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Van Hove et al. Plast Aesthet Res 2023;10:8 https://dx.doi.org/10.20517/2347-9264.2022.59 Page 9 of 14

Figure 9. A portion of the pulp must include a skin bridge to preserve the tiny and fragile veins in the skin that drain into the more
prominent dorsal veins (blue dots). The yellow arrow points to the constant transverse digital artery (©Dr Piñal 2014) [36] .

A segment of the lateral digital nerve is always included, and depending on the size of the toe pulp
harvested, a part of the medial digital nerve can be included. After the dissection of the pulp of the phalanx,
to reproduce the thumb shape, the bone should be trimmed in the sagittal and coronal planes [Figure 10].

Nerve(s) and vessels are passed through subcutaneous tunnels to avoid scarring. We usually revascularize a
single artery and vein by end-to-end anastomoses with 10-0 nylon on a 100-µm needle.

The donor site is closed using a V-Y advancement flap from the medial side. If the whole nail has been
elevated, we also place a skin graft on top of the periosteum to provide a nail-like appearance [Figure 11]

Postoperatively, patients are perfused with heparin 500 U/h for two days, reduced to 250 U/h for another
two days, and then switched to subcutaneous heparin for two weeks.

INTERCALATED DEFECTS
Traditionally, our attention has been focused on terminal defects of the thumb; however, intercalated
injuries can cause as much damage as a complete loss. The reconstructive surgeon has tools to replace any
intermediate portions lost. The foot is the primary donor site to replace like with like. Major nerve/
vasculature/soft tissue and bone defects are usually managed by resorting to the second toe as the chief
donor site [47-50] [Figure 12]. However, any area of the body that may fit into the defect and complete the
jigsaw of any loss is most welcome.

Tibial second-toe vascularized neurocutaneous free flap
The surgeon may encounter an alive thumb that is poorly by dorsal arterial branches [Figure 13]. If
untreated, the result is a painful atrophic thumb with a dystrophic nail, poor sensation, and cold
intolerance. The results of flow-through versions of the toe neurocutaneous flap are unparalleled for these
indications . These flaps provide suitable cover, which is always necessary, excellent quality vessels to
[51]
bypass small defects, and a vascularized nerve graft to provide sensibility [Figure 14]. Planning is essential to
prevent dangerous crossover of vessels that may jeopardize arterial or venous flow. Rehearsals on paper are
strongly recommended .
[48]