Anatomical Measurement And Clinical Studies On The Aesthetic Refinements In Second Toe-to-thumb Transfer Surgery

Objective:To measure the absolute value of second toes, big toes, thumbs and their nail’s width, length and circumference in-vivo and analyze the ratio of different between those value.To oberserve the effect of double flaps based on the same vascular pedicle employed for expanding finger’s circumference on DIP level on toe-to-thumb transfer, compare the clinical outcomes of two kinds of nail bed expanding technique for the new aesthetic modifies in second toe-to-hand transfer surgery and investigate the treatment outcomes of the new aesthetic modifies in toe-to-thumb transfer surgery.Methods:1. The absolute value of second toes, big toes, thumbs and their nail’s width, length and circumference were measured on40normal Chinese adult (23male,17female) on the double hands and feet. Combined with modern statistical techniques(SPSS19.0), we computed the value of corresponding anatomical site, to provide the anatomical data and analyze the ratio of different between those value.2. There are significant diffirence of both sides and sex between the ratio of L1/L2, W1/W2, C1/C2. L1/W1of the second toes and the thumbs.3.18cases of defected thumbs were treated with the techniques of transfer of second toe with double flaps based on the same vascular pedicle for reconstruction of thumb;. The second toe transferred along with the tibial digital artery flap from the second toe pulp and fibular flap from the big toe.4.20cases suffered by finger defected were treated by second toe-to-hand transfer surgery. They were divided into two groups; During the operation,3mm length eponychium was resected for the first10cases and the Adani rectangular advanced flap was performed in the second10cases. The expanded nails were the same length. The operative times for only nail lengthening were recorded and the length of the nail, appearances, the scarring around the nail and patients self satisfaction comparison evaluation in two groups were compared12months postoperatively.5. We describe a modified second toe transfer which addresses cosmesis in6patients. These include:1) Harvesting a flap from the adjacent side of the great toe and insetting it into the volar aspect of the second toe to give more bulk,2) Skin excisions are made on each side of the tip reduce the bulbous appearance, and3) Excision of part of the distal skin near the eponychium and advanced the eponychium flap to produce apparent lengthening of the nail.Results:1. There are significant diffirence of both sides and sex between the ratio of L1/L2, W1/W2, C1/C2.L1W1of the second toes and the thumbs.2.18thumbs all survived. There was no flap loss. Follow-up duration raged from6-17months, According to the evaluation criteria for the finger replantation and reconstruction issued by Hand Surgery Society of Chinese Medical Association, results of15thumbs were graded as excellent while the results of3thumbs were fair. The reconstructed finger’s circumference on DIP level were expanded10.27mm in average and the circumference radio between The overall satisfactory rate is100%.3. The operation time of eponychium resection was an average of7.5minutes; The time of the Adani rectangular advanced flap average15minutes;12months postoperative follow-up, no skin necrosis around the nail in both groups cases; A bed expand length for the duration of2.7mm in both groups; The smoothness of the nail is consistent, without obvious deformity happened. The self satisfaction score (MHQ) of eponychium resection group is average of12.1; The score of the Adani rectangular advanced flap is average of11.8. The differences between the two groups were no statistically significant.4. The mean follow up period was1.5yrs (6-36months). All six cases resulted in good function and improved cosmesis. Part of the great toe flap was lost in one case. The mean two-point discrimination in the transferred toes was10.1mm with protective sensation present in the flaps. The mean range of motion of the transferred toe was14to38o at the metatarsophalangeal joint,16to55°at the proximal interphalangeal joints, and20to36°in the distal interphalangeal joints.Conclusion:1. The absolute value of second toes, big toes, thumbs and their nail’s width, length and circumference in-vivo are valuable supplement for the anatomical data. Based on the significant diffirence between the ratio of C1/C2. L1/W1of the second toes and the thumbs, the methods that the second toe’s nail lengthening and circumference expanding can be chosed as the key points for the management of new aesthetic modifies in toe-to-thumb transfer surgery.2. Thumb defect can be reconstructed by way of transfer of second toe with double flaps based on the same vascular pedicle. The appearance of the reconstructed thumb is more comparable to the normal thumb3. Both of the two kinds of nail lengthening in second toe-to-hand transfer surgery are simply and effective; the results are satisfactory; the procedure of eponychium resection is of advantages of short operative time and easy and simple to handle.4. This novel approach will allow patients to take advantage of the lower morbidity to the donor site afforded by second to thumb transfer, while providing the patient with a more aesthetic appearance of the new thumb.