Introduction Regions of Thumb Reconstruction Region A Primary closure Toe to Thumb (wrap around) Local flaps Region B Web deepening Metacarpal lengthening Toe to thumb Region C Toe to thumb Osteoplastic thumb reconstruction Dorsal rotational flap Region D Pollicization Reconstruction of the thumb requires an intact carpometarcarpal joint that not only is stable, but is appropriately functional. Treatment Toe to thumb procedure great toe receives blood supply from the first dorsal metatarsal artery and dorsalis pedis The Morrison/wrap around flap allow for maintenance of length of the hallux. Size and appearance are best replicated. second toe is not as stable for transfer Vascular pedicle can be based on dorsalis pedis /1st dorsal metatarsal artery 2nd dorsal metatarsal artery Web deepening Z plasty (2 or 4 flap) 2 flaps provide greater depth if completed at 45 degrees, relative length is increased by 50%; 60 degrees leads to an increase in length of 75% Brand flap index finger is used to provide a full thickness (dermoepidermal flap) can close the donor site primarily Dorsal rectangular flaps Take from dorsum of metacarpals May require skin grafting Arterialized palmar flap May use axial or island flaps (locally vs distally) Osteoplastic reconstruction Iliac crest is used to establish mechanical length to the thumb an island flap from the radial aspect of the 4th ray is combined with a reverse radial forearm flap to aid in coverage