Within the last three decades, toe-to-hand transplantation has become a well-established method for function and appearance reconstruction after trauma and in congenital hand anomalies.
An otherwise healthy and cooperative patient is the ideal candidate for toe transplantation after trauma. In such patient, even primary toe transplantation is possible, if the stump is clean and viable. If secondary reconstruction after completed wound healing is considered, emphasis should be laid on tissue sacrifice during the acute management of non-replantable amputations at the hand. Specific considerations regarding selection of toe(s) to be transplanted, technique of toe harvest and inset, sequence of transplantations if more than one digit is to be reconstructed such as in the metacarpal hand, and postoperative regimen are important to achieve satisfying functional and aesthetic results on both recipient and donor sites. A trimmed great toe is ideal for thumb reconstruction if the amputaiton is located at or distal to the middle metacarpal shaft. However, in more proximal amputations a second toe may be more suitable as it allows transmetatarsal harvest without increasing donor site morbidity. Distal finger reconstruction with partial toe or second toe warp around flap gives most gratifing result to those patients who are critically concerned about their body images and also those who need distal fingers for jobs or recreation activities. Combined second and third toe or third and fourth toe transplantations are particular useful in metacarpal hand reconstruction to provide tripod pinch. The role of toe-to-hand transplantation in the new millenium assuming progress in tissue engineering, gene transfer, and the development of new immunosuppressive drugs is discussed. (Chang Gung Med J 2002; 25:568-76)

Key words: digital amputation, microsurgery, toe transfers.

"All men have a mind which cannot bear to see the suffering of others"
(Mencius IIa, 6)

The first reported two-stage toe-to-hand transplantation was performed in 1897 by Nicolardoni. In 1969, Cobbett(1) transplanted a great toe to replace an amputated thumb in a human following successful microsurgical one-stage toe-to-hand transplantations in monkeys done by Buncke in 1966.(2) Improve-ment of instruments and knowledge rapidly progressed the development of microsurgery. In toe-to-hand transplantation, various combinations of toe transplantations and refinements in the technique have been decried since then.(3-19) Primarily employed for thumb reconstruction as alternative to the politicization(20) or bone lengthening,(21) toe-to-hand transplantation became a well established method for reconstruction of single or multiple digits,(22-35) of distal digits,(36-40) and of congenital deficits.(41-45) With progress in rehabilitation such as early motor rehabilitation and sensory reeducation, coordination, dexterity, and sensory recovery of the reconstructed hand could be improved.(46-51) Thorough section of toes to be transplanted and specific considerations in harvest techniques helped avoiding major donor site morbidity especially in multiple toe transplantations.(47,50,52,53) Secondary procedures such as pulp plasty enhanced the appearance and function of the transplanted digits.(54,55) In this article, based on the experiences of more than 1350 toe transplantations guidelines are proposed for toe-to-hand transplantation with emphasis on specific technical procedures. Extensive reconstructions such as the metacarpal hand(50,52,53) which needs formulation of an thorough reconstructive plan before any toe is harvested and detailed rehabilitation programs(46,47,50) are beyond the scope of this article.

Selection of patients

An otherwise healthy, cooperative and interested yound patinet is the ideal condidate for toe transplantation. In such case, a primary toe transplantation before completed wound helaing of the stump an be considered, if the stump is clean and viable.(56) Contraindications to primary or secondary toe transplantation include all conditions which may impair microsurgical procedures such as vascular diseases, major illness, severe mental diseases with lack of compliance, or trauma to the foot and arteriosclerosis that prevent toe harvest.(50)

Prerequisite for toe transplantation

In the acute management of non-replantable amputations of the hand when future toe-to-hand transplantation is considered, emphasis should be laid on tissue preservation instead of tissue sacrifice. This serves three purposes: (1) To enable a good match in length of the toe transplanted to the remaining digits of the hand, (2) To achieve the best possible function of the new toe-digit-unit, and (3) To avoid extensive dissection at the foot which is associated with increased donor site morbidity.

