Microsurgical thumb reconstruction--report of six cases with a wrap-around free flap from the big toe and an iliac bone graft.

Six patients with amputated thumb had reconstruction of the thumb using a free wrap-around flap from the big toe with a free autologous iliac bone graft. The wrap-around flap was based on the dorsalis pedis and the first dorsal metatarsal arteries and included the skin of the lateral two-thirds of the hallux with the nail and the nail-bed of the toe and the lateral digital nerve. This method reconstructed in one stage a thumb that closely resembled a normal thumb in girth, length and appearance without having to sacrifice a whole toe. Compared to a toe to thumb transfer, the appearance of the reconstructed thumb was superior. Although the reconstructed part did not have any joint, the sensibility was superior and the functional result was excellent. The donor toe defect however required a skin flap cover from a adjacent toe and split skin grafts. Some degree of graft resorption occurred in all cases. It is therefore advisable to harvest as big a graft in diameter as could possibly be accommodated within the width of the wrap-around flap without tension.