HAND/PERIPHERAL NERVE

Partial Second Toe Pulp Free Flap for

Fingertip Reconstruction
Dong Chul Lee, M.D.
Background: The authors present their clinical experience and surgical meth-
Jin Soo Kim, M.D., Ph.D. ods of fingertip coverage using a short-pedicle partial medial second toe pulp
Sae Hwi Ki, M.D. free flap. The surgical steps for reducing surgical time and donor-site morbidity
Si Young Roh, M.D. are described.
Jae Won Yang, M.D. Methods: Between April of 1999 and September of 2006, 929 partial second toe
Kevin C. Chung, M.D., M.S. pulp free flaps were performed in 854 patients. The indications for this flap were
Kyung-Ki Do, Korea; preservation of digital length to cover exposed bone and replacement of skin
and Ann Arbor, Mich. over unstable fingertip scars. A total of 156 patients were assessed more than 1
year postoperatively with the two-point discrimination test.
Results: The mean patient age was 34 years (range, 20 months to 72 years); 747
of 854 were male. The overall survival rate was 99.7 percent. Fifty-seven patients
had two fingertip defects covered with bilateral second toe pulp flaps and nine
had three defects covered with bilateral second toe pulp flaps and a third toe
pulp flap. Donor-site complications occurred in 59 cases (hematoma, n ⫽ 39;
wound separation, n ⫽ 20). No gait disturbance or painful toes were observed
at the donor site. Static two-point discrimination averaged 8 mm (range, 4 to 15
mm). A total of 264 patients required additional surgical procedures, including
skin grafting at the recipient site (n ⫽ 154) and secondary flap revision (n ⫽
110).
Conclusions: The shorter pedicle and smaller flap can reduce the surgical time
and morbidity associated with this procedure. This flap is the authors’ first line
of treatment for covering fingertip wounds by transferring similar pulp tissue
from the toe to the finger. (Plast. Reconstr. Surg. 121: 899, 2008.)

F
ingertip amputation is a common injury
around the world. The treatment for this
injury is controversial. Many techniques have
been described, including simple revision ampu-
tation, skin grafting, local flaps, island flaps, dis-
tant flaps, and free flaps.1–9 If the bone is not
exposed, allowing the wound to heal by secondary
intention can yield surprisingly good outcomes.1,2
No one technique is applicable to the wide variety
of fingertip injuries. The optimal treatment de-
pends on many factors, such as patient preference,
national culture, health care system, and expertise
From the Department of Plastic and Reconstructive Surgery,
Kwang-Myung Sung-Ae General Hospital, and the Section
of Plastic Surgery, Department of Surgery, University of
Michigan Health System.
Received for publication February 6, 2007; accepted April 5,
2007.
Presented at the 10th Triennial Congress of the International
Federation of Societies for Surgery of the Hand, in Sydney,
Australia, March 11 through 15, 2007.
Copyright ©2008 by the American Society of Plastic Surgeons
DOI: 10.1097/01.prs.0000299945.03655.0d
of the treating surgeon. We prefer the toe pulp
free flap because it replaces the glabrous tissue
over the fingertip with a similar tissue type, and
our technical refinement has markedly decreased
the operative time associated with this free flap
procedure.
It is crucial that the treating surgeon has clear
goals to preserve functional and aesthetic appear-
ance of the injured digit. Although revision am-
putations may be the most expedient treatment
option, painful neuromas can occur, and the aes-
thetic appearance associated with the amputation
stumps can be quite bothersome to certain
patients.1,2 The hand is the second most noticeable
part of the body after the face, and restoring the
aesthetic appearance of the hand is increasingly rec-
ognized as an important goal of reconstruction.10
Disclosure: None of the authors has a financial
interest in any of the products, devices, or drugs
mentioned in this article.