Skin
All viable soft tissue should be retained. Local flaps should be avoided, whereas the pedicled groin flllap is recommended for most cases requiring imported tissue for stump coverage.

Tendon
(1) Flexor tendon: Preservation of viable tendon length even in zone II helps to maintain the integrity of the pulley system and to avoid future tendon grafts. (2) Entensor tendon: Whenever possible, the extensor apparatus should be left in situ on the digital stump to preserve the balance between intrinsic and extrinsic extensor mechanism.

Vessels
Preserving the length of a healthy artery at the base of the proximal phalanx or in the distal palm allows reliable anastomosis with good size match of donor and recipient arteries. The same accounts for a healthy vein at the dorsum of the hand.

Nerve
Debriding the nerve back to normal or near normal looking architecture instead fo excising it far proximally allows a relatively distal nerve repair resulting in earlier sensory recovery.

Bone and joint
Wherever possible, the skeleton should be preserved distal to the insertion of the flexor digitorum sublimus. Excessive bone shortening may preclude a good match in length of the toes transplanted to the remaining digits. If possible, the most distal mobile joint should be preserved since a 5 mm metaphysis of a phalanx is sufficient for toe fixation using intraosseus wiring technique.(57) If joint salvage is not attainable, conservation of the articular cartilage and the local capsular tissue in the metacarpophalageal joint will facilitate a composite joint reconstruction.

Operative technique

Simultaneously two teams prepare the donor site and the recipient site. Both preparations are performed under tournique control.

Specific considerations
(1) If two adjacent fingers need to be reconstructed, the combined second and third toe transplantation(58,59) is recommended whenever the reconstructionis performed proximal to the web space and the remaining fingers are not longer than that of the little finger. Separated second and third toes or two second toes are better when the web space between the fingers is preserved.
(2) In thumb reconstruction a total or trimmed great toe(33) is usually chosen for reconstruction in patients with more proximal amputations. In such cases, transmetatarsal harvest of the second toe is necessary for compensation of length.(60)
(3) Harvest of the great toe and the second toe in the same foot should be avoided for maintaining foot balance.

Toe harvest
Pedicle dissection
Dissection of the pedicle starts distally in the first web space. After idenitification of the lateral digital artery of the great toe and the medial artery of the second toe, proximal dissection continues both plantarly and dorsally for 1-2 cm. Either the first dorsal metatarsal artery (FDMA) is dominant or the FEMA and the first metatarsal plantar artery (FPMA) are of equal size in approximately 70% of patients. If this is the case, the FDMA is traced further proximally until enough length is obtained. If the FPMA is the dominant vessel with either hypoplastic or aplastic FDMA, the FPMA is dissected from the plantar side fo the foot. Use of a vein graft for inadequate pedicle length is recommended when a long pedicle is necessary. This avoids extensive dissection proximal to the middle of the metatarsal bone resulting in increased donor site morbidity, because the artery becomes deep at this point.

