Cross-toe flap from great toe to second toe: a novel reconstructive approach for distal toe salvage

Cross-toe flaps are traditionally harvested from the second toe to reconstruct great toe defects. We present a novel approach using the great toe pulp to reconstruct a second toe dorsal defect, providing durable coverage while preserving toe length and aesthetics. A 19-year-old female sustained full-thickness soft tissue and extensor tendon loss over the right second toe following a road traffic accident. After initial debridement, definitive reconstruction was performed using a cross-toe flap from the lateral plantar pulp of the great toe. The flap was designed elliptically based on the plantar digital neurovascular bundle. A medial incision was made, and dissection proceeded to just above the periosteum, preserving a thin layer of soft tissue over bone. The flap was elevated laterally and dorsally to the extent required for a tension-free inset over the second toe defect. Flap division was performed ten weeks after the index reconstructive surgery. The flap demonstrated excellent perfusion post-inset and remained neurovascularly intact after division. The second toe was salvaged with good aesthetic and functional outcomes while avoiding disarticulation, and the great toe donor site healed without complication. To the authors' knowledge, this is the first reported case of a cross-toe flap harvested from the great toe for reconstruction of the second toe, providing a viable option for distal toe salvage in selected patients seeking optimal aesthetic and functional outcomes.