Digital augmentation for ectrodactyly: management and planning.

Selection of the most appropriate operations for a patient is as important as technical expertise in performing the procedures. Web deepening may be performed alone or in addition to tissue augmentation and should be planned in conjunction with bone lengthening. Skeletal augmentation is useful if fingers are missing or inadequate, and it is necessary to add bony tissue. In general, in order to grow, skeletal transfers must be performed on very young children or must include vascularized physes; complex cases may require microvascular composite toe-to-hand transfer. Distraction-lengthening for intercalary skeletal enhancement is indicated for patients with multiple hypoplastic, aplastic, and missing digits, but the cosmetic result is limited. The major procedures should be started by age 2 years and finished by age 4; unfortunately, it is most often not advisable to perform microvascular surgery at such an early age. Modification of functional patterns, even though they are abnormal or the result of incomplete anatomy, should be avoided in the older child or adult because tinkering does not lead to significant benefits. For a cooperative, and often difficult, staged venture to be maximally successful, physicians and parents must share realistic expectations of aesthetic and functional results.