Numerous refinements in toe transfers have been proposed, but the variability of the first dorsal metatarsal artery (FDMA) remains an obstacle to standardization to this procedure. Although the FDMA is the dominant artery to the first and second toes in approximately 70% of patients, it can be inadequate in a significant number of patients. Moreover, the course of the FDMA in relationship to the interosseous muscle and the deep transverse metatarsal ligament is highly variable. This report provides a simplified method for harvesting the first or second toe for microvascular transfer.

Harvest of the first or second toe begins with dissection of the dorsal veins. Dissection is continued proximally to the level of the saphenous vein, or further, as is required given the anatomy of the recipient vessels. No attempt is made to dissect the FDMA. Plantar dissection is then undertaken, with identification of the digital arteries, nerves and flexors. Proximal dissection of the digital arteries is limited to the extent of the proper digital arteries, avoiding dissection through the fibrofatty tissue on the plantar surface. After the complete division, the toe is taken to the back table for creation of an arterio-venous loop between the saphenous vein and the proper digital artery. The toe transfer is then taken to the hand for bone fixation and repair of the tendons and nerves. The AV loop can then be divided to allow for an appropriate length of arterial and venous pedicles, and most importantly allows the arterial pedicle to be positioned on the volar aspect of the hand.

This technique has been used in three pediatric toe-to-hand transfers for congenital hand anomalies and one adult 1st toe pulp transfer to a traumatized thumb. In all cases, there was no significant size disparity between the saphenous vein and the proper digital artery. All microvascular anastomoses were performed without difficulty.

The specific advantages of this approach is avoiding the potentially tedious or unnecessary dissection of the FDMA, and providing a “correct” palmar orientation of the artery for anastomosis in the hand. Palmar positioning of the arterial anastomosis is particularly important in toe-to-finger transfers, to avoid directing the FDMA through the interdigital cleft to the donor vessels volarly. Although this method does require an additional microvascular anastomosis, this can be performed readily on the back table. However, the time required for this end-to-end anastomosis is more than compensated for by the simplified toe harvest.