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Page 2 of 14 Van Hove et al. Plast Aesthet Res 2023;10:8 https://dx.doi.org/10.20517/2347-9264.2022.59

The objective in reconstruction is a normal thumb, and we should stress that nothing is like the original. No
reconstructive procedure can be compared to a successful replantation; therefore, it is mandatory to attempt
[2]
replantation in every amputation . The goals for reconstruction are (first and foremost) a pain-free thumb
simply because a painful one will not be used. Similarly, length is critical-a short thumb will be relatively
unable to grab large objects or pinch and pick up smaller ones.

Before managing any thumb injury, it is worth stressing the importance of not introducing scars that might
hinder the definitive reconstruction. If the surgeon is unsure of the appropriate procedure, the wisest thing
is to clean the wound, debride devitalized tissues, and send the patient to a specialized center. One should
avoid attempting primary closure if doing so entails sacrificing essential tissue, particularly functioning
[3,4]
joints. If this is not feasible, a suitable alternative is to cover the stump with a groin or other flap ; doing so
prevents the sacrifice of structures that might be crucial for later reconstruction and will allow time for
proper planning.

TERMINAL DEFECTS
We adhere to the classification system of Dr. Strickland set out in the first edition of Green’s [Figure 1]. It
[5]
is most beneficial to define the precise anatomical location of the amputation. Length is essential; however,
one should also consider thenar muscle damage, skin quality, nerve avulsion, and the functionality of the
joints proximal to the amputation.

There is no one-size-fits-all method for treating distal defects. The choice depends on the obliquity, the nail
defect, and the amount of missing bone. Of these, the nail defect should have the most impact on decision-
making. Amputations proximal to the eponychial fold are more conducive to a hallux transfer.

Soft tissue defects
In the most common type of distal amputation, a part of the sterile matrix is preserved. In these cases,
efforts to preserve length and to provide sensitive, non-painful cover are the goal. Immediate wound
coverage is the highest priority to prevent further tissue desiccation and length loss. In recent years, we
witnessed considerable advances in flap design, owing to a better understanding of the blood supply to the
[7-9]
thumb . This has entailed that cross-finger flaps and many distant flaps are currently either reserved for
extreme situations, or plainly discarded, and thus will not be discussed.

Smaller than 50% of the pulp surface
Semi-occlusive dressing
Healing by secondary intention by application of semi-occlusive dressing, as described by Mennen and
Weiss, is a simple and inexpensive method for small defects without fracture or tendon exposure; it
provides a consistent pulp with excellent contouring and a satisfactory return of sensation [10-13] .

The stump is covered with a semi-occlusive transparent adhesive dressing after cleaning and debridement,
which is changed weekly. The patient is allowed to use the thumb freely. The patient should be informed
that a foul odor is normal and advised of the importance of keeping the dressing in place while healing
occurs.

Volar advancement flap