www.PRSJournal.com 899
 Plastic and Reconstructive Surgery • March 2008
In the national culture of Korea, the need to
restore missing body parts is based on ancient
Confucian teaching of respecting the body that
was given to one by their parents. Korean patients
invariably will demand replantation following all
types of finger injuries even though they recognize
that the function may not be optimal and the
rehabilitation period may be prolonged. In addi-
tion, patients are keen to restore the aesthetic
appearance of the finger when replantation at-
tempts are not successful. Based on this demand,
we have an extensive experience in performing
partial second toe pulp free flaps to restore the
functional and aesthetic needs after fingertip am-
putations. We have developed a technique to har-
vest partial second toe pulp for transfer by means
of a short pedicle that minimizes donor-site mor-
bidity. This technique avoids the extensive dorsalis
pedis artery harvest, and the expediency of per-
forming this procedure has expanded our indica-
tions for the partial-pulp toe free flap. The specific
aim of this article is to share our experience and
present the outcomes of 929 cases of second toe
partial-pulp free flap transfer for reconstructing
fingertip soft-tissue defects.
PATIENTS AND METHODS
We retrospectively performed a chart review to
collect demographic and surgical data. A group of
patients returned for sensory outcomes evalua-
tion. One hundred fifty-six patients had more de-
tailed examinations using the two-point discrimi-
nation test when they returned for additional
reconstructive procedures for associated injuries
or when they had medical checkups for other dis-
eases. Our indications for performing this free
flap procedure are defects at the fingertips with
exposure of bone after amputations. We also per-
form this procedure for painful atrophic fingertip
injuries associated with soft-tissue deficits. We
chose not to perform this procedure in patients
who had uncontrolled diabetes and vascular dis-
eases because we had flap failures in the first two
patients with these risk factors, before the data
collection for this series.
Five surgeons contributed patients to this se-
ries that consisted of 929 flaps in 854 patients
treated from April of 1999 to October of 2006. For
reconstructing multiple defects, the surgeon har-
vested flaps from the second toes of both feet. For
occasional cases of three-finger defects, we har-
vested both second toes and a flap from the third
toe using similar techniques.
The flap is limited to the tibial half of the pulp
tissue. We harvested the medial plantar digital
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artery, plantar subcutaneous vein, and the plantar
digital nerve at the level of the metatarsophalan-
geal joint. The donor site is often closed primarily.
To prevent excessively tight closure, we apply skin
grafts for donor wounds that cannot be closed
primarily.
Surgical Technique
We prefer to use brachial plexus block and
spinal anesthesia for the surgical procedure, but
seven patients requested general anesthesia. All
children’s procedures were conducted under gen-
eral anesthesia. For 15 cases, we performed meta-
carpal block for the fingers and metatarsal block
for the toes under minimal sedation. The opera-
tion was performed under tourniquet control and
moderate amount of exsanguination to preserve
the visibility of the small volar digital veins.11 The
skin, the medial plantar artery, and the subcuta-
neous vein were harvested. The digital nerve sup-
plying the flap was used for sensory innervation. At
the recipient finger (Fig. 1), we anastomosed the
vessels to the digital artery and volar subcutaneous
veins of the finger.
After adequate debridement of the recipient
finger, the defect was measured with a pattern. We
used a zigzag incision over the volar finger, taking
great care to preserve the subcutaneous veins lo-
cated on either side of the joint crease. The flap
incision was made over the medial or tibial side of
the second toe (Fig. 2). The flap incision does not
extend beyond the midline so that the donor site
can be closed. The average flap measured 2.7 cm
in length and 1.7 cm in width. The largest flap that
could be harvested and donor site closed was 3.3
cm in length and 2.3 cm in width. However, to en-
Fig. 1. A 29-year-old industrial worker with a total pulp defect of
the middle finger.
Volume 121, Number 3 • Partial Second Toe Pulp Free Flap
Fig. 2. Design of the flap; flap A should be elevated by preserving
the subcutaneous vein.
sure primary closure of the donor site, the largest
flap that we could harvest was less than three-fifths of
the width of the glabrous toe pulp. We retained a
2-mm width of skin adjacent to the eponychial fold
distal to the nail matrix to prevent nail problems.
Proximally, the flap was designed in a teardrop
shape, with zigzag incision extending to the medial
plantar surface of the toe for vessel harvest.
The subcutaneous vein was located just under
the dermal layer and the incision made carefully
to prevent injuring the underlying veins (Fig. 3).
The medial flap (Fig. 4) was elevated with sharp
dissection just under the subcutaneous tissue. We
often massage the calf to fill the subcutaneous
veins to help see the veins. The veins usually run
along the sides of the joint creases. At the base of
the teardrop flap, careful dissection under 3.5⫻
loupe magnification will enable identification of
the tenuous subcutaneous vein entering the flap
(Fig. 5). We have not encountered situations in
which the veins were absent, but there are size
variations of the subcutaneous vein ranging from
0.8 to 2 mm in adults. The flap may be supplied
by one or two subcutaneous veins. After identify-
ing the vein attaching to the flap, we incised the
flap to the pretendinous layer on either side of the
pulp tissue (Fig. 6). We performed the dissection
distally by dividing the vertical fibers attaching the
skin to the bone. After clearing the distal vertical
fibers, we can then locate the digital artery of the
toe supplying the flap. A landmark that can assist
in finding the medial digital artery is to find the
connecting branch with the fibular side of the
digital artery at the level of the proximal distal
phalanx. The bleeding point that is seen in Figure
7 came from the divided crossing vessel between
the two proper digital arteries. Flap dissection con-
Fig. 3. The flap incisions are made to the subdermal layer.
tinued proximally by separating the vertical fibers.
At the level of the distal interphalangeal joint, we
also found an arterial branch that looped the pha-
lanx in its course to the dorsal phalanx (Fig. 8).
This side branch must be carefully cauterized to
fully expose the arterial pedicle to the level of the
metatarsophalangeal joint. This teardrop-shaped
flap contained a 2-cm-long neurovascular pedicle
(Fig. 9).
The donor site could be closed primarily in
most situations (Fig. 10). We have found that, in
certain cases of tight closure, blanching of the toe
may occur but perfusion will return after 1 hour.
If the toe still shows decreased perfusion after 1
hour, a skin graft can be used to cover a portion
of the wound after selected suture removal.
The diameter of the digital artery of the toe fits
the digital artery of the finger quite well at the level
of the middle phalanx. We often use 9-0 or 10-0
nylon suture for repair. We repair the nerve as
close to the flap as possible to encourage early
sensory recovery. For distal flap procedures, nerve
repair may not always be necessary. However, the
sensory nerve to the flap is incorporated into the
flap design, and repairing the nerve does not add
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 Plastic and Reconstructive Surgery • March 2008

