British Journal of Plastic Surgery (2005) 58, 873876

CASE REPORT

Anatomic correction of polysyndactyly of the fifth

toe fused with the fourth toe
Daegu Son*, Hyunji Kim, Junhyung Kim, Kihwan Han
Department of Plastic and Reconstructive Surgery, Dongsan Medical Center, Keimyung University,
194 Dongsan Dong, Daegu 700-712, South Korea
Received 11 May 2004; accepted 11 January 2005

KEYWORDS
Postaxial polydactyly;
Toe polysyndactyly

Summary
A new surgical technique for correction of polysyndactyly with the
fifth toe fused with the fourth toe was devised. The technique consists of the
creation of a dorsal rectangular flap on the dorsum of the syndactyly web for
the new fourth web, making a medially based plantar rectangular flap on the
plantar surface of the fifth toe, and a sixth toe-tip-based rectangular hinge flap
to reconstruct the lateral side of the fourth toe and medial side of the new
fifth toe, respectively. All suture lines are intended to be located in the
transition of the plantar and dorsal surfaces of the web and digit. This
technique is characterised by accurate anatomic reconstruction, which produces
better aesthetic results with no wasting of any skin components.
q 2005 The British Association of Plastic Surgeons. Published by Elsevier Ltd. All
rights reserved.

Polysyndactyly of the fifth toe fused with the fourth

toe is the most common congenital malformation of
the forefoot. This postaxial polydactyly of the foot
has been classified by Watanabe et al.1 as fifth-ray
duplication. Although several surgical techniques
for desyndactylization of the foot have been
devised primarily for aesthetic rather than functional improvement, the incision scars are visible on
the foot dorsum or lateral side of the fifth toe and
their shapes are not as natural. Here we present our
new surgical technique of anatomic reconstruction,

* Corresponding author. Tel.: C82 53 250 7636; fax: C82 53

255 7632.
E-mail address: handson@dsmc.or.kr (D. Son).

which produces a preferable aesthetic result, and a

typical case.

Patients and methods

This surgical technique was used in patients with
polysyndactyly of the fifth toe fused with the fourth
toe. The patients included four children, aged 19
years at operation, and one 26-year-old female.
The patients were followed for between 12 and 42
months.
A rectangular flap (a) on the dorsum of the
syndactyly web; a plantar rectangular flap (b),
based on the medial side on the plantar side of the
fifth toe to reconstruct the lateral side of the fourth

S0007-1226/$ - see front matter q 2005 The British Association of Plastic Surgeons. Published by Elsevier Ltd. All rights reserved.
doi:10.1016/j.bjps.2005.01.023

874

D. Son et al.

Figure 1 The operative technique. (Above, left) Dorsal view: flap (a) indicates the dorsal rectangular flap. (Above,
right) Plantar view: flap (b) indicates the fourth toe plantar rectangular pedicled flap. (Center, left) Anterior view: flap
(c) indicates the fifth toe rectangular pedicled hinge flap. (Center, right) Schematic diagram of flaps. (s) indicates the
full thickness skin graft. (Below, left) Postoperative dorsal view. (Below, right) Postoperative plantar view.

toe; and a sixth toe-tip-based rectangular hinge flap

(c), to create the medial side of the new fifth toe,
were designed (Fig. 1). Flap (b) should be designed
to be exactly the same size of the expected defect,
which can be estimated by using the normal side as
a reference. All drawing lines were intended to
locate the transition of the plantar and dorsal
surfaces of the web and digit.
After the three flaps are elevated, the nail
components and bony structures from the fifth toe
are removed completely. The new fourth web is
created by flap (a). The lateral surface of the fourth
toe is covered by flap (b) after excision of a small
amount of fat from the flap, without damaging the
neurovascular bundle, to avoid bulkiness. Flap (c) is
used to cover the medial surface of the fifth toe and
create the typical triangular shape of the toe. Full

thickness skin from the medial side of the foot is

grafted, if necessary, to the fifth toe.

Case report
A 1-year-old girl presented with duplication of
the right fifth toe and polysyndactyly of the left
fifth toe fused with the fourth toe. Our new
surgical method was carried out on the left side
at 1 year of age. Two years postoperatively,
there were well-reconstructed fourth and fifth
toes with a natural interdigital space. Above all,
the dorsal and plantar scars are almost invisible
and the typical triangular shape of the fifth toe
was well created (Fig. 2).

