The hand is an important functioning organ requiring rest and performing the greatest activities, including locomotion. Moreover, the thumb is used in nearly every hand maneuver and plays a key role in hand function.
There are many of the favored conventional methods in the hand reconstruction, which continue to be useful and valuable in specific patients.
But the introduction of microsurgery of the hand has added a new dimension to reconstructive surgery of the hand, eapecially when the thumb is involved. Prevision of adequate soft tissue coverage and restoration of sensibility & near normal length to the hand present major challenges to the reconstructive hand surgery. The development of microsurgical technique has made possible the transfer of sensory free flaps, which must provide the hand with sensibility, for protection and precise prehension. Because the receptor site is on the hand, the flap must have specific characteristics-thinness, a small size occasionally complex shapes, and good sensory discrimination. By reason of its anatomic similarity, the foot is the donor site of choice, supplying according to needs, its dorsal skin, its first commissure and the pulp of toe.
With the development of another microsurgical technique, the era of the thumb reconstruction by free microvascular one stage transfer was also introduced in the form of toe-to-thumb, partial toe flap ("wraparound") and vascularized joint transfer. This one stage reconstruction not only allows for excellent return of sensibility, restoration of near normal hength and usually freedom from pain, but also leads to prompt return of hand function and better cosmetic appearance than do most other reconstructive procedures.
This is the report of 16 micrevascular reconstructive surgeries of the hand, using the foot as a donor site.
Breakdown of 16 cases is a follows:
1. 6 of a total of 16 cases were innervated free flaps from the dorsum & first commissure of the foot, 1 were microsurgical joint transfer after progressive thumb lengthening of Matev procedure, 3 were toe-to-thumb transfers, (the donor sites of 2 cases were great toes and that of 1 case was 2nd.toe)and 6 were partial toe transfers. (3 cases were "wraparound" flap & the others were toe pulp flaps).
2. We experienced all types of anatomic variations of 1st. dorsal metatarsal artery except Gilbert’s typeⅢ.
3. As the skin on the hand was insuffient, in 2 cases, groin flap coverage of the redial side of the hand with additional skin restoration was done before performing great toe-to-thumb transfer.
4. Toe-to-thumb transfer was esthetically & functionally excellent method of the thumb reconstruction. As donor site, great toe was more excellent than 2nd. toe and no significant gait disturbance was seen after toe-to-thumb transfer.
5. The procedure of a "wraparound" flap was more esthetically excellent than any other reconstructive procedures of the thumb, even than toe-to-thumb transfer.
6. We experienced 3 cases of extensive soft tissue loss in the thumb (2 cases) & index finger (1 case). We performed free pulp flaps from the lateral hemipulp of great toes, which is the best method for the restoration of sensation and skin quality of the hand pulp, because local sensory flap was not feasible.
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