Trimmed great toe harvest
Toe harvest starts with a wedge-shaped skin incision both dorsally and plantarly.(31) At the medical aspect of the toe, 1.5 cm skin strip, tapering to a point at the tip of the toe, is elevated, leaving 2 mm of skin beneath the nail to facilitate closure. The medical collateral ligament, capsule, and periosteum are elevated as a hemicircumferential flap. The medical joint prominence is reduced 4-6 mm, and the phalangeal shafts are reduced 2-4 mm with a longitudinal osteotomy through the distal and proximal phalanges, and through the interphalangeal joint. The medial hemicircuferential flap is resutured after having trimmed the excess tissue to resore stability of the interphalangeal joint. Retrograde dissection of the artery is performed as described above. Dorsal superficial veins are traced proximally until adequate length is obtained. During dissection, both vein and artery are skeletonized gently with instruments to prevent vessel spasm and allow smooth passage of the pedicle through skin tunnel for vascular anatomosis at a more proximal site (Fig. 1). Flexor and extensor tendons are harvested as long as necessary. The lateral plantar nerve is carefully split to preserve continuity of the nerve tot he second toe and traced proximally until enough length is gained. Osteotomy can be performed at any level but distal to the metatarsophalangeal joint leaving 1 cm of the proximal phalanx to preserve push-off function of the foot. During osteotomy, all important soft tissue structures are held back for protection using a wet sponge. The medially elevated skin strip can be employed for stump coverage.(50)
Lesser toe harvest
As in the trimmed great toe harvest, dissection starts with a wedge-shaped skin flap. Skin incisions should not extend beyond the middle of the first and third web spaces to allow primary closure of the donor site in combined second and third toe harvest. To avoid a bulky anteroposterior diameter of the toe resulting in impaired metatarsophalangeal joint flexion, thinning of the plantar skin flap is recommended. Artery, vein, tendons, and nerves are dissected as described above. However in lesser toe harvest, both lateral and medial nerves are split to maintain sensation of the adjacent toes. In combined second and third toe harvest, in addition to either the FDMA or FPMA, the second and third plantar metatarsal arteries are dissected and preserved for possible need of second anatomosis, if the blood supply to the third toe is doubtful after first anastomosis between either FDMA or FPMA and the recipient artery.(62) Transmetatarsal osteotomy can be performed if indicated.

Preparation fo the amputation stump
At the time of toe harvest, careful stump preparation is performed.(47) Two cruciform (anteroposterior and transverse) incisions over the amputation stump (Fig. 2) open the stump for dissection fo tendons, nerves, and arteries. This way skin incision followed by adequately undermining, thinning, and trimmming of the resultant four skin flaps prevents and ugly "cobra" appearance of the junction between the digital stump and the transplanted toe.(63) Venous anatomosis is usually performed at the dorsum of the hand or at the dorsum of the phalanx. Digital or common digital arteries in the palm commonly serve as recipient arteries. To avoid a long skin incision in distal transplantations, recipient artery and vein are dissected through a separate incision in proximal phalanx or distal palm. The donor artery and vein reach them through a tunnel underneath the skin. Bone shortening is performed when indicated.

Toe inset and fixation
At the level of the metacarpophalangeal joint (MPJ), composite MPJ reconstruction is possible whenever the metacarpal articular surface and capsular tissue are preserved. The metatarsophalangeal joint (MTP) capsule, the plantar plate, and the collateral ligaments of the toe are connected tot he corresponding structures on the metacarpal head with nonabsorbable sutures.(47) For amputations proximal or distal to the MPJ, osteosynthesis using intraosseous wiring is performed. In a dorsal-palmar direction, two parallel 1 mm holes are made through both cortices of either the phalanx or the metacarpal bone. After determing the angle and rotation of the toe, the same procedure is repeated at the toe. Two stainless steal wires are pulled through the holes and twisted dorsally. The wire ends are cut short and turned away from the extensor tendon. The extensor tendon of the toe is sutured to the finger extensor tendon with nonabsorbable material in full extension position. In flexor tendon repair only deep flexor tendon is performed. To prevent a claw deformity in lesser toe transplantation, sometimes the extensor digitorum longus attachment needs to be released from the capsule of the MTP joint and the extensor digitorum brevis is sutured to the dorsal expansion or the interosseous tendon if possible. A two weeks lasting K-wire fixation of the interphalangeal joints in complete extension additionally helps to prevent clawing. Then, donor artery, vein, and nerves are placed close to the recipient structures. The skin flaps are adjusted to the local skin. The skin is closed before microanastomoses are performed to optimize the appearance of the reconstructed digit as it is difficult to make perfect tailoring of skin flaps at the junction of the transplanted toe and the amputation stump once microvascular anatomoses are completed. Finally, microanastomoses and coaptation of the nerves are performed as usual. A loose bandage with sponges is used for wound dressing.(50)