Anatomic correction of polysyndactyly of the fifth toe fused with the fourth toe

875

Figure 2 A 1-year-old girl with left fifth toe polysyndactyly fused with the fourth toe. (Above, left) Preoperative
dorsal view. (Above, right) Preoperative plantar view. (Below, left) Two years postoperatively, the inconspicuous dorsal
operation scar was identified. (Below, right) Two years postoperatively, the anatomical triangular-shaped fifth toe and
deep fourth web space were maintained.

Discussion
There are controversies between authors as to which
toe should be removed in these polysyndactylys, the
fifth or sixth. Nakamura2 describes fifth-ray duplications, as classified by Watanabe et al.,1 as characterised by a dominant fifth toe and a hypoplastic sixth toe,
and prefers to excise the sixth toe, as the literature
recommends.3,4 However, some authors prefer to

excise the fifth toe to achieve better interdigital web

spaces and avoid scarring of the outermost aspect of
the foot,5 and is especially recommended if fusion
exists between duplicated digits and the fourth toe,
such as in our cases. We do not consider that the most
lateral digit is always dominant, and we believe that
excision of the more medial digit of a fifth-ray
polydactyly is preferable to allow maintenance of
the natural lateral contour of the foot.

876
Our technique differs from that of Nogami5 in
that we have designed a rectangular plantar flap (b)
based on the medial side of the plantar side of the
web to reconstruct the lateral side of the fourth
toe, while Nogami5 designed the flap based on the
lateral side for the medial side of the fifth toe. The
advantages of our technique are that all suture lines
are located in the transition zone and it avoids
placing lines on the tip of the fifth toe. The fifth toe
is more triangular than other toes and the angle
between the medial and plantar sides is very acute
and has a thick border. Our suture line on the
plantar side of the fifth toe is located exactly on the
angle, which makes the reconstructed fifth toe
more natural looking. In addition, the medially
rotated sixth toe-tip-based rectangular hinge flap
(c) may be helpful in preventing valgus deformity of
the toe. Also, if the flap is sufficiently wide and long
to cover the medial side of the new fifth toe, a skin
graft is not required; however, you should not force
the reconstruction of the web without a skin graft,
as we think that a deeper web space is preferable
and more natural than a shallow and tight one. The
grafted full thickness skin from the medial side of
the foot did not pigment, and so matched very well
with the surrounding skin. Care must be taken to
avoid thick sole skin when harvesting skin from the
medial foot, as this results in thick unnaturally
white skin at the recipient site. We recommend
Allevynw and Opsitew compressive dressing, for not
only complete survival of the grafted free fullthickness skin to the fifth toe, but also to avoid

D. Son et al.
unwanted pressure on the flaps. All of the flaps we
designed are rectangular in shape and with wide
bases, which is a good reason why we did not
observe any flap necrosis.
The purpose of surgery for postaxial polysyndactyly is aesthetic improvement, and our newly
devised technique fully satisfies this goal, with
minimal scaring, no wasting of any skin component,
and accurate anatomic reconstructions.

Acknowledgements
We thank Dr Dongchul Won for drawings and expert
assistance.

References
1. Watanabe H, Fujita S, Oka I. Polydactyly of the foot: an
analysis of 265 cases and a morphological classification. Plast
Reconstr Surg 1992;89:85677.
2. Nakamura K, Ohara E, Ohta E. A new surgical technique for
postaxial polydactyly of the foot. Plast Reconstr Surg 1996;
97:1338.
3. Lovell WW. Fore foot deformities. In: Lovell WW, Winter RB,
editors. In: Pediatric orthopaedics, vol. 2. Philadelphia: JB
Lippincott; 1978. p. 9703.
4. Sage FP. Anomalies of toes. In: Edmonson AS, Crenshaw AH,
editors. Campbells operative orthopaedics. St Louis: CV
Mosby; 1980. p. 17528.
5. Nogami H. Polydactyly and polysyndactyly of the fifth toe.
Clin Orthop 1986;204:2615.