Aesthetic refinements in second toe-to-thumb transfer surgery

BACKGROUND: Second toe-to-thumb transfer is a good alternative to using the great toe for reconstruction of the thumb. It achieves excellent function and reduces morbidity to the donor foot. However, cosmesis is often poor. The second toe has three unattractive features, a narrow "neck," a bulbous tip, and a short nail.

METHODS: The authors describe a modified second toe transfer that addresses cosmesis in six patients. These include (1) harvesting a flap from the adjacent side of the great toe and insetting it into the volar aspect of the second toe to give more bulk, (2) making skin excisions on each side of the tip to reduce the bulbous appearance, and (3) excising the eponychium to produce apparent lengthening of the nail.

RESULTS: The mean follow-up period was 18 months (range, 6 to 36 months). The procedure resulted in good function and improved cosmesis in all six cases. Part of the great toe flap was lost in one case. The mean two-point discrimination in the transferred toes was 10.1 mm, with protective sensation present in the flaps. The range of motion of the transferred toe was 14 to 38 degrees at the metatarsophalangeal joint, 16 to 55 degrees at the proximal interphalangeal joints, and 20 to 36 degrees in the distal interphalangeal joints. All patients except one were happy with the appearance of the transferred toe.

CONCLUSION: This novel approach will allow patients to take advantage of the lower morbidity to the donor site afforded by second toe-to-thumb transfer and provide the patients with a more aesthetic appearance of the new thumb.