Plea to save the great toe in total thumb reconstruction.

Thumb reconstruction remains a controversial field. In young, well-motivated patients, in the absence of avulsion injuries, toe to hand transfer is an accepted procedure. With refinement, it is possible to avoid sacrifice of the great toe and in many cases avoid resorting to a second toe which is functionally and cosmetically insufficient. Custom-made reconstruction allows us both to save the donor great toe and to improve function and cosmesis of the donor site. Three basic techniques are reviewed: the modified wrap-around, bipolar lengthening, and twisted two-toes techniques.