, K., Okumoto, K., andMoriguchi, T. Fingertip reconstructions using partial-toetransfers. Plast. Reconstr. Surg. 105: 1666, 2005.

18. del Pinal, F. The indications for toe transfer after “minor”finger injuries. J. Hand Surg. (Br.) 29: 120, 2004.

19. Dautel, G., Corcella, D., and Merle, M. Reconstruction offingertip amputations by partial composite toe transfer withshort vascular pedicle. J. Hand Surg. (Am.) 23: 457, 1998.

20. Foucher, G., Sammut, D., Greant, P., Braun, F. M., Ehrler, S.,and Buch, N. Indications and results of skin flaps in painfuldigital neuroma. J. Hand Surg. (Am.) 16: 25, 1991.

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Partial Second Toe Pulp Free Flap for Fingertip Reconstruction