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The work of the Spanish surgeon was distinguished last year with the PRS Best Paper Award for the best article in the hand category.

The February edition of the digital magazine of the International Federation of Societies for Surgery of the Hand (IFSSH) publishes an interview with Dr Francisco del Piñal, in which the Spanish surgeon presents the keys of his article on reconstructive surgery for extreme thumb losses for ‘Plastic and Reconstructive Surgery‘ (publication of the American Society of Plastic Surgeons, APS).

‘Extreme Thumb Losses: Reconstructive Strategies’ was honored last year with the PRS Best Paper Award for the best article in the hand category, among those published by the magazine of the US plastic surgeons society in 2019.

This paper by Dr Piñal presents new strategies to address proximal thumb amputations in a single step, using pre-existing muscles, free tissue transfer and toe to hand transplants (big toe or hallux), under the Switching-Two-Toe-Transfer (STTT) procedure, developed by the Spanish surgeon.

In his interview for the IFSSH Ezine, Piñal defends his one-step procedure over the conventional approach of pollicitazion: “The literature recommends pollicization as the first-choice procedure, but my experience and beliefs were different”. “On one side -he says- patients much preferred to have five digits rather than four. Furthermore, rarely in my protected work-related environment would a patient return to work after a pollicization”. “In other words -continues Piñal- “patients were both unhappy and unfit to work by current standards”.

In this clinical context, the use of hallux to restore missing length in proximal thumb amputations generated a very high impact on the donor foot. In order to solve this problem, Piñal developed the STTT (a variation of the original Foucher’s technique) approximately two decades ago, “with the advantages of providing a ‘big-thumb’ of any length and with limited donor site sequela”.

Likewise, Dr Piñal emphasizes the importance of early reconstructions “to get the most out of what was left after the traumatic event”: “We have seen that delaying reconstructions -he insists- causes tendon transfers or arthrodesis (that is, joint fusions) inevitable”.

Asked what every surgeon or hand therapist who reads his article for ‘Plastic and Reconstructive Surgery’ should understand, Piñal affirms that the “most important” message he wanted to convey is that “proximal thumb amputations benefit enormously from reconstruction with great toes”.

During his interview, the Spanish surgeon once again stressed the need to involve the patient in the process: “As proximal injuries are often combined injuries, a plan needs to be laid down so that the patient understands the steps that will be taken and why . Patient participation eases the sufferance associated with these devastating injuries and increases cooperation”.

Extreme thumb losses

As a background to the PRS Best Paper Award-winning article, Dr. Piñal notes how complex thumb amputations have historically been managed in two phases, and often require soft tissue and tendon transfer to achieve satisfactory results.

In his presentation of innovative strategies to deal with this type of injury, the Spanish surgeon considers that proximal thumb amputations go beyond the “simple” loss of a finger, grouping them under the denomination of extreme thumb reconstructions due to their complexity.

In order to evaluate the immediate reconstruction of the thumb in a single step, Piñal’s work analyzes the cases of 24 patients (from a series of more than 500 toe-to-hand transplants) to validate this approach. All of them rated the functional and cosmetic results of their procedures on a scale of 0 to 10, with an average of 8.5 and 8.4, respectively.

In his conclusions, Piñal states that in cases of thumb amputation, the surgeon should pay attention not only to the loss of the thumb per se, but also to the first web and the thenar muscles, among other variables. In turn, he recommends abandoning the standard practice of using pedicled groin flaps followed by toe-to-hand transfer, otherwise, he states, “the thenar muscles become useless, the first metacarpal contracts and the need for tendon transfers skyrockets”.

The Spanish surgeon has performed more than 500 toe to hand transfers, constituting a world reference in this type of microsurgical procedure. Born in 1960 in Santander, Dr Francisco del Piñal is considered one of the world’s best hand surgeons.

Full interview at https://www.ifssh.info/pdf/issue-41-february-2021.pdf pp. 42-44

Related content:

• ‘Plastic and Reconstructive Surgery’ récompense un article du Dr Piñal comme le meilleur de 2019 en chirurgie plastique et reconstructive de la main

• Plastic and Reconstructive Surgery publie les travaux du Dr Piñal sur la chirurgie reconstructive pour les pertes de pouce extrêmes

• Extreme Thumb Losses: Reconstructive Strategies