Fig. 4. Flap A is elevated to identify the subcutaneous vein. Fig. 6. The midline incision goes through the pulp to the pre-
tendinous layer.

additional effort for us but may enhance patient phalanx level. Occasionally, the vein may not be
sensory outcome. The volar finger veins are typi- sufficient for drainage and the flap can be con-
cally 1.2 to 1.5 mm in diameter in the middle gested. We have found that using medicinal

Fig. 5. The subcutaneous vein can be seen rather clearly.

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Volume 121, Number 3 • Partial Second Toe Pulp Free Flap

Fig. 7. The flap is retracted medially. It shows the arterial bleed- Fig. 8. The digital artery is now exposed along the medial side of
ing at the mid pulp of flap, which is the bleeding point from di- the skin flap.
vided arterial arch.

leeches for 2 to 5 days is quite effective in reversing

venous congestion. Our protocol requires the use
of dextran-40 for 5 days and occasional use of
heparin in the subtherapeutic dose. The flap is
sutured in place, and outcomes are quite satisfac-
tory in most cases (Figs. 11 through 13).

RESULTS
The anatomical areas for flap coverage in-
cluded 426 flaps for coverage at the nail level, 287
distal to the distal interphalangeal joint, and 216
at the middle phalanx level. Five surgeons per-
formed 929 flaps in 854 patients from April of
1999 to October of 2006. This patient group con- Fig. 9. The harvested flap will be dissected under the micro-
sisted of 747 male patients with ages ranging from scope to isolate the artery, vein, and nerve.
2 to 72 years (mean, 34 years). The demographic
data are listed in Table 1.
The overall survival rate of this procedure is with a regional flap, and one had a revision am-
99.7 percent; three flaps failed completely. Com- putation. The data are summarized in Table 2.
plications included 72 flaps that experienced ar- We used leech therapy in 58 flaps for transient
terial spasm: 15 required segmental arterial resec- venous congestion, and all of them were treated
tion and primary repair and 57 required repair successfully. Although the use of leeches consti-
with vein grafting. Of these 72 flaps with problems, tutes only 6.2 percent of this series, it does not
three failed completely, two required coverage imply that venous anastomosis is not necessary,

