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

Figure 8. A customized flap has treated the problem of a non-adhering nail. In the inset, the donor site (©Dr Piñal 2014) [36] .

Total distal amputation
While a substantial number of papers concede that in amputations distal to the interphalangeal joint of the
thumb, the loss of function is negligible [43,44] , our experience is radically different. Patients whose thumb was
amputated at the distal phalanx performed delicate tasks poorly and expressed a deep concern for the
cosmetic outcome . Furthermore, the locking effect of the thumb distal phalanx (the so-called “vice grip”,
[36]
[45]
as termed by Buncke and Valauri) is also lost. Several surgeons reported the salutary effect of
reconstruction by a partial great toe transfer and the minimal morbidity on foot [36,37,46] .

Partial hallux transfer
Partial toe is not beginner’s stuff. Apart from the need for familiarity with handling small vessels and
anastomosis, in order to achieve a good cosmetic result, the dissection must go to the tip of the hallux to
reduce the bone in the sagittal and coronal planes. The hallux is much larger than the thumb. I strongly
recommend early transfer for distal amputation cases, not only for preserving exposed tissue but (above all)
for smooth and straightforward surgery. Furthermore, early coverage of the stump-with the toe-preserves
structures without needing temporary flaps.

There are some technical particularities worth emphasizing when dealing with mini-hallux flaps. The
ipsilateral hallux is preferred as this permits the dominant artery and nerve to be oriented along the ulnar
side of the thumb. Veins are dissected first, and this procedure is greatly facilitated if there is some blood in
the veins; therefore, we elevate the tourniquet without emptying the limb using an Esmarch bandage.

Harvesting is facilitated by including the entire nail, as large dorsal veins proximal to the eponychial fold
can be included. By contrast, partial nail harvesting obliges one to dissect the veins on the lateral aspect of
the pulp, which are minute, fragile, and easily torn.

Regarding the arterial inflow, in most cases, I take only the peroneal digital artery. This maneuver
accelerates harvesting at the price of a smaller vessel for the anastomosis. Most importantly, it minimizes
donor site morbidity. We take utmost care in identifying, isolating, and ligating a constant branch
immediately proximal to the neck of the first phalanx. Should this structure be avulsed, it could endanger
the blood supply to the transfer [Figure 9].