Staged hand-foot flap reciprocity: A microsurgical protocol utilizing great toenail flap for finger defect reconstruction

Background

Finger defect reconstruction requires functional and aesthetic restoration. The great toenail flap demands advanced microsurgical skills. We propose a staged approach: initial pedicled flap coverage, followed by second-stage exchange of the great toenail flap with the finger flap, enhancing donor site repair while reducing complexity and expanding access in resource-limited settings.

Method

Sixteen patients (2017–2024) underwent staged reconstruction: primary pedicled flap followed by great toenail flap-finger flap exchange. Outcomes included complications, functional metrics (Semmes-Weinstein monofilament test, Michigan Hand Outcomes Questionnaire [MHQ], static two-point discrimination [2-PD]), and donor foot pain (Visual Analog Scale [VAS]). Healthy sides served as controls.

Results

At mean 12-month follow-up, reconstructed fingers showed mean static 2-PD of 5 mm and Semmes-Weinstein result of 3.67 g; MHQ averaged 89.6. Foot donor sites demonstrated mean 2-PD of 5.5 mm and VAS of 1. Complications included partial flap necrosis (1 case) and significant donor foot pain (1 case). Interphalangeal joint motion, 2-PD, and MHQ scores differed significantly from healthy sides (p < 0.001)..

Conclusion

This staged protocol provides a safe, practical solution for finger reconstruction, particularly in settings with limited microsurgical resources. It reduces primary hospital treatment thresholds and addresses suboptimal aesthetic/functional outcomes.

Therapeutic

Level III.