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 Plastic and Reconstructive Surgery • March 2008
Fig. 10. The donor site is closed primarily.
Fig. 11. Nine months after surgery.
Fig. 12. Good flap contour on the finger.
and the flap survives as a composite graft. Given
that most of the flaps we harvest are sufficiently
large, they will not survive as composite grafts with-
out adequate blood inflow and outflow.
904
Fig. 13. Donor toe appearance.
In 57 patients, we covered two finger defects
with partial second toe free flaps from each foot.
In nine patients with three fingertip defects, we
used bilateral second toe partial toe free flap for
two of the fingers and a partial toe free flap from
the third toe.
The mean pedicle length was 2.5 cm for this
short pedicle technique. The mean operative time
was 90 minutes for the entire procedure because
we have gained a great deal of proficiency in flap
harvest. Initially, flap harvest took 40 minutes, but
we have decreased the mean flap harvest time to
14 minutes in recent cases.
Donor-site complications included 59 cases.
Thirty-nine were from hematomas and the re-
maining 20 were attributable to wound dehis-
cence and were treated with secondary closure.
These data are summarized in Table 2. All wounds
that could not be closed primarily were left to close
by secondary intention. Most patients were able to
walk 5 days after surgery, and gait disturbance was
usually not seen 3 weeks after surgery. We per-
formed revision procedures in 264 fingers that
required flap contouring or split-thickness skin
grafting for coverage of open wounds. The addi-
tional surgical procedures required were usually
attributable to patient demand. In some of these
cases, it was difficult initially to contour the flap to
the recipient site sufficiently to have an acceptable
aesthetic outcome for some patients. In 81 pa-
tients, volar skin contractures at the fingers were
released with Z-plasties. We were careful about not
harvesting an excessive amount of tissue from the
toe that would cause donor-site problems. There-
fore, we have not observed hammer-toe deformity,
gait disturbance, or painful toes at the donor site.
We had functional outcomes evaluation in 156
patients who had more than 1-year follow-up. We
Volume 121, Number 3 • Partial Second Toe Pulp Free Flap

Table 1. Demographic Data for the Study Subjects

Age Group No. of Subjects Thumb Index Middle Ring Little Total Digits
0–9 years
Male 14 2 4 5 2 1 14
Female 10 1 3 4 2 0 10
10–19 years
Male 47 4 14 15 11 3 47
Female 18 2 5 5 4 2 18
20–29 years
Male 201 26 79 77 37 13 232
Female 24 4 7 8 4 3 26
30–39 years
Male 216 27 88 78 42 11 246
Female 33 5 11 10 6 3 35
40–49 years
Male 198 17 75 64 39 13 208
Female 14 0 4 7 1 2 14
50–59 years
Male 61 7 17 19 12 6 61
Female 8 1 2 2 3 0 8
ⱖ60 years
Male 10 2 3 1 4 0 10
Female 0 0 0 0 0 0 0
Total 854 98 312 295 167 57 929

Table 2. Recipient- and Donor-Site Complications:
Arterial Spasms*
Type of
Complication Repair/Treatment
Recipient site
Arterial spasms* Segmental arterial resection
and primary repair
Vein grafting
Total
Donor site
Hematoma Evacuation and repeated
closure
Wound dehiscence Secondary closure
Total
*Three of these flaps failed completely. Two required coverage with
a regional flap and one had a revision amputation.
found that the mean sensory two-point discrimi-
nation was 8 mm (range, 4 to 15 mm). Patients
younger than 35 years had better sensory recovery
(two-point discrimination, 6 mm) than those
older than 35 years (9 mm).
DISCUSSION
Since the introduction of the microsurgery
field over 40 years ago, refinement of flap con-
structs and better surgical expertise have markedly
improved the performance of free flaps.12–17 Given
that very small vessels (⬍1 mm) can now be anas-
tomosed with a high rate of success, it is not nec-
essary today to harvest a bulky flap using an ex-
tensive proximal exposure incision to find vessels
sufficiently large for anastomoses.15–20 With this
technique, we have markedly decreased the op-
erative time required to harvest a short pedicle
and still have a greater than 99 percent success rate
No. repairing vessels that are in the range of 1 mm.
of This short pedicle technique has the advantage of
Cases more expedient flap elevation, less trauma to the
foot, and less conspicuous donor-site scarring by
15 obviating a dorsal foot incision to harvest more
57 proximal vessels. There is also less concern with
72 kinking of a long pedicle and potential compres-
sion of the pedicle when tunneling it to reach
39
larger diameter vessels at the recipient site. How-
20 ever, the disadvantages of this technique must be
59 acknowledged. The volar toe vein is tenuous, and
the surgeon must be quite meticulous in handling
this tenuous vessel. However, with experience, sur-
geons should be able to find these vessels in a
predictable fashion. Our relatively short flap har-
vest time indicates that, with practice, this tech-
nique can be performed with relative ease.19 The
survival rate is based on the number of flaps that
survived after all surgical intervention (926 of
929). However, the high survival rate does not
indicate a high rate of patient satisfaction out-
come. A high proportion of the reconstructed
fingers do require secondary procedures.
Methods proposed for reconstructing finger-
tip injuries can be controversial. Some surgeons
prefer simpler techniques such as cross-finger
flaps or shortening of the digits in an effort to
decrease the complexity of the surgical recon-
struction. However, the surgeon must also con-
sider other more optimal options based on the
complexity of the fingertip wound, patient re-