Secondary procedures
Most common secondary procedure is the pulp plasty which can be performed as soon as three months postoperatively in under local anesthesia(54) (Fig. 3). A longitudinal wedge resection of the pulp of the transplanted toe is performed. This results in improved appearance and funciton since the reduction of the bulky pulp reduces the shearing movement with pinch. Other secondary procedures include tenolysis, arthrodesis, and web space deeping. However given adequate operative techniques and early motor rehavilitation, such procedures are rarely needed.(55)

Perspectives

"We still have to go forward with the present. We cannot keep ourselves still."
(Commentary on the Chuang-tzu, ch. 6)

Functional results of toe-to-hand transplantations are insurmountable by other conventional reconstructive methods. Survivial rate in a large series of 400 cases was 96.5%.(64) Donor site mrobidity is negligible after one lesser toe harvest and acceptable after multiple toe transplantations if guidelines as mentioned above are considered. However, so far a donor site with one or more missing toes remains. Electromechanical prostheses lack of sensitivity. The recently performed allograft hand transplantation(65) may solve this problem, but still bears a high risk owing to possible side effects of immunsuppressive drugs. Whether locally placed immunsuppressive genes at the junction between finger and transplanted allografted toe will replace the need for systemic administration of such agents needs to be awaited. Besides, so far functional results are pending. Except for the donor site morbidity, the basic principles in toe harvest and inset remain the same, if this option should become popular in future. An engineered new digit using a scaffold imitating the lost digit would be optimal. However up to now and most likely in the near future, the microsurgical toe-to-hand transplantation has its established place in reconstructive mirosurgery for the benefit of the patients. Its demand for severe multating hand reconstruction may decrease with increasing safety measures in industrial plants, but as single and distal digit amputations from leisure activities or out of work are still often seen distal toe transplantation shall remain a useful method for finger reconstruction. Such kind of reconstruction may be more demanded in countries with moderate climate and stable social system than in countries with cold weather and with low social care. Although, toe-to-hand transplantation for single or distal finger reconstruction at present time still remains controversial among surgeons, our ongoing outcome research has shown result in favor of reconstruction. In distal lower arm amputation, single toe transplantation can provide a pinch grip(unpublished data, 66) or help controlling an electromechanical prosthesis.(67) In metacarpal hands with loss of all fingers with or without thumb or in severe congenital deficits, multiple toe transplantations can provide prehensile funciton in children(41-45,68) (Fig. 4) and adults(7,16,18,19,22-23,28-30,34,35,50,52,53,64) better than any other method so far. Also in the new millenium, multile toe transplantations are a great channlege requiring adeuqate experience that usually starts with the transplantation of one toe as described in the operative techanique section above.

Footnote: Quotations from FungYu-Lan. A short history of Chinese philosophy. Der Bodde, ed., New York: The Free Press, pp. 75, 223.

REFERENCES

1. Cobbett JR. Free digital transfer. Repot of a case transfer of a great toe to replace an amputated thumb. J Bone Joint Surg Br 1969;51:677-9.
2. Bunke HJ, Bunke CM, Schulz WP. Immediate Nicoladoni procedure in Rhesus monkey hallux-to-hand transplantation utilizing microminiature anastomosis Br J Plast Surg 1966;19:332-7.
3. Bunke HJ. Toe digital transfer. Clin Plast Surg 1976;3:49-57.
4. Doi K, Hattari S, Kawai S. New procedure on making a thumb one-stage reconstruction with free neuro-vascular flap and iliac bone graft. J hand Surg 1981;6:346-60.
5. Dongyue Y, Gu YD. Thumb reconstruction utilizing second toe transplantation by microvascular anastomosis: Report of 78 cases. Chin Med J 1979;92:295-309.
6. O'Brian BM, Brennen MB, McLeod AM. Microvascular free toe transfer. Clin Plast Surg 1978;5:223-37.
7. O'Brian BM, Brennen MB, McLeod AM. Simultaneous double toe transfer for severely disabled hands. Hand 1978;10:232-40.
8. May JW, Daniel PK. Great toe to hand free tissue transfer. Clin Orthop Rel Res 1978;133:140-53.
9. Srauch B. Microsurgical approach to thumb reconstruction. Orthop Clin North Am 1977;8:319-27.
10. Leung PC. Thumb reconstruction using second toe transfer. Hand 1983;15:15-21.
11. Lister GD, Kalisman M, Tsai TM. Reconstruction of the hand with free microscascular wrap-around flap from the big toe. J Hand Surg 1980;5:575-83.
12. Morrison WA, O'Brien BM, MacLeod AM. Thumb reconstruction with a free neurovascular wrap-around flap from the big toe. J Hand Surg 1980;5:575-83.
13. Morrison WA, O'Brien BM, MacLeod AM. Experience with thumb reconstruction. J Hand Surg Br 1984;9:223-33.
14. May JW Jr. Anesthetic and functional thumb reconstruction: Great toe to hand transfer. Clin Plast Surg 1981;8:357-62.
15. Urbaniak JR. Wrap around procedure for thumb reconstruction. Hand Clin 1985;1:259-69.
16. Wei FC, Chen HC, Chuang CC, Noordhoof MS. Reconstruction of a hand, amputated at the metacarpophalangeal joint level, by means of combined second and third toes from each foot: A case report. J Hand Surg Am 1986;11A:340-4.
17. Wei FC, Colony MH. Microsurgical reconstruction of distal digital function. Clin Plast Surg 1989;16:443-55.
18. Wei FC, Colony LH. Microsurgical reconstruction of opposable digits in mutilating hand injuries. Clin Plast Surg 1989;16:491-504.
19. Gu YD, Zhang GM, Cheng DS, Yan JG, Chen XM. Free toe transfer for thumb and finger reconstruction in 300 cases. Plast Reconstr Surg 1993;91:693-700.
20. Buck-Gramcko D. Pollicization of the index finger. Methods and results in aplasia and hypoplasia of the thumb. J Bone Joint Surg Am 1971;53:1605-17.
21. Matev IB. Thumb reconstruction through metacarpal bone lengthening. J Hand Surg 1980;5A:482-7.
22. Gordon L, Leitner DW, Buncke HJ, Alpert BS. Hand reconstruction for multiple amputations by double microsurgical toe transplantation. J Hand Surg 1985;10A:218-25.
23. Holle J, Freilinger G, Mandl H, Frey M. Grip reconstruction by double toe transplantation in cases of fingerless hand and a handless arm. Plast Reconstr Surg 1982; 69:962-8.
24. Lichtman DM, Ahbel DE, Murphy RB, Bunk HJ. Microvascular double toe transfer for opposable digits - case report and rationale for treatment. J Hand Surg Am 1982;7:279-83.
25. Rose Eh, Bunke HJ. Simultaneous transfer of the right and left second toes for reconstruction of amputated index and middle fingers in the same hand. J Hand Surg Am 1980;5:590-3.
26. O'Brian BM, McLeo AM, Sykes PJ, Donahoe S. Hallux-to-hand transfer. Hand 1975;7:128-33.
27. Ohsuka H, Torigai K, Shioya N. Two toe-to-finger transplants in one hand. Plast Reconstr Surg 1977;60:5611-4.
28. Tsai TM, Jupiter JB, Wolff TW, Atasoy E. Reconstruction of severe transmetacarpal mutilating hand injuries by combined second and third toes transfer. J Hand Surg Am 1981;6:319-28.
29. Yu CJ. Reconstruction of a digitless hand. J Hand Surg Am 1987;12:722-6.
30. Wei FC, Chen HC, Chuang CC, Noordhoff MS. Simultaneous multiple toe transfers in hand reconstruction. Plast Reconstr Surg 1988;81:366-74.
31. Wei FC, Chen HC, Chuang CC, Noordhoff MS. Reconstruction of the thumb with a trimmed toe transfer technique. Plast Reconstr Surg 1988;82:506-13.
32. Wei FC, Chen HC, Chuang CC, Chen S, Noordhoff MS. Second toe wrap-around flap. Plast Reconstr Surg 1991; 88:837-43.
33. Wei FC, Yim KK. Single third-toe transfer in hand reconstruction. J Hand Surg Am 1995;20:388-94.
34. Wei FC, Coessens B, Ganos D. Multiple microsurgical toe-to-hand transfer in the reconstruction of severely multilated hand: A series of fifty-nine cases. Ann Chir Main Semb Super 1992;10:177-87.
35. Wei FC, Strauch RJ Chen HC, Chuang CC. Reconstruction of four damaged or destroyed ipsilateral fingers with free toe-to-hand transplantations. Plast Reconstr Surg 1994;93:608-14.
36. Foucher G, Nagel D, Briand E. Microvascular great toenail transfer after conventional thumb reconstruction. Plast Reconstr Surg 1999;103:570-6.
37. Hirase Y, Kojima T, Matsui M. Aethetic fingertip reconstruction with free vascularized nail graft: a review in 60 flaps involving partial toe transfers. Plast Reconstr Surg 1997;99:774-84.
38. Dautel G, Corcella D, Merle M. Reconstruction of fingertip amputations by partial composite toe transfer with shrot vascular pedicle. J Hand Surg Br 1998;23:457-64.
39. Wei FC, Epstein HC, Chen HC, Chuang CC, Chen HT. Microsurgical reconstruction of distal digits following mutilating hand injuries: results in 121 patients. Br J Plast Surg 1993;46:181-6.
40. El-Gamal TA, Wei FC. Microvascular reconstructionof the distal digits by partial toe transfer. Clin Plast Surg 1997;24:49-55.
41. Gilbert A. Toe transfers for congenital hand defects. J Hand Surg Am 1982;7:118-26.
42. Kay SP, Wiberg M. Toe to hand transfer in children. Part I: technical aspects. J Hand Surg Br 1996;21:723-34.
43. Boyer MI, Mih Ad. Microvascular surgery in the reconstruction of congenital hand anomalies. Hand Clin 1998;14:135-42.
44. Van Holder C, Giele H, Gilbert A. Double second toe transfer in congenital hand anomalies. J Hand Surg Br 1999;24:471-5.
45. Spokevicius S, Radzevicius D. Late toe-to-hand transfer for the reconstruction of congenital defects of the long fingers. Scand J plast Reconstr Surg Hand Surg 1997; 31:345-50.
46. Ma HS, El-Gammal TA, Wei FC. Current concepts of toe-to-hand transfer: Surgery and Rehabilitation. J Hand Ther 1996;9:41-6.
47. Wei FC, El-Gammal TA. Toe-to-hand transfer, current concepts, techniques, and research. Clin Plast Surg 1996;23:103-16.
48. Wei FC, Ha HS. Delayed sensory reeducation after toe-to-hand transfer. Microsurg 1995;583-5.
49. Wilson MC. Sensory reeducation. In: Gelberman RH, ed. Operative nerve surgery and reconstruction. Philadelphia: JB Lippincott, 1991:827.
50. Lutz BS, Wei FC, Chen SHT, Lin CH. Functional reconstruction of the metacarpal hand with multiple toe transplantations. Tech Hand Upper Extremity 1999;3:37-43.
51. Chu NS, Wei FC. The time course of recovery in somatosensory evoked potentials and sympathetic skin reponse after toe-to-finger transplantation. In: Recent advances in human neurophysiology, Hashimoto I, kakigi R, eds., New York, Elsvier Science BV, 1998;163-8.
52. Wei FC, El-Gammal T, Lin CH, Chuang CC, Chen HC, Chen SH. Metacarpal hand: Classification and guidelines for microsurgical reconstruction with toe transfers. Plast Reconstr Surg 1997;99:122-8.
53. Wei FC, Lutz BS, Cheng SL, Chuang DC. Reconstruction of bilateral metacarpal hands with multiple toe transplantation. Plast Reconstr Surg 1999;104:1698-704.
54. Wei FC, Yim KK. Pulp plasty after toe-to-hand transplantation. Plast Reconstr Surg 1995;96:661-6.
55. Yim KK, Wei FC. Secondary procedures to improve function after toe-to-hand transfer. Br J Plast Surg 1995; 48:487-91.
56. Lutz BS, Wei FC, Yim KK. Primary toe-to-hand transplantation. Inaugural Sci Meet Asian Pacific Fed Soc Hand Surg Perth, Australia, March 21-26, 1997.
57. Yim KK, Wei FC. Intraosseus wiring in toe-to-hand transplantation. Ann Plast Surg 1995;35:66-9.
58. Wei FC, Chen HC, Chuang CC, Noordhoof MS. Combined second and third toe transfer. Plast Reconstr Surg 1989;84:651-661.
59. El-Gammal TA, Wei FC. Combined second and third toe transfer: current practice. Hand Surg 1996;1:11-6.
60. Wei FC, Chen HC, Chuang CC, Chen SHT. Microsurgical thumb reconstruction with toe transfer: selection of various techniques. Plast Reconstr Surg 1994;93:345-51.
61. Wei FC, Silverman RT, Hsu WM. Retrograde dissection fo the vascular pedicle in toe harvest. Plast Reconstr Surg 1995;96:1211-4.
62. Cheng MH, Wei FC, Santamaria E, Cheng SL, Lin CH, Chen SH. Single versus double arterial anastomoses in combined second- and third-toe transplantation. Plast Reconstr Surg 1998;102:2408-12.
63. Wei FC, Chen HC, Chuang CC, Jeng SF, Lin CH. Anesthetic refinements in toe-to-hand transfer surger. Plast Reconstr Surg 1996;98:485-9.
64. Gu YD, Cheng DS, Zhang GM, Chen XM, Xu JG. Long-term results of toe transfer: retrospective analysis. J Reconstr Microsurg 1997;13:405-8.
65. Breidenbach W. Human hand transplantation. 7th Congr Int Fed Soc Surg Hand, Vancouver, Canada, May 24-28, 1998.
66. Yu ZJ, Huang YC, Yu S, Sui S. Thumb reconstruction in a bilateral upper extremity amputee: an alternative to the Krukenberg procedure. J Hand Surg Am 1999;24:194-7
67. Chen ZW, Hu TP. A reconstructed digit by transplantation of a second toe for control of an electromechanical prosthetic hand. 13th Symposium of the Int Soc Reconstr Surg, Los Angeles, USA, June 22-26, 1999.
68. Wei FC, El-Gammal TA, Chen HC, Chuang CC, Chiang YC, Chen SH. Toe-to-hand transfer for traumatic digital amputations in children and adolescents. Plast Reconstr Surg 1997;100:605-9.

From the Department of Plastic Surgery, Medical Centre Orebro, Sweden; 1Department of Plastic Surgery, Chang Gung Memorial Hospital, Taipei; Chang Gung University, Taoyuan.
Received: Jul. 4, 2002; Accepted: Aug. 21, 2002
Address for reprints: Dr. Fu-Chan Wei, Department of Plastic Surgery, Chang Gung Memorial Hospital. 5, Fu-Shin Street, Kweishan, Taoyuan 333, Taiwan, R.O.C.Tel.: 886-3-3281200 ext. 3355; Fax: 886-3-3287260; E-mail: fcw2007@cgmh.org.tw