title: The tibial second toe vascularized neurocutaneous free flap for major digital nerve defects.
abstract: OBJECTIVE
  Most digital nerve defects can be reconstructed by means of nonvascularized nerve grafts or artificial tubes, for example. When the bed is poor, the defect is long, or there is a concomitant soft-tissue loss; however, a vascularized nerve graft may be a better option. Our purpose is to introduce a method of 1-stage reconstruction of complex neurocutaneous defects in the fingers and to report the results and clinical effectiveness at a minimum 1-year follow-up period.
  
  
  METHODS
  From 1997 to 2005 there were 6 consecutive patients who had a combined soft-tissue and digital nerve defect reconstructed by a vascularized neurocutaneous flap from the tibial (medial) side of the second toe. Three were acute and 3 were chronic cases. One flap was used for the ulnar side of the thumb, 2 for the radial aspect of the index finger, 1 for the radial of the small finger, and 2 for the ulnar side of the small finger. The nerve gap averaged 4.2 cm, and the flap size averaged 3.2 x 2.1 cm. The flaps were revascularized with standard microsurgical techniques to local vessels in the fingers. The nerves were sutured with epineural stitches. A split-thickness skin graft was used to close the donor site of the toe.
  
  
  RESULTS
  All flaps survived without complications. At the latest follow-up evaluation static two-point discrimination (s2PD) averaged 8 mm on the pulp. Three patients had normal sensation when tested with Semmes-Weinstein filaments. Subjective feeling was 78% of that of the normal side. Five patients rated their feeling as excellent on a subjective scale. The Disabilities of the Arm, Shoulder, and Hand questionnaire score averaged 5.
  
  
  CONCLUSIONS
  The tibial neurocutaneous second toe free flap is suitable for reconstructing a missing nerve and soft-tissue defect in the finger. We found good functional recovery and high satisfaction in this group of patients. The donor site morbidity has been minimal, although delayed healing is common.
  
  
  METHODS
  Therapeutic IV.
authors.affiliation: Instituto de Cirugía Plástica y de la Mano, Hospital Mutua Montañesa, Santander, Spain. drpinal@drpinal.com
authors.forename: Francisco
authors.initials: F
authors.lastname: del Piñal
authors.forename: Francisco J
authors.initials: FJ
authors.lastname: García-Bernal
authors.forename: Javier
authors.initials: J
authors.lastname: Regalado
authors.forename: Alexis
authors.initials: A
authors.lastname: Studer
authors.forename: Leopoldo
authors.initials: L
authors.lastname: Cagigal
authors.forename: Higinio
authors.initials: H
authors.lastname: Ayala
mesh_terms: D000328:Adult; D004185:Disability Evaluation; D005260:Female; D005383:Finger Injuries / Q000601:surgery*; D006801:Humans; D008297:Male; D008875:Middle Aged; D009460:Neurologic Examination; D017060:Patient Satisfaction; D012677:Sensation; D013524:Surgical Flaps / Q000098:blood supply* / Q000294:innervation*; D014034:Toes / Q000098:blood supply* / Q000294:innervation*; D016896:Treatment Outcome