Restoring Function After Devastating Hand Injuries

Hand function is easy to take for granted—until it is lost. From basic daily tasks to highly skilled work and artistic expression, the hand’s role in quality of life cannot be overstated. In a recent episode of the Resident Review Podcast, Duke residents Denise (PGY-3) and Ethan Song (PGY-5) sat down with Dr. Harvey Chim, an internationally recognized hand, upper-extremity, and peripheral nerve microsurgeon, to discuss complex hand reconstruction with a particular focus on toe-to-thumb and toe-to-finger transfers.

What followed was a wide-ranging, technically rich discussion on why these reconstructions matter, how they are performed, and where the field is heading.

About Dr. Harvey Chim

Dr. Harvey Chim is Chief of the Division of Plastic and Reconstructive Surgery at Louisiana State University in New Orleans. He trained at the National University of Singapore School of Medicine, completed plastic surgery residency at Case Western Reserve University, and pursued hand and microsurgery fellowship training at the Mayo Clinic.

He is a past recipient of the Richard H. Gelberman Scholar Award from the American Society for Surgery of the Hand (ASSH), a Leonard Tow Humanism in Medicine Award recipient, and has served as an ASSH Visiting Professor and Buncke Fellow. Dr. Chim has authored more than 180 peer-reviewed publications and currently serves on multiple national boards and journal editorial teams.

Why Hand Surgery—and Why Toe Transfers?

Dr. Chim’s interest in hand surgery developed during residency, driven by the uniquely meaningful functional outcomes the specialty offers. Unlike many reconstructions that focus primarily on coverage, hand surgery demands restoration of movement, sensibility, and dexterity.

You don’t really know what you’re missing until you can’t use your hand anymore. Being able to give that function back is incredibly meaningful.

Toe-to-thumb transfer, in particular, stood out to him early on as one of the most technically demanding yet rewarding procedures in reconstructive surgery—combining complex microsurgery with true functional restoration.

Indications for Toe-to-Thumb and Toe-to-Finger Transfers

According to Dr. Chim, the strongest indications include:

• Thumb amputations at or proximal to the MCP joint
• Multiple digital amputations, especially loss of the index through small fingers
• Cases where tripod pinch is required to restore meaningful hand function

In patients missing four digits, bilateral second-toe transfers can be used to recreate tripod pinch—something no other reconstruction reliably achieves.

Cultural Perspectives on Amputation vs Reconstruction

Dr. Chim highlighted a key difference between Western and Asian patient populations. In parts of East Asia, patients are often culturally inclined to preserve all digits and actively request toe transfers. In the U.S., by contrast, many patients prefer revision amputation to expedite return to work.

This makes early counseling critical. Patients introduced to toe transfer options at the time of injury are far more likely to accept reconstruction than those seen months later, after adapting to digit loss.

Preoperative Planning and Imaging

Successful toe transfer begins well before the operating room. Dr. Chim routinely uses:

• CT angiography (CTA) of the foot
• High-resolution ultrasound to assess pedicle depth and dominance

Most patients (approximately 70%) have a dorsal-dominant circulation, which simplifies dissection. Plantar-dominant systems are more challenging, often requiring vein or arterial grafts to achieve sufficient pedicle length.

Surgical Strategy: Go Proximal

One theme Dr. Chim emphasized repeatedly was this:

Harvest the pedicle as proximally as possible.

A longer, more proximal pedicle reduces vasospasm, provides larger-caliber vessels, and significantly lowers the risk of flap failure. This principle applies whether performing a standard second-toe transfer or more advanced reconstructions.

While a two-team approach is ideal, Dr. Chim has successfully performed toe transfers as a single surgeon, noting that operative time is often comparable to standard free flaps.

Managing Vasospasm and Technical Challenges

Toe transfers are particularly prone to arterial spasm. Dr. Chim recommends:

• Allowing the harvested toe to reperfuse for 15–20 minutes before transfer
• Avoiding short-pedicle harvests whenever possible
• Using larger, proximal vessels for anastomosis

In plantar-dominant systems, he often incorporates the dorsalis pedis system as an interposition graft to achieve safe reach and vessel caliber.

Sensibility and Nerve Reconstruction

For sensory recovery, Dr. Chim prioritizes coaptation of:

• Plantar digital nerves to native digital nerves
• Deep peroneal nerve branches when available, sometimes connected to superficial radial nerve branches

While sensation never fully matches a native digit, patients typically achieve two-point discrimination in the 6–11 mm range, which is functionally meaningful.

Advanced Concepts: Functional Units from the Foot

Dr. Chim recently published work describing the foot as a donor of modular functional units, rather than just whole toes. This approach allows:

• Customized reconstruction using skeletal components from the second toe
• Skin envelopes from the great toe
• Preservation of all ten toes via interposition grafts or secondary flaps

Techniques such as the “twisted toe” concept allow surgeons to create a thumb that is better proportioned than a traditional great-toe transfer while maintaining vascular reliability.

Postoperative Care and Rehabilitation

Postoperative management mirrors free flap and thumb replant protocols:

• Aspirin therapy for one month
• Standard DVT prophylaxis
• Inpatient monitoring for approximately one week

Early mobilization is encouraged:

• Gentle passive motion at 1 week (if circulation is stable)
• Active motion between 2–4 weeks

Foot morbidity is minimal, particularly when the great toe is harvested distal to the MTP joint or when using the second toe. Most patients require no formal foot therapy.

Outcomes and Patient Satisfaction

When properly selected and counseled, patients are generally highly satisfied. Dr. Chim reports minimal long-term donor-site complaints and durable functional gains—especially when tripod pinch is restored.

Compliance with hand therapy remains a key determinant of final motion and dexterity.

Advice for Surgeons Interested in Toe Transfers

For trainees and early-career surgeons, Dr. Chim offered clear guidance:

• Take the pedicle as proximal as possible
• Do not hesitate to involve a senior partner for early cases
• Plan reconstructions from the moment of injury
• Tag nerves and tendons during initial debridement

He also emphasized the importance of learning beyond traditional Western training pathways, noting that his own confidence grew after observing high-volume toe transfer centers in East Asia.

Looking Ahead: Innovation and Technology

While artificial intelligence and 3D printing may eventually play a role—such as printed skeletal frameworks combined with vascularized skin flaps—Dr. Chim believes current toe transfer techniques already provide unmatched outcomes for proximal thumb loss.

Final Thoughts

Toe-to-thumb and toe-to-finger transfers remain among the most powerful tools in reconstructive microsurgery. Their success depends on early counseling, meticulous planning, proximal pedicle harvest, and disciplined execution.

As Dr. Chim succinctly put it:

I would always rather have a functional hand than a missing toe.

For patients facing life-altering hand injuries—and for surgeons willing to master the complexity—toe transfers continue to offer outcomes that no prosthetic or alternative reconstruction can truly match.