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 Plastic and Reconstructive Surgery • March 2008
quirements, and surgeon preference to creatively
reconstruct the fingertip to minimize deformity
and to enhance function.15,18 Certain patients who
want aesthetic refinement of finger contour after
amputation may be best served by replacing lost
tissue with like tissue from the foot to enhance the
aesthetic appearance of the fingers.13–19 In addi-
tion, the rapid sensory regeneration to highly sen-
sate glabrous toe skin can minimize neuroma pain
associated with a lack of a distal sensory organ.20
From this standpoint, the partial second toe free
flap is an alternative consideration for fingertip
reconstruction when this technique can be per-
formed with acceptable surgical operative time
and minimal mobility.
The culture preference in Korea has placed
great demands on reconstructive surgeons in re-
plantation procedures and reconstruction of fin-
gertip injuries. Most patients will request replan-
tation even when the outcome may not be
favorable because of the extensive amount of in-
jury. When replantation is not successful, Korean
patients will demand the most suitable procedure
with which to replace similar tissue on the finger.
From this societal standpoint, complex microsur-
gical procedures such as the partial second toe
transfer are particularly well suited for restoring
the functional and aesthetic appearance of the
finger. Although this type of reconstruction may
not be applicable in certain cultures and health
care systems because of economic strains, this
technique is an acceptable form of reconstruction
for certain patients, such as musicians or surgeons.
We have found that many of our patients will
choose this technique when compared with other
conventional techniques because of better aes-
thetic appearance of the fingertip.
The toe pulp is round and has sufficient tissue
to harvest for fingertip reconstruction. Our expe-
rience has shown that half of the toe pulp can be
harvested (Fig. 14) and the toe can still be closed
primarily. Even if primary closure is not possible,
skin grafting on the noncontact surface of the foot
will not cause painful toe problems. Vasospasm
can be a problem in some patients because of
smoking or small caliber of the vessels. It has been
estimated that among Koreans, 57 percent of men
and 15 percent of women smoke. With this high
national prevalence of smoking, smoking was not
a contraindication for this procedure in this series.
However, we do prohibit patients from smoking
after surgery. We use only five sutures for 1-mm
vessel repair to decrease the operative time and to
avoid excessive suture trauma to the vessels in an
effort to decrease the incidence of vasospasm.
906
Fig. 14. Coronal view of the toe flap harvest.
When the procedure is performed under metacar-
pal and metatarsal blocks, we have not found any
problems associated with vasospastic events. It is pos-
sible that this operation can be performed under
regional block anesthesia, given that the foot and the
hand procedure each required less than 30 minutes
of tourniquet time. Because of the short pure sen-
sory nerve in the flap, nerve regeneration is quite
rapid. Sensory recovery between 4 and 8 mm at the
fingertip is quite acceptable.
CONCLUSIONS
We present a large experience with use of the
partial second toe flap with a short pedicle for
fingertip reconstruction. This technique has the
ability to replace skin and soft-tissue defects of the
fingertips using a similar tissue type. With increas-
ing experience in repairing small-caliber vessels,
microsurgeons now have greater flexibility in cre-
ative flap design, with acceptable operative time.
Our low failure rate indicates that this procedure
can be performed with a high rate of success. The
complications associated with this technique are
manageable with relatively simple reconstructive
procedures. We present this technique as an al-
ternative to the more traditional regional flap or
revision amputation procedures for certain pa-
tients who require flap reconstruction for finger-
tip amputations.
Kevin C. Chung, M.D.
Section of Plastic Surgery
Department of Surgery
University of Michigan Health System
2130 Taubman Center
1500 East Medical Center Drive
An Arbor, Mich. 48109
kecchung@med.umich.com
Volume 121, Number 3 • Partial Second Toe Pulp Free Flap

ACKNOWLEDGMENT
The authors thank Elizabeth A. Petruska for orga-
nizing the tables and editing